HEALTH ISSUES IN ADOLESCENT REFUGEES Dr. Emma Burns Senior Medical Officer Parks Primary Health Care Services and The Second Story Youth Health Service

HEALTH ISSUES IN HEALTH ISSUES IN ADOLESCENT REFUGEESADOLESCENT REFUGEES

Dr. Emma BurnsDr. Emma Burns

Senior Medical OfficerSenior Medical OfficerParks Primary Health Care Services and The Parks Primary Health Care Services and The

Second Story Youth Health ServiceSecond Story Youth Health Service

““I know that nobody wants refugees, I know that nobody wants refugees, but do they know that we don’t want but do they know that we don’t want to be refugees” Said 14, Somalito be refugees” Said 14, Somali

BACKGROUNDBACKGROUND

Humanitarian program (8.1% of all visas)Humanitarian program (8.1% of all visas) OffshoreOffshore

Refugee: majority are identified and referred by Refugee: majority are identified and referred by UNHCR for resettlement. No choice about leaving, UNHCR for resettlement. No choice about leaving, little choice in where going.little choice in where going.

Special Humanitarian Program: requiring an Special Humanitarian Program: requiring an Australian based proposer.Australian based proposer.

OnshoreOnshore PPV if apply with a valid visaPPV if apply with a valid visa TPV for 3 years if arrive “unauthorised”TPV for 3 years if arrive “unauthorised”


2007-2008 Program2007-2008 Program Humanitarian program of 13,014 placesHumanitarian program of 13,014 places

6004 refugee places6004 refugee places 2008-2009 Program2008-2009 Program

Humanitarian program of 13,500 places Humanitarian program of 13,500 places 6500 refugee places (an increase of 500 to allow 6500 refugee places (an increase of 500 to allow

greater number of Iraqis).greater number of Iraqis). 33% Africa, 33% Middle East, 33% Asia and 1 % 33% Africa, 33% Middle East, 33% Asia and 1 %

contingenciescontingencies In S.A., approx. 70-100 humanitarian In S.A., approx. 70-100 humanitarian

arrivals per month.arrivals per month.


Countries of originCountries of origin over past 5 years, up to 70% per year from over past 5 years, up to 70% per year from

Africa, single largest group from Sudan.Africa, single largest group from Sudan. over last year, large numbers from Myanmar/ over last year, large numbers from Myanmar/

Burma, Iraq, Afghanistan, Sudan and West and Burma, Iraq, Afghanistan, Sudan and West and Central Africa.Central Africa.

recent S.A. arrivals from Afghanistan, Congo, recent S.A. arrivals from Afghanistan, Congo, Iraq, Myanmar/ Burma, Somalia and Iraq, Myanmar/ Burma, Somalia and Uzbekistan.Uzbekistan.

Representing a diverse range of cultural, Representing a diverse range of cultural, religious and language backgrounds, both religious and language backgrounds, both across and within national groups.across and within national groups.


Refugees’ Age:Refugees’ Age: 28% between Jan 2005 and Jul 2008 were 28% between Jan 2005 and Jul 2008 were

aged between 10-19 yearsaged between 10-19 years Approximately the same percentage aged Approximately the same percentage aged

0-9 years0-9 years 3.5% were aged 50 or over and only 1% 3.5% were aged 50 or over and only 1%

were aged 60 and over.were aged 60 and over. Less than 1% unaccompanied minorsLess than 1% unaccompanied minors Recent increase in proportion of young Recent increase in proportion of young

peoplepeople

PREFLIGHTPREFLIGHT

Deprivation - food, water, warmth, nurturing, Deprivation - food, water, warmth, nurturing, rest, sleep, education, play, friendship, health rest, sleep, education, play, friendship, health carecare

Loss – home, family members, friends, Loss – home, family members, friends, possessions, trust in authority figures possessions, trust in authority figures including parents, ability to make sense of including parents, ability to make sense of worldworld

Trauma – exposure to violence, abuse, Trauma – exposure to violence, abuse, combat, forced labour, extreme distress in combat, forced labour, extreme distress in others, isolationothers, isolation

“ “ We didn’t know where we were going We didn’t know where we were going to, we just ran….We didn’t know to, we just ran….We didn’t know where our mother or father were, we where our mother or father were, we didn’t say goodbye. When there is didn’t say goodbye. When there is shooting, when you hear BANG! shooting, when you hear BANG! BANG! BANG!, you don’t think about BANG! BANG!, you don’t think about your friends or your mother, you just your friends or your mother, you just run to save your life” Chol 14, Sudanrun to save your life” Chol 14, Sudan

FLIGHTFLIGHT

DeprivationDeprivation Loss – societal and cultural place, local Loss – societal and cultural place, local

language and ability to communicate, language and ability to communicate, community and neighbourhood, family and community and neighbourhood, family and generational transfer of knowledge, ability to generational transfer of knowledge, ability to problem solveproblem solve

Trauma – constant instability and Trauma – constant instability and unpredictability of environment, hyperarousal unpredictability of environment, hyperarousal and mistrust, fear of further deprivation, loss, and mistrust, fear of further deprivation, loss, trauma, death.trauma, death.

““He came and chased the refugees He came and chased the refugees away. We couldn’t do anything, what away. We couldn’t do anything, what could we do? It was not our country” could we do? It was not our country” Chol 14, SudanChol 14, Sudan

RESETTLEMENTRESETTLEMENT

New challenges and potential for trauma rather New challenges and potential for trauma rather than the end of the ordealthan the end of the ordeal

World remains incomprehensibleWorld remains incomprehensible No possibility of resuming normal lifeNo possibility of resuming normal life Practical challenges – finances, languages, new Practical challenges – finances, languages, new

legal system, school, employment, housing, food, legal system, school, employment, housing, food, loss of status in family and community, lack of loss of status in family and community, lack of age-appropriate education levelage-appropriate education level

Racism, isolation, negative or ignorant Racism, isolation, negative or ignorant stereotypingstereotyping

Learned helplessness, misunderstoodLearned helplessness, misunderstood Expectation of gratitude, appreciationExpectation of gratitude, appreciation


Different rates of acculturation within Different rates of acculturation within families and communities, young people families and communities, young people often faster than parentsoften faster than parents

Loss of family roles and of basic Loss of family roles and of basic understanding between generationsunderstanding between generations

““Loss” of parents due to parental mental Loss” of parents due to parental mental health issueshealth issues

Exacerbated by missing generationsExacerbated by missing generations Adolescent as “cultural broker”Adolescent as “cultural broker”


Integrated humanitarian settlement strategy: Integrated humanitarian settlement strategy: case coordination, information, referrals, on case coordination, information, referrals, on arrival reception, accommodation, short term arrival reception, accommodation, short term trauma and torture counsellingtrauma and torture counselling

Highly variable initial health and other input Highly variable initial health and other input depending on where they godepending on where they go

Access affected by competing demands, lack Access affected by competing demands, lack of awareness of services, lack of transport, of awareness of services, lack of transport, fear about cost/ language/ confidentiality, past fear about cost/ language/ confidentiality, past experience of health workers involved in experience of health workers involved in torturetorture

ADOLESCENCEADOLESCENCE

Adolescence – as we understand it:Adolescence – as we understand it: If successful growth and development in If successful growth and development in

childhood, the child ready to become an adultchildhood, the child ready to become an adult Physical growth and development including Physical growth and development including

sexual development occurs, if physical safety sexual development occurs, if physical safety and adequate nutrition are present.and adequate nutrition are present.

Development of own identity occurs – sexual and Development of own identity occurs – sexual and gender identity, sociocultural identity, ideals, gender identity, sociocultural identity, ideals, goals – if there are emotional safety, stability and goals – if there are emotional safety, stability and clear social norms and role-modelling.clear social norms and role-modelling.

ADOLESCENCEADOLESCENCE

Western models of “normal” development Western models of “normal” development and adolescence not universaland adolescence not universal

Similarly, incomplete understanding of Similarly, incomplete understanding of refugee experience, esp. in young peoplerefugee experience, esp. in young people

Avoid one-dimensional view of refugees as Avoid one-dimensional view of refugees as traumatised, damaged peopletraumatised, damaged people

Avoid one-dimensional view of adolescent Avoid one-dimensional view of adolescent refugee experience as disruption to refugee experience as disruption to normal developmentnormal development

RESILIENCE AND STRENGTHRESILIENCE AND STRENGTH

Formation of strong relationships, new Formation of strong relationships, new communitiescommunities

Acquisition of practical skills e.g. proficiency Acquisition of practical skills e.g. proficiency in multiple languages, ability to get adult in multiple languages, ability to get adult help, ability to discern dangerhelp, ability to discern danger

Acquisition of emotional skills e.g. active Acquisition of emotional skills e.g. active and courageous coping, self-calming, sense and courageous coping, self-calming, sense of humour, making meaningof humour, making meaning

Admittedly few health benefits in preflight Admittedly few health benefits in preflight and flight, although many did not start the and flight, although many did not start the journey in good health nor with adequate journey in good health nor with adequate health care.health care.

INITIAL CONTACTINITIAL CONTACT

Outline the purpose of the consult and norms Outline the purpose of the consult and norms such as confidentiality, medical decision such as confidentiality, medical decision makingmaking

Are basic needs being met?Are basic needs being met? Do they have basic necessary information e.g. Do they have basic necessary information e.g.

scripts, emergency services, costs, money?scripts, emergency services, costs, money? Establish family relations, legal guardianshipEstablish family relations, legal guardianship Explain approach to young people to familyExplain approach to young people to family Interpreter present, phone may be bestInterpreter present, phone may be best


Explore path to resettlement from country of Explore path to resettlement from country of originorigin

Allow clients to set the pace, especially with Allow clients to set the pace, especially with regard to disclosure of traumaregard to disclosure of trauma

Be up front about your ignorance on cultural and Be up front about your ignorance on cultural and religious issues, where appropriatereligious issues, where appropriate

Try to be aware of major events on the religious Try to be aware of major events on the religious or community calendar e.g. Ramadanor community calendar e.g. Ramadan

Try to be aware of ongoing trauma e.g. newsTry to be aware of ongoing trauma e.g. news Primary job – make sure they want to come back.Primary job – make sure they want to come back.


Workers as representatives of all that has Workers as representatives of all that has been lost – a voice, status, money, place in been lost – a voice, status, money, place in societysociety

Underlying mistrust of authority figuresUnderlying mistrust of authority figures Be aware that western models not universalBe aware that western models not universal

Neutrality seen as sympathy or collusionNeutrality seen as sympathy or collusion Lack of self-disclosure may increase mistrustLack of self-disclosure may increase mistrust Frankness seen as rude or invasiveFrankness seen as rude or invasive Assumptions that young people (especially Assumptions that young people (especially

females) have input in decision-makingfemales) have input in decision-making Understandings of why sickness occurs, what Understandings of why sickness occurs, what

symptoms mean and how to treatsymptoms mean and how to treat

““.. People would come and take .. People would come and take photographs of us and ask about our photographs of us and ask about our terrible life. We thought they would terrible life. We thought they would help….Nobody came back to help. help….Nobody came back to help. Don’t ask me about my problems. Don’t ask me about my problems. You will just go away too” Bor 17, You will just go away too” Bor 17, SudanSudan


The adolescent client may also be a The adolescent client may also be a resilient, capable young person enthusiastic resilient, capable young person enthusiastic about opportunity to access health care about opportunity to access health care and about other aspects of new lifeand about other aspects of new life

If we expect and look for damage, we may If we expect and look for damage, we may introduce or increase feelings of guilt about introduce or increase feelings of guilt about survival and interfere with coping/ healingsurvival and interfere with coping/ healing

Allow the client to be expert on experience Allow the client to be expert on experience and its meaning – individual, family, and its meaning – individual, family, community, culturecommunity, culture

GENERAL HEALTH ISSUESGENERAL HEALTH ISSUES

For offshore applicants, International Office For offshore applicants, International Office Migration MAY coordinate a health check Migration MAY coordinate a health check including:including: Fitness to travelFitness to travel Screening for malaria and TBScreening for malaria and TB CXR if over 11 yearsCXR if over 11 years HIV if over 15 yearsHIV if over 15 years Treat for helminths and malariaTreat for helminths and malaria UTD immunisations NOT requiredUTD immunisations NOT required

May be some time before departure.May be some time before departure. Australia checks HIV and active TB.Australia checks HIV and active TB.


Wide range of health issues that may Wide range of health issues that may be unfamiliar to Australiansbe unfamiliar to Australians

Clients may not have ever had Clients may not have ever had adequate screening, even after years adequate screening, even after years

MHS has screening guidelinesMHS has screening guidelines Physical well-being a foundation for Physical well-being a foundation for

social and emotional well-beingsocial and emotional well-being

NUTRITIONAL DEFICIENCIESNUTRITIONAL DEFICIENCIES

Vitamin D low or deficient up to 80% Vitamin D low or deficient up to 80% young refugees in Australia, local young refugees in Australia, local study of S.A. African refugees 69%study of S.A. African refugees 69% Especially dark-skinned, veiled womenEspecially dark-skinned, veiled women May complain of aches and painsMay complain of aches and pains

Vitamin A deficiency – 19-38%Vitamin A deficiency – 19-38% Iron deficiency – 19%, 34% in local Iron deficiency – 19%, 34% in local

studystudy

INFECTIOUS DISEASESINFECTIOUS DISEASES

Hepatitis B – 5-15%, 16% in local studyHepatitis B – 5-15%, 16% in local study Likely perinatal transmissionLikely perinatal transmission 20-25% serious complications20-25% serious complications

Hepatitis C – 1-3%Hepatitis C – 1-3% Malaria – prevalence 8%-25% in children Malaria – prevalence 8%-25% in children

from endemic areas, 5 % in local studyfrom endemic areas, 5 % in local study If symptomatic, hospitaliseIf symptomatic, hospitalise

Tuberculosis – high positive Mantoux 63%, Tuberculosis – high positive Mantoux 63%, routine screening recommended.routine screening recommended.

PARASITESPARASITES

Schistosoma – 11% positive serology, 24% Schistosoma – 11% positive serology, 24% positive in local study from serology and positive in local study from serology and urine/faeces (10% of positives were urine/faeces (10% of positives were serology negative)serology negative) A worm found in water that can damage liver, A worm found in water that can damage liver,

kidneys and bladder.kidneys and bladder. Other intestinal parasites – up to 37%, Other intestinal parasites – up to 37%,

24% in local study, mainly Giardia24% in local study, mainly Giardia Strongyloides (threadworm) – up to 10%, Strongyloides (threadworm) – up to 10%,

definitely check if unexplained eosinophiliadefinitely check if unexplained eosinophilia Helicobacter pylori – screen if symtpomaticHelicobacter pylori – screen if symtpomatic

INHERITED DISORDERSINHERITED DISORDERS

Haemoglobinopathies Haemoglobinopathies Sickle cell – cells sickle at low oxygen and are Sickle cell – cells sickle at low oxygen and are

removed by spleen, may cause hemolytic removed by spleen, may cause hemolytic anemia or vaso-occlusion.anemia or vaso-occlusion.

ThalassaemiaThalassaemia SpherocytosisSpherocytosis

Most commonly encounter sickle cell trait Most commonly encounter sickle cell trait and alpha thalassaemic trait and alpha thalassaemic trait

Warn about partner issuesWarn about partner issues

GROWTH AND GROWTH AND DEVELOPMENTDEVELOPMENT

At increased risk of delayed growth and At increased risk of delayed growth and developmentdevelopment Parental concern highly suggestiveParental concern highly suggestive Try to ascertain correct ageTry to ascertain correct age Try to work out how long delay has been evidentTry to work out how long delay has been evident Serial measurements useful, especially if just Serial measurements useful, especially if just

arrivedarrived Early referral – reduce social costsEarly referral – reduce social costs

Obesity – past hunger, new high calorie dietObesity – past hunger, new high calorie diet


Dental healthDental health At risk due to poor nutrition including At risk due to poor nutrition including

vitamin D deficiency, poor dental hygeine vitamin D deficiency, poor dental hygeine and care, exposure to injuryand care, exposure to injury

May be experienced as invasive, May be experienced as invasive, frighteningfrightening

Immunisations – refugee camps offer Immunisations – refugee camps offer limited immunisations, but records limited immunisations, but records unreliable. Consult SAICU, NARI for unreliable. Consult SAICU, NARI for catch-up program.catch-up program.


Trauma and torture injuriesTrauma and torture injuries Genital mutilation – especially North East Genital mutilation – especially North East

Africa, females approx 6 yoAfrica, females approx 6 yo Missed or botched procedures along the wayMissed or botched procedures along the way Non Western beliefs, attribution and Non Western beliefs, attribution and

interventions – dietary restrictions or interventions – dietary restrictions or changes, beliefs about exercise, curses, changes, beliefs about exercise, curses, unknown procedures (uvulectomy)unknown procedures (uvulectomy)

Unfamiliar Western interventions – e.g. Unfamiliar Western interventions – e.g. counselling, Pap smears, lack of antibiotic counselling, Pap smears, lack of antibiotic useuse

MENTAL HEALTH ISSUES MENTAL HEALTH ISSUES

Extremely high levels of PTSD and Major Extremely high levels of PTSD and Major Depressive Disorder – figures range from Depressive Disorder – figures range from 35% to 93% in different preflight and flight 35% to 93% in different preflight and flight settings, higher in unaccompanied minors, settings, higher in unaccompanied minors, lower in resettled populationslower in resettled populations

Also other anxiety, eating, sleep disordersAlso other anxiety, eating, sleep disorders Amount or type of loss or trauma Amount or type of loss or trauma

suggestive, not predictive of mental heathsuggestive, not predictive of mental heath Depressive symptoms drop more sharply Depressive symptoms drop more sharply

over time after resettlement than PTSD over time after resettlement than PTSD symptomssymptoms

MENTAL HEALTH ISSUESMENTAL HEALTH ISSUES

Varying cultural idioms of distress mean young Varying cultural idioms of distress mean young people may present with hyperactivity, isolation, people may present with hyperactivity, isolation, aggression, depression, somatisation, anything..aggression, depression, somatisation, anything..

Let client and family determine what is normalLet client and family determine what is normal Look for flagsLook for flags

Client’s belief that something is wrongClient’s belief that something is wrong Family stability before and now, parental copingFamily stability before and now, parental coping Feelings about new and original culturesFeelings about new and original cultures Signs of ideological, religious commitment, sense-makingSigns of ideological, religious commitment, sense-making

Client and family input on treatmentClient and family input on treatment BUT, parents underestimate child traumaBUT, parents underestimate child trauma

REPRODUCTIVE HEALTHREPRODUCTIVE HEALTH

Difficult enough in Australian Difficult enough in Australian adolescentsadolescents

Fear about being culturally Fear about being culturally inappropriate or causing offenceinappropriate or causing offence

Assumptions made about sexual Assumptions made about sexual behaviour of certain groupsbehaviour of certain groups

Assumptions made about young Assumptions made about young people who are not sexually activepeople who are not sexually active

Easy to let ourselves off the hookEasy to let ourselves off the hook


Loss of mothers, aunties, fathers, uncles, Loss of mothers, aunties, fathers, uncles, grandparents, peers and “rites of passage”grandparents, peers and “rites of passage”

Disruption of generational transfer of Disruption of generational transfer of knowledgeknowledge

Exposure to high risk situations for sexual Exposure to high risk situations for sexual abuse or exploitation, esp. females, both abuse or exploitation, esp. females, both before and after arrivalbefore and after arrival

Sex and marriage exchanged for food, safetySex and marriage exchanged for food, safety Education to primary level with variably poor Education to primary level with variably poor

delivery of sexual health (females > males)delivery of sexual health (females > males) High level of exposure to misinformationHigh level of exposure to misinformation


““if you do not have a baby by 20, you won’t be able if you do not have a baby by 20, you won’t be able to”to”

““contraception damages your body”contraception damages your body” ““not having regular periods does harm to you inside”not having regular periods does harm to you inside” ““after what happened, I wanted to know I could get after what happened, I wanted to know I could get

pregnant”pregnant” ““everyone can tell if you have had sex”everyone can tell if you have had sex” ““I think I might have damaged myself”I think I might have damaged myself” ““I don’t know if what I did could make me pregnant”I don’t know if what I did could make me pregnant” ““you can’t get pregnant/ STIs if…”you can’t get pregnant/ STIs if…”


Need for clear information aboutNeed for clear information about How the body works, male and femaleHow the body works, male and female How pregnancy occursHow pregnancy occurs How to prevent pregnancyHow to prevent pregnancy That contraception and a variety of sexual That contraception and a variety of sexual

practices are PHYSICALLY safepractices are PHYSICALLY safe How STIs are transmitted and preventedHow STIs are transmitted and prevented Virginity and the hymenVirginity and the hymen

Don’t assume schools or parents will or Don’t assume schools or parents will or cancan

Avoid making universal moral claimsAvoid making universal moral claims


““once they show signs of growing up, we watch them once they show signs of growing up, we watch them closely to make sure they do not get into bad closely to make sure they do not get into bad situations”situations”

““we do not have to worry about the boys so much”we do not have to worry about the boys so much” ““if your child has sex before marriage, they have if your child has sex before marriage, they have

ruined themselves and their family” ruined themselves and their family” ““it is OK to talk about health but not about sex and it is OK to talk about health but not about sex and

contraception, our children are not having sex” contraception, our children are not having sex” ““my children need to know everything Australian my children need to know everything Australian

children know” children know” ““if you talk about it, they will think they can or should” if you talk about it, they will think they can or should” ““it is so good if you talk, because I don’t know how” it is so good if you talk, because I don’t know how” ““we were all circumcised so it was different for us”we were all circumcised so it was different for us”


See adolescents alone?See adolescents alone? Gives privacy, treats them with respectGives privacy, treats them with respect May alienate parents, family and unnerve young May alienate parents, family and unnerve young

peoplepeople Ask the young personAsk the young person Give targeted information in any and all Give targeted information in any and all

settings and formats, frame as cultural settings and formats, frame as cultural exchangeexchange


Is there a gender issue with you or your Is there a gender issue with you or your referrals?referrals?

Does the presence of certain family Does the presence of certain family members, friends, an interpreter, make members, friends, an interpreter, make history or exam inappropriate?history or exam inappropriate?

Does torture or trauma including FGM Does torture or trauma including FGM preclude normal or comfortable exam?preclude normal or comfortable exam?

Is diagnostic testing appropriate e.g. Is diagnostic testing appropriate e.g. vaginal swab or us?vaginal swab or us?

Ask..Ask..


If sexually active ever, offer STI testing If sexually active ever, offer STI testing with initial screen (esp. urine)with initial screen (esp. urine)

Don’t rule out pregnancy on basis of Don’t rule out pregnancy on basis of cultural backgroundcultural background

Bring up contraception to allBring up contraception to all If persistent concern about sexual health If persistent concern about sexual health

or pelvic pain with no clear cause, suspect or pelvic pain with no clear cause, suspect past or current abuse and offer reassuring past or current abuse and offer reassuring investigationsinvestigations

SAFETYSAFETY

Not a culturally relative conceptNot a culturally relative concept Same obligations to report abuse or Same obligations to report abuse or

neglect of people under 18neglect of people under 18 Explain to young people and their adults Explain to young people and their adults

their legal obligations and rightstheir legal obligations and rights Talk about illegality of family violenceTalk about illegality of family violence Be aware of ongoing FGM Be aware of ongoing FGM Be aware of unwanted arranged Be aware of unwanted arranged

marriagesmarriages

OTHER ISSUESOTHER ISSUES

Is the male adolescent now head of the familyIs the male adolescent now head of the family Does a male-only family know how to cookDoes a male-only family know how to cook Is the female adolescent now solely Is the female adolescent now solely

responsible for cooking, childcare, cleaning, responsible for cooking, childcare, cleaning, shoppingshopping

Is a female-only family able to deal with Is a female-only family able to deal with banks, landlords etc?banks, landlords etc?

Are they having their day-to-day adolescent Are they having their day-to-day adolescent health needs addressed as well as their needs health needs addressed as well as their needs as refugees?as refugees?

SUMMARYSUMMARY

All adolescents have complex needsAll adolescents have complex needs Adolescent refugees may have Adolescent refugees may have

particularly complex physical and particularly complex physical and emotional needs, as well as emotional needs, as well as particular skills and strengthsparticular skills and strengths

Make them want to come back againMake them want to come back again

Documents

HEALTH ISSUES IN ADOLESCENT REFUGEES Dr. Emma Burns Senior Medical Officer Parks Primary Health Care Services and The Second Story Youth Health Service