K ONKLUSION OG ANBEFALINGER
E NGLISH ABSTRACT
Refugees and immigrants experience inequality in health, this is well-known. So far, research has mostly focused on preemptive treatment and general access to healthcare. But we know less of what happens inside the healthcare system, once persons belonging to an ethnic minorities become ill.
This review answers two questions: do hospitals contribute to hidden inequality in the quality of the treatment and care offered to ethnic minorities and does it therefore make sense to speak of Immigrant and refugee Medicine? The Migrant Health Clinic at Odense University Hospital has existed now for five years, but what are their experiences and what can we learn in general about the healthcare system, from the socially most vulnerable patient-groups?
The conclusion of this review is, that doctors and nurses, consciously or subconsciously, yield discriminatory practice in regards to their selections of examinations, treatments and re-examinations, and that likewise the information given is not given at all, or delivered in a language too intricate. There are political, legal,
organizational and administrative barriers within the healthcare system, which directly inhibit equal treatment when there are language-barriers present. Leadership and the political dimension for this aspect of the inequality has propably been underestimated so far. Doctors and nurses lack the basic clinical and ethnical qualifications and competencies, that would enable them to offer quality of care that approximates that of ethnic Danish patients. Health professionals must learn to incorporate the fundamental conditions of life in exile as a minority in the assessment of the patient's needs and resources.
In a new aspect on ethnical minorities in the healthcare system, the review demonstrates, with patient cases, how a lack of respect for language-barriers from the side of the health care system and health workers threatens patientsafety and conflicts with both legislation, the Hippocratic oath and the Danish model of quality. The want of clinical ethnic competencies among doctors and nurses, both politically and administratively, is the pivotal point.
Cultural differences, religion, ethnic pain and unqualified interpreters are some of the ”cognitive shortcuts”
doctors and nurses utilize in order to avoid providing the service which they are required to perform.
Experiences from the Migrant Health Clinic however, show that the cultural x-ray is the best clinical tool: who is the person with the disease and what does it imply for this person to have this disease. Headscarves, skin color and stereotypical conceptions of ethnical minorities have no place in the selection of diagnostics and treatment.
Language-barriers are critical and present a risk for patient-security. Language-barriers lead to delay in diagnosis, prescription errors, including pharmacies and in regular practice and patients derive grave side-effects and serious complications. Video-interpretation is the professional tool, which should be the national standard, with twentyfour-hour operations and the need for interpreter-assistance should not be decided by a secretary on the basis of a foreign-sounding name or economic, political or personal, irrelevant grounds, as is the current
instance.
The equal access to the Danish healthcare system has brought along a case of democratic sloth: we are here, but you must approach the health care system yourself, find your own way around here and find your home again.
Meanwhile, the hyperspecialisation has made it simple for medical specialists in hospital departments to reject a patient with more than one disease or a vague symptom. Social vulnerable patients are lost in the specialization process and become too sick for the hospital.
The dominant political idea of letting ”the normal system cope with it”, is unfortunately contributing to health being deadlocked. The normal healthcare system has neither the frame nor the expertise to address patients with complicated health-issues and linguistic barriers. It is necessary to establish a function within the healthcare system, that can manage those patients, that a modern, efficient and highly specialised healthcare system cannot and who are misplaced in the hands of a practicing physician. Neither the Danish National Board of Health, The Ministry of Health or the regional authorities have a focus on clinical inequality and there are no plans to reinforce their professional referencebase in this area. The remarkable thing is that it is the Ministry for
Refugees, Immigrants and Integration which formulates the bill-proposal for improved screening of newly arrived refugees, which becomes effective from 1. July 2013.
It is therefore recommended that there be established one Migrant Health Clinic in every region, at the level of a University hospital, that can manage the development of competency, document discriminatory practice and suggest improvements in regards to a more desirable continuity of care and finally becoming the clinical special-department for particularly complicated or serious courses of disease. There is as of May 2013 a newly
established Migrant Health Clinic at Hvidovre Hospital in Copenhagen, but the other regions will, with this review, find it difficult to sustain their refusal of a need for this type of clinic. It is furthermore proposed that a national center of expertise be established for the strengthening of clinical ethnic qualifications and the aid of interpretation.
Post graduate training in clinical ethnic competencies has proven effective and is in high demand. Ethnic qualifications should be a part of every education in the area of social and health sciences, both as part of the curricula and as part of post graduate training. “Readiness for astonishment” must be turned into a professional clinical tool. In the USA, there was at one point a trend of driving ones old mother to the mall once she began to speak nonsense and had become too demanding of care. The family would hurry away, leaving the senile grandmother without identity papers, thereby leaving the government to pay for the expenses at the nursing home. The practice was, with good reason, called ”Granny Dumping”. The reality for ethnic minority patients is not far from the same situation: municipal authorities and hospitals dump time consuming- and interpreter demanding problem patients with each other and sneak away leaving the other to solve the problem and the bill.
The title of the review is a quote from a patient, when she was discharged from the clinic. The patient was much happier with the model of herself that we had developed together in the clinic. Our hope, with this review, is that it can provide the starting point in the making of a better model of our healthcare system, with the help of the experiences of the brave patients.
P
UBLIKATIONER OG FORMIDLING, I
NDVANDRERMEDICINSK KLINIK, 2008-2013.
ARTIKLER- VIDENSKABELIGE
Sodemann, Morten, Arndis Svabo, and Arne Jacobsen. "De hårde kampe starter, når krigen er slut." Ugeskrift for Laeger 172.2 (2010): 141-4
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Teletolkning er vejen frem. Ugeskr Læger 172/47 den 22. november 2010.Livet med diabetes som indvandrermedicinsk patient
Nielsen, D. , Svabo, A. , Rønde Kristensen, T. & Sodemann, M.jan 2011I : Medlemsblad for Fagligt selskab for diabetessygeplejersker FS 19.s. 37-40.
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Sodemann M. Medicinsubstitution er farlig og skaber ulighed. http://www.e-pages.dk/laege/498/swf/80.swf Sodemann M og Svabo A. Sygdomstolkning. http://sprogmuseet.dk/tolkning/sygdomstolkning/
RAPPORTER
Jacobsen A og Sodemann M. Hospitalsbaseret forløbskoordination blandt flygtninge/indvandrere med komplicerede helbredsproblemer. 2010.
http://www.ouh.dk/dwn151718
Sodemann M og Nielsen D. Tolkelovens præmisser og sundhedsmæssige konsekvenser. 2011. http://www.ouh.dk/dwn148108 Seminar rapport: Seminar om kompliance/adherence og patientuddannelse. 2010. http://www.ouh.dk/dwn146821
Seminarrapport: Forløbskoordination i sundhedsvæsenet. http://info.ouh.dk/dwn200320
Sodemann M og Nielsen D. Tolkerapporten: Kun en tåbe frygter ikke sproget. Tolkning - fra de professionelle tolkes synspunkt. Erfaringer fra Indvandrermedicinsk Klinik, Odense, Oktober 2010. http://www.ouh.dk/dwn130466
BØGER
Patientologi. At være patient. Kapitel: Mødet med den etniske minoritetspatient. Dorte Nielsen . E-bog, Forlaget Gad. Www.gad.dk. 2013.
Forord: Den gode Dialog. Lisa Duus. Viasystime. 2013. Faglig redaktør: Morten Sodemann.KOL inspiration til Almen praksis. En anerledes bog om behandling af KOL. Kapitel om Indvandrermedicinsk klinik. Dagens Medicin 2012.
KRONIKKER
For syg til sygehus. Kronik. Jyllands Posten. 2012. http://jyllands-posten.dk/protected/opinion/kronik/ECE4585640/for-syg-til-sygehus/Sundhed på mit sprog.
Dagbladet Information. 2011. http://www.information.dk/276918Velkommen til en sundhedsskadelig lov. Politiken. 1. juni 2011.
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DEBAT INDLÆG
Tolk – det kan du selv være. Jyllands Posten. 1.9.2009. http://www.ouh.dk/dwn90191 Det ultimative kærlige skub. Jyllands Posten. 14.9.2009
Læger: Besparelser på tolke kan koste liv. Dagbladet Information.2010. http://www.information.dk/249353
En lille lov med en stor negativ effekt. Jyllands Posten juni 2011. http://jyllands-posten.dk/opinion/breve/ECE4538322/en-lille-lov-med-en-stor-negativ-effekt/
Et forkert billede. Sodemann, M.3 jan 2012 Fyens Stiftstidende
Finanslov var et løft for bedre integration. Sodemann, M.17 apr 2012 1, Politiken. http://c14316918.r18.cf2.rackcdn.com/politiken-POLPNDAB170412L10B005.pdf
Fyens Stiftstidende, 18. december 2012: Ikke alle patienter fødes med gps Politikken, 12. december 2012: Uligheden er stigende blandt patienterne Jyllandsposten, 29. november 2012: En revolution for flygtninge
Har velfærdsforskere forstand på velfærd? Kristeligt Dagblad, 26. maj 2012 http://www.ouh.dk/dwn228495 Dagens Medicin 25. maj 2012: Indfør problemskadestuer til de svære patienter
Patienter fødes ikke med GPS. Debatindlæg. Fyns Stiftstidende. 18.12.12 Uligheden er stigende blandt patienterne. Politiken. 12.12.2012.
BLOGINDLÆG
Syv system synder der cementerer ulighed. Dagens Medicin. 28.10.2009. http://www.dagensmedicin.dk/blog/den-ulige-sundhed/syv-system-synder-der-cementerer-ulighed/
Fattige tager fattige valg. Dagens Medicin. 21.10.2009. http://www.dagensmedicin.dk/blog/den-ulige-sundhed/fattige-tager-fattige-valg/
Happy healthy migrant? Dagens Medicin. 14.10.2009. http://www.dagensmedicin.dk/blog/den-ulige-sundhed/happy-healthy-migrant/
Lige adgang til sundhed betyder at de skæve ikke passer. 12.10.2009. http://www.dagensmedicin.dk/blog/den-ulige-sundhed/lige-adgang-til-sundhed-betyder-at-de-skave-ikke-passer/
Sodemann M. Lighed i sundhed: Snart er vi alle udsatte og sårbare. 2012. http://www.ugeskriftet.blogspot.dk/2012/12/lighed-i-sundhed-snart-er-vi-alle.html Sodemann M. Den grimme ælling fra Odense har fået en kønnere lillesøster. 2012. http://www.ugeskriftet.blogspot.dk/2012/10/den-grimme-lling-fra-odense-har-faet-en.html
Svabo A og Sodemann M. Kroppen, sproget og psyken. 2012. http://www.ugeskriftet.blogspot.dk/2012/08/kroppen-sproget-og-psyken.html Sodemann M. Udeblivelse eller ikke inviteret? 2012. http://www.ugeskriftet.blogspot.dk/2012/06/udeblivelse-eller-ikke-inviteret.html Sodemann M. Pjusket pjækkeafgift til patienter. 2012. http://www.ugeskriftet.blogspot.dk/2012/06/pjusket-pjkkeafgift-til-patienter.html Sodemann M. Tid til overklasse etik. 2012. http://www.ugeskriftet.blogspot.dk/2012/03/tid-til-overklasse-etik.html
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Sodemann M. Myten om normalsystemet – og forslag til en løsning. 2012. http://www.ugeskriftet.blogspot.dk/2012/01/myten-om-normalsystemet-og-forslag-til.html
Sodemann M. Hvorfor gå i stangvarer? 2012. http://www.ugeskriftet.blogspot.dk/2012/01/hvorfor-ga-i-stangvarer.html Sodemann M. En for alle eller alle for en? 2012. http://www.ugeskriftet.blogspot.dk/2012/01/en-for-alle-eller-alle-for-en.html Sodemann M. Patienter forlænger lægers liv. 2011. http://www.ugeskriftet.blogspot.dk/2011/12/patienter-forlnger-lgers-liv.html
Sodemann M. Politikeres mavefornemmelser og deres konsekvenser. 2011. http://www.ugeskriftet.blogspot.dk/2011/10/politikeres-mavefornemmelser-og-deres.html
UDVALGTE RADIO INDSLAG
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P4 Østjylland, 29. november 2012: Ensomhed blandt indvandrere. http://www.dr.dk/P4/Aarhus/Nyheder/Aarhus/2012/11/29/063355.htm
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Ubearbejdede traumer gør Indvandrermænd mere syge http://www.dr.dk/P1/orientering/indslag/2011/12/08/175118.htm MASTER OPGAVER
Twesigye R. Lived Experiences of Immigrants with Chronic Illnesses in Denmark‐A Case of HIV Patients. Master thesis. 2011. http://www.ouh.dk/dwn177662 Schmidt J. Blandt fortællinger, patienter ogsundhedsprofessionelle En antropologisk undersøgelse af hvilke erfaringer etniske patienterog deres behandlere har med mødet i det danske sundhedsvæsen ogom et narrativt perspektiv kan bidrage til en dybere forståelse afhvad der er på spil i dette møde? Master i sundhedsantropologi. 2011. Aarhus Universitet. http://sydvestjysksygehus.dk/dwn171797
FORSKNINGSÅR OG KANDIDATOPGAVER
Lars Tigerström. Lægebias og klinisk kvalitet. Kandidatopgave.SDU. 2011 Jian Bozo. Urininkontinens og stigma. Kandidatopgave. SDU. 2012.
Lina Zeraiq. Opfattelse af HPV blandt etniske minoriteter. Forskningsårsrapport. SDU. 2011