Practising medicine in the global village: use of guidelines and virtual networks.

CMAJ • SEPTEMBER 6, 2011 • 183(12) © 2011 Canadian Medical Association or its licensors E926 The Clinical Preventive Care Recommendations for Newly Arriving Immigrants and Refugees to Canada are launched with this issue. Immigrant-specific, evidence-based clinical guidelines have been lacking in the medical literature, and these guidelines are an important addition to the world literature on migration medicine. Developed using a rigorous 14-step process for review of the evidence and involvement of relevant experts and stakeholders, these are the first comprehensive published guidelines on preventive care tailored specifically to immigrants and refugees. In 2010, the number of international migrants is estimated to reach 214 million. Time taken to circumnavigate the globe since 1850 has decreased from over 365 days to 1–2 days, whereas world population has increased from less than one billion to over six billion. The United States is expected to be the largest recipient of international migrants in 2010 (42.8 million), followed by the Russian Federation (12.3 million), Germany (10.8 million), Saudi Arabia (7.3 million) and Canada (7.2 million). However, patient care for international migrants and medical education for clinicians who care for them have not kept pace with world population growth and mobility, resulting in inequities in care and patient outcomes for globally mobile populations. Refugees and immigrants come from locations throughout the world and thus have widely disparate health concerns and socioeconomic status. Because they migrate most often from underdeveloped countries, they also have much in common. These include more infectious diseases, fewer chronic health concerns initially, language, cultural and structural barriers to care, and all too often, health care providers and health delivery systems less than adequately prepared to care for globally mobile populations. Health care providers in the 21st century can no longer conceptualize “diseases over there” or “diseases seen here.” Each patient needs to be asked two fundamental questions: “Who are you?,” thereby assessing genetics, and socioeconomic and cultural issues, and “Where are you from or where have you travelled?,” thereby assessing risk of disease prevalence in countries of origin (and of first asylum for refugees and immigrants). The development of immigrant health guidelines should be based on country or region of origin and data on incidence of disease, as well as on specific patient-centred issues including genetic predisposition, such as prevalence of G6PD deficiency, sickle cell trait and other inherited genetic disorders. The Clinical Preventive Care Recommendations for Newly Arriving Immigrants and Refugees to Canada cover wideranging topics, from infectious disease screening (hepatitis B, HIV and tuberculosis) to noncommunicable chronic diseases, mental illness, anemia, oral and visual health, and women’s health, including contraception, pregnancy and cervical cancer screening. With evidence-based literature reviews and a Delphi consensus process, recommendations for screening, quality of evidence and clinical considerations are all carefully outlined. The development process included involvement of immigrant groups and relevant experts in specific diseases and immigrant and refugee health. The result is a rigorous, evidence-based set of recommendations for screening globally mobile populations that is applicable to migrants from underdeveloped countries worldwide. The US Centers for Disease Control and Prevention has also recently developed recommendations for screening new refugees on arrival, which are based on a rigorous review process (www.cdc.gov /immigrantrefugeehealth/guidelines/refugee-guidelines.html). Guidelines that are not geared for immigrants and refugees Practising medicine in the global village: use of guidelines and virtual networks