People facing multiple vulnerabilities have even higher needs than the general population. The data collected by MdM over the years show how both their perceived and diagnosed health needs are worse, as they face social determinants that negatively impact their health. And yet, the NGOs that effectively deal with these vulnerabilities generally have few means to do so. Nevertheless, Network members have built a lot of expertise in developing strong links with the communities, maintaining a high level of quality contacts despite having to work with very limited resources. Update work on the list in progress.

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Resources on dealing with violence

Asking about past experiences of violence allows detecting psychological problems (depression or post-traumatic stress disorder [1]), and allows ruling out diagnostic errors when faced with unexplained physical disorders [2]. It also allows the detection of sexually transmitted infections arising from sexual violence.

A number of studies have shown the importance of identifying previous experiences of violence among migrant populations, taking into account their frequency [3] and their impact on the mental and physical health of the victims, as well as in the long term, many years after the original episode.

The patients met in our programmes rarely raised experiences of violence spontaneously during their consultation and there are not always outward signs that lead one to detect it. Conversely, patients are usually quite open, in all studies, to such a line of questioning in the systematic examination of past violent experiences – provided, of course, adequate time and a quiet room were given to address these issues, regardless of their origin, culture or social environment (the same is true for detecting domestic violence [4]). Patients understand, accept and are very supportive of routine questions about these issues. Reluctance to ask these questions comes mostly from the doctors because of lack of information, lack of time and medical misconceptions [5].

In a context where stigmatisation of ‘foreigners’ is one of the main obstacles to a better awareness of the situation of exiles fleeing torture and political violence [6], and also knowing the countries of origin and the living conditions experienced by migrants during their journey to the destination country, it is important to listen attentively to accounts of previous experiences of violence. As migrants do form the majority of the people who receive support in our programmes, the impact of our services amongst these people and the quality of the healthcare provided are both dependent on taking into account this violence the patients may have faced. It is a real opportunity for the patients and an issue of good medical practice (and responsibility). The issue of female genital mutilation can also be cited as women will not speak about it spontaneously, nor would it be identified by a GP unless there was specific focus on it; the same is also true for domestic violence…

It is therefore essential that the teams are sensitized and trained on this screening. They should systematically build networks with organizations dedicated to support victims of violence in order to refer the concerned patients, sometimes including providing specific care. This is not always necessary as the needed care can often be provided through usual primary healthcare services.

 

[1] Loutan L, Berens de Haan D, Subilia L. La santé des demandeurs d’asile: du dépistage des maladies transmissibles à celui des séquelles post-traumatiques. Bull Soc Pathol Exotique 1997; 90: 233-7.

Vannotti M, Bodenmann P. Migration et violence. Med Hyg 2003; 61: 2034-8.

[2] Weinstein HM, Dnasky L, Lacopino V. Torture and war trauma survivors in primary care practice. West J Med 1996; 165: 112-8.

[3] Baker R. Psychological consequences for tortured refugees seeking asylum and refugee status in Europe. In: Basoglu M., ed. Torture and its consequences. Cambridge, Cambridge University Press, 1992, pp. 83-106.

[4] Bradley F, Smith M, Long J, O’Dowd T. Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 2002; 324: 271.

Chen PH, Rovi S, Washington J, et al. Randomized comparison of 3 methods to screen for domestic violence in family practice. Ann Fam Med 2007; 5: 430-5.

Garcia-Esteve L, Torres A, Navarro P, Ascaso C, Imaz ML, Herreras Z, Valdés M. Validación y comparación de cuatro instrumentos para la detección de la violencia de pareja en el ámbito sanitario. Med Clin (Barc) 2011; 137: 390-7

Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the U.S. Preventive Services Task Force recommendation. Ann Intern Med 2012; 156: 796-808.

Abrahams N, Devries K, Watts C, Pallitto C, Petzold M, Shamu S, García-Moreno C. Worldwide prevalence of non-partner sexual violence: a systematic review. Lancet 2014, in press (DOI: 10.1016/S0140-6736(13)62243-6).

[5] Sprague S, Madden K, Simunovic N, Godin K, Pham NK, Bhandari M, Goslings JC. Barriers to screening for intimate partner violence. Women Health 2012; 52: 587-605.

[6] Collective. Soigner les victimes de torture exilées en France. Livre blanc. Paris, Centre Primo Levi, May 2012, p.9.

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Anna screen captureWatch the French short film ‘Anna’ (with English subtitles) directed by Johanna Bedeau and Laurent Benaïm that was shown at our kick-off meeting in Amsterdam

https://www.youtube.com/watch?v=ArYXp_JjEUY.

 

The short film was originally taken from http://stop-violences-femmes.gouv.fr/2-Outils-pour-l-animation-sur-les where you can also see a second interesting film (only in French).

 

This educational tool towards health professionals deals with

  • Mechanisms and impact of (domestic) violence,
  • Screening during medical consultation,
  • Follow-up and referral of women that are victims of violence.

 

Download the presentation by Pierre Chauvin on violence & migration, a review of the literature (presented in Amsterdam, 02/2015) or a French version (copil migrants Paris, 11/2014).

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Other resources

WHO Sexual & reproductive health programme: estimated prevalence of violence against women, health impact, guidelines for health sector response, and healthcare worker intervention

 

Internal reference documents

Age assessment for unaccompanied minors. When European countries deny children their childhood. September 2015 reference document. Not intended for dissemination outside of the MdM network & close partners.

In this (unpublished) policy paper by the DRI, the European framework on age assessment of unaccompanied minors is analysed. There is a legal basis for intervention by the Commission towards EU Member States if we can gather testimonies about age assessments performed without informed consent, if the decision of majority is based solely on a child’s refusal to undergo medical examination, if invasive methods are used (e.g. genital examination), if minors are not being explained the possibility to appeal the conclusions of an age assessment.

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Immunisation coverage across Europe for groups facing multiple vulnerability factors. April 2014 reference document. Not intended for dissemination outside of the MdM network & close partners.

©MdM France – Vaccination card given by MdM team
©MdM France – Vaccination card given by MdM team

Vaccination is a key issue for vulnerable people’s health. This reference document firstly covers a selection of vaccines (clinic, epidemiology, public health objective) that are either considered essential throughout the world and / or that prevent diseases typically associated with poverty: . Offering universal access to vaccination is more cost-effective than having to treat high morbidity and being confronted with higher mortality rates. Chapter 2 focusses on some of the scientific evidence that sheds light on this aspect. The third chapter focusses on the reasons why population groups most in need of vaccination often do not have access to them. These are the same groups that are also the most exposed to incidence and morbidity excess. Social determinants such as poor or no housing, malnutrition, limited access to water and basic sanitary installations, etc. play a crucial role in explaining the disproportionately higher incidence and morbidity rates…

And yet, the right to preventive care is a basic human right – chapter 4 gives an oversight of the relevant international human rights instruments covering this point. Although health is not a formal competence of the EU, the European Commission does undertake some action – directly or through its European Centre for Disease Prevention and Control (ECDC) – to manage the spread of vaccine-preventable diseases and to encourage Member States to improve vaccination coverage. Consequently, chapter 5 focusses on recent EU policy documents relating to immunisation of people facing multiple vulnerability factors. Lastly, chapter 6 focusses on what the International Network of Doctors of the World, based on its field experiences throughout Europe, asks from the EU and from the EU Member States where it is present.

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Healthcare across EU borders – general EU framework. Legal reference document – March 2014

ehicnet3The free movement of persons constitutes one of the fundamental freedoms of EU citizens. Yet in practice, the right to healthcare for EU citizens (with only moderate or no revenues) who effectively use their right to free movement is far from guaranteed. The first question in analysing a Union citizen’s right to healthcare is determining his or her residence status within the host Member State. For short-term residents, the question then emerges whether that person still has health insurance in his or her Member State of origin, in which case the person falls under Regulation 2004/883 and / or Directive 2011/24 on cross-border healthcare. For unplanned care, insured EU citizens can use the European Health Insurance Card which opens the same rights as if the person were insured in the host country. There are major discrepancies between the 2004 Regulation and the 2011 Directive, but they mainly concern whether a patient needs to pay treatment costs up-front or not in the case prior authorisation has been obtained for planned care. This situation hardly ever concerns the vulnerable patients that visit MdM health centres who mostly come for care that does not require prior authorisation.

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Schengen agreement and free movement of persons. Legal reference document – March 2014