When the BMJ makes you write an essay

The big problem with reading the BMJ, is that sometimes an article or letter will stick with you.


And then – when you eventually read something else on the topic – the combination might force you to change your plans for the day.


This is how I came to write the essay below, and, without much chance of it making any difference, ended up submitting it to a foreign jurisdiction in the faint hope of changing a policy that harms children’s health.

I am a senior UK family physician (general practitioner) who is a partner in a group practice serving over 9,000 patients, from babies to centenarians. I work in an ethnically diverse area of London with a large refugee and ex-refugee population. I have 20 years post-qualification experience, 15 in my current job.

[self-promotional blurb truncated here]

The reason I am writing, is to express my concerns about the practice of separating migrant children from their families. My hope is that the perspective of an overseas doctor who deals with similar issues, but in a differently structured healthcare system, may be of some value. The viewpoint I come from is informed by experience: I have worked alongside dedicated and talented colleagues whose families were killed in the Holocaust; doctors who cared for the victims of Saddam Hussein’s gassing of Kurdish civilians at Halabja; staff who fled as children from Idi Amin’s persecution of Asian Ugandans, or ran with their parents from war in Iraq or Somalia.

I have also cared for many patients of widely varying ages and backgrounds affected by these issues over the years.  For example, I have looked after unaccompanied minors from overseas who were placed in UK foster care; Jewish retirees who had fled Nazi persecution via the Kindertransport; young adults who had watched their parents executed in front of them; women who were raped as children by soldiers or drug gangs; bomb victims; students who were imprisoned and tortured for failing to go along with State propaganda; families who fled war or persecution in Kosovo, Somalia, Afghanistan, Eritrea or Iraq; young people who were trafficked in countries adjacent to the European Union.

Because so much of my work is related to the early and late effects of the refugee experience, especially as it affects families, I have done my best to keep up with the research literature in this area, and to compare it with my own experiential knowledge. The Royal College of Paediatrics and Child Health has published useful specific guidance about caring for unaccompanied children so that as practitioners we can address the “often complex health care needs of this vulnerable group” https://www.rcpch.ac.uk/resources/refugee-unaccompanied-asylum-seeking-children-young-people

Longterm adverse consequences of involuntary migration frequently include complex post-traumatic stress disorder, anxiety, depression https://adc.bmj.com/content/87/5/366.info We also often see personality change, psychosis, somatic pain disorders, cognitive difficulties, suicidal thoughts, self-harm and permanent inability to work or study. https://www.ncbi.nlm.nih.gov/pubmed/25162447  We are now accumulating additional scientific evidence on the longterm physical effects of such traumas. For example, adverse childhood experiences are very strongly associated with marked premature mortality and morbidity from – amongst other things – cancer and cardiovascular disease https://www.ncbi.nlm.nih.gov/pubmed/19840693 . Because we are a family practice serving a geographically-defined community, I see firsthand how these experiences also adversely affect people’s families, friends and neighbours, and how easily a multigenerational trauma can start. https://www.ncbi.nlm.nih.gov/pubmed/23118312

Thankfully, I have also been lucky enough to witness beautiful human stories of recovery: children who had similarly traumatic experiences, but, having been able to slowly rebuild their lives in a new, safe country, have gone on to start successful careers, and to raise happy and thriving families. They retained the scars of their past, but with the respect, support and love of the receiving community, were able to adapt and recover. Without exception, these many ‘success stories’ I have seen were in those patients and colleagues who were not further traumatized on arrival in the UK, and who were able to draw strength from the dedicated care of a biological or newly formed family. My personal experience here is consistent with findings in research going back to the second world war, as well as more recent research https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613765/

Institutional care is a well-known risk factor for serious psychological harm even in children not known to have been previously traumatized . https://www.ncbi.nlm.nih.gov/books/NBK73291/   It has also, very sadly, been commonly associated with child abuse over the years, and recent studies indicate this is still problematic even in a modern, well regulated environment https://www.tandfonline.com/doi/abs/10.1080/0886571X.2018.1455561?journalCode=wrtc20 .

It is accepted wisdom that for the vast majority of children, the safest place to grow up is with their biological families, ideally their parents. A safe, nurturing environment is even more necessary to rehabilitate traumatized children, as their neuropsychological functioning is often badly damaged https://www.researchgate.net/publication/311223824_The_effect_of_trauma_on_the_brain_development_of_children_Evidence-based_principles_for_supporting_the_recovery_of_children_in_care .  We already know a good deal about the poor outcomes for children detained via the criminal justice system https://www.tandfonline.com/doi/full/10.1080/23761407.2015.1013367  and about the additional traumas suffered by detained adult refugees. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681439/  Such harms would be multiplied by using detention as a mechanism to look after child migrants, who are especially vulnerable. I also understand that, due to operational constraints, the existing regulatory requirements may have to be relaxed – at least temporarily – for any largescale expansion of child detention in the USA. I can only see this as a wholly predictable disaster in the making.


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