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Friday, 21 October 2011

Dr Paquita de Zulueta fights for those on the margins of society

Dr Paquita de Zulueta
Paquita de Zulueta has been volunteering at Project:London as a doctor for over two years. She’s helped many vulnerable people who are unable to register with a GP. When she’s not volunteering she works as a locum doctor. She has been a GP for 26 years. 

Paquita is passionate about Project: London and supports Doctors of the World UK’s work in this area. Paquita feels an affinity with immigrants and asylum seekers having lived abroad and met many people from different cultures and backgrounds while she was growing up. Paquita has worked with many asylum seekers in different areas of London during her time as a GP.  

She says she enjoys the challenge that comes from working at Project:London and the feeling that her work makes a big difference.

Here Paquita’s documents her experiences at the clinic which featured in the BMJ in October 2011 in an article entitled: ‘Asylum seekers and undocumented migrants must retain access to primary care’.

"They come singly, or in huddled clusters, subdued, their eyes downcast, their shoulders stooped. They tell us tales of loss, of devastation, of living in the penumbra, always fearful of exposing themselves to bureaucratic scrutiny. They sleep, if lucky, on the sofas of friends or in hostels, otherwise in doorways, on park benches, in churches and bus stations. They are like Dante’s lost souls, shadows wafting in limbo, neither in heaven or hell, but in a cold and lifeless purgatory, a place the world refuses to acknowledge. They tell me their stories, their faces etched with suffering, their eyes reflecting dull despondency or despair. And yet, as I bear witness, I am humbled by their grace, dignity, and endurance.  Somehow they manage to look clean, orderly and well presented. The tell-tale sign may just be the tightly clutched plastic bag. That bag may hold all their possessions, including documents such as a dog-eared letter, years old, from the Home Office blandly reporting information regarding the status of their asylum appeal. Many of them have not sought medical help for several years despite serious medical problems - some brought on by the lives they lead or the trauma they have experienced.
A support worker assists a service user at the clinic
The stories are varied and at times harrowing. A woman flees her village and elopes with a man she has fallen in love with. But he brings her to the UK in order to sell her to other men, not to marry her. He steals her passport, drugs her, and forces her into sexual slavery. Now she is pregnant and too sad to care, yet she cares enough to refuse abortion. A couple have been refused asylum. Local gangs threatened his life and they cannot go back home. The pregnant wife is in the third trimester. A depressed young woman fled the house where she had been enslaved since she was 14 and is forced to sell her body to get some food. A teenager with severe post-traumatic stress disorder has difficulties controlling his anger and is at risk of harming himself or others (he has already made a serious suicide attempt). A woman in her forties has rheumatic heart disease and is breathless with heart failure. These individuals are all in clinical need yet have been unable to access primary healthcare in the UK. Despite pleas to my colleagues to take them on, and even when they undertake to do so, they still turn them away when they arrive on their doorstep. Secondary care, including antenatal care, may be available, but carries the threat of unpayable fees. Do healthcare professionals expect women to deliver their babies in the street? In fact, some women we see have delivered at home without any clinical supervision. What do they think happens to those who are suffering from severe mental health disorders and chronic untreated diseases? Have they at least considered the risks to public health? The litany of misery continues and I take note of the small acts of unkindness and indifference meted out by my peers. But there are shining exceptions, and some GPs do manage to overcome bureaucratic barriers and register patients irrespective of their residential status. 

Paquita seeing a patient in the clinic
I am a general practitioner and work, when time permits, as a clinical volunteer at Project:London, a health advocacy programme set up by Doctors of the World UK in the East End of London. Here I treat those who cannot access primary care. These include those accepted or refused by the asylum system and undocumented migrants. The BMA reminds doctors that there is no requirement to determine someone’s immigration status to access primary care services. The GMC’s Good Medical Practice requires that doctors do not discriminate unfairly, but provide care and treatment to meet the clinical needs of all patients. The Royal College of General Practitioners (RCGP) endorses this:  “Based on the principle that General Practitioners have a duty of care to all people seeking healthcare, the RCGP believes that GPs should not be expected to police access to healthcare and turn people away when they are at their most vulnerable.

When people evince a lack of compassion and callousness, they use various tricks to preserve their self-esteem. One of these is to comply with bureaucratic diktats and elide responsibility for the consequences of ones actions. Another is to dehumanise individuals and view them as dangerous and unworthy of normal human decency. In mitigation, I recognise that some Primary Care Trusts send officious and misleading guidance. Receptionists and practice managers are exhorted to reject individuals who do not present a range of documents such as utility bills and passports – not easy if you are homeless or someone else holds your passport. These impositions carry no valid legal or ethical authority, but some may believe they do.
A Support worker sees a service user

What does the future hold? Finances are tight. Consortia may be more draconian. The government seeks to expand its existing restrictions to free secondary care and include primary care. This does not augur well for the vulnerable and dispossessed in need of humane clinical care – particularly as compassion appears to be a dwindling resource in modern medicine. "

This article was originally published 18/10/11 on the BMJ blog at

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