Health care for Syrian refugees: is Canada ready?

This month, the first surge of Syrian refugees will arrive in Canada. They’ll enter in remarkable numbers, with 25,000 arriving before the end of February, and as many as 25,000 more in the rest of 2016.

That’s a victory to many who fought to allow them in – but the work isn’t done. Having their first years in Canada go smoothly is crucial to helping Syrian refugees overcome the traumas they’ve been through. They need the chance to learn English or French, find work and safe housing, and, of course, have access to health care.

“These people are newly born,” says Izzeldin Abuelaish, a physician and peace activist who grew up in a refugee camp. “We need to prepare for them to have a healthy, safe delivery. For them not to be traumatized again; for Canada to be a good place for them, with the joint efforts of the community, the political leaders, and the health care providers.”

Syrian refugees will mainly need primary care and mental health services, both of which will be complicated by language barriers and cultural differences. It’s a task that’s causing “a lot of angst among [family physicians],” says Kevin Pottie, founder of the Immigrant Health Clinic of Ottawa and researcher at the Bruyere Research Institute. But he and others who regularly treat refugees are confident that the system will be ready for them.

Still, the sheer numbers means there are a lot of unknowns. “A migration like this is unprecedented – we’ve never seen these kinds of numbers in such a short period of time,” says Meb Rashid, medical director of the Crossroads Clinic at Women’s College Hospital. “We’ll just put on our seatbelts and go for a ride.”

Coordination efforts, language barriers and federal health-care coverage

Both government-assisted refugees and privately sponsored ones will have their health screening overseas, including in Lebanon, Jordan and Turkey. That includes testing for infectious diseases such as tuberculosis and HIV, but the rates of both are expected to be low in Syrians, and those that have them will still be allowed to come.

Once they enter Canada, they’ll need primary care. Refugee clinics like Crossroads, the Immigrant Health Clinic of Ottawa, and Calgary’s Mosaic Refugee Health Clinic are leading the efforts to prepare. They’re coordinating existing refugee clinics and training community health centres, family health teams and individual physicians on the needs of the Syrians.

They’re also offering ongoing support: in Ottawa with e-consults, and in Calgary through a hotline the Mosaic refugee clinic is running for physicians.

But that’s not enough, says Philip Berger, co-chair of Canadian Doctors for Refugee Care. “It’s bizarre that the doctors across Canada have had to organize themselves. We have the capacity [to treat the Syrian refugees]; it’s the logistics that are missing.” He’d like to see the federal and provincial governments establish central coordinating offices, which would organize and manage connecting refugees to health care providers. And “a doctor or hospital staff should be able to phone up a central number and get somebody live.”

Right now, refugees are connected to doctors through service provider organizations funded by Immigration, Refugees and Citizenship Canada, their private sponsors, or refugee clinics. In Ontario, Health Care Connect links people to doctors taking new patients – a service Pottie says could be ramped up to serve as a central hub to connect doctors and refugees. A nationwide list of providers that cover refugee patients is also available on the Medavie Blue Cross’s website.

Another crucial concern is the language barrier between Syrian refugees and doctors. In Ottawa, they’re training 30 international medical graduates that speak Arabic in the ethics and techniques of medical interpretation. Calgary’s Mosaic clinic is funding a phone interpretation service for local  primary-care providers. And Toronto hospitals have excellent interpretation services.

But regular family doctors don’t have many options. “We are very concerned in Ontario that there is no access to telephone interpreters for community family doctors, as a backup to in-person interpreters,” says Pottie. “Australian GPs have access to telephone interpreters – this is not impossible. We really should have it.”

The Syrian refugees will be covered by their province’s health plans. Ontario is considering expediting the process to give refugees an OHIP number within 24 hours. Additional services, like limited dental and vision care, prosthetics and counseling, have traditionally been covered by the federal government’s Interim Federal Health Program, but the previous Conservative government’s controversial cuts to the program meant that privately sponsored refugees were left without it.

The Liberals campaigned on a promise to reverse those cuts, and Immigration, Refugees and Citizenship Canada confirmed in an email that “privately sponsored Syrian refugees resettled under this initiative will be provided with full health-care coverage under the Interim Federal Health Program.” Doctors are still waiting on the official announcement that it’s happening.

PTSD and other mental-health needs

Syrians will have mostly primary care needs, says Rashid. “We’ll probably see a lot of chronic diseases that have been neglected, kids who have never had primary care, missing vaccinations and war related trauma,” he says.

Their care is made easier by the fact that Syrians received good medical care prior to the conflict. “It’s mostly just normal, everyday chronic disease, except this group of people will have had very little access to comprehensive health care for four or five years,” says Ashna Bowry, a physician in the family health team at St. Michael’s Hospital, one of the main groups taking in refugees in Toronto.

The challenges of overcoming the trauma of war – and the mental health issues that come with that – will be the biggest difference for physicians. Routine screening for mental health problems in refugees actually isn’t recommended, though doctors should remain alert for signs of PTSD. “There is the risk of overdiagnosis, and of triggering traumatic memories and not being trained to handle that,” says Pottie.

Mental health issues stemming from trauma resolve themselves spontaneously in 80% of immigrants and refugees. “The vast majority of people who we see have endured horrific trauma, and most of them don’t have PTSD,” says Rashid. “Those who are suffering from it will give us other clues – often they’ll come with symptoms of anxiety, or sleeplessness.”

Depression, anxiety or PTSD may also reveal themselves months after coming to Canada. “When refugees first come, they’re overwhelmed with meeting their basic needs, and they often have a number of supports,” says Annalee Coakley, a physician at the Mosaic Refugee Clinic. But after that “honeymoon” period, mental health issues begin to present themselves. 

Syrian refugees who do have PTSD may be cared for by primary care doctors, referred to psychologists or counselors for group or individual therapy, or given medication. Refugee mental health expert Morton Beiser is a proponent of narrative exposure therapy, and is working on a pilot project called Lending a Hand to Our Future that uses it to help children recover. Pottie is interested in Beiser’s program and trying to bring it to Ottawa as well.

For guidance on all of this, physicians can turn to the 2011 guidelines on treating refugees, and an accompanying evidence-based checklist for adults and children. The checklists are broken down into multiple visits – they’ve  been compared to a well-baby program – and cover things like vaccinations, dental pain, even weather-appropriate clothing.

An update to the guidelines that confirms the recommendations are valid for Syrian refugees and provides context will be published next week in the CMAJ. “We talk more about Syria, the ethnic origins, and the war,” says Pottie, who wrote both the last guidelines and the update. “A middle income country has become one of the worst humanitarian disasters in the last 100 years … we want the practitioners to appreciate what that means.”

Treating the whole person

The last time Canada saw such an influx of refugees was when we accepted 60,000 “boat people” after the Vietnam War. Beiser did a 10 year follow up study on those refugees, and says they offer lessons for the Syrians. “Primary health care was no problem,” he says. “Mental health care, not so much. For a lot of refugee communities, mental health needs are overlooked.”

To ensure that doesn’t happen to the Syrians, we need to look at both mental-health issues like PTSD and beyond, into social determinants of health. “For their mental health, it’s not a typical disease model,” says Pottie. “If someone has good housing, their kids are in school, and they have a new job, their mental health is 90% looked after.”

If we do it right, the Syrians have the potential to thrive in Canada. “They’re used to living in cities, they’re literate, their health system isn’t that dissimilar,” says Coakley. “They’re not terribly sick in the medical sense. As long as they’re supported and not isolated, I think they should do very well.”