Forensic and Health Challenges of Refugees in Turkish Emergency Departments: A Retrospective Analysis

Introduction

The ongoing refugee crisis is one of the most pressing humanitarian challenges currently facing the global community. As of 2023, the United Nations High Commissioner for Refugees (UNHCR) has reported that over 35.3 million refugees have been displaced worldwide, fleeing war, persecution, and human rights violations [1]. In the context of Turkey, refugees are individuals who have been forced to flee their home countries due to conflict, persecution, or violations of human rights and have sought protection in Turkey [2]. Unlike tourists or residents, refugees often lack legal status, stable living conditions, and access to resources comparable to the local population. This distinction is critical for accurately understanding their unique challenges and needs [1,2]. Turkey is currently the country with the largest refugee population globally, with approximately 3.3 million refugees under temporary protection, primarily from Syria [1]. This significant influx has placed considerable demands on the healthcare system, particularly emergency departments, which often serve as the primary point of care for refugees facing acute medical and forensic challenges [1,2].

Refugees frequently encounter intricate health and social challenges as a consequence of the violence, trauma, and inadequate living conditions to which they are subjected during their period of displacement. These vulnerabilities give rise to a range of health issues that are frequently observed in emergency departments [2]. These include infectious diseases, including respiratory and gastrointestinal infections, which are exacerbated by poor sanitation and overcrowded conditions [1,2]. Chronic diseases such as diabetes and hypertension are also prevalent and are often exacerbated during displacement and by inconsistent access to medical care in host countries [3].

Mental health disorders are a significant concern among refugees. The prevalence of post-traumatic stress disorder (PTSD), depression, and anxiety is a testament to the profound psychological impact of forced migration and the associated challenges of resettlement [2,3]. The provision of mental health care in EDs is particularly challenging due to the presence of cultural and linguistic barriers, as well as the acute nature of emergency care settings [4].

In addition to medical issues, forensic cases are frequently encountered among refugee populations presenting to EDs. Such injuries may be the result of interpersonal violence, assault, or domestic violence, and may be associated with the traumatic experiences associated with displacement and resettlement [5]. Refugee women and children are particularly susceptible to gender-based violence and human trafficking, which further complicates their healthcare needs [6]. The identification, documentation, and management of forensic cases in emergency departments necessitate the application of specialized knowledge and resources, which are frequently constrained [5,6].

The lack of access to healthcare services is an additional obstacle for refugees in Turkey, further exacerbating the challenges they face. The presence of language barriers, cultural stigmas, and limited awareness of available healthcare services impedes the timely diagnosis and treatment of medical conditions [1]. In Turkey, the healthcare system predominantly operates under the General Health Insurance (GHI) scheme, which is administered by the Social Security Institution (SGK). This system ensures that the majority of medical expenses for Turkish citizens and registered refugees are covered, reducing the financial burden on patients [2,3]. However, for specific services not covered by the GHI or for uninsured individuals, costs may be borne out-of-pocket or through private funding [1,3,4]. Furthermore, the high patient volume in emergency departments, driven by the large refugee population, places considerable strain on healthcare resources and affects the quality of care for all patients [7].

The objective of this retrospective study was to provide a comprehensive overview of the forensic cases and medical challenges faced by refugee patients in Turkey’s largest hospital. By identifying the clinical and forensic characteristics of this patient population, the study aims to contribute to the growing body of knowledge on refugee health in emergency settings. This will enable the development of strategies to enhance emergency care delivery and inform decision-making on the unique healthcare needs of this patient group. Therefore, this retrospective study aimed to evaluate the demographic and clinical findings in 5729 refugees presenting to a major emergency department in Turkey during 2023.

Material And Methods

PATIENT COHORT:

This retrospective study was conducted at Ankara Bilkent City Hospital, analyzing the records of refugee patients who presented to the ED between January 1, 2023, and January 1, 2024. All patient data were retrieved from the hospital’s electronic medical records system. The study was conducted in accordance with the ethical standards of the Helsinki Declaration and was approved by the Ankara Bilkent City Hospital Ethics Committee (Approval No: E2-23-3910).

Demographic characteristics, clinical presentations, and outcomes were systematically reviewed. The key variables included age, gender, nationality, and the primary complaints that resulted in emergency department visits. Furthermore, the presence of pre-existing chronic diseases was documented to evaluate the prevalence of comorbid conditions among refugee patients.

To evaluate healthcare utilization and patient outcomes, the following data were collected: discharge rates were calculated, representing the number of patients treated and subsequently released from the emergency department, rates of hospital admission (indicating cases requiring inpatient care), intensive care unit admission rates, and mortality rates, and billing records were also consulted to evaluate the financial implications of the healthcare services provided, as detailed in the charges issued by the hospital for each patient’s care.

In our study, patients’ clinical presentations were categorized into 2 main groups: internal medical cases (non-accidental injuries) and medicolegal cases (accidental injuries). Internal medical cases included various non-traumatic conditions requiring emergency intervention. Medicolegal cases, representing accidental injuries, encompassed a range of trauma-related presentations, including simple falls, firearm injuries/assaults, non-vehicular traffic accidents, falls from height, and cases of abuse. These classifications helped differentiate between medical and legal considerations in emergency care, providing insight into the diverse spectrum of injuries encountered in the emergency department. The analysis included all patients aged 18 years and older with valid records. Patients with missing or incomplete data were excluded.

STATISTICAL ANALYSIS:

The study data were analyzed using the IBM SPSS Statistics for Windows, Version 22.0 (Armonk, NY: IBM Corp.) software package. The Kolmogorov-Smirnov test was employed to ascertain the normality of the distribution of the study data. In the case of normally distributed study data, the mean±standard deviation was reported, whereas non-normally distributed study data was reported as median (min–max). Non-normally distributed quantitative data were compared using the Mann-Whitney U test, while normally distributed quantitative data were compared using the independent samples t-test. A p-value of less than 0.05 was considered statistically significant.

Results

CLINICAL PRESENTATIONS AND PATIENT CHARACTERISTICS:

Among all refugee patients, 4230 (73%) presented with internal medical conditions, while 1498 (27%) were classified as medicolegal cases. The most common medicolegal causes were simple falls (896, 59.8%), firearm injuries and assaults (342, 22.8%), non-vehicular traffic accidents (148, 9.8%), falls from height (59, 3.9%), abuse (52, 3.4%), and suicide attempts (23, 1.5%). A total of 1040 patients (18%) had chronic diseases, yet only 103 patients (1.7%) were under regular physician follow-up (Table 2).

OUTCOMES FOR PATIENTS:

Most patients (n=4584, 80%) were discharged from the emergency department following treatment. A total of 488 patients (8.5%) required hospitalization, including 286 (5%) who required ICU admission. Ten patients (0.1%) were transferred to other healthcare facilities due to the unavailability of beds. A total of 353 patients (6%) were discharged from the emergency department without having completed their treatment, and 7 patients (0.1%) died during their stay in the emergency department (Table 3).

NATIONALITY DISTRIBUTION:

The largest group of refugee patients were Syrian nationals (2238, 39%), followed by Iraqis (1319, 23%), Afghans (1013, 17.6%), Iranians (247, 4.3%), and individuals from other nationalities (912, 16%) (Table 3).

FINANCIAL IMPLICATIONS:

The aggregate hospital billing for refugee patients during the study period was $326 800 000 USD. Billing for medicolegal cases amounted to $122 900 000 USD, while internal medical conditions accounted for $203 900 000 USD (p=0.02) (Table 4).

STATISTICAL SIGNIFICANCE:

A comparative analysis of the demographic and clinical characteristics of the 2 case categories (medicolegal and internal medical) revealed no statistically significant differences in age or gender distribution (P>0.05). Subsequent analysis of outcomes, including discharge rates, hospitalization rates, and ICU admission rates, also demonstrated no statistically significant variation between patient subgroups (P>0.05).

Discussion

LIMITATIONS:

A limitation of our study is that it was conducted retrospectively, which may have resulted in incomplete data. Our study used on descriptive data from hospital records, and the lack of advanced statistical analyses to compare different patient groups or conduct national-level comparisons is acknowledged as a significant limitation. Furthermore, the study was conducted at a single center, which limits the generalizability of our findings.

Conclusions

This study underscores the complex interplay of medical, forensic, and financial challenges in refugee healthcare, emphasizing the critical role of EDs in managing these issues. To address these challenges, a unified approach is necessary, involving collaboration between policymakers, healthcare providers, and international organizations. It would be beneficial for future research to concentrate on longitudinal studies, with the aim of evaluating the long-term health outcomes of refugees and the effectiveness of targeted interventions.