The Russian invasion of Ukraine has led to thousands of refugees arriving in Ireland and refocused attention on migrant health in general. David Lynch reports.
“What happened on 24 February was absolutely horrific…. I was in total shock. We never expected a full-scale invasion. The first 72 hours were just a daze for me. Looking at the scenes on television, [being] scared for my loved ones and the uncertainty for their future was just terrifying.”
Dr Kateryna Kachurets, a Dublin-based GP, originally from Kyiv, spoke at the recent IMO AGM about the impact of the Russian invasion of her country, and the challenges facing Ukrainian refugees arriving in Ireland.
Since the Russian invasion, Dr Kachurets has been working with the HSE and the ICGP in Ireland’s response to the arrival of over 33,000 refugees so far.
“The HSE has been coordinating with many different departments, and it was great to see how everybody came together for this emergency response to this crisis in a very challenging situation,” outlined Dr Kachurets, who noted the “generosity of the Irish people”.
However, the refugees face numerous challenges – from dealing with trauma, accessing childcare, employment, and the overall “uncertainty of their future”.
“I think accommodation is the biggest challenge,” Dr Kachurets told the Medical Independent (MI).
“There’s a huge shortage in long-term accommodation. People are staying in Citywest [transit centre for Ukrainian refugees in Dublin] longer than initially expected. As more and more Ukrainians arrive, it is becoming more difficult to find accommodation for them. The situation is evolving.
“The HSE and the Department of Social Protection are looking at different options, but it is very challenging. We had a housing crisis in Ireland before the [Russian] invasion. So, I think accommodation is the top problem.”
She warned that high numbers of Ukrainians are currently forced to stay in shared facilities such as hotels, “and even with the best Covid measures, outbreaks are inevitable. The next on the list, we think, will be chickenpox or norovirus.”
Dr Kachurets said that the “second top problem” is GP access. “Again, we had a shortage of GPs before this crisis. So we have 33,000 Ukrainians that will ultimately need GPs,” she told MI.
She is hopeful that a new framework agreement established recently between the ICGP, IMO, and HSE will help.
“I think it’s going to make a huge difference. It is a very structured approach,” Dr Kachurets said.
“There are financial incentives there, and it is very well outlined. I think GPs don’t like uncertainty. But, when it is all outlined for them, how it is going to happen and that they will be well supported, I think it is going to encourage them more and more.
“Certain GPs have already started doing this [taking on Ukrainian patients], leading by example. I think it’s shown other GPs that it is possible to do.
“But this framework is great, I think it took nearly a month for them to pass it, because a lot of negotiations were happening between the IMO, the ICGP, and the HSE.”
People from Ukraine who are here under temporary protection are eligible to obtain healthcare services from the HSE, including access to Covid-19 vaccinations, GPs, community care, and hospital or emergency care.
A HSE spokesperson added: “As well as access to services for children’s health, mental health, disabilities, maternity care, older people, and many more. Ukrainian people are able to get the same health services as people who are already living here, including Irish citizens.”
The HSE, in conjunction with the IMO, “has prepared and is putting in place a range of specific GP service options for people from Ukraine who are accommodated in hotels and other communal settings provided by the State across the country.”
A streamlined medical card application process for people from Ukraine is in place and “working well”, according to the Executive.
All point of entry services are due to move to Citywest in Dublin “shortly”.
Asked whether the arrival of Ukrainians has led to a significant reconfiguration of the health service, the spokesperson said “all our services across hospitals and community services, along with our social inclusion, GP, and pharmacy colleagues, have been involved in the response to support people fleeing the war in Ukraine”.
“We’d like to acknowledge the rapid mobilisation of people, services, and resources across the health service, and the work that is ongoing to support and integrate people.”
In light of the arrival of Ukrainian refugees and more long-standing challenges in migrant health, the Irish Society of Specialists in Public Health Medicine (ISSPHM) recently called for the establishment of a ‘migrant health programme’.
The ISSPHM said that the Ukrainian crisis had highlighted “a long-standing need for a structured, adequately resourced migrant health programme”.
The programme should “provide a national strategy, guidance, development of standards and the clinical governance to meet the health and social care needs of all people seeking international protection in this country, and of other vulnerable migrants.”
Ukrainian doctors under fire
Over 170 Ukrainian doctors have arrived in Ireland fleeing the Russian invasion.
Ukrainian GP Dr Kateryna Kachurets told the Medical Independent that “we know of at least 170 Ukrainian doctors who are here in Ireland”.
“The majority of them are from paediatrics, gynaecologists… most are female doctors, which is reflective of the population, because it is mainly women and children who are escaping.”
In regard to the doctors who have arrived in Ireland, “we are working with the Medical Council and the ICGP in trying to create a pathway for maybe making it easier for doctors to adjust to the medical system here.”
“There are no promises so far in terms of licensing. But hopefully, we could create a different pathway, or maybe do a few things to make it easier for Ukrainian doctors to possibly start working here.”
She added that “obviously a lot of doctors had to stay in Ukraine”.
“Especially male doctors who are surgeons who are operating on soldiers and civilians,” she added.
“I think we need to keep on supporting them, because the infrastructure there [in Ukraine] has been disrupted. It is very, very difficult for them to get the supplies in the country. So, they rely hugely on what is given to them from outside Ukraine.”
Dr Kachurets works with the Medical Help Ukraine Charity Campaign (for further information, visit www.medicalhelpukraine.com.
The ISSPHM noted that even before the Russian invasion of Ukraine, the numbers of people applying for international protection in Ireland was “approximately 150 per week since August 2021”.
This “was challenging the direct provision system with increasing numbers of hotels deployed as emergency temporary accommodation”, according to the group.
“While providing much needed immediate shelter and accommodation, hotels are unsuitable in the long-term and lack proportionate and adequate health and social supports needed (ie, mainstream GP and primary care). These high-density settings also increase the risk for outbreaks of infectious diseases such as Covid-19.”
Dr Fiona Cianci, Specialist in Public Health Medicine, Department of Public Health East and member of the ISSPHM, praised the response of the health service to the crisis.
Overall, the HSE has responded “well” to the unprecedented number of Ukrainian refugees and “continues to do a lot of great work” to address this humanitarian crisis, Dr Cianci told MI.
“However, it is working within certain constraints, which are extremely challenging.”
The constraints include the “lack of a funded, structured migrant health programme” and of “clear governance structures and understanding of roles and responsibilities” of all parties involved in the response.
“This has led to a lot of great work being done, but in a fragmented and diverse way across the country, which is creating inequitable access to health services,” she added.
Dr Cianci said that a migrant health programme would have established governance structures in place before a crisis.
“It would have clear, established pathways to guide refugees and asylum seekers, regardless of their country of origin, through our health service to meet their medical needs appropriately,” she added.
Given that much of the current migrant healthcare provision comes through general practice and primary care, she added that a new programme should “absolutely” support and strengthen the current migrant health provision.
She believed this would especially be the case in terms of priority health assessment and infectious diseases screening.
“Any migrant health programme would have to be integrated with primary care to allow for streamlined provision of care in the community, as ultimately our primary care colleagues are the ones who will care for the individuals concerned.”
Lost in translation?
The HSE has recently signed new contracts with companies to provide translation services to Ukrainian refugees who have arrived in Ireland, Ukrainian GP Dr Kateryna Kachurets told the recent IMO AGM. “Both in person and virtual translations are available,” she said.
However, the general lack of translation facilities for migrants in Ireland accessing healthcare has been a long-standing issue.
Last year, the Medical Independent (MI) reported on concerns raised at a HSE safety and quality committee about interpretation services for migrants.
Interpreters and “key workers” available to refugees engaging with health services are “extremely limited in Ireland”, the meeting heard in September 2021.
The “access to services, the language barrier, isolation, and mental health issues were some of the biggest challenges faced” by Syrian and other refugees here, the committee was told.
According to minutes, the committee “agreed that key workers and interpreters are available to assist refugees in other countries, but those services are extremely limited in Ireland”.
Last November, Safetynet Primary Care and other organisations informed the joint Oireachtas committee on children, equality, disability, integration, and youth about challenges in the area.
“Safetynet have voiced concerns over a number of years. Put quite simply GP care is provided through effective communication,” Dr Fiona O’Reilly (PhD), CEO, Safetynet Primary Care, told MI.
“Without it, [care] is open to high degrees of risk. Where the GP and the patient do not speak the same language, it is not possible to provide safe care without the use of good translators.”
Safetynet is funded largely through the HSE social inclusion offices.
“We budget for interpreters across our services for those that need them. This is funded by the HSE social inclusion. We are aware that throughout the HSE CHO [Community Healthcare Organisation] areas there are some that make interpreters available to those working in primary care. In others, GPs would need to apply for this kind of funding and in others it doesn’t appear to be in place.
“What is needed is a national standard across CHOs for GP practices. Similar to the practice nurse grant that all GP can apply for, there needs to be an interpreter grant.”
But the barriers to effective communication between GP and patient are not only on the side of funding provision, Dr O’Reilly added.
“We have noted that there can be a reluctance among GPs to utilise [an] interpreter even when it is available to them,” she said.
“There is a perception that it is difficult to organise and that it will be time-consuming. While any change to practice takes time and organisation, we have found that the routine organisation of this vital part of quality care is something [where the] benefits far outweigh the effort in making the change. It is, however, time-consuming and consultation takes twice as long utilising interpreters.”
However, she said conducting inaccurate or inappropriate consultations, using ‘Google translate’ or family members, have other risks that may take more time to undo in the long run.
“Quite simply this is a standard that needs to be nationally implemented and monitored. The alternative is denying safe healthcare to those who don’t speak the dominant language – English.”
Dr O’Reilly told MI that there “has been small improvement” in recent years with “more and more non-English speakers and some GP practice-taking initiative to get these services funded”.
“However, this remains a significant barrier for non-English speakers to get access to care, particularly GP care.”
She said that the HSE needed to “establish a national standard and mechanisms to access funding for interpreters by primary care, particularly GP practices”.
Lack of communication between departments and significant IT deficits continue to create challenges for migrant health, Dr Cianci also told this newspaper.
“This partly stems from lack of clarity of which department is leading and is responsible for the response and partly stems from entirely inadequate IT systems.”
She said there needs to be a “common understanding of which department and agency are responsible for the overall response to this humanitarian crisis”.
“We need improved communication between departments to be able to plan health services around the health needs of the population. Health intelligence is critical to planning. If we do not have information on where the Ukrainian refugees will be living, for how long, and what their health needs are, we cannot plan adequately.
“However, the information provided to the HSE may not be timely, complete or adequate to inform a public health response or service planning at present.”
She added that “we are still very much in need of a unique patient identifier, which could be very useful in ensuring integrated care for not just the migrant population, but for our whole population, especially given the lack of integration in our IT infrastructure nationally”.
Dr Cianci also noted that the wider “ongoing health crisis” has an impact on migrant health provision. This included lack of GP capacity to take on new patients and long waiting lists for other services like mental health, psychology, disability services, and dentistry. This “has been particularly challenging”, she said.
“Our resources were already overstretched under the strain of the needs of the population before the war in Ukraine, and there is now very little flexibility in the system to provide health services to the unprecedented numbers of people who have come to Ireland seeking protection.”
The HSE said that the Government is committed to implementing a model of enhanced healthcare for people in direct provision.
The vision is contained in A White Paper to End Direct Provision and to Establish a New International Protection Support Service, which was published by the Government in February 2021.
“The Department of Children, Equality, Disability, Integration, and Youth white paper sets out a model to provide accommodation and other supports in health, housing, education, and employment for people in international protection,” the HSE spokesperson told MI.
“This future model for enhanced migrant healthcare will include strengthening clinical roles and public health supports, and the HSE’s experience of providing services to applicants for international protection, refugees and people under temporary protection will certainly inform this development.
“This work will complement the actions being implemented by the HSE under the second National Intercultural Health Strategy 2018-2023.”