Medical disclosure and refugees. Telling bad news to Ethiopian patients.
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The strong value in American medical practice placed on the disclosure of terminal illness conflicts with the cultural beliefs of many recent refugees and immigrants to the United States, who often consider frank disclosure inappropriate and insensitive. What a terminally ill person wants to hear and how it is told are embedded in culture. For Ethiopians, "bad news" should be told to a family member or close friend of the patient who will divulge information to the patient at appropriate times and places and in a culturally approved and recognized manner. Being sensitive to patients' worldviews may reduce the frustration and conflict experienced by both refugees and American physicians. (+info)
MEDICAL ASSESSMENT OF LATE EFFECTS OF NATIONAL SOCIALIST PERSECUTION.
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Emotional involvement of the examiner, hostility and mistrust on the part of the examinees and the long interval since the original events comprise some of the problems facing medical assessors of survivors of National Socialist persecution. Experience with over 100 such persons confirmed the high incidence of irreversible and usually disabling disorders, mainly functional and psychiatric-"late damage" as it has been designated in recent reports on this subject. The most common disorders encountered in the assessments of 70 survivors are reviewed. A number of organic diseases such as organic brain damage, active tuberculosis and fractures were revealed only after careful search. Recent findings by psychiatric assessors are reviewed; their plea for greater familiarity with late effects in survivors of National Socialist persecution is echoed, and the need for medical, psychiatric and social support of these unfortunate individuals is emphasized. (+info)
Mortality among displaced former UNITA members and their families in Angola: a retrospective cluster survey.
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OBJECTIVE: To measure retrospectively mortality among a previously inaccessible population of former UNITA members and their families displaced within Angola, before and after their arrival in resettlement camps after ceasefire of 4 April 2002. DESIGN: Three stage cluster sampling for interviews. Recall period for mortality assessment was from 21 June 2001 to 15-31 August 2002. SETTING: Eleven resettlement camps over four provinces of Angola (Bie, Cuando Cubango, Huila, and Malange) housing 149 000 former UNITA members and their families. PARTICIPANTS: 900 consenting family heads of households, or most senior household members, corresponding to an intended sample size of 4500 individuals. MAIN OUTCOME MEASURES: Crude mortality and proportional mortality, overall and by period (monthly, and before and after arrival in camps). RESULTS: Final sample included 6599 people. The 390 deaths reported during the recall period corresponded to an average crude mortality of 1.5/10 000/day (95% confidence interval 1.3 to 1.8), and, among children under 5 years old, to 4.1/10 000/day (3.3 to 5.2). Monthly crude mortality rose gradually to a peak in March 2002 and remained above emergency thresholds thereafter. Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%). Most war victims and people who had disappeared were women and children. CONCLUSIONS: This population of displaced Angolans experienced global and child mortality greatly in excess of normal levels, both before and after the 2002 ceasefire. Malnutrition deaths reflect the extent of the food crisis affecting this population. Timely humanitarian assistance must be made available to all populations in such conflicts. (+info)
Refugee health and medical student training.
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BACKGROUND AND OBJECTIVES: Cultural awareness training is an increasingly important priority within medical curricula. This article describes an academic family practice-community partnership focusing on health care needs of refugees that became the model for a medical school selective on cultural sensitivity training. METHODS: The monthly Refugee Health Night program featured dinner with preceptors and patients, international sessions on special medical needs of refugees, and actual clinical encounters with patients. Students were not expected to become culturally competent experts but, rather, health care providers sensitive to and appreciative of cultural context, experience, and expectations. We worked with students to develop sensitive methods of inquiry about mental health, especially around issues of war and torture. We used problem-based cases to emphasize primary care continuity and the benefit of establishing trust over time. RESULTS: Over 2 years, 50 students and nearly 300 refugees (more than 73 families) participated. Students reported that their interactions with the refugees provided positive learning experiences, including expanded knowledge of diverse cultures and enhanced skills for overcoming communication barriers. Patients of refugee status were able to have emergent health care needs met in a timely fashion. CONCLUSIONS: Providing health care for refugee individuals and families presents many challenges as well as extraordinary opportunities for patients and practitioners to learn from one another. (+info)
Evidence in support of foster care during acute refugee crises.
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OBJECTIVES: The United Nations High Commissioner on Refugees (UNHCR) and United Nations Children's Fund (UNICEF) policy encourages foster care during refugee emergencies. We examined evidence to support this policy using data from the 1994 Rwandan refugee crisis. METHODS: The association of weight gain and acute illness with family status (foster children vs children living with their biological families) was examined using latent growth curve and repeated measures logistic regression analysis. RESULTS: Weight gain for all children averaged 0.40 kg/month and was associated with child's age but not with family status, child's or caregiver's sex, caregiver's marital status, possession of blankets or plastic sheeting, severe malnutrition, month of enrollment, or acute illness. Illness was not more common among foster children than among children living with their biological families. CONCLUSIONS: This analysis supports the UNHCR/UNICEF recommendation of fostering for unaccompanied children during an acute refugee crisis. (+info)
Breastfeeding status as a predictor of mortality among refugee children in an emergency situation in Guinea-Bissau.
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OBJECTIVE: To identify the population risk factors in emergency situations, we studied breastfeeding status as a predictor for child mortality during a war in Guinea-Bissau. METHODS: Data on breastfeeding status are routinely collected by the surveillance system of the Bandim Health Project in Bissau. We used data collected during a 3-month period prior to the war in Guinea-Bissau in June 1998 to assess the impact of breastfeeding status on mortality in an emergency. We compared the war cohort with two cohorts of children who had had their breastfeeding status assessed in a similar way by the surveillance system in the 3 months prior to June 1996 and June 1997. As very few are weaned prior to 9 months of age and the median age of weaning is 22 months, we assessed the risk of dying over a 3-month period for breastfed and weaned children aged 9-20 months. RESULTS: Controlling for age, weaned children experienced a sixfold higher mortality [mortality rate (MR) = 5.73 (95% CI 2.40-13.71)] during the first 3 months of the war compared with children still breastfeeding. In the two control cohorts from 1996 and 1997, weaned children did not have higher mortality than the breastfed children over a similar 3-month period. Mortality in weaned children was five times higher [MR = 4.96 (1.44-16.63)] during the first 3 months of the conflict than in a similar group of weaned children from early June 1996 and June 1997, whereas there was no significant difference in mortality between breastfed children during the conflict and the preceding years [MR = 1.46 (0.84-2.55)]. Control for other background factors, including living with mother, gender, ethnic group, mother's schooling and district, did not change these differences. CONCLUSION: The protective effect of breastfeeding against infections may be particularly important in emergencies. Continuing or recommencing breastfeeding should be emphasized in emergency situations. (+info)
Iron deficiency is unacceptably high in refugee children from Burma.
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Iron-deficiency anemia (IDA) in refugees is reported to be among the major medical problems worldwide. Because food rations are typically inadequate in iron, long-term reliance is a key predictor of anemia among displaced people. Comprehensive nutritional assessments of refugee children from Burma have not previously been completed. Refugee children aged 6-59 mo were studied to determine 1) the prevalences of anemia, iron deficiency (ID) and IDA and 2) the factors associated with anemia and ID. Cluster sampling in three camps and convenience sampling in two additional camps were used. Hemoglobin (Hb) levels were measured and micro mol zinc protoporphyrin/mol heme were determined in 975 children. Logistic regression analyses (95% CI) determined predictors of anemia and ID. The prevalences of IDA, anemia and ID in these refugee children were 64.9, 72.0 and 85.4%, respectively. Predictors of anemia included young age (P < 0.001), food ration lasting <1 mo (P = 0.001), daily consumption of dietary iron inhibitors (P < 0.05), weight-for-height Z-score of <-2 (P < 0.05), male gender (P < 0.05) and uneducated father (P < 0.001). Predictors of ID were young age (P < 0.001) and recently reported illness (P < 0.05). Laboratory tests confirmed that anemia and ID are major health problems among these refugee children and that ID is the leading cause of anemia. A comprehensive nutrition and public health-focused approach to combating anemia and ID is essential. Following the presentation of results to policy makers, the improvement of the micronutrient content of rations has been initiated. (+info)
Adherence to the combination of sulphadoxine-pyrimethamine and artesunate in the Maheba refugee settlement, Zambia.
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Artemisinin-based combination therapy (ACT) is one strategy recommended to increase cure rates in malaria and to contain resistance to Plasmodium falciparum. In the Maheba refugee settlement, children aged 5 years or younger with a confirmed diagnosis of uncomplicated falciparum malaria are treated with the combination of sulphadoxine-pyrimethamine (1 day) and artesunate (3 days). To measure treatment adherence, home visits were carried out the day after the last treatment dose. Patients who had any treatment dose left were considered certainly non-adherent. Other patients' classification was based on the answers to the questionnaire: patients whose caretakers stated the child had received the treatment regimen exactly as prescribed were considered probably adherent; all other patients were considered probably non-adherent. Reasons for non-adherence were assessed. We found 21.2% (95% CI [15.0-28.4]) of the patients to be certainly non-adherent, 39.4% (95% CI [31.6-47.6]) probably non-adherent, and 39.4% (95% CI [31.6-47.6]) probably adherent. Insufficient explanation by the dispenser was identified as an important reason for non-adherence. When considering the use of ACT, the issue of patient adherence remains challenging. However, it should not be used as an argument against the introduction of ACT. For these treatment regimens to remain efficacious on a long-term basis, specific and locally adapted strategies need to be implemented to ensure completion of the treatment. (+info)