Asylum seekers and undocumented migrants must retain access to primary careBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6637 (Published 18 October 2011) Cite this as: BMJ 2011;343:d6637
- Paquita de Zulueta, general practitioner, London, and honorary clinical senior lecturer, Department of Primary Care and Public Health, Imperial College, London
They come singly or in huddled clusters, subdued, their eyes downcast, their shoulders stooped. They tell us tales of loss, of devastation, of living in the shadows, always fearful of exposing themselves to bureaucratic scrutiny. They sleep, if lucky, on the sofas of friends or in hostels, otherwise in doorways, on park benches, or in churches and bus stations. They are like Dante’s lost souls, wafting in limbo, neither in heaven nor hell, but in a cold and lifeless purgatory, a place the world refuses to acknowledge.
They tell me their stories, their faces etched with suffering, their eyes reflecting dull despondency or despair. And yet I am humbled by their grace, dignity, and endurance. Somehow they manage to look clean, orderly, and well presented. The tell tale sign may just be the tightly clutched plastic bag. That bag may hold all their possessions, including documents such as a dog eared letter, years old, from the Home Office, blandly reporting information about the status of their asylum appeal. Many of them have not sought medical help for several years despite serious medical problems, some brought on by the lives they lead or the trauma they have experienced.
The stories are varied and at times harrowing. A woman has fled her village and eloped with a man with whom she fell in love. But he brought her to the United Kingdom to sell her to other men, not to marry her. He stole her passport, drugged her, and forced her into sexual slavery. Now she is pregnant and too sad to care; yet she cares enough to refuse abortion. A couple have been refused asylum. Local gangs threatened his life, and they cannot go back home. The wife’s pregnancy is in the third trimester. A depressed young woman has fled the house where she had been enslaved since she was 14, and is forced to sell her body to get food. A teenager with severe post-traumatic stress disorder has difficulties controlling his anger and is at risk of harming himself or others; he has already attempted suicide. A woman in her 40s has rheumatic heart disease and is breathless with heart failure.
These people are all in clinical need yet have been unable to access primary healthcare in the United Kingdom. Despite pleas to my colleagues to take them on (and even when they undertake to do so), they still turn them away. Secondary care, including antenatal care, may be available but carries the threat of unpayable fees. Do healthcare professionals expect women to deliver their babies in the street? In fact, some women I see have delivered at home without any clinical supervision. What happens to people who have severe mental health disorders and chronic untreated diseases? And what of the risks to public health? The litany of misery continues and I take note of the small acts of unkindness and indifference meted out by my peers. But there are shining exceptions, and some general practitioners do manage to overcome bureaucratic barriers and register patients irrespective of their residential status.
I am a general practitioner and work, when time permits, as a clinical volunteer at Project:London, a health advocacy programme set up by Doctors of the World UK in the east end of London (www.doctorsoftheworld.org.uk/projectlondon/). Here I treat those who cannot access primary care. These include undocumented migrants and those accepted or refused by the asylum system. The BMA reminds doctors that there is no requirement to determine someone’s immigration status to access primary care services (www.bma.org.uk/employmentandcontracts/independent_contractors/providing_gp_services/overseasvisitors.jsp). The General Medical Council’s Good Medical Practice guidance requires that doctors do not discriminate unfairly but provide care and treatment to meet the clinical needs of all patients. The Royal College of General Practitioners (RCGP) endorses this: “Based on the principle that General Practitioners have a duty of care to all people seeking healthcare, the RCGP believes that GPs should not be expected to police access to healthcare and turn people away when they are at their most vulnerable” (www.rcgp.org.uk/policy/position_statements/failed_asylum_seekers.aspx).
When doctors show callousness and a lack of compassion they may use various tricks to preserve their self esteem. One of these is to comply with bureaucratic diktats and abdicate responsibility for the consequences of their actions. Another is to dehumanise people and view them as dangerous and unworthy of normal human decency. In mitigation, I recognise that some primary care trusts send officious and misleading guidance. Receptionists and practice managers are sometimes exhorted to reject patients who do not present documents such as utility bills and passports—not easy if you are homeless or if someone else holds your papers. These impositions carry no valid legal or ethical authority, but some may believe they do.
What does the future hold? Finances are tight. Consortiums may be more draconian. The government seeks to expand its existing restrictions to free secondary care and include primary care (www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_125271). This does not augur well for the vulnerable and dispossessed in need of humane clinical care—particularly as compassion seems to be a dwindling resource in modern medicine.
Cite this as: BMJ 2011;343:d6637
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.