Evidence-based practice in the Calais refugee camp

DPhil student Jack O’Sullivan spent the Easter break providing first aid care to the 6000 refugees of Calais, France with other Oxford students, medical volunteers and the charity Care4Calais. Jack shares his reflections below.

Reblogged from the Centre for Evidence-Based Medicine.

“More cough syrup please”

With incessant, spluttering coughs, one cannot blame the refugees of Calais requesting one of the only treatments available to them. Aided by Farsi, Arabic, Urdu and Pashto translators and 13 other first aid volunteers, I spent the Easter break providing first aid care to the 6000 refugees of Calais, France. This northern port has served as a makeshift home to refugees since 1999, most of which are hoping to make the United Kingdom their home.

Within the camp, myself and other volunteers provided first aid out of three small caravans. Our typical care pathway was: triage by a first aid volunteer and translator followed by further assessment and treatment in one of the three caravans (again by a first aid volunteer and translator). Largely, we provided care to men, who the camp is mainly made up of, presenting with a variety of symptoms. Overwhelmingly, however, we treated patients with wounds, respiratory tract infections and scabies. Given the paucity of resources, all three conditions presented numerous therapeutic challenges. For me, the outstanding challenge was providing evidence-based care.

In more developed settings, adult patients with a cough are rarely offered syrup to improve their symptoms. This is largely because there is no evidence to suggest cough syrup improves a patient’s symptoms. A recent Cochrane reviewconcluded ‘there is no good evidence for or against the effectiveness of (over the counter) OTC medicines in acute cough’(1). As such, I felt somewhat reluctant providing cough syrup to these Calais refugees. As trivial as OTC syrups may appear, they can cause nausea, vomiting, headache and drowsiness(1). Burdened by this knowledge, it was difficult for me to ignore my binding medical principle: primum non nocere (first, do no harm).

My reflections on non-maleficent care led me to a fundamental principle of evidence-based practice. External validityrefers to the appropriateness by which a study’s results can be applied to your individual patient or patients. 18 primary studies (of adults) were synthesised in the Cochrane review: ‘Over-the-counter (OTC) medications for acute cough in children and adults in community settings’(1). Of these, eight were based in the USA, five in the UK, two in India, one in Germany, one in South Africa and one in Finland. None were set in refugee settings within these countries.

Although many would assume evidence-based medicine can only be practiced with high quality evidence, in fact, despite the lack of the highest quality of evidence, we were providing evidence-based care in the Calais refugee camp.
Jack O'Sullivan

This is important because I was looking after patients that were living in makeshift tents, in close proximity to numerous other sick people, had unknown vaccination histories and had (largely) never lived in any of the above countries. The evidence synthesised in the aforementioned Cochrane review related to patients very different to those in Calais. Thus, the evidence supporting my reluctance to offer cough syrup was not valid for my patients. In fact, for my clinical question (PICO: For adults living in a refugee camp presenting with an acute cough does cough syrup improve cough symptoms?) no evidence exists.

Although many would assume evidence-based medicine can only be practiced with high quality evidence, in fact, despite the lack of the highest quality of evidence, we were providing evidence-based care in the Calais refugee camp.

A fundamental principle of evidence-based practice is applying the highest quality evidence available to you, discussing this with your patient and reaching a shared decision. Given the complete lack of evidence addressing my clinical question, the highest quality evidence available to me was anecdotal: my own accumulating experience in the Calais refugee camp. During my time in Calais, we treated a large number of refugee patients re-presenting requesting cough syrup, most had been given it before and most described a therapeutic effect. Most significantly, they found it stopped their cough waking them through the night. The large majority had taken this cough syrup without complication and with therapeutic effect. Via the translator they understood the risk of side effects and, most importantly, wanted to take the cough syrup.

Although purist purveyors would appropriately argue that the level of evidence we were basing our suggestions on is weak, we practised all the principles of evidence-based practice. We identified and appraised the highest quality of evidence available, objectively presented it to the patient and collectively make a treatment decision, taking into account the individual lifestyle and preferences of our individual patient.

Thus, I have an answer to my clinical question: according to the highest quality of evidence available: cough syrup does improve symptoms for adult patients presenting with an acute cough in a refugee camp.

Although I would like to test this as a randomised controlled trial!

See the news report from BBC South Today documenting Jack’s trip.