RN and CAF Capt. Tyler McNaughton puts a young Syrian girl at ease during an assessment at an airport in Jordan.

Transcription

1 RN and CAF Capt. Tyler McNaughton puts a young Syrian girl at ease during an assessment at an airport in Jordan.

2 OPEN Arms Nurses play a key role in ensuring thousands of Syrians get off to a safe and healthy start in Canada. by Daniel Punch A family of six Syrian refugees steps off a bus in Amman, Jordan and into a massive airport hangar. Their clothes are dirty and ill-fitting. The father s shoes are falling apart. His young son one of four children under the age of seven wears flip flops in the 10-degree weather, and his pants are held up by a string. Amman is just 100 kilometres from the Syrian border, but this family hasn t been home for some time. A brutal civil war has killed hundreds of thousands of Syrians and forced millions to flee, living in refugee camps or barely scratching out a living in neighbouring countries. The family is led through the hangar and into a high-walled cubicle. Visibly exhausted from untold struggles, they are greeted by a man wearing a uniform and a warm smile. Welcome. We re here to help you, Capt. Tyler McNaughton, nurse generalist in the Canadian Armed Forces (CAF), says through an interpreter. He tells them he s got a list of questions to ask about their health, but they need not worry. You are going to Canada. Registered nurse journal 13

3 mcnaughton is part of Operation PROVISION, a CAF deployment helping to process thousands of Syrian refugees. The project is led by Immigration, Refugees and Citizenship Canada (IRCC), which set up shop in the airport alongside the Jordanian air force to screen Syrians before they are accepted to Canada. First, potential refugees are brought into the screening centre for day-long interviews, where their fingerprints and photos are taken. Once approved, they are called back to the hangar and screened for various health concerns, including communicable disease, chronic illness, and immunizations. The IRCC originally contracted health screenings to an international agency, but when the newly elected Liberal government committed to bringing 25,000 Syrians into Canada by the end of February 2016, the CAF was brought in to assist. McNaughton and the team of six nurses, eight physicians, and about 15 other health practitioners began their mission on Dec. 14. By mid-january, they were screening 150 to 200 people each day, and had seen more than 3,500 in total. The goal of the screenings is to identify refugees resettlement needs, which will help determine where in Canada they end up, and if they require referrals to health professionals when they get here. If McNaughton s team gives a refugee a clean bill of health, they can be in Canada within the week. If health issues are detected, they may have to stay in Jordan for a few weeks of treatment, or until resources can be co-ordinated at their destination. Either way, it marks one of the last stops in a long journey which, for so many Syrians, is marred by chaos and violence. McNaughton and his colleagues have heard numerous horror stories about the past few years. One client was imprisoned and tortured. Another was shot twice in both legs. Still others had lost their homes and their limbs to bomb blasts. This particular family of six, with their weary faces and tattered clothes, stood out for McNaughton. I could see how downtrodden they ve been. That just made me want to help them more. After completing their screening, he reassured them they would soon be flying to their new home. He also gave them most of his lunch, and collected snacks from his colleagues to stock them up. By the time the screening was over, McNaughton says he could see a new sparkle in the children s eyes. Just to see them relax and forget about all their troubles for a few CAF Capt. Tyler McNaughton was in Jordan as a member of Operation PROVISION until mid-january minutes...it s very rewarding, he says. I m so happy they re able to go to Canada. The road ahead for Syrian refugees in Canada may be hopeful, but the future is bleak for the country they leave behind. Following President Bashar al-assad s violent crackdown on anti-government protests in 2011, a full-scale civil war erupted as rebel groups fought government troops for control. The conflict soon became more layered, as militants from various ethnic and religious groups began to fight with each other, as well as al-assad s forces. Both sides have been accused of war crimes and atrocities, including rape, torture and the use of chemical weapons. Half of the estimated 250,000 Syrians killed in the conflict are believed to be civilians. To make matters worse, the now-infamous militant jihadist group, Islamic State of Iraq and Syria (ISIS), has seized the opportunity, capturing large areas of northern and eastern Syria, and ruling under an extremist interpretation of Islamic law. Caught in the middle are the Syrian people. About half of the country s population more than 11 million people has been displaced, and more than four million have sought refuge outside Syria s borders. Aid agencies are calling it the largest humanitarian crisis since the Second World War. Desperate Syrians have risked their lives to find safe haven in Europe, only to be exploited by human traffickers and turned away by countries unsure how to handle the influx of asylum seekers. Their plight finally gained international attention in September 2015, when photos of a lifeless Photo: Fred Cattroll 14 January/February 2016

4 Photo: Stefanie neves three-year-old Syrian boy washed up on a Turkish beach spread around the world. Western countries have since committed to taking on more refugees, and Prime Minister Justin Trudeau made it a government priority after taking office in November. For many refugees, leaving a warzone doesn t mean the end of their struggles. RN Hannah Bell was reminded of this fact when caring for a five-year-old girl who was brought into Refuge: Hamilton Centre for Newcomer Health by her mother. The girl wasn t sleeping or eating. Through conversations with her mother, Bell found out they had been captured by militants, and the girls father was killed in front of them. She was...traumatized from what happened before she came, Bell recalls. The girl was referred to a pediatric psychologist. Although shocking, stories like these are part of life at Refuge, a volunteer-led health centre providing specialized care to immigrants and refugees. In her role as a volunteer RN, Bell focuses on immunization and newborn health for young newcomers. But she s also on the lookout for signs of mental health issues, such as post-traumatic stress disorder (PTSD), common among refugees fleeing warzones. Though she s never experienced that kind of trauma, Bell is able to find some common ground with incoming Syrian refugees. She was born in Lebanon in 1991, during the aftermath of the Lebanese civil war. Neighbouring Syria occupied large portions of the country at that time, and fighting continued through her childhood. She remembers bombs exploding on her parents property. The daughter of British missionaries who owned an orphanage, she grew up alongside 70 orphan boys, many of whom were directly affected by wartime violence. Still, she says it was nothing compared to what has happened over the last five years in Syria. There s always been war (in that region), but the amount of people who are fleeing is sad, says Bell, who often visited Syria as a child. If you look at images of Syria now, it s totally destroyed as compared to when we were there. She moved to Canada as a 10-year-old, but her experience in the Middle East sparked her interest in international health, and led her to Refuge. The health centre offers multidisciplinary primary care, pediatrics, maternal health, social work, and a host of other services for Hamilton s newcomers, but it also serves as a hub to connect newcomers with health and social services throughout the community. It has more than 2,000 clients from various parts of the world, including Somalia, Sudan and the Roma population of Hungary. Bell s colleague Sue Grafe has been practising newcomer health since becoming a nurse practitioner 15 years ago, and has volunteered at Refuge since the day it opened in She says there are a number of considerations that must be carefully navigated when working with refugees, including language barriers and residual trauma from the events that displaced them. But perhaps the biggest challenge for a health-care provider is that newcomers will often arrive without adequate health records. While nurses like McNaughton are working to change that, there will still inevitably be gaps. Starting from a blank page means the initial assessment done largely by RNs must be comprehensive, but it must also be efficient. The more quickly health-care providers can run tests, update immunizations, and connect refugees with available resources, the more quickly they can move forward with their new lives. We just want to help people settle and be well in a timely manner, so they can move on and...go to school, work and live, Grafe says. Refuge staff has been gearing up for an increase in Syrian clients, though only a small group of the 25,000 to arrive early this year are expected to land in Hamilton. In Toronto, health-care organizations have made preparations on a larger scale. This is the case at the Crossroads Clinic at Women s College Hospital. When the federal government raised its resettlement targets, health practitioners at Crossroads knew thousands of Syrians were bound for the city, and it would take a collaborative effort to care for them all. They recruited more than 20 community health centres (CHC), family health teams, and other primary care organizations across the GTA to operate rotating clinics for Syrian newcomers from December 2015 into the spring Because Syria was a middle-income country with a decent health-care system before the war, Crossroads NP Vanessa Wright says the health concerns of Syrians are different compared to populations from sub-saharan Africa and other refugee producing regions. Infectious diseases are less prominent, and health practitioners are more commonly encountering diabetes, hypertension, asthma, and other chronic conditions that may have gone undiagnosed and untreated during years of being displaced. There are also instances of war-related injuries which have not been properly treated. Thousands of Canadians have stepped up to provide homes and support for Syrians including Wright, who is part of a private sponsorship group. About half of the first wave of Syrian refugees coming to Canada were privately sponsored, and arrived with a strong support system that often included primary health care. But Born during a period of unrest in Lebanon in 1991, RN Hannah Bell is able to connect with the struggles of incoming refugees in her position as a volunteer at Refuge.

5 What is the Interim Federal Health Program (IFHP)? Launched by the federal government in 1957, IFHP pays for healthcare services for refugees and refugee claimants for a limited time after they arrive in Canada. It is intended for newcomers who are not yet covered by provincial or territorial health plans, but can also supplement these plans for a period of time. The extent and duration of the coverage depends on the status of the refugee. All refugees (except those whose claims have been denied or suspended) are covered for basic medical needs, including hospital services and care received from licensed health-care providers. This coverage remains until refugees are eligible for provincial or territorial health plans. Government-sponsored refugees are also covered for certain prescription medications, as well as supplemental care, including vision, dental, home and long-term care, services from allied health practitioners, and equipment such as prosthetics and mobility aids. This coverage lasts up to two years. Privately sponsored refugees do not receive supplemental coverage, and are only covered for medications and vaccines for illnesses that pose a risk to public health or public safety (PHPS). This lasts for the duration of their sponsorship. IFHP-eligible children are provided with prescription drugs and supplemental care coverage until they turn 19, as long as they remain eligible. Refugee claimants get basic coverage and PHPS drug coverage until their claim is processed. Syrian refugee crisis by the numbers 23 million Syria s pre-war population 12 million Syrians displaced 4.6 million registered Syrian refugees 250,000 killed in Syrian civil war 25,000 Syrian refugees expected in Canada by the end of February ,157 Syrian refugees arrived in Canada as of Feb. 1, ,790 Syrians arrived in Ontario via chartered flights as of Feb. 2, 2016 Sources: United Nations, Ministry of Health and Long-Term Care, Lifeline Syria the majority of refugees still to come will be government-assisted, highlighting the need for refugee-oriented health care, and not just in primary care settings like Crossroads. I think it s the responsibility of nurses to be aware of some of the general issues facing refugees and to be a source of support for patients that they see, Wright says, suggesting nurses in all health sectors prepare by reading refugee health guidelines, and learning about community support programs available in their area. At the moment, Wright feels refugees are well-supported, thanks in large part to the federal government. But this was not always the case. In 2012, then Prime Minister Stephen Harper made dramatic cuts to the Interim Federal Health Program (IFHP), the health insurance program for refugees and refugee claimants. IFHP covers health-care costs for asylum seekers until they can access provincial insurance, and in many cases supplements provincial insurance with coverage for medications, emergency dental and vision. The 2012 changes took supplemental coverage away from all but government-sponsored refugees, and eliminated all medical coverage for refugee claimants coming from certain countries. RNAO quickly recognized the danger of these cuts. Advocating to restore full IFHP coverage, the association issued action alerts and members responded passionately and in droves, writing letters, speaking out in the media, and attending protests across Ontario. In 2014, the Federal Court of Canada deemed the cuts cruel and unusual and ordered the government to reverse its decision, but Harper immediately appealed. As the court date approached, RNAO secured intervener status in the appeal and was set to speak about the damage caused by the cuts. But the case never made it to court. In December 2015, new federal Health Minister Dr. Jane Philpott announced the Liberal government was not only dropping the appeal, but would seek to enhance IFHP coverage. As Canada stepped up its efforts to help Syrian refugees, so did RNAO. In November, the association put out a joint media release with the Ontario Medical Association announcing the province s RNs, NPs, physicians, as well as nursing and medical students, were ready to meet the health needs of Syrians. RNAO is also an active participant in weekly teleconferences with the ministry of health to discuss refugee issues, and has reached out to members on multiple occasions to gauge the range of skills, experience, and fluency in Arabic that RNs, NPs and nursing students can bring to this humanitarian initiative. The association has amassed a list of resources including multiple BPGs to help health practitioners caring for the large influx of Syrian refugees, and launched a webinar series in February to connect members and non members with information and volunteer opportunities. Nurses make natural advocates for refugee health, according to Lynne Haslett, NP at Toronto s East End CHC, which sees more newcomer clients than Canadian citizens. This is where nursing really shines, she says. Skilled at taking a psychosocial approach, nurses may pick up on cues indicating underlying depression, or notice subtle trauma on a patient s skin, without having to ask the tough questions, she explains. They also see health from a holistic, well-rounded perspective. My doctor doesn t ask me if I brush my teeth twice a day, but I ask all my clients. It s just what we do, says Haslett. 16 January/February 2016

6 NP Lee-Anne Quinn (far right) joined a group of private sponsors in Peterborough who have opened their hearts to Syrian mother Amal Alkhalaf (third from left) and her three children, Ibrahim (second from left), Dalya (centre, in pink), and Ansam (fourth from right). One of the refugee family s first experiences upon arrival in Canada: tobogganing Peterborough NP joins group to give Syrian family a second chance As an NP and 23-year veteran of the Canadian Armed Forces (CAF), Lee-Anne Quinn has traveled the world from Afghanistan to Rwanda and Somalia to help families in desperate situations. But when news came that, after months of waiting, her private sponsorship group could finally welcome a Syrian refugee family to her hometown of Peterborough, she could barely contain herself. We were so excited and so anxious to see their faces and hug them, she recalls. The next day, group members packed into two vans and drove to Toronto s Pearson International Airport to pick up Amal Alkhalaf and her three children, 13, 10 and nine. Alkhalaf s hometown in western Syria came under siege in Her husband went missing that July, and she was forced to flee to the eastern town of al-bukamal. After ISIS took control of that region in 2014, the family fled again to Lebanon. They slept on the floor of a tiny Beirut apartment down the road from where a suicide bomber killed 43 people in November 2015 until 14 strangers halfway around the world stepped forward. It all started when one Peterborough teacher posted on Facebook that she was looking for other local residents to help sponsor a Syrian family. Quinn and her two sisters jumped at the chance, joining educators, a police officer, a veterinarian and other community members. The group raised more than $12,000 and promised to house and support the family financially for the next year. Just weeks after their Dec. 30 arrival, all three children were in school for the first time in years, and Amal was starting English classes at Fleming College. The kids also experienced an important part of Canadiana: their first toboggan ride. Quinn says watching the smiles on their faces as they zipped down the snowy hill is all the thanks she needs. The reward for me is to see those children playing, having fun, and not having to run from the enemy. Quinn sees the family almost daily, often drives the kids to school, and says they have developed a special bond. I expect they ll be a part of our lives forever, whether they stay in Peterborough...or move back home, she says. That s how much impact they ve had on us. And the relationships developed from this holistic care can make a world of difference in refugees lives. Wright recalls one Crossroads patient a 20-something Roma man who had recently escaped persecution in Hungary. An autoimmune disorder had left him with limited mobility and in a lot of pain. Wright was constantly amazed by the support he received from his partner, who helped him dress, bathe, and looked after his medication. She was so moved, she commented on what a wonderful, supportive relationship they had. A few months later, the man s health had turned for the better. At one of his appointments, he told Wright he wanted to talk to her about what she d said about his relationship with his partner. Tears were running down his face. That s how I feel about the way I m treated here (in Canada). I ve never been treated so well before in my life, he told her. Back in Jordan, McNaughton takes pride in knowing the Syrian refugees he meets will be well-received in Canada. It s great to be able to support them and tell them...they are going to get the services they need and be welcomed and supported when they arrive, he says. RN daniel punch is staff writer for rnao. Registered nurse journal 17