HEALTH ISSUES IN ADOLESCENT REFUGEES

1. HEALTH ISSUES IN ADOLESCENT REFUGEES Dr. Emma Burns Senior Medical Officer Parks Primary Health Care Services and The Second Story Youth Health Service

2. “I know that nobody wants refugees, but do they know that we don’t want to be refugees” Said 14, Somali

3. BACKGROUND • Humanitarian program (8.1% of all visas) • Offshore • Refugee: majority are identified and referred by UNHCR for resettlement. No choice about leaving, little choice in where going. • Special Humanitarian Program: requiring an Australian based proposer. • Onshore • PPV if apply with a valid visa • TPV for 3 years if arrive “unauthorised”

4. BACKGROUND • 2007-2008 Program • Humanitarian program of 13,014 places • 6004 refugee places • 2008-2009 Program • Humanitarian program of 13,500 places • 6500 refugee places (an increase of 500 to allow greater number of Iraqis). • 33% Africa, 33% Middle East, 33% Asia and 1 % contingencies • In S.A., approx. 70-100 humanitarian arrivals per month.

5. BACKGROUND • Countries of origin • over past 5 years, up to 70% per year from Africa, single largest group from Sudan. • over last year, large numbers from Myanmar/ Burma, Iraq, Afghanistan, Sudan and West and Central Africa. • recent S.A. arrivals from Afghanistan, Congo, Iraq, Myanmar/ Burma, Somalia and Uzbekistan. • Representing a diverse range of cultural, religious and language backgrounds, both across and within national groups.

6. BACKGROUND • Refugees’ Age: • 28% between Jan 2005 and Jul 2008 were aged between 10-19 years • Approximately the same percentage aged 0-9 years • 3.5% were aged 50 or over and only 1% were aged 60 and over. • Less than 1% unaccompanied minors • Recent increase in proportion of young people

7. PREFLIGHT • Deprivation - food, water, warmth, nurturing, rest, sleep, education, play, friendship, health care • Loss – home, family members, friends, possessions, trust in authority figures including parents, ability to make sense of world • Trauma – exposure to violence, abuse, combat, forced labour, extreme distress in others, isolation

8. “ We didn’t know where we were going to, we just ran….We didn’t know where our mother or father were, we didn’t say goodbye. When there is shooting, when you hear BANG! BANG! BANG!, you don’t think about your friends or your mother, you just run to save your life” Chol 14, Sudan

9. FLIGHT • Deprivation • Loss – societal and cultural place, local language and ability to communicate, community and neighbourhood, family and generational transfer of knowledge, ability to problem solve • Trauma – constant instability and unpredictability of environment, hyperarousal and mistrust, fear of further deprivation, loss, trauma, death.

10. “He came and chased the refugees away. We couldn’t do anything, what could we do? It was not our country” Chol 14, Sudan

11. RESETTLEMENT • New challenges and potential for trauma rather than the end of the ordeal • World remains incomprehensible • No possibility of resuming normal life • Practical challenges – finances, languages, new legal system, school, employment, housing, food, loss of status in family and community, lack of age-appropriate education level • Racism, isolation, negative or ignorant stereotyping • Learned helplessness, misunderstood • Expectation of gratitude, appreciation

12. RESETTLEMENT • Different rates of acculturation within families and communities, young people often faster than parents • Loss of family roles and of basic understanding between generations • “Loss” of parents due to parental mental health issues • Exacerbated by missing generations • Adolescent as “cultural broker”

13. RESETTLEMENT • Integrated humanitarian settlement strategy: case coordination, information, referrals, on arrival reception, accommodation, short term trauma and torture counselling • Highly variable initial health and other input depending on where they go • Access affected by competing demands, lack of awareness of services, lack of transport, fear about cost/ language/ confidentiality, past experience of health workers involved in torture

14. ADOLESCENCE • Adolescence – as we understand it: • If successful growth and development in childhood, the child ready to become an adult • Physical growth and development including sexual development occurs, if physical safety and adequate nutrition are present. • Development of own identity occurs – sexual and gender identity, sociocultural identity, ideals, goals – if there are emotional safety, stability and clear social norms and role-modelling.

15. ADOLESCENCE • Western models of “normal” development and adolescence not universal • Similarly, incomplete understanding of refugee experience, esp. in young people • Avoid one-dimensional view of refugees as traumatised, damaged people • Avoid one-dimensional view of adolescent refugee experience as disruption to normal development

16. RESILIENCE AND STRENGTH • Formation of strong relationships, new communities • Acquisition of practical skills e.g. proficiency in multiple languages, ability to get adult help, ability to discern danger • Acquisition of emotional skills e.g. active and courageous coping, self-calming, sense of humour, making meaning • Admittedly few health benefits in preflight and flight, although many did not start the journey in good health nor with adequate health care.

17. INITIAL CONTACT • Outline the purpose of the consult and norms such as confidentiality, medical decision making • Are basic needs being met? • Do they have basic necessary information e.g. scripts, emergency services, costs, money? • Establish family relations, legal guardianship • Explain approach to young people to family • Interpreter present, phone may be best

18. INITIAL CONTACT • Explore path to resettlement from country of origin • Allow clients to set the pace, especially with regard to disclosure of trauma • Be up front about your ignorance on cultural and religious issues, where appropriate • Try to be aware of major events on the religious or community calendar e.g. Ramadan • Try to be aware of ongoing trauma e.g. news • Primary job – make sure they want to come back.

19. INITIAL CONTACT • Workers as representatives of all that has been lost – a voice, status, money, place in society • Underlying mistrust of authority figures • Be aware that western models not universal • Neutrality seen as sympathy or collusion • Lack of self-disclosure may increase mistrust • Frankness seen as rude or invasive • Assumptions that young people (especially females) have input in decision-making • Understandings of why sickness occurs, what symptoms mean and how to treat

20. “.. People would come and take photographs of us and ask about our terrible life. We thought they would help….Nobody came back to help. Don’t ask me about my problems. You will just go away too” Bor 17, Sudan

21. INITIAL CONTACT • The adolescent client may also be a resilient, capable young person enthusiastic about opportunity to access health care and about other aspects of new life • If we expect and look for damage, we may introduce or increase feelings of guilt about survival and interfere with coping/ healing • Allow the client to be expert on experience and its meaning – individual, family, community, culture

22. GENERAL HEALTH ISSUES • For offshore applicants, International Office Migration MAY coordinate a health check including: • Fitness to travel • Screening for malaria and TB • CXR if over 11 years • HIV if over 15 years • Treat for helminths and malaria • UTD immunisations NOT required • May be some time before departure. • Australia checks HIV and active TB.

23. GENERAL HEALTH ISSUES • Wide range of health issues that may be unfamiliar to Australians • Clients may not have ever had adequate screening, even after years • MHS has screening guidelines • Physical well-being a foundation for social and emotional well-being

24. NUTRITIONAL DEFICIENCIES • Vitamin D low or deficient up to 80% young refugees in Australia, local study of S.A. African refugees 69% • Especially dark-skinned, veiled women • May complain of aches and pains • Vitamin A deficiency – 19-38% • Iron deficiency – 19%, 34% in local study

25. INFECTIOUS DISEASES • Hepatitis B – 5-15%, 16% in local study • Likely perinatal transmission • 20-25% serious complications • Hepatitis C – 1-3% • Malaria – prevalence 8%-25% in children from endemic areas, 5 % in local study • If symptomatic, hospitalise • Tuberculosis – high positive Mantoux 63%, routine screening recommended.

26. PARASITES • Schistosoma – 11% positive serology, 24% positive in local study from serology and urine/faeces (10% of positives were serology negative) • A worm found in water that can damage liver, kidneys and bladder. • Other intestinal parasites – up to 37%, 24% in local study, mainly Giardia • Strongyloides (threadworm) – up to 10%, definitely check if unexplained eosinophilia • Helicobacter pylori – screen if symtpomatic

27. INHERITED DISORDERS • Haemoglobinopathies • Sickle cell – cells sickle at low oxygen and are removed by spleen, may cause hemolytic anemia or vaso-occlusion. • Thalassaemia • Spherocytosis • Most commonly encounter sickle cell trait and alpha thalassaemic trait • Warn about partner issues

28. GROWTH AND DEVELOPMENT • At increased risk of delayed growth and development • Parental concern highly suggestive • Try to ascertain correct age • Try to work out how long delay has been evident • Serial measurements useful, especially if just arrived • Early referral – reduce social costs • Obesity – past hunger, new high calorie diet

29. GENERAL HEALTH ISSUES • Dental health • At risk due to poor nutrition including vitamin D deficiency, poor dental hygeine and care, exposure to injury • May be experienced as invasive, frightening • Immunisations – refugee camps offer limited immunisations, but records unreliable. Consult SAICU, NARI for catch-up program.

30. GENERAL HEALTH ISSUES • Trauma and torture injuries • Genital mutilation – especially North East Africa, females approx 6 yo • Missed or botched procedures along the way • Non Western beliefs, attribution and interventions – dietary restrictions or changes, beliefs about exercise, curses, unknown procedures (uvulectomy) • Unfamiliar Western interventions – e.g. counselling, Pap smears, lack of antibiotic use

31. MENTAL HEALTH ISSUES • Extremely high levels of PTSD and Major Depressive Disorder – figures range from 35% to 93% in different preflight and flight settings, higher in unaccompanied minors, lower in resettled populations • Also other anxiety, eating, sleep disorders • Amount or type of loss or trauma suggestive, not predictive of mental heath • Depressive symptoms drop more sharply over time after resettlement than PTSD symptoms

32. MENTAL HEALTH ISSUES • Varying cultural idioms of distress mean young people may present with hyperactivity, isolation, aggression, depression, somatisation, anything.. • Let client and family determine what is normal • Look for flags • Client’s belief that something is wrong • Family stability before and now, parental coping • Feelings about new and original cultures • Signs of ideological, religious commitment, sense-making • Client and family input on treatment • BUT, parents underestimate child trauma

33. REPRODUCTIVE HEALTH • Difficult enough in Australian adolescents • Fear about being culturally inappropriate or causing offence • Assumptions made about sexual behaviour of certain groups • Assumptions made about young people who are not sexually active • Easy to let ourselves off the hook

34. REPRODUCTIVE HEALTH • Loss of mothers, aunties, fathers, uncles, grandparents, peers and “rites of passage” • Disruption of generational transfer of knowledge • Exposure to high risk situations for sexual abuse or exploitation, esp. females, both before and after arrival • Sex and marriage exchanged for food, safety • Education to primary level with variably poor delivery of sexual health (females > males) • High level of exposure to misinformation

35. REPRODUCTIVE HEALTH • “if you do not have a baby by 20, you won’t be able to” • “contraception damages your body” • “not having regular periods does harm to you inside” • “after what happened, I wanted to know I could get pregnant” • “everyone can tell if you have had sex” • “I think I might have damaged myself” • “I don’t know if what I did could make me pregnant” • “you can’t get pregnant/ STIs if…”

36. REPRODUCTIVE HEALTH • Need for clear information about • How the body works, male and female • How pregnancy occurs • How to prevent pregnancy • That contraception and a variety of sexual practices are PHYSICALLY safe • How STIs are transmitted and prevented • Virginity and the hymen • Don’t assume schools or parents will or can • Avoid making universal moral claims

37. REPRODUCTIVE HEALTH • “once they show signs of growing up, we watch them closely to make sure they do not get into bad situations” • “we do not have to worry about the boys so much” • “if your child has sex before marriage, they have ruined themselves and their family” • “it is OK to talk about health but not about sex and contraception, our children are not having sex” • “my children need to know everything Australian children know” • “if you talk about it, they will think they can or should” • “it is so good if you talk, because I don’t know how” • “we were all circumcised so it was different for us”

38. REPRODUCTIVE HEALTH • See adolescents alone? • Gives privacy, treats them with respect • May alienate parents, family and unnerve young people • Ask the young person • Give targeted information in any and all settings and formats, frame as cultural exchange

39. REPRODUCTIVE HEALTH • Is there a gender issue with you or your referrals? • Does the presence of certain family members, friends, an interpreter, make history or exam inappropriate? • Does torture or trauma including FGM preclude normal or comfortable exam? • Is diagnostic testing appropriate e.g. vaginal swab or us? • Ask..

40. REPRODUCTIVE HEALTH • If sexually active ever, offer STI testing with initial screen (esp. urine) • Don’t rule out pregnancy on basis of cultural background • Bring up contraception to all • If persistent concern about sexual health or pelvic pain with no clear cause, suspect past or current abuse and offer reassuring investigations

41. SAFETY • Not a culturally relative concept • Same obligations to report abuse or neglect of people under 18 • Explain to young people and their adults their legal obligations and rights • Talk about illegality of family violence • Be aware of ongoing FGM • Be aware of unwanted arranged marriages

42. OTHER ISSUES • Is the male adolescent now head of the family • Does a male-only family know how to cook • Is the female adolescent now solely responsible for cooking, childcare, cleaning, shopping • Is a female-only family able to deal with banks, landlords etc? • Are they having their day-to-day adolescent health needs addressed as well as their needs as refugees?

43. SUMMARY • All adolescents have complex needs • Adolescent refugees may have particularly complex physical and emotional needs, as well as particular skills and strengths • Make them want to come back again