challenge + transformation

healthcare for forced migrants

Andy Lephard asks us to take another look at those who have experienced forced migration and how we care for their physical and mental health.

In a world where migrants face a narrative of blame and dehumanisation, Jesus’ kingdom challenges us to serve with a radically different perspective. When we do, it is transformational.

‘Doctor, this is Susan; she is suicidal.’ Susan had left a war-torn East African country to work for a Saudi household, but entered a life of domestic servitude and sexual abuse. Accompanying the family on a trip to the UK, she had fled. But her asylum claim was not accepted, nor was her appeal. She suffered destitution and further sexual assault whilst homeless. Lately, whilst temporarily housed, she was unexpectedly detained and threatened with deportation. Her solicitor intervened, but now, terrified of further detention, she can see no other option than to end her life.

I’m a GP in inclusion health. Most of my patients are forced migrants; they have left their country due to force or obligation..1,2 Some are seeking asylum in the UK under the Geneva Convention. Others have been granted asylum and are now refugees; others have come via refugee schemes or family reunification, and still others are victims of human trafficking. They come from Iraq, Iran, Afghanistan, Sudan, Syria, Eritrea, Pakistan, Vietnam, Somalia and at least 60 other countries. They speak over 70 different languages. They have made perilous journeys driven by persecution, hardship and catastrophes and inspired by hope. Their stories are windows on human brutality. But their stories are not yet finished.

It still amazes me to be entrusted with such extraordinary stories of trauma and survival. On this holy ground, we are given the opportunity to walk alongside people with the kindness, humanity and dignity of Jesus’ kingdom as it disrupts the world’s story of fear, racism, and ambivalence.

whose problem, whose neighbour?

Having survived great hostility, forced migrants arriving in the UK must face more. ‘You are a big problem for us’ say our media and politicians. This is the dominant narrative, and it is rarely challenged. But why?

‘Because you are too many to cope with…’ Yet the UK, as the world’s sixth largest economy, hosts under one per cent of the world’s refugees. People seeking asylum represent a very small proportion of overall UK immigration (seven per cent in 2023). 3

‘Because you cheat our system…’ Yet, the high proportion of positive asylum decisions (66 per cent from 2018-2020) suggests otherwise. 4

‘Because we cannot afford you…’ Yet asylum support costs increased during a period of deliberate inattention to the asylum system, during which we instead strove to create a ‘hostile environment’. This deterrent failed to reduce arrivals but harmed the mental and physical health of countless individuals. 5,6 The neglected system accumulated a huge backlog of cases, keeping people stripped of dignity and agency on asylum benefits, out of work, and massively increasing dependence on contingency hotel accommodation.

‘Because you are illegal…’ Much recent attention has been on arrivals via small boats across the English Channel and the facilitating role of people smugglers. 7 Whilst considering every drowning to be a tragedy, this narrative tells forced migrants that their successful crossing was a travesty. This, despite our failure to sustain, let alone increase, numbers arriving in the UK via safer managed migration schemes.

Why, in our national discourse, do we not hear more about the problems of forced migration from the perspective of forced migrants themselves? We rarely listen to their voices explaining what drives such desperate journeys or of the psychological impact of multiple traumas and ongoing loss. But perhaps that is to be expected. As UK citizens, can we really be responsible for the plight of those fleeing dangers elsewhere? Should we not prioritise our limited resources on our own problems: our own families and our local communities? Otherwise, how could we ever define whose problems we are responsible for? Where should we draw the line if not at our national borders?

That was a question thoughtfully asked of Jesus. ‘And who is my neighbour?’ It was a very practical question with an unstated corollary: To keep the law of Moses, who are the people I must love as myself? And, given my limited resources, who might I consider somebody else’s responsibility? Jesus’ surprising and transformational answer is a story that invites us beyond theory and into action. 8 I am mugged, beaten, and left for dead. I awake in an inn, head throbbing but still alive. Bandaged, sutured, in bed, even. And, I am told, the man who brought me here at his own risk and expense is a foreigner. All my life I have looked down on his culture, despised his compromised politics and distorted religion. I have avoided and distrusted his people. Yet, when days later he enters the room, smiles and introduces himself, my whole worldview has been changed. This man has saved my life. His act of sacrifice for me has evaporated all enmity, strangeness, fear, and mistrust between us. For as long as we both live, we will be friends. We will be neighbours.

In loving a stranger as ourselves, we somehow both become more whole and more human, as Jesus’ Kingdom takes back territory from a world of dehumanising tribalism. We all experience this personally in many contexts. But here are some ways in which providing healthcare to forced migrants has been both challenging and transformational for me.

communication

Omar has booked a telephone consultation for back pain. I wait ten minutes for a telephone interpreter, then, frustratingly, Omar doesn’t answer. Later, he picks up. ‘I was collecting my daughter from school’, he explains. ‘I need an interpreter. My English is not adequate.’ It sounds adequate to me and I’m running behind, so I suggest we try it in English. That goes well until our safety-net discussion on saddle anaesthesia and incontinence. ‘I don’t understand doctor. Here, speak to my daughter.’

Good communication is fundamental. It is also complex and extremely challenging. Whether in the room or on the phone, we (patient, relatives, interpreter, and I) each bring our life experience, cultural expectations, emotions, and language ability. I frequently underestimate the impact of that. But reassurances about confidentiality, remaining patient, and keeping everyone focused are invaluable. Inevitably, we will still misunderstand one another. It is easy to misinterpret intensity as anger or respectful deference as agreement with my plan. I have found humour to be essential and humility indispensable.

person-centred care

I am seeing Mustafa to review his cardiovascular disease. At least that is my plan. We’re both worried he can’t manage two flights of stairs without his angina spray. But Mustafa’s solution is a letter from me requesting a ground-floor flat. He doesn’t believe me that it will carry little weight. He isn’t aware he missed two cardiology appointments last month and so was discharged. He will adjust his tablets if I think it will help but quitting smoking? He smiles and shakes his head. Life is far too stressful for that.

Healthcare for forced migrants requires a radically patient-centred approach. That doesn’t come naturally to me! I prefer it when patients bring medical problems I was trained to fix and then engage with my advice. That feels efficient and affirming. But my patients’ agendas rarely match my own. This is my crucible. In our shared frustration, patients slowly teach me that to serve them well, I must adapt to their perspective. I try to imagine leaving a beloved country and family. A bitter journey and a seemingly endless wait to rebuild my life in a bewildering place.

From this perspective, health services often appear designed around providers rather than patients. Opt-in and missed appointment policies can increase inequalities for transient populations who also struggle with transport costs and English literacy. So can the increased digitalisation of consultations, appointments, and records, which has not yet tapped the enormous potential of embedded interpretation. The charging of ‘non-ordinarily resident’ patients, including refused asylum seekers, for some services causes additional unintended delays for other migrants who are required to prove their entitlement to care and who can misunderstand regulations. 9

My clinical skills must often play second fiddle to advocacy, perseverance, and trying to support patient engagement. I am often asked for a medical report or supportive letter. My letters are sometimes useful. At other times I must limit expectations of my influence and take care that information gathered for clinical care is not liable to be misinterpreted by an immigration decision-maker.

Trauma-Informed Care and vicarious trauma

A warning on Farid’s home page tells me he was recently verbally aggressive in the reception. He has chronic pelvic pain and erectile dysfunction. My colleague booked him with me because he wanted to see a male clinician. ‘I need to see the urologist again’ he says. ‘No one is taking me seriously. No one knows what is wrong.’ I can see that he has been referred twice already. Extensive investigations were normal. The urologist noted his history of genital torture and recommended we refer for psychological therapy, which Farid previously declined. Cautiously, I ask Farid if we might discuss what happened to him in prison.

Trauma-Informed Care seeks to create a safe environment that minimises the potential for care to further traumatise. It aims to foster autonomy, empowerment, and trust. 10 Forced migrants have already been required to recount their multiple traumatic events and losses in detail to immigration authorities. Survivors of torture have told me that recounting their story in an unpressured healthcare environment can be greatly helpful, but feeling rushed or pushed for information can do the opposite. Simple grounding techniques and trauma tapping exercises can help people not ready for trauma-focused therapy.

As we listen to stories of brutality and injustice, and support people who are psychologically distressed, the trauma impacts us too. As a younger GP, I often felt helpless and overwhelmed. I have been sustained through the support of colleagues and through reflective practices such as Balint groups. 11 Most essentially of all, prayer – alone, with colleagues, and occasionally with patients – draws me ever deeper into dependence on God.

an asset-based approach

George ran a shipping company. He came to faith in Jesus through Greek sailors and held Bible studies for his staff. He was detained and tortured. Then, due to be executed, a guard helped him escape. Now, knee pain limits his mobility, and nightmares plague his sleep. He tells me, ‘The Holy Spirit keeps me alive’. Sometimes he just weeps. Recently, he has found a church with other Iranian believers. ‘They are young’, he says. ‘I encourage them in their faith. And I pray for you too, doctor.’

In our sorrow and desire to help, we can easily come to view forced migrants exclusively through the lens of loss or unmet need. We can view people simply as victims. Yet many arrive in the UK as highly skilled individuals. Refugee communities are a resource to their own members and beyond. Volunteering opportunities can reduce isolation, increase agency, improve English language, and prepare people for work in the UK, including the many with a background in health care. I am hugely grateful for the skill of occupational therapists and social prescribers in my team who empower people in ways I cannot.

Many of my patients say their faith in God means everything. For some, it is the reason they are here. For others, it is what keeps them going against all the odds. Occasionally, patients ask about my faith. Sometimes, when I explain I follow Jesus, they smile and their whole body seems to relax.

Refugees and Asylum Seekers Health (RASH) course

10 January 2026

CMF office, London, 6 Marshalsea Road SE1 1HL

God calls us to care for the stranger in our midst, to protect orphans and widows, to ‘act justly and love mercy’. (Micah 6:8) Come along to explore how we can do this well. Andy Lephard will also be speaking at the RASH course. Bookings will open soon via cmf.li/RASH26