First Encounter With Health Services

The introduction of communicable diseases by foreigners and travellers has always been of concern to health authorities. International regulations, quarantine procedures and medical screening have been designed to control the spread of diseases. At a time of worldwide mobility of millions of travellers, medical screening is still implemented for immigrants and refugees before or at the time of entry in the receiving country. It is most frequently mandatory and in some instances it determines acceptance for entering the country. No doubt migrants may be afraid that such a medical examination that may hinder them from reaching their destination. Medical screening is aimed mainly at identifying communicable diseases such as tuberculosis, hepatitis B, syphilis, HIV or other health conditions that may cause a financial burden on the receiving country. Preventive measures such as vaccinations are often implemented at that time. Much of the data available on the health of migrants are drawn from medical screening at time of entry.

Obviously, mandatory medical screening is the result of public health concern both for protecting the host population and identifying sick individuals in order to provide them with care. This is not patient-centred medicine. Immigrants and refugees have health needs that often are not met by medical screening and many health professionals question its medical soundness, moving towards a normal medical interview and examination, promoting access to local medical facilities and responding to specific health needs individual migrants have.

Furthermore, the diminishing impact of classical infectious diseases in a globally mobile world forces us to explore new approaches and responses. Until recently, most of the emphasis has been put on the diseases responsible for epidemics (yellow fever, cholera, smallpox). Access to clean water, immunisation and use of antibiotics have reduced drastically their prevalence and population health impact, thus reducing the effectiveness and need for mass medical screening (Gushulak and MacPherson, 2000b). With mobile populations becoming a larger component of societies, diseases with long latency periods or subclinical or chronic stable infectious periods pose problems not solved by screening at the time of entry. Chronic infectious diseases, such as tuberculosis, hepatitis B or C, schistosomiasis or diseases with a long latency such as malaria vivax, will often be recognised after many months in the host country. Even in the case of tuberculosis, 47% of cases recorded in foreign-born people in the USA are detected more than 5 years after their arrival (Binkin et al., 1996). This shift towards chronic diseases creates a situation where the first interaction with the health care system is likely to be at community level with primary care providers. This has direct implications on how and where to reinforce surveillance systems and provide the family doctors with adequate knowledge and training in recognising and managing diseases they are not familiar with.

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