As Ukranian refugees start to enter into the UK, the Home Office needs to turn their attention to their health needs, including physical and mental trauma, as well as chronic diseases, many of which will require urgent attention at the port of arrival, say doctors preparing to manage the influx.
However, the lack of knowledge around numbers and time frame of refugee arrival is a sticking point, with latest reports suggesting that over 25,000 visas have now been granted under the two schemes designed to enable Ukranians fleeing the conflict seek refuge in the UK. When and how these people will actually physically arrive in the UK is unknown.
There are two schemes open to Ukranian refugees in the UK: the Ukraine Family scheme (to join a family member in UK) and the Ukraine Sponsorship scheme (someone in the UK supports a Ukranian individual under ‘Homes for Ukraine’).
Durga Sivasathiaseelan, MBBS, leads the Outreach Services for Doctors of the World (DOTW), part of humanitarian organisation, Médecins du Monde. DOTW provides care to people who find it hard to access official healthcare, including refugees and the homeless.
Dr Sivasathiaseelan, who is also a GP, has provided medical help to newly arrived refugees from Syria and Afghanistan, and is now trying to prepare for the imminent arrival of refugees from Ukraine.
Prioritisation Needs to be Set Up for Medical Care
Although countries bordering Ukraine have largely taken the impact from refugees fleeing the war to date, soon thousands will seek refuge here in the UK, many in desperate need of healthcare. But how many will arrive, over what time frame, and the logistics around the arrival mean England’s Clinical Commissioning Groups (CCGs) are at a loss for how to plan and prepare to ensure refugee health is prioritised, and the harms of the conflict on both physical and mental health are mitigated.
"Triage needs to happen when someone initially enters the country, ideally at the port of entry. It has taken a while for the Home Office to understand the importance of this. They think healthcare interventions can wait until people get to their disperse accommodation because they’re unaware of what the medical issues can be," explains Dr Sivasathiaseelan.
She points out that a system is needed whereby refugees feed into healthcare in an organised way. "There needs to be prioritisation. But because we don’t have information about the people arriving then we don’t know what system we need to put in place."
When refugees arrive in the UK (including those who will come from Ukraine), Dr Sivasathiaseelan provides an outreach service. She visits the temporary hotel accommodation and offers consultation and screening for health and social care needs. “I support people in registering with a GP as their gateway into the NHS and explain how the NHS works and their entitlement. The health system in Ukraine would have been very different.”
More information is needed quickly, not least by local authorities and CCGs who need to know when and how people will be arriving to make preparations. "With information, CCGs can mobilise teams to help, including reaching out to organisations such as Doctors of the World to help meet the need. CCGs need time to plan."
Medscape UK asked the Department of Health and Social care (DHSC) what plans were in place to manage the specific health needs related to people fleeing Ukraine and arriving in the UK, including numbers arriving and the associated time frame. In a comment, they said they recognised the trauma faced by the people of Ukraine, and that, "Ukrainians fleeing their home country will be guaranteed free access to NHS healthcare, including mental health care services and registration with a GP."
It is also understood that Ukrainian refugees will be entitled to free NHS health care at the point of use. In a written statement on March 22 by Minister for Health Edward Argar, the Government said that they had "amended the Charging Regulations to allow everyone who is ordinarily resident in Ukraine, and their immediate family members, who are lawfully in the UK to access NHS care in England for free, including those who transfer here under official medevac routes".
Prior to this announcement, overseas visitor NHS charging legislation meant that the Government recovered NHS secondary care treatment costs from anyone who does not ordinarily live in the UK, unless exempt. Primary and emergency care is free to all, regardless of someone’s home, the statement adds.
Health on UK arrival: Conflict-Related Medical Issues and Chronic Diseases
Despite asking the Government for greater clarity on how refugees would be managed upon arrival in the UK and the numbers and time frame of arrival, Medscape UK received no clear answers.
Dr Sivasathiaseelan emphasises that based on her prior experience, Ukrainian refugees will potentially be accommodated in a hotel upon arrival. Such hotels usually have with capacity for around 400 to 500 people. Figures from this month show that there are currently 12,391 Afghan refugees accommodated in bridging hotels across the UK. "Without enough warning, the local GP practice will be expected to look after all these extra people."
DOTW do not have capacity on their own to deal with the expected influx of refugees. The outreach team consists of Dr Sivasathiaseelan.
"Capacity-wise, currently, we can dedicate 2 days a week to refugee and asylum work. We have a static clinic in Stratford [London], and can do a lot over the phone, such as register a someone with a GP, and offer a remote consultation. Wherever they arrive in the country, they can access our support. But we cannot deal with thousands, only hundreds - and then only if they arrive bit by bit."
Many will be in desperate need of medical care for both communicable and non-communicable diseases upon arrival, having foregone care as the conflict broke out and during their journey across Europe.
"If a patient is on renal dialysis, they should go straight from the port to the hospital, and there will also be those who have not had access to their medication," says Dr Sivasathiaseelan, adding that, "some people might have stockpiled medication for their long journey, but by the time they arrive here, the chances are that they will be running out, and will need more."
Clinicians can expect to see patients with a split between conflict-related physical and mental health issues, and various chronic diseases upon arrival in the UK. Drawing on her experience with refugees from Afghanistan and Syria, she explains that conflict-related medical matters might include ongoing burns, broken bones, and lacerations. Some refugees who departed Ukraine after hostilities became more widespread might present with these.
"When these injuries happened in the conflict zone, people probably did not have access to good health care so their injuries might have poorly healed, and this often leads to chronic pain."
Dr Sivasathiaseelan also has experience of managing the horrific longer-term harm of chemical weapons. "From Syria and Afghanistan, we have seen patients with effects to their respiratory system as well as the skin and the eyes," she says, fearing such an event could occur in Ukraine.
Psychological trauma is expected to fall into one or both of two categories: trauma related to the conflict per se, and/or that due to the trauma of being displaced.
"This is especially true since displacement happened in such a sudden and unprepared way," explains Dr Sivasathiaseelan. "Some of this trauma is due the enforced separation from their family members who might be left in the war zone, while other families have split during the process of displacement. Other refugees have trauma related to bereavement and loss."
Ukrainian Refugees - Largely Women and Children
Many of the Ukrainian refugees will be women and children who will arrive with maternal health requirements, and severe psychological trauma, among other needs.
"Health issues relating to pregnancy are a priority for being seen as soon as possible. Trauma will be common." Women and children experience trauma in different ways, says Dr Sivasathiaseelan. "Sometimes people are constantly distressed and angry, or in the other extreme, people are very withdrawn."
Conflict-related withdrawal is typical of children in the initial phase. "They are very withdrawn, and when we try to play with them, they don’t engage. Under the age of 5, all a child normally wants to do is play, no matter who you are. But a child who has experienced trauma, closes in and stops having that instinct. We need to pick up on these cues, in order to respond appropriately."
Children have witnessed extremes of distress, violence and sometimes bereavement too. They have been surrounded by parents and carers who are crying and upset constantly.
"Children find it very difficult to express themselves and understand what they have seen and why they are in a new country where they can’t understand what people are saying."
Refugee women are also extremely vulnerable to gender-based violence during migration.
"They are also more vulnerable to exploitation when they don’t have the man in their life who would help to protect and support them in this sense. Plus, women who experienced violence prior to the conflict find it only worsens," she adds.
Cross-Border Infectious Diseases: TB, HIV, and COVID-19
Ukraine is recorded as having the fourth highest incidence of tuberculosis (TB) in the WHO Europe region. Often, in times of crisis, the immediate war-related casualties are given attention while other ongoing health conditions are an aside, for example, cancer, cardiovascular or infectious diseases, including, of particular note in Ukraine, TB, HIV, and COVID-19.
The most recent data show that there are approximately 260,000 people living with HIV in Ukraine. Compared to elsewhere in Europe, prior to the conflict, COVID-19 vaccination rates dwindle at around 35%.
The European Centre for Disease Prevention and Control (ECDC) has urged countries bordering Ukraine to ensure early detection of infectious diseases is prioritised. Drug-resistant TB (DR-TB) is also a significant public health threat in Ukraine. WHO estimates from 2018 report that drug-resistant TB has been found in 29% of new TB patients, and 46% of previously treated patients. These rates are high compared to other countries in the WHO Region.
Paul Smith. PhD, is senior scientist at LifeArc (previously MRC Technology) Edinburgh, a not-for-profit organisation that develops diagnostics and treatments from early discovery into clinical use. He is currently involved in developing new more rapid diagnostic and monitoring tools for TB, and stresses the importance of rapid diagnosis of TB to identify suspected TB cases among refugees, especially those coming from areas of high prevalence and with high incidences of drug-resistance.
"The timely discovery of TB-positive cases allows both the stratification of infected people and prompt commencement of anti-TB therapy," he notes. "Unidentified cases among large groups of people can result in the uncontrolled spread of disease and encourage the emergence of anti-TB drug-resistance, thus exacerbating an already urgent medical emergency."
The Office for Health Improvement and Disparities (OHID) in DHSC produces the Migrant Health Guide, a free-to-use, online resource designed to support primary care practitioners in caring for patients who have come to the UK from overseas. It includes information on migrants’ entitlement to the NHS, guidance for assessing new patients, tailored health information specific to over 100 countries of origin and guidance on a range of communicable and non-communicable diseases, and health issues.
Medscape UK also understands from the government that it will publish a welcome pack for people arriving from the Ukraine that will include health advice, encouraging refugees to register with a GP as soon as possible.
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Cite this: Becky McCall. Ukrainian Refugee Health Needs to be Central to UK Home Office Response to Crisis, Say Doctors - Medscape - Apr 05, 2022.
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