In August 2021, evacuated families from Afghanistan arrived at short notice in UK hotels. A WhatsApp group under the banner ‘Clinicians for Refugees’ was rapidly set up to manage the outpouring of offers of help from UK clinicians. Contrast this to 76% of vulnerable patients excluded from registering with GP practices due to lack of documentation. The issues faced by asylum seekers and refugees (ASR) are unfortunately not new; however, the situation in Afghanistan brings them to the forefront of people’s attention. Primary care is best suited to providing holistic and appropriate care, but it cannot be done in a 10-minute consultation, nor with short-term interventionist strategies relying on volunteers and goodwill. Using the example of Afghanistan, we highlight long-term best practice.
ACCESS
Two assistance programmes are offered for Afghan refugees to the UK — the Afghan Relocations and Assistance Policy scheme, or the Afghan citizens’ resettlement scheme. Afghan citizens may also arrive as asylum seekers and not have the same welfare support. Regardless of immigration status or nationality, everyone in the UK is entitled to free primary care. Lack of documentation is never considered reasonable grounds to refuse registration. Doctors of the World ‘Safe Surgeries’ commit to these values.
HEALTH CHALLENGES
Public Health England has published guidance on some of the common health challenges to be mindful of in Afghan evacuees. Life expectancy is about 51 years for men and 54 years for women. Best practice includes offering initial health checks, TB screening, catch-up immunisations, mental health screening, contraception, and treating nutritional needs.
COMMUNICATION
The main languages spoken in Afghanistan are Pashto and Dari. Language preferences and communication support needs should be recorded in the medical record. Double appointments should be standard, and independent professional interpretation used rather than relatives or children. Consider the dialect and gender of the interpreter and speak to the patient in the first person.
LISTENING
Remain curious, listen and build trust before asking about more sensitive issues such as torture. Approximately a quarter of vulnerable migrants who access primary care use somatisation to express distress. Formal independent medico-legal reports must be commissioned by a solicitor and evidence of torture documented under the Istanbul Protocol by trained clinicians.
CULTURAL CURIOSITY
Virtually all Afghanistans are Muslims, so consider individual preferences over medication containing prohibited constituents, fasting over Ramadan, and the sex of the clinician. Cultural responsiveness increases engagement of minority populations with health care. Women may struggle to access health care, so engage in opportunistic questioning.
ADVOCACY
The NHS is confusing. It helps to explain how to access care in simple terms, and in the patient’s own language. HC2 certificates allow for free prescriptions. Do not charge destitute patients for letters and reports. Give people choice, they have lost control of much of their lives. Autonomy is key, but shared decision making may not be something they recognise from medical staff in their country of origin, so explain it.
MANAGING DISTRESS
Afghanistan has endured intermittent war since 1978. As well as pre-migration trauma, many Afghans face ‘post-migration stressors’ including limited English proficiency, social isolation, poor accommodation, being moved, and worrying about family back home. Asylum seekers are unable to work so can feel they lack meaning and purpose, and only receive £39.63 a week. New refugees have advantage in terms of welfare rights, but acculturation can be hard. Asylum claims impact health much more than health impacts asylum claims. Mental distress is a normal response to bad situations, so medication has limitations. Most people recover well if basic needs are met. Simple anxiety management techniques, explaining the effects of trauma, and psychological first aid can help. Diagnosis can help if function is poor, and to open up care pathways. Voluntary and community organisations provide purposeful activities — find out what is available to you locally. Nearly half the population of Afghanistan is under 15 years of age, and these children need to engage in normal play and education.
CONCLUSION
The recent news around Afghanistan is a welcome chance to reflect on how we provide primary care for those who have had a difficult time. Care, perseverance, time, and advocacy are the pillars of the NHS, so this is the time to embed these into the provision of care for ASRs.
KEY MESSAGES
Short-term interventionist strategies relying on volunteers and goodwill is insufficient to provide holistic and appropriate care to ASR in the UK.
Best practice for these groups in primary care includes supporting meaningful access to the NHS, recognising health challenges, communication, listening with respectful curiosity, advocacy, and managing distress.
The recent news around care for ASR sparked by the Afghanistan crisis provides a chance for clinicians to reflect on how they care for those who have had a rough journey in the long term.
- © British Journal of General Practice 2022
