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Health Care Guidelines Aim To Help MDs Tailor Health Care For Immigrants, Refugees: Dr. Kevin Pottie Of The Canadian Collaboration For Immigrant And Refugee Health

TORONTO - Doctors now have a comprehensive set of guidelines to help them care for immigrants and refugees, whose often complex health needs can differ significantly from those of home-grown Canadians.

The guidelines -- all based on rigorous international research -- cover a wide range of health issues, from infectious diseases and chronic conditions like diabetes to women's health and psychiatric disorders such as trauma-induced stress.

"We reviewed the world's evidence to create this one-stop resource for physicians to treat immigrants and refugees," said co-author Dr. Kevin Pottie of the Canadian Collaboration for Immigrant and Refugee Health, which created the guidelines published in this week's issue of the Canadian Medical Association Journal.

For instance, newcomers to Canada may be susceptible to several childhood infectious diseases because they may not have been vaccinated in their countries of birth.

"Clinicians often wonder what do you do if you have no records and you can't figure out if someone's been vaccinated," said Pottie, an Ottawa primary-care doctor whose patients include immigrants and refugees.

Rather than time-consuming and expensive testing to determine any existing immunity to diseases like measles, mumps, chickenpox and hepatitis B, "we should just be vaccinating," he said. "The harms of revaccination are so low and the benefit so high that I think we clearly feel that it's a big contribution of cost-savings to vaccinate these populations."

Primary-care physicians should also refer newcomers to Canada for eye tests, an examination they may never have had in their country of origin, Pottie advised.

"I've had patients who couldn't find their way to my clinic until I realized they couldn't see far enough to read a bus sign or a street sign ... A simple visual acuity check is important for all immigrants and refugees to identify people who may be at real risk for other eye diseases."

The guidelines also recommend that doctors perform a dental exam to look for broken and missing teeth, cavities or abscesses, and refer the person to a dentist.

Because Canada has good dental care, chlorinated water and most people understand about brushing with toothpaste, "physicians have tended to not worry about the teeth," he said.

However, doctors often will test for parasites in patients coming from countries where the organisms are endemic, requiring multiple stool tests. With a family of six, for instance, that could mean providing more than 40 stool samples over several days -- an onerous undertaking for newcomers trying to settle in a new country, said Pottie.

"So this family is trying to get their kids in school, trying to find a house, trying to connect with family again and get a job ... And in the end, we actually find that most of these things will resolve on their own, like the tropical eye diseases, once you're removed from the endemic region.

"So it's very important at that time as a clinician to be very efficient."

Yvonne Chiu, executive director of Edmonton Multicultural Health Brokers, said immigrants and refugees can find it difficult to access even basic health care, let alone that tailored to their specific needs.

Language and cultural differences can lead to misunderstandings, said Chiu, whose organization of community health workers helps newcomers navigate the health-care system.

"Even when the language barrier is bridged (with interpreters), much of the time the interaction is guided or biased towards the health-care provider," she said. "So if the health-care provider didn't know much about the pre-migration experience of the person, didn't know this person is a refugee ... then the provider wouldn't ask or try to figure out whether their health problems could be tied to their environment pre-migrationally."

Many physicians might not think about post-traumatic stress disorder among refugees from war-torn or politically unstable countries, she said, yet "something in the hospital environment or a certain procedure might trigger trauma or flashbacks."

"So the provider might design the experience around what he or she is familiar with, rather than the context of where (the patient) came from. So you could imagine the irrelevant care that would be provided."

Pottie said the guideline authors would like to see their work incorporated in medical school curricula as well as used as a model for other countries to deal with their own migrant populations.

Additional resources, including e-learning on refugee and global health and podcasts for clinicians, are available online at

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