Case Studies from Vulnerable Children's Clinic: Dr. Kemal Ibrahim Evaluation
These case studies from the Vulnerable Children's Clinic in Edinburgh, conducted by Dr. Kemal Ibrahim in September 2017, shed light on the experiences of a 16-year-old female Unaccompanied Asylum Seeker Child (UASC) from Vietnam who was trafficked and faced various traumas. The cases highlight the challenges faced by vulnerable children, including physical assault, exploitation, and the journey to seek asylum in a foreign land. Dr. Ibrahim's documentation reveals the resilience and struggles of these young individuals as they navigate complex and harrowing circumstances.
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Experiences from the Vulnerable Childrens Clinic, RHSC, Edinburgh Dr Kemal Ibrahim Clinical Evaluation CSA Update 29thSeptember 2017
Case Study 16y/o female UASC Thought to have been trafficked out of Vietnam. Tricked into believing that the offer was for a better life. Mother died in her early childhood, brought up by paternal grandmother. Father disappeared when she was 6. Grandmother died when she was 12. Immediate family gone; education came to a halt. Dr Kemal Ibrahim September 2017
Case Study Went to work as house maid. Struck to the face by drunk house owner for not cleaning well enough. Tear to lip; unable to pay for medical attention. Scar a constant reminder of the reason she left Vietnam. Represents the most obvious aspect of her previous trauma, that others might see. Dr Kemal Ibrahim September 2017
Case study Approached by unknown (friendly) Vietnamese male. Brighter future in the West beckoned. Group of 12-14 young people (male/female) herded across different countries by a smaller group of 4 or 5 adult males. No-one else from her local community. With each jurisdiction change, handover between the agents /traffickers/captors. Speaking generally prohibited. Dr Kemal Ibrahim September 2017
Case study Occasional physical assault, slapped or punched; often threatened, but never hit with an implement. Sexually assaulted on two separate occasions by two different traffickers. Reticent to explain as both the interpreter and I were male. Hesitant as she thought we might be embarrassed about what she would describe. Travelled for about a year. Found in an Edinburgh nail bar, 2/12 after arrival into UK. Dr Kemal Ibrahim September 2017
Case study: the process IRD raised; LAC (s.25); staying at YPC. VRI Initial Health Assessment (LAC Nurse) Vulnerable Children s Clinic Referral to Sexual Health Clinic (Chalmers) Dr Kemal Ibrahim September 2017
Definitions taken from the Refugee Council Asylum Seeker: someone who has lodged an application for international protection on the basis of the Refugee Convention (1951) or Article 3 of the European Convention on Human Rights, whose claim has not yet been determined. Unaccompanied children seeking asylum (UASC): Unaccompanied children seeking asylum are children, i.e. aged under 18 years, who have applied for asylum in their own right, who are outside their country of origin and are separated from their parents, or from their previous legal/customary primary caregiver. Dr Kemal Ibrahim September 2017
Definitions taken from the Refugee Council Refugee: A refugee is a person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country . In the United Kingdom, refugee status is awarded to someone the Home Office recognises as a refugee as described in the Refugee Convention. A person given refugee status is normally granted leave to remain in the UK for 5 years, and at the end of that period can apply for indefinite leave to remain. Dr Kemal Ibrahim September 2017
Just to clarify... Modified from the slides of Catriona McSween, Scottish Refugee Council Scottish Guardianship Pilot (since 2010) People smuggling is a crime against a country s borders money is paid to allow an individual s escape from what is considered to be an unsafe situation in their home country. The individual travels willingly, albeit reluctantly... Dr Kemal Ibrahim September 2017
Child Trafficking This is a crime against the individual (below 18y/o). It represents child abuse and should be dealt with accordingly; there is usually violence, threat, control and a sense of being debt-bonded. The plan will be for the individual to be exploited somehow subsequently. Sense that the individual has been tricked into movement for a better life, work, money or for access to education. Dr Kemal Ibrahim September 2017
Types of exploitation Of those seen at Valac so far: Forced labour/nail bars Cannabis growing Suspected sexual exploitation Domestic servitude Dr Kemal Ibrahim September 2017
Why does it remain hidden? The individual may not self-identify (// to CSE) Fear and trauma for themselves and family back home Control and manipulation Coercion and deceit Isolation language, poverty of education Dr Kemal Ibrahim September 2017
Potted Case Histories First arrivals (x2) from Eritrea, both smuggled out of Africa, seen in Valac in August 2014. Very different young men, one 16, the other 17. One from a rural community, little education, frightened and anxious; previous malaria and chronic left flank discomfort, but in the end, normal blood tests, but persistent splenomegaly. The other from the city, appeared confident and chatty; educated and keen to study further, treated for scabies, and inadvertently found to have Hep B. Dr Kemal Ibrahim September 2017
Potted Histories 2 Between April and December 2016: further 7 arrivals, a mix of trafficked and smuggled, equally traumatised: 3 Vietnamese, an Afghan, an Iraqi, a Sudanese and a female from Albania (seen by Dr Arora). None had any understanding that they were coming to the UK, or indeed where that was! Dr Kemal Ibrahim September 2017
Potted Histories 3 Of the 2016 set of 7 arrivals, one had been sold by his foster carer he was an orphan and had only known this man as his primary carer but the FC had accrued debts because of drinking. Typical for trafficked YP, his group was shepherded from one country to the next, with an exchange of the YP from one set of traffickers to the next. As is a very common storyline for the Vietnamese males, this young man s destiny was to be trapped and kept sufficiently fed and watered to tend to marijuana. He would be beaten if the plants failed. Dr Kemal Ibrahim September 2017
Potted Histories 4 Other Vietnamese have ended up in the nail bars, no doubt working for a pittance, although they do not always see this as such, and fail to acknowledge that they are trapped there as things seem to be so much better here than their experience from home. The usual route appears to be from Vietnam to China, perhaps with a flight to Russia, through to Poland and then Europe. A direct flight from Vietnam to Edinburgh is over 9000 km. But these people don t fly in directly. They travel by truck, on foot, across mountains and through woods. And generally at night. Dr Kemal Ibrahim September 2017
Potted Histories 5 The Ethiopian boys (x3) all suffered PA back home by police protests against government. For one, his brother was murdered, his father had disappeared likely killed. The other two both hospitalised following police beatings, one unconscious for 2 days. All 3 had flashbacks, interrupted sleep, and felt discouraged from contacting family. Dr Kemal Ibrahim September 2017
Potted Histories 6 A 17y/o Sudanese young man was tortured in Libya to confess to crimes he had no knowledge of; pliers to his scrotum, his head was repeatedly submerged into a tank of water. Another African recalled being rescued by the Italian coastguard as their boat began to sink; didn t witness drowning, but one Somali woman died on board. He made it to the Calais jungle , but it was safer living on the streets in Paris . These are just some of their stories... Dr Kemal Ibrahim September 2017
Use of interpreters Working in the clinic means working through interpreters and being very dependent on them. So far, Vietnamese and Arabic in the main. Despite what some of the Arabic interpreters tell you - that there is only one Arabic - it only appears true if you have been educated, but less so if you have always lived rurally or spoken only in your home dialect, or if you have had limited schooling the Taliban was not overly keen on that. Dr Kemal Ibrahim September 2017
Working with interpreters The three Ethiopians were the trickiest for me to see; Oromo-speaking interpreters in short supply. The first two of them seen at the end of March, but they had arrived in Edinburgh at the end of November 2016 following the closure of the Calais camp! The third one s assessment was actively obstructed by SW, unable to understand why he needed to be seen he appeared physically well and she was keen I didn t interrupt his schooling further - but in the end, he proved to have LTBI. Dr Kemal Ibrahim September 2017
UASC Appointments: personal practice I offer a 2-hour appointment in order to accommodate working... Through an interpreter, With their often wordy translations of my questions about health issues, which often need explanation, and to allow the creation of as safe a space as is possible in what to all intents and purposes will be a one-off appointment with me. There is no magic to my practice, there are a number of different areas that should be covered [RCPCH guidelines], but listening and engaging in a non-judgemental way is essential. It s just about showing some humanity to traumatised children. It isn t for everyone. Dr Kemal Ibrahim September 2017
Personal practice 2 Of the first 9 YP seen by the end of 2016, one key SW was directly involved in their assessments. She had growing experience and was consistent and paid attention to detail. A small, close-knit group of us was evolving. Following her departure at the end of 2016, I will have met with a further 22 trafficked or smuggled YP since the start of 2017. Working with these YP have been 14 new SW, based at WHHLC, and a 15th SW (for two Ethiopian males) based in Dalkeith. Some of the SW are more interested and adept and supportive than others. I think many feel quite burdened and anxious by the added stress of having to take on these YP and their stories (in addition to their usual workload). It isn t for everyone. Dr Kemal Ibrahim September 2017
Personal practice 3 Know as much as you can know about them beforehand; initial health assessments by the LAC team, social work background reports, VRI. Knowing where to explore further, and where not to push too far with the YP always pay attention to their non-verbal responses. Taking time to explain the Valac consent, that the report will be shared with the relevant professionals involved in their care, including their SW, and potentially other medics, or education. Reiterating to them that this assessment is about their health; there are no tricks that might compromise them it s about gaining their trust. This assessment has nothing to do with their asylum application really important to stress this to them. Dr Kemal Ibrahim September 2017
Personal practice 4 Radiologists agreed that all the YP seen ought to have a CXR, despite a potential lack of signs or symptoms, as we/they can never be sure which infections that might have been travelling with. Screening blood ix, including BBV and quantiferon gold (for TB screening). I also include coeliac screening (zero pick-up so far) and Vitamin D deficiency surprisingly (or not) positive in almost 70% of the YP seen so far though all but one have had normal bone chemistry. Dr Kemal Ibrahim September 2017
Personal practice 5 Routine questions include enquiries about: Headaches fluid intake, eyes, teeth; Sleep/flashbacks many sleep with the lights on, but don t like it being talked about; Diet/changes in bowel habit some gorge, not knowing when their next meal might be coming; FH, impact of consanguinity; Episodes of PA back home (reason to leave) or PA/CSA/scarring en route to UK or since their arrival; Level of education/literacy. Dr Kemal Ibrahim September 2017
Personal practice 6 Close working with invaluable LAC nursing team. IHA (within 4 weeks). LAC nursing RHSC review (to engage/establish rapport) and screening blood tests/CXR. Results available for Valac appointment. Close links with YPC, ensuring GP registration, vaccines, optician assessment. SDQ. Liaison with (elusive) SW; attend r/v LAAC meetings. Dr Kemal Ibrahim September 2017
Data Analysis : COUNTRY OF ORIGIN Vietnam: Sudan: Afghanistan: Ethiopia: Eritrea: Iraq: Somalia: Albania: TOTAL: 17 3 3 3 2 1 1 1 31 Dr Kemal Ibrahim September 2017
Data Analysis 2 Gender: 23 males; 8 females Declared age: Males 11y: 1 13y : 4 14y: 2 15y: 4 16y: 8 17y: 5 Females: 1 2 5 Dr Kemal Ibrahim September 2017
Data Analysis 3 Outcomes & Referrals: Chronic Hepatitis B carriage: 3 [L Jones] Active TB: 1 ; latent TB: 3 [L Jones] Vitamin D deficiency: 10; insufficiency: 11 (21/31 = 68%) Plastics : - sebaceous gland (tumour) removal to scalp - possible revision of scar to lip ENT TM perforations (x2); chronic, intermittent discharge; review of nasal obstruction following nasal bone # Opticians: astigmatism (x1); need for glasses (x3) Chalmers: x2 (disclosed sexual assault en route to UK) Meadows: x1 since formally diagnosed with PTSD; 3 others referred to CAMHS re anxiety symptoms. Breakdown of FC placements: x5 Dr Kemal Ibrahim September 2017
Home Office Statistics 91% of all children arriving by boat into Italy in 2016 were unaccompanied, although it is clear that they did not always set off from their homes without parents. This represents almost 26,000 children/YP in 2016, half of which have since gone missing in Europe. Average age 15 17, although increasingly younger. The European Police Office suggested that 10,000 children who entered (and were registered) in Europe in 2015 have disappeared, though it is likely that this is a gross underestimate. Dr Kemal Ibrahim September 2017
Shocking Statistics 2 Majority of unaccompanied (male) children/YP into Italy were from Eritrea over 3700 in 2016 who flee the dictatorship there to avoid forced conscription into the army. There is usually a different end plan for the boys (compared to the girls) which is organised for them: forced/slave labour or domestic servitude, marijuana cultivation and there are now even reports of organ harvesting. For those entering the UK (2016), majority of UASC come from Eritrea, Afghanistan and Albania, and these 3 countries make up 59% of all the UASC applications for asylum very different to those who have come to Edinburgh. Dr Kemal Ibrahim September 2017
Shocking Statistics 3 Reports that up to 80% of Afghani boys in one child sanctuary in Belgium had been sexually exploited en route. Only one of the young males and one female to date have acknowledged and disclosed their sexual assault in their VRIs, but both were clear that they would not share details with me in clinic. It is likely that such assaults are more common, but will be slow to be disclosed, especially by the boys/young men. This reps a further factor that will likely increase their risk of mental health difficulties & PTSD: key factors fear and loss of control. Dr Kemal Ibrahim September 2017
Helpful Reading RCPCH guidance: refugee and unaccompanied asylum seeking children and young people: paediatric health assessment. Vaccinations of individuals with uncertain or incomplete immunisation status Green Book. Hirani et al, Health of adolescent refugees resettling in high-income countries , Archives, 101 (7), July 2016, pp.670 76. Rehabilitation of traumatised refugees and survivors of trauma , Metin Ba o lu, BMJ (333) pp.1230-31 Dec 2006. New Scots: Integrating Refugees in Scotland's Communities 2014 - 2017 Dr Kemal Ibrahim September 2017
