Delivering primary care in a refugee camp
Dr Marian Davis, Chair of RCGP Adolescent Health Group
I had resigned from the practice where I had worked for 28 years, not yet ready to give up medicine. During the late spring and summer, I spent two short spells working for Doctors of the World (Médecins du Monde- MdM) in Northern Greece. At that time, refugees were being transferred from the closed Macedonian border to seven camps in old warehouses and factories around the edge of the city of Thessaloniki. MdM are working in two of these camps at Oreokastro and Diovata. I was part of a multinational team of doctors, nurses, social workers and interpreters. The project is managed by MdM Greece.
Oreokastro (pictured) is in an old warehouse. There are about 240 tents pegged to the ground inside and more outside. There were 60 toilets and 30 cold showers for the approximately 2000 residents. The refugees were mostly from Syria, but also from Iraq and Afghanistan. Most were frustrated, having been close to joining a well-established route through Europe, to a hoped-for fresh start when, as they saw it, the door was shut. Now they were stuck, living in difficult conditions, not knowing what the future might hold.
Many patients had long term conditions and, when first seen, had not had their medications for several weeks as they travelled through Turkey and across the Aegean.
There was a limited supply of a limited number of drugs. An 80 year old woman carried empty packets of her three medications - for hypertension, Type II diabetes and hypothyroidism. We didn't have any of her drugs but having checked her BP and blood glucose, I gave her a week's supply of amlodipine, arranged to check her blood sugar on camp food in a couple of weeks, and ordered in her previous dose of thyroxine. Priorities, during my time there, were to develop a basic formulary and a patient held record.
Both camps had a number of unaccompanied minors, a particularly vulnerable group. Nineteen-year-old Ahmed was carried in to the medical room, in a blanket, by his three friends. He had been moved to Oreokastro from the border earlier that day by bus. He had collapsed suddenly and was unresponsive. All his observations were normal. I introduced myself, speaking to him at first via the interpreter. His eyes flickered and I realised that he was understanding some of what I said. Gradually, Ahmed told me that he had left his family in Damascus on 15 February, planning to go to Germany and set up home there so that his mother, father and two younger brothers could join him. Now he didn't know what the future held. He missed his family. He felt a sense of failure and hopelessness and that somehow he had let them down. He was lost. The social worker arranged for him to help in the school that was just being established, and he joined the unaccompanied minors group in the camp.
Many adolescents (as with other patients) presented with psychosomatic symptoms. Aisha, aged 15, had been to the clinic on three previous occasions with abdominal pain. It was no better in spite of the medicines. She came on this day with her older sister who was worried about her. There was no obvious physical cause and examination was unremarkable. I asked her what life was like in the camp. She became tearful as she told me about living with her parents, her eight sisters and brother in two tents. She just wanted a normal life. This was told to me via an interpreter, in a room which also held a paediatrician seeing a mother and baby, a nurse dressing a burn, and a social worker. Confidentiality was difficult to achieve.
The role of the interpreter is vital. With limited scope for investigation, an accurate history becomes fundamentally important. Another challenge, that I hadn't predicted, was the varied approach of doctors of different nationalities to treatment e.g. giving an infant with gastroenteritis an antibiotic, antiemetic and antidiarrhoeal medicine c.f. advice and electrolyte replacement sachets. Understandably, the refugees often preferred the first approach.
I found the work challenging and rewarding - using my medical skills to assess and try and make a plan with each patient. However there was frustration when considering the bigger picture. One young man showed me the before and after pictures of his bombed house on his mobile phone. 'Do you expect us to go back there?' I had no answer.