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Between chaos and hope

In September 2015, following several boat tragedies and the emotive photos of three-year-old Alan Kurdi washed up on a Greek beach, German chancellor Angela Merkel made the controversial decision to grant special asylum rights to refugees of the Syrian civil war. Over a million entered Germany in 2015, and the trend continues.1, 2 The first arrivals were greeted with enthusiasm but the atmosphere has long since become more pessimistic. It has become clear what a massive challenge the situation poses for the whole country – not least its health services. The list of problems is extensive, from financial and staffing issues in the medical provision for refugees to trickier cultural differences. In this muddle, it is impossible to provide a complete picture of medical care for refugees in Germany. I will attempt, however, to present some of them through my experiences at one ward I visited as part of my paediatrics rotation abroad.

 

Rudolf-Virchow-Klinikum, Central Berlin: the 19th-century hospital grounds are spacious, with sprawling lawns, park benches and sculptures between ornate hospital pavilions, some of which have been replaced by more functional modern buildings, amongst them the children’s hospital. As of November 2015, the 12 beds on the nephrological and general paediatric ward accommodate a number of refugee children as well as the usual bronchiolitis and post-streptococcal glomerulonephritis patients. The refugee cases are fraught with complexity, for medical but often also for social reasons.

 

Take, for example, the two-year-old girl J, toddling the corridors. Over the weeks, the ward has become her home, and the nurses her family. She is cosseted by all and has become something of a mascot – however, her story is sad and complicated. Under J’s rabbit jumper is a curled mass of peritoneal dialysis tubing.  She is in hospital for renal failure due to a congenital problem (genetic analysis of her consanguineous family is pending) but is stable on dialysis and could have been discharged weeks ago to continue her treatment on an outpatient basis. However, discharge planning is complex. J’s Yazidi family has fled from the now IS-controlled areas of Northern Iraq, where this ethnic and religious minority faces severe prosecution, and are struggling with life in Berlin. Her parents have never learned to read or write, arrived with little more than their two young children and the clothes they were wearing, and don’t speak a word of German. They have recently been assigned their own flat in an attempt to expedite J’s discharge from the hospital, but the next and, so far, nearly insurmountable problem is attending outpatient appointments and administering J’s medication. The nurses have filled dosette boxes and tried to teach the parents how to read a clock. They even put J’s father through watching her dressings being changed to dispel his anxieties about the tubes hanging from his tiny daughter’s stomach, but progress has been slow. Sitting in a waiting room the whole day for an appointment at a clock time which means nothing to him means that J’s father cannot join the endless queues for documents that are part of refugee life in Berlin, or attend his language course. Hence J remains in hospital – 3 months and counting.

 

As medical students, we all need to memorise the criteria for a complicated febrile seizure during our paediatrics rotation. The seizure of A., a four-year old Syrian boy, was complicated not only by its 20-minute duration but also by the fact that it occurred in one of the queues outside the city’s Health and Social Bureau (Landesamt für Gesundheit und Soziales, LaGeSo for short) where refugees have to come for registration and any other issues – a day-long wait is the norm. For now, A and his whole family have been admitted. A’s father is traumatised and exhausted. His wife drowned when the family attempted the sea crossing from Turkey into Greece. The children have at least superficially recovered from their tribulations and are enjoying the simple pleasures of a real bed and some toys from a volunteer collection.  A has fully recovered from his seizure and could be discharged, but for once the whole team seems to be dragging their feet. Newly arrived in Berlin, A’s family have no accommodation save the disused Tempelhof airport which has been reopened for the refugees. Nobody wants to send them back there, but there isn’t a choice – the next day, with A still stable, they are shown out.

 

Stories like theirs are sadly commonplace. Funding for refugees, who aren’t covered by one of the state or private health insurances, is a problem in Germany, so hospitals treat patients out of their own pockets. The Charité hospital chain, which Virchow-Klinikum belongs to, is reaching the limits of how much treatment it can provide for free. Currently, there is no plan to resolve the situation as the clerks at LaGeSo have enough to do working through piles of asylum documents. Total chaos has so far only been prevented through the efforts of citizen volunteers. They provide the welcome and orientation not available through the official bureaus, sort out material, legal help, and sometimes even provide accommodation. The junior doctors on the ward have signed up to rotas to provide medical aid in large refugee accommodations like Tempelhof in their spare time. Often, however, the limiting factor is not readiness to help, but the language barrier. A society of volunteers has started producing welcome packs for refugee children which contain basic items like a toothbrush and a small stuffed toy, as well as some German-Arab translation booklets. Getting an official interpreter requires waiting a few days at least, so the few doctors and nurses who can speak Arab or Kurdish are in great demand. Google Translate or the pictorial charts used for children in A&E are also catching on, but more progress is still required to stop the refugee patients receiving substandard medical care due to language issues.

 

This is also illustrated by the case of M, probably around 16 years old but without a passport, who fled Syria alone. Entering via Italy, one of his first actions was to present himself  to a university clinic in Bologna and convey to the doctors there that he had a kidney condition for which he used to receive treatment in Syria. In the absence of more information, the Italian doctors produced a complete work-up. However, before any decision could be made, he had caught one of the trains across the Brenner pass into Germany. With some detective work and the benefit of the new Europe-wide registration system for refugees, the doctors in Berlin managed to track down M’s medical records, only to discover they were all in Italian. After a third set of work-ups, it transpired that M suffered from another rare genetic kidney condition, nephronophthisis, which was complicated by outflow obstruction. M had to start twice-daily self-catheterisation to salvage his remaining kidney function. While self-catheterisation would be an unpopular option for any teenager, it is a small catastrophe for M, who is determined not to be more of an outsider than necessary at his new school – not easy if he has to carry around disposable catheters. Compliance is difficult, to say the least.

Another problem is his discharge. Initially accommodated in a disused school along with other unaccompanied minors, M would like to live with his grown-up brother. However, the brother’s family’s tiny flat in refugee accommodation does not have the sanitary standards required for M’s self-catheterisation programme. The ward’s social worker has found several flats that would have fulfilled the hygiene criteria, but during the lengthy process of getting permission and funds from LaGeSo the flats kept being snapped up by other takers. Determined to end this frustrating process, M has previously even set off on his own to queue outside LaGeSo for a whole day in a desperate attempt to get the documents for his move, in vain. By that evening, his U&E values had worsened dramatically and he was forbidden any further expeditions except for attending school. A German patient’s mother, while visiting her son sharing M’s hospital room, was so moved by his story that she offered to accommodate him in her own house until a more suitable placement could be found – another plan which didn’t get past bureaucratic hurdles, this time because of child protection. However, M remains positive. In his lengthy stay and at school, he has already picked up enough German to translate for other patients, which fills him with pride – a much-needed distraction from the routines and passivity of inpatient existence. He hopes that the rest of his family will be able to come to Europe some day, not least because they could then be evaluated as kidney donors.

 

There are many voices decrying the chaos of the refugee crisis, its cost to the taxpayer and the social systems, and the cultural clashes it entails, as recently shown by the Cologne attacks. However, despite the things that don’t go well, it is important that we do not forget the human faces behind this crisis. While I had myself, in England, shaken my head over reports of how developments seemed to be spiralling out of control, going back to Germany for four weeks convinced me that an open policy was the only humane thing to do. In fact, some doctors resentfully told me that part of the mayhem is deliberately caused by federal states trying to reduce refugee numbers assigned to them, a particular problem in Berlin which is surrounded by Brandenburg – a former German Democratic Republic state now infamous for its xenophobia and right-wing extremists. Despite these problems however, there are many things that run smoothly and many others that are on the way to being addressed – but these rarely hit the headlines. When we encounter the photos of drowned Alan Kurdi on that Greek beech, we should also think of children like J or M who would not have survived in their war-torn country save for the opportunity to find asylum and medical care elsewhere.


Eva Dumann is a sixth year medical student at New College.

 

References

  1. Lpb-bw.de. Flüchtlingsproblematik [Internet]. 2016 [cited 9 January 2016]. Available from: http://www.lpb-bw.de/fluechtlingsproblematik.html
  2. Huggler J. Germany expects up to 1.5 million migrants in 2015 [Internet]. Telegraph.co.uk. 2015 [cited 9 January 2016]. Available from: http://www.telegraph.co.uk/news/worldnews/europe/germany/11911291/Germany-expects-up-to-1.5-million-migrants-in-2015.html

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