Understanding the health needs of those fleeing from war and persecution

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Understanding the experience of asylum seekers and refugees and what they had lived through and survived was important in knowing what their health needs were today, Dr Jennifer Hayes, Principal Psychology Manager in HSE South, told a meeting of HMI South Region, in May.

She was speaking on “Supporting the Health Needs of People Fleeing War”.

Annemarie Byrne, General Manager Human Resources, South/South West Hospital Group, who chaired the meeting said that in her role as a Principal Psychology Manager, Jennifer has been working with Syrian refuges and with traumatised families who had survived war and conflict and were now settling in Ireland. She had assisted the Department of Justice with UN Selection missions in Beirut and Jordan and was therefore no stranger to working in very challenging circumstances and coping with the personal impact of raw human suffering.

In terms of psychological challenges, people fleeing war and persecution had two areas in which they needed support – the psychological effects of trauma and PTSD

Dr Hayes said there were barriers and facilitators for refugees and asylum seekers in accessing our health services. Everyone in the health service in Ireland had a unique health opportunity to help people in this country who were seeking protection, by ensuring that they got access to a good health service.

“Everybody is acutely aware of the fact that we have thousands of Ukrainian families arriving in Ireland and Ireland can be proud of how it has opened its doors and the offers of health support and solidarity shown by those in the health service and across Ireland generally.

“But we have lots of other people seeking protection, refuge, and safety in Ireland. Thousands of Syrians are living in Ireland and people are seeking protection in lots of direct provision centres. All these people need our support and our help.

“It is very important that we understand the war experience to understand the needs with which people are presenting. Living in a war zone is catastrophic for people and the impact on their mental health needs. Then there is the challenge of adjusting to life afterwards. Living in a war zone is horrendous. It is as traumatic as it gets. There is evidence of war crimes emerging from Ukraine and they are extremely common in Syria, executions, people witnessing execution, kidnapping, torture. deliberating targeting civilians, the use of banned weapons, rape, sexual exploitation. starvation as a means of warfare. People are trapped in a war zone, with no way to get out. There is systemic highly organised violence and it is not possible to protect children from war.

“In an active war zone there is a lack of basic resources, food, water, medication, shelter, loss of your life, loss of childhood, disrupted family relationships.”

Dr Hayes said the experiences of people who had fled active war zones showed that their health needs were radically different from our general population and our health services were structured to meet the needs of the general population.

“Sixty five per cent of adults who have fled war in Syria and are now living in Ireland have Post Traumatic Stress Disorder. Living in a war zone and fleeing a war zone is very traumatic and coming to a new country and culture and not having the language, with your head reeling from what you have experienced is very difficult.

Their capacity to fill in a form to access a service is not the same as that of Irish people and it is our responsibility to ensure equity of access

“When thinking about delivering health services to people who have fled war, we need to think of their particular physical, psychological and oral health needs as a result of war/persecution and we do not generally find these needs in the general Irish population. We also need to think of health needs of those associated with people from those regions prior to war. People who come from very poor areas of the world will also have unique needs that we wouldn’t typically see in Ireland and many people in direct provision come from poor areas. Then we need to think about the typical health needs that everyone would have.”

Dr Hayes said that in terms of psychological challenges, people fleeing war and persecution had two areas in which they needed support – the psychological effects of trauma and PTSD. Then there were the psychological demands that were massive, in terms of adjusting to a new life, integrating into a new community, new schools, trying to find a job, learn a language and move past ever thing they had experienced.

“Areas where support matters are health needs, language/education, participation and inclusion in society, housing and transport and reunification. You have a unique opportunity to help people who have survived an awful situation to have their physical and mental health needs met. Meeting these health needs is critical for their health reasons, but also for their integration and adjustment.

Dr Hayes said that people fleeing from war and persecution were less likely than other members of our society to have their needs met, in Ireland and in most other western countries. This was not due to lack of hard work or goodwill, it was because of the particular set of circumstances that refugees and asylum seekers found themselves and the fact that our services were structured around the general population. We should be informed of the particular types of health needs that war survivors would have. “If we don’t know what they are we won’t look for them and then we won’t find them.”

She advised people to get involved, to examine what were the possible potential barriers for refugees and asylum seekers accessing their particular services. There were barriers in accessing services for the general Irish population, not to mind people fleeing war.

“Be very practical and support their engagement in the delivery of your service. Form filling is a barrier to families that survive war. Their capacity to fill in a form to access a service is not the same as that of Irish people and it is our responsibility to ensure equity of access. Language and interpretation is an area we need to think about to ensure the needs of families are met. Ask if English is their mother tongue. If not, then you need to think if interpretation support is needed. Discussing health issues can be very tricky for people at the best of times. Think about paperwork, consent forms, if people cannot read or understand a letter, they are unlikely to respond to it. It is generally hugely inappropriate to rely on family and friends, but sometimes it may be OK. It is never OK for children. You should work out the supports that are needed and get those in place.”

Dr Hayes said cultural differences were another barrier around our health services. Cultural constructs around health differed in different places. “Don’t assume people can understand concepts like autism mental illness etc. Another barrier to services are trauma and psychological problems.

“Refugees and asylum seekers don’t know the structure of our service. In some countries they don’t have GPs or Psychologists, so they can’t be expected to know what they are and how they might be helpful to them. “We can’t expect them to know how to use referral pathways. Flexibility is key. If people living in direct provision miss their meal that is it and we need to think about their childcare needs. If we want to get equal outcomes for everybody in our health service then we have to find a way to give a bit more to some people. Some might need more time or a bit of extra help to get the same outcome as everyone else . That is difficult when we are working in a system that is overstretched, but we must remember that everybody who comes to Ireland is entitled to a health service.”