Vol.3, No.2, 106-109 (2011) Health
doi:10.4236/health.2011.32019
Copyright © 2011 SciRes. Openly accessi ble at http://www.scirp.org/journal/HEALTH/
Psycho-medical aspects on migrants’ he alth of III˚ world
pedi atric surgical patients
Andreas Fet t e1, 2*, Kurosh Paya2, Istvan Szilard1
1 Medical School, University of Pécs, H ungary
2National Research Center of Maternal and Child H ealth, Astana, Kazachstan; *Correspon ding A uthor: andreas. fett e@ gmx.de
Received 27 January 2011; revised 15 February 2011; accepted 21 February 2011
ABSTRACT
The constantly expanding world wide mobility
and globalization within the pediatric commu-
nity puts new demands on pediatric surgical
health care systems worldwide, forcing carers
to pay attention not only on their best surgical
and medical performance like in the past. In
contrary, they are forced to pay much more at-
tention on psycho-medical aspects like finance,
rehabilitation, socialization and integration,
culture, management and logistics, health edu-
cation and language skills. Then, according to
our opinion the se as pects shoul d be c onsi dered
as Post Traumatic Stress Disorder (PTSD)-like
syndrome and treated accordingly. Then han-
dling this problem successfully, would be es-
sential for the future survival of any health care
system.
Keywords: Developing World Children Health Care;
Psycho -M ed ic al Aspec ts; Pediatric Surgery
1. INTRODUCTION
Our constantly expanding world wide mobility and
globalization within the pediatric community starts put-
ting new demands on pediatric surgical health care sys-
tems. It mainly happens in those in I˚ World Countries,
due to the common assumption that their economy and
systems are still po werful and well developed enough t o
tackl e s uc h i ss ues . And , it is b ecause of the never getting
silent public voice insisting on the I˚ World Countries’
obligation for humanitarian aid in any case. Forcing us
carers to pay future attention not only on our best s urgi-
cal and medical performance like we did in the past,
quite contrary, forcing us even more to pay attention on
other i mporta nt asp e c ts like:
- FINANCE
- REHABILITATION
- SOCIALIZATION & INTEGRATION
- CULTURE
- MANAGEMENT & LOGISTICS
- HEALTH EDUCATION
- LANGUAGE SKILLS
Therefore, this short communication is rather based on
large statistics and basic science than on short case sto-
ries of strong characters like III˚ Wor ld Co untr y children,
who have been treated by or in a I˚ World Country insti-
tution after their severe homeland accidents.
2. PSYCHO-MEDICA L A SPECTS
2.1. Finance
In any health care system of the world financing is of
key importance. In general, health care is usually fi-
nanced by charity, sponsoring and voluntee rism or by
grants from hospita l foundations operatin g either private
or clerical. Or, in the most traditional way by health in-
surance companies, national or international active, op-
erated b y the gover nment or pr ivate o r even i n co mbina-
tion. Western children usually do not have to worry
about any health care issue at all, since their parents`
healt h in sura nce protects them well right fro m birth until
the end of their childhood. Even in complicated cases
like in this recently emigrated Kazach boy, suffering a
simple forearm fracture while visiting his homeland for
the first time. Initial local maltreatment caused conver-
sion of his simple fracture into a complicated one, how-
ever, he and his family could stop wor- ryi ng. The n, im-
mediately after being repatriated back to Germany, full
insurance cover and specialized medical treatment ac-
cording to German standards started immediately.
Somehow comparable to the case of a little girl and her
family, e migrated to Switzerland from Albania years ago.
While visiting her homeland, an unattended serious in-
fection caused a brain abscess and blindness. The little
girl was repatriated back to Switzerland on her parents’
o wn expenses after local non treatment in a pre- final

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condition, where she finally could be resuscitated in an
ICU se ttin g. B ut in t he large maj o rity III˚ World children
are too poor to get any access to local health care.
Maybe except during I˚ World Country charity missions,
because then, some of them have the chance to be se-
lected by a humanitarian aid organisation with the capa-
bility to bring them abroad for their urgently needed
specialist treatment. Like an A ngolan girl, suffering fr om
multiple dislocated, non-healing fractures, osteomyelitis
and discharging fistulas for many years after survival of
her terrible accident. If being charged and reimburse d in
the German system, her hospital bill alone after a dozen
successful surgeries would have reached approximately
150 000 Euros. Others might be lucky enough to rely on
a rich grandfather, who can afford to buy them any (spe-
cialist) treat ment here or there. An Arabian father paid a
foreign (expert) surgeon a fortune of money to fix his
little daughter ’s fracture properly. However, the surgeon
failed and the father gets advice to have another surgery
on her. Standi ng rig ht in t he co nsul tatio n ro o m, he cal led
her primary surgeon on his mobile and shouted at him,
before his daughter finally get her fracture revision ac-
cording to the standard Swiss health care tariffs with a
good final result.
2.2. Rehabilitation
After every treatment rehabilitation should follow in
due course. But rehabilitation is always expensive, very
time consuming, needs a lot of patience, motivation and
a special team of experts in a well prepared setting. And
in contrast to their beautiful and relaxing landscape, re-
habilitatio n facilities in the III˚ Wor ld Countr ies are usu-
ally less well equipped and staffed. Handicapped chil-
dren and their future perspectives are called “less im-
portant”, and the active support during the rehabilitation
process, by classmates or peers, which is seen to be very
motivative in our culture, is more or less unknown, less
common and sometimes nearly impossible according to
their cultural backgrounds. Next to any physical and
psychological rehabilitation process, educational reha-
bilitation is of utmost importance either here or there.
But go ing to school for childr en in a II I˚ World Country
is very expensive, a nd when going to school, these chil-
dren are definitely “lost” for the all day work load of
their families. And la st but not le ast, there is nothi ng like
a carer work-off leave for parents of sick children like
there is in the I˚ World social syste ms.
2.3. Socialization and Integration
Integration versus separation is the burning headline
in the constantly ongoing socialization and integration
process. First of all, you have to consider that you are
the “stranger”, who have to form and lead your profes-
sional team with high intercultural respect. And you are
the one who is responsible to build up a “family-like”
environment, where both the carers and patients can live
in comfortable and survive. From our point of view it is
also essential for our little patients to build up a/their
“big family” here and there to avoid “home sick feeling”
and loneliness as much as possible. And to give the at
home waiting parents, worrying all day about their be-
loved child, a strong support by knowing that there is an
“adopted” mother caring for their beloved child overseas,
temporarily. In addition, it is essential that the older
children learn how to build up new transcultural friend-
ships, either lasting short or long term, and that they
learn how get their self-confidence and self-esteem back
after years of being “called names” and teased at their
homes because of their handicaps.
2.4. Culture
Culture is the most difficult and colourful term to ad-
dress with the doctor-patient-parent triangle relationship
to start. Ranging from the high impact the traditional
healer has the different pre- and postoperative counsel-
ling mode o f the p arent s to your p ersiste nt hi gh re cogni-
tion as “the doctor”. Second, the tasks that had to be
done by the relatives for the patient and not b y the health
care per s onnel like in our I˚ World facilities. Sex and
gender is rated completely different among the cultures.
In Germany for example, everybody is eagerly interested
prenatall y, if it will be a girl or a boy. It is even standa rd
in every obstetrical department to do sex determination
and present colourful 3 D sonograms to the designated
parents. While in co ntrast in I ndia, it i s strict l y forbid den
by national law to do any sex determination before b irth
at all. A puberty-related case comes out of an interdisci-
plinary child protection group appointment. A teenage
girl originating from India but living in Switzerland
since birth accused her father of child abuse on her. Fi-
nall y, this was no t tr ue. She j ust d id it , be ca use her father
didn’t allow her to get out late in the e vening. Neverthe-
less, this caused major trouble, namely the arrest of her
father in prison for several weeks. While staying for
training in ho te l service a broad two teenager s originating
from the Far Eastern World have a love affair. A baby
with a huge myomeningocele was born. None have any
financial or family back up, neither here nor there. The
only thing they got were reproaches of the parents and
relatives from overseas, because they were belonging to
different casts and their next of kin have been informed
only partially by the teenagers to avoid banishing. Sur-
gical performance was more or less easy, compared to
the efforts that have to be undertaken by the child pro-
tection group. Finally, the teenage parents could accept

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their relationship in the European setting and their baby
here and no w. They wer e a b le t o t hi nk t ho ro ug h f ul ab o ut
adoption of the child by a spe c ia liz e d Swiss institution to
avoid further culture-cast problems and harms between
their families and countries. In Nepals, it is tradition to
hang up your sick babies over the warming fire to cure
them. It is less recognized that the hemp rope burns
through and the b aby will fall directly into the op en fire.
A fortnight after their burn injury two severely burned
babies were found by accident during a consultant ward
round during a surgical mission in a terrible condition
covered solely by the pashimas of their mothers. Every-
thing possible was done and everything available in-
vested to save these babies lives, but all failed. Well
trained in crisis counselling, feeling very sad ourselves,
we have to learn that grieving and mourning is very
much different in these families. Father and mother were
not trying to support themselves, in contrary they were
punishing each other many times after receiving this
horr o rful me s sa ge. And the y do ( have to ) d i ffere n tiate, i f
the passed a way is a girl or a boy. Finall y, their tr adition
says, that the dead body has to be transported home in
the rear baggage compartment of a taxi with the relatives
walki ng ne ar b y. This taxi rid e alone means the fi nancial
ruin for the next generations of this family, not even
been thinking about pa yme nt of the hospital bill.
2.5. Management and Logistics
After receiving a child’s emergency call in a I˚ World
Country, the management and logistic system is able to
respond quickly by sending a rescue team, even an am-
bulance jet if needed, 24 h/365 d, with highly educated
and well trained staff. The situation in the III˚ World
Country might engage high motivated people, too, but
they will have to deal with different (less high tech)
equipment in an uncomfortable set up with only limited
resources. But to handle different on scene and disaster
scenarios properly a well developed emergency medi-
cine infrastructure like in the I˚ World Countries is es-
sential.
2.6. Health Education
Health education and body knowledge and access to
the relevant information is very much different between
the I˚ and III˚ World Countries. In the III˚ World most of
the knowledge is coming from the grandmothers and
their life experience, because there is no basic health
education at school, nor any internet nor any second
medical opinion easily accessible. And, nearly always
the service and professionalism of a translator is needed,
who is without doubt interfering extremely into the vul-
nerable doctor-patient -parent relationship as well. The
opinion and advice of the traditional healer about the
disease or illness is of utmost importance for the III°
Wor ld p atient and a si mple visit to the denti st here, i s the
mysteriously so called “angle’s day” there. Pharmaceu-
tical and blood products or alimentation and nutrition
and their fortification are rated differently in the two
worlds and are prone to different values.
2.7. Language Skills
Language and language skills are essential for any
communication among human beings. Communication
usually is based on the mother tongue. Like in the little
girl with the brain abscess mentioned above. She has just
started to learn her mother tongue, when she and her
family were confronted with a life threatening diagnosis,
a long ter m ICU stay while st ill being in an o ngoing so-
cial integr ation pr ocess. T he ca re for he r sibli ng and go-
ing through an extensive neuro-rehabilitation added to
the language barrier for sure as well. Her mother was t he
only family member able to speak a few words French
forming later the base of communication. Another way
of communication is “with hands and feet” like in the
Angolan girl. All carers expected English to be the lan-
guage of choice, but she was only fluent in Portuguese
or Angolan, which no ne of he r care r was. Finall y, no t to
forget b ody la ngua ge co mmunic ation : Whi le li stenin g to
the Western consultant’s orders, the Nepalese junior
doctor shook his head continuously horizontal like our
“no”. Until we all have learned the lesson that this
means “yes sir” in his culture.
3. DISCUSSION
Starting with a very personal and empathic carer ’s ap-
proach o n these psycho-medical aspects, focusing less on
the medico-surgical tha n mo r e o n the p s ychological ones,
our suggestion would be the interpretation as a “new” Post
Traumatic Stress Disorder (PTSD)-like syndrome. Briefly,
PTSD is an emotional illness that usually develops as a
resul t of a terribly frightening, life-threatening, or oth-
erwise highly unsafe experience to the individual. PTSD
was first described in 1980. At the beginning, only
life-threatening events, severe comprises of the emo-
tional well bein g or causes of intensi ve fear fo r the ind i-
viduum fulfilled the definition criteria. However, today
clinicians have recognized that even patients with an
uneve ntful me dical co urse o f their i njury co uld ex- peri-
ence a PTSD syndrome. Currently, 3 groups of symp-
toms are required to assign the d iagnosi s: 1) night mares,
2) phobias and 3) signs of hyper arousal like sleeping
problems. Treatment options and management include
psychological and medical interventions, mainly
child-adapted psychotherapy.

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To give a common example: A little Swiss girl suf-
fered a severe squeezing injury of her middle finger. Her
surgery was successful and everything healed well. She
has a reliable and trustful rela tionship to her parents and
to her doctor. Not to forget a stable family support with
her b o th p ar ent being professional child carer as nannies.
Everything was based in a well developed health care
system. However, this girl developed a “classical” PTSD
for approximately 3 months.
If such a diagnosis has to be established in the so
called safe environment of a I˚ World Country, how
much more fr equen t and str iki ng this diagno sis mi ght be
among III˚ World Country children and their families.
Victims, who are first injured and traumatized in a much
more unsafe environment, before they second have to
seek for help in a foreign and unfamiliar environment of
the I˚ World. Especially, if all the different cultural
backgrounds, health education and language skills are
taken into consideration. However, to solve this (global)
problem would be essential for survival of any (global)
health ca re system in t he future.
REFERENCE S
[1] Ku rs mat er i al i en: “Fernlehrgang Migranten und
Migrantinnen im Gesundheitswesen”, cekib, Nümberg,
German y.