Intended for healthcare professionals

Clinical Review

Healthcare challenges from the developing world: post-immigration refugee medicine

BMJ 2004; 328 doi: (Published 24 June 2004) Cite this as: BMJ 2004;328:1548
  1. Kristina M Adams, acting instructor (,
  2. Lorin D Gardiner, acting assistant professor2,
  3. Nassim Assefi, senior program manager3
  1. 1Department of Obstetrics and Gynecology, University of Washington, School of Medicine, Seattle, WA, USA
  2. 2Department of Psychiatry, University of Washington and Harborview Medical Center, School of Medicine, Seattle
  3. 3Rural Expansion of Afghanistan's Community-based Healthcare Project, Management Sciences for Health, Kabul, Afghanistan
  1. Correspondence to: K Adams, Immunogenetics, D2-100, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave North, Seattle, WA 98109-1024, USA
  • Accepted 18 May 2004


Worldwide, there are approximately 13 million refugees and asylum seekers.1 Flight of refugees often occurs in the setting of war, famine, or human rights violations, resulting from a “well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion.”2 Physicians in host countries increasingly encounter refugees in their practices and, owing to inadequate training, may not fully meet their complex medical needs.

Sources and selection criteria

Limited evidence exists to support many aspects of refugee health care. When scientific evidence is not available, recommendations stem from our experience in caring for a diverse group of refugees (East African, Balkan, and South East Asian) in a multidisciplinary setting involving primary care physicians, obstetrician-gynaecologists, psychiatrists, nurses, cultural interpreters, and social workers. This article is based on clinical expertise and a review of the literature obtained from a Medline search using the key words “refugee” and “asylum seekers.” We suggest an approach to obtaining the refugee history, screening for infectious diseases and common psychiatric disorders, and dealing with special problems such as ritual female genital surgery (female circumcision).

Refugee camps and medical interventions before embarkation

Refugee camps represent the first point of escape, but continued interethnic strife, sexual violence, and disease epidemics often perpetuate the dangerous environment from which people fled. Although the United Nations High Commission for Refugees promises protection and basic medical care, refugees may actually have higher mortality in camps than in their home country. Major causes of mortality in refugee camps include diarrhoeal diseases, measles, acute respiratory tract infections, tuberculosis, and malaria. Mandated medical screening of refugees before arrival in the United States identifies those with “inadmissible conditions,” including active infections such as tuberculosis, leprosy, and HIV infection. Typical screening of adult refugees involves a physical examination, brief mental health assessment, chest radiograph (sputum testing for tuberculosis if abnormal), …

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