Habibullah arrived in the UK three weeks ago. He thinks he is 16 years old. He left Afghanistan with his elder brother four months ago - a week after their father was killed.
Their journey began on a long distance bus. Somewhere in Iran they walked over high mountains, hiding from border guards. They spent some time in Istanbul until an agent arranged for them to travel in separate lorries through Europe.
Habibullah lived rough in the 'Calais jungle' for about a month, waiting for his brother to arrive, but he never found him. Eventually, he and another young Afghan hid on the wheel axle of a lorry and crossed the English Channel to Dover.
Through a Pashto interpreter, contacted via the PCT's telephone interpreting service, he complains of itching, a cough and chest pain. He also cannot sleep at night and has no appetite.
For some GPs this clinical scenario will be familiar, but other doctors may only occasionally see a newly arrived migrant patient.
The Health Protection Agency's Migrant Health Guide provides an instantly accessible resource that will help all health professionals to feel more confident when consulting with patients like Habibullah.1
The migrant health guide
The guide is divided into four main sections: general information, which includes information on entitlements to NHS care and translation services; countries A-Z, which gives relevant information about children's health, infectious diseases, nutritional and metabolic concerns and women's health relating to more than 100 different countries of origin; health topics, which provides further details about infectious diseases and other relevant health concerns, and a final section on assessing migrant patients, which includes checklists and diagnostic algorithms.
The highest numbers of migrants to the UK have come from the EU.2 Most are young, healthy adults and unlikely to have any health needs that differ from the majority of the UK population. However, some will have health problems relating to ethnicity, their reasons for and experience of migration, and/or their living conditions in the UK.
Vulnerable migrants, such as unaccompanied asylum-seeking children, may have special needs to consider.
It is useful to approach health care for a newly arrived patient according to a sequence of need. Habibullah's immediate needs are to deal with the itching, cough and chest pain. Clicking on the section headed 'assessing migrant patients' brings up a link to useful disease-orientated algorithms to guide assessment of his respiratory problems.
The assessment checklist links to country-specific pages, listed A-Z. The page on Afghanistan confirms that TB prevalence is high and Habibullah should be screened for TB with an immediate chest X-ray, even if empirical treatment for an acute chest infection is prescribed. This page reminds me to consider the risk of vitamin deficiency in a young person who is poorly nourished and has an acute illness.
Habibullah is likely to need treatment for scabies, an urgent chest X-ray and an appointment for a Mantoux test. Through the guide's link to language and interpreting, an appointment card in Pashto can be printed out to make clear when he needs to return for follow-up.
When he returns two weeks later, his itching and cough are better, his chest X-ray is normal and his Mantoux test is negative. However, he is still not sleeping or eating well and he has lost 1.5kg in weight. He looks unhappy and there are several superficial scars on his left forearm, consistent with injuries from self-harm.
Several sections in the guide are useful in approaching this phase of Habibullah's care. It is important to understand the context in which these expressions of distress are developing in order to avoid the risk of overmedicalising his symptoms.
This young man has come from an unstable and violent country, is in poor health and has suffered multiple losses. He will be using the strengths and weaknesses of his particular cultural context to find meaning in his situation.
In addition, he has good reasons for being confused and anxious. As an unaccompanied child, he will be referred to social services, who will subject him to a process of interviews and examinations to assess his age and hence his entitlement to support.
Within the first few weeks in the UK, the credibility of his asylum claim will be assessed through detailed and searching interviews by the UK Border Agency. Links in the guide connect to websites that look at mental health, set out the steps in the asylum process and provide information about the geopolitical contexts of refugees.
As an asylum seeker, Habibullah is entitled to the full range of NHS services, but healthcare professionals and managers do not always understand this. Doctors who look after migrant patients find they often have to advocate for them in a hostile healthcare system; the guide's links to the relevant sections of the DoH website on entitlement to NHS care are invaluable to support these challenges.
- Dr Montgomery is a GP in Kent
2. Office for National Statistics Long Term International Migration Statistics www.statistics.gov.uk/statbase/product.asp?vlnk=15053.