Refugee primary care: lessons in advocacy, cultural competence and self-reflection

CMAJ Photograph OgunyemiBoluwaji Ogunyemi is a Dermatology Resident Physician in Vancouver, BC, and a freelance writer for the Huffington Post, Ubyssey Newspaper, and the Online Journal for Community and Person-centered Dermatology

As one of my last off-service rotations in residency, I completed an elective rotation in refugee primary care. I was attracted to the idea of a global population placed locally, because I plan to work internationally as part of my future practice, and I enjoy cross-cultural aspects of medicine.

It would turn out that I received a lot more than I had bargained for!

Of all of the CanMEDs roles I took on during my rotation, perhaps none was as important as that of health advocate. I may have underestimated the enormity of the factors that place refugees in a particularly vulnerable position during their first year after arrival.

Staying abreast of and even taking on activist roles in provincial and federal politics as they reflect access to health care for refugees and refugee claimants is seen as an extension of the role of primary care physician for many who work with this population

With four out of every five of patients that I saw in the clinic lacking fluency in English or French, I found it humbling that my medical knowledge, in and of itself, was of little use in this arena.

When tasked with providing medical documentation for a patient applying for disability due to a shoulder injury, I was taken aback to learn that the mechanism of injury was from torture. The patient was hanged before fleeing his home country because of religious persecution. Similarly, trauma from torture became part of the differential diagnosis for cutaneous scars and back pain for too many of my patients.

When working with populations from different countries and health care systems, I found it instructive to reflect on medical practices and beliefs in the Western biomedical model. Some patients were frazzled after receiving diagnoses of hypertension and prediabetes when they previously considered themselves perfectly healthy. Discussing the cause of disease in a manner that was both informing and aligned with patients’ health beliefs often proved challenging but rewarding.

I have re-evaluated my understanding of human resilience. Many patients had witnessed or experienced torture firsthand. For a number of refugees, their immediate families were separated by thousands of miles while awaiting reunification. For many government-assisted refugees, overcrowded camps served as their place of immediate refuge from persecution, often for years at a time. These realities factored into the post-traumatic stress disorder and other forms of anxiety that were commonplace in this population. Knowing that every prescription of anxiolytic corresponded to a story of grief from which I had been saved simply by being born in North America was disheartening.

Social history was no longer fulfilled by determining occupation and smoking status. In the context of this patient population, this section of the medical history can include details about the patient’s persecution and other circumstances in their native country and transitory residences before entering Canada. Although one’s mother tongue has obvious practical importance for translation, country of origin proves useful in a more broad sense, including diseases endemic to the country. I learned never to underestimate the importance of social circumstances in this population. One patient expressed that the most useful part of their visit was that I took the time to ask about the well-being of his family member overseas who was facing trial. One patient stated “Thank God o!” in relief when she read my nametag. This Nigerian patient would later describe that, as my name is typical of a person of Nigerian ancestry, she had yet to interact with a health care professional who shared her ethnicity in Canada and could therefore let her guard down about her cultural idiosyncrasies.

With the globalization and increasing ethnic and linguistic diversity of many Western nations, it stands to reason that cultural competency be seen as a priority for those entrusted with something as central and sensitive to people as their health. The increasing numbers of refugees worldwide further underscore this need.

At the end of my rotation, it seemed reductionist to translate my learning to a list of objectives and checkboxes. I feel that the perspective that I have gained from these patients far exceeds my contributions to their care, and I trust that it will make me a better physician.

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