Healthcare in the Asylum
January 6, 2009 by Webmaster
By Justin Healy
It is a peculiar feeling watching the steady stream of people walk through the door. It is a constant procession of anxious young families, smiling elderly men, and bored young women. Children sit quietly while their mothers talk quickly. Some stay for a cup of tea while others hurry away. It is a peculiar feeling hearing stories of midnight flights and dawn arrivals.
These are asylum seekers who have come to a charitable organisation for support as they tentatively trace a path through the asylum process. The people here are often misunderstood, often maligned and often desperate.
Almost every physician will at some point come in contact with asylum seekers as patients. We will briefly peer into their world from the warm safety of a medical consultation. However the evidence suggests that all too often the meeting will be an awkward one for both doctor and patient.(1) The doctor may grow frustrated at the impenetrable language barrier while the medical history may be convoluted and peppered with vital gaps. Meanwhile the patient may feel that the doctor didn’t understand what was wrong and that they focussed too much on the unimportant problems. The consultation may end in weariness and dissatisfaction: the patient walks dimly back out into a world still clouded by depression; the doctor frustrated at the lack of resources and the prospect of a clinic now running fifty minutes late.
There are elements of this picture which may never be resolved. Interpreting services are thinly stretched and there is often little opportunity in a modern medical setting to fully explore the nuances of an individual’s story. However, a degree of understanding about the realities asylum seekers face and an insight into their own unique health problems may reduce the frustration and lead to a better standard of care.
This article does therefore not intend to make a judgment on asylum. To do so would be near impossible such is the political complexity surrounding the asylum system. This article aims to ensure that flicker of time that the medical profession comes into contact with asylum seekers does not occur in an atmosphere of wary suspicion but rather one of understanding and a willingness to work together despite difficult situations.
Asylum: The Facts
Asylum seekers can be found in almost every country on Earth and the right to asylum is enshrined as a fundamental human right:
“Everyone has the right to seek and to enjoy in other countries asylum from persecution.” - Article 14, Universal Declaration of Human Rights
By the end of 2007 there were estimated to be 11.4 million refugees across the world. There is a commonly held belief that these refugees from predominantly poorer parts of the world flock to the wealthy industrialised nations with their generous welfare systems and liberal democracies. In fact most refugees flee to neighbouring countries which often lack the resources or capacity to adequately care for them. For example, the UK is host to 2.5% of the world’s refugees while Pakistan is host to 17%.(2)
Asylum seekers are often viewed with a disproportionate level of suspicion and distrust by their host country. There are misconceptions that asylum seekers put an unfair strain on public services, get preferential benefits and are responsible for unemployment. Research indicates that these misconceptions often arise from an imbalanced media and weak political leadership.(3) The fact is that in many countries across the world, the life of an asylum seeker is harsh and often unfair.
In the United Kingdom for example, an asylum seeker is barred from working for an independent income during their application, rather they are obliged to live on benefits which are set at just two-thirds of what a British unemployed citizen is entitled to. They have no choice about their accommodation and when provided it is often of a poor quality in an area with little social support. Asylum seekers, educated professionals ones, can live in relative poverty through no fault of their own. Indeed, a 2008 review by the Independent Asylum Commission found that the treatment of asylum seekers in the UK falls ‘seriously below the standards expected of a humane and civilised society’.(4)
Asylum seekers are a vulnerable and transient population, caught in an almost unique moment in time with their entire future hanging upon a single decision. The often uncomfortable realities of their social situation must be taken into consideration when considering a medical management plan.
Asylum and Medical Problems
A fundamental fact to be aware of when discussing the health of asylum seekers is that they often arrive in a country in relatively good health but this health then deteriorates in the years following arrival.(5) Their health needs are predominantly related to the poverty and overcrowding that they experience once in the asylum system.
Common medical problems associated with asylum seekers: (5)(6)
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In addition to the factors they face on arrival, asylum seekers are by definition fleeing from an unstable and dangerous situation. They may be victims of rape, assault or torture. They may come from nations that do not have extensive health care systems and so may have chronic conditions that have been ignored for years, or immune systems that have not be bolstered by childhood vaccinations. Asylum seekers are therefore a population with pre-existing medical risk factors and these are exacerbated by a poor social situation.These health problems are often compounded by the fact that asylum seekers are poor users of health services. The rules governing asylum seeker’s access to healthcare are in a well-publicised state of flux and, although asylum seekers are entitled to free primary and secondary care, they are often unsure of their rights.(7)(8) Indeed, some asylum seekers actively avoid using health services for fear it might negatively impact upon their asylum application.(9) Many physicians are also wary about taking on asylum seekers as patients, feeling that the investment needed in for their care is so large that the care of other patients may be compromised.(10) Recent efforts by the government to charge failed asylum seekers for NHS care has further confused matters, leading to many physicians and asylum seekers now being unsure about what services asylum seekers are entitled to.
When managing asylum seekers, there should be a high level of suspicion for dangerous infectious diseases. Conditions such as HIV, tuberculosis and hepatitis can immediately threaten an individual’s health and also the wider community. It is important that the patient is fully engaged with the health system due to the nature of these communicable diseases.
Asylum and Mental Health
The refugee experience has been described as a ‘cultural bereavement’.(11) A refugee has lost their social cornerstones: their language, attitudes, values and social structures have all been suddenly uprooted. When this is compounded by traumatic personal stories and an immigration system that denies an independent income and permits arbitrary detention, it is perhaps not surprising that two thirds of asylum seekers experience symptoms of depression and anxiety.(12)
The importance of an asylum seeker’s social situation in terms of developing mental illness cannot be overlooked. Indeed, a study suggested that the social factors Iraqi refugees experienced in the UK were better predictors for the development of mental illness than the trauma in their past.(13) A recurring theme in the psychological health of asylum seekers is that of the isolation and exclusion of families and individuals as they find themselves on the hazy margins of society. They often lack friendship groups or know people who have similar backgrounds and experiences. They find themselves disempowered and disenfranchised. Fathers can no longer provide effectively for their families while often poorly educated women and children must now adapt to the values of an alien culture. It is this social instability and loss of cultural landmarks that is commonly cited as factors for developing mental illness.(5) (6)
Symptoms associated with psychological unease in asylum seekers: (5)
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However, though the problems that emerge may relate to conditions of anxiety, depression or post-traumatic stress disorder, it is important to recognise the cultural differences in dealing with mental health.(14) Mental illness can be very culturally specific, with different backgrounds having different approaches to problems. Our own Western approach of counselling and talking-therapies may not work for patients who feel uncomfortable discussing psychological issues. While it is important to address these problems should they arise, it should be done in a culturally sensitive way.(15) In addition, patients may not present with mental distress in the typical way. The evidence suggests high levels of somatisation, arising as complaints of vague physical symptoms, masking underlying psychological problems.(16)
Asylum: What the Doctor Should Know
The original asylum seekers were medieval fugitives, cowering in the sacred sanctuary of places of worship. National boundaries and immigration officials have replaced the old church walls and solemn priests but the duty to guarantee protection remains the same. The difficulty today is that it is not enough to merely escape the pursuers. Gaining entry into the sanctuary is a long and arduous process and one that may in fact threaten the refugee’s health
A physician’s first responsibility when faced with an asylum seeker as a patient is to care for their physical and mental health. It is important to be aware of the infectious diseases, the poorly managed chronic conditions and the assorted psychiatric problems that this population commonly experience. Language and cultural barriers may make the conventional history taking and examination difficult, so it is important to have a high level of suspicion when it comes to these conditions. The social problems that asylum seekers experience will only be exacerbated by ill health and it is the doctor’s role to spot the medical problem in front of them.
Some of the social stressors and psychological tensions that asylum seekers experience may not be straightforward to resolve. It may not be possible for a doctor to ease a father’s anxiety about providing for his family or a mother’s worry about her child’s education. These are problems which cannot be solved by a single doctor in a single consultation. However, doctors can begin to ease to ease the burden and start to reach beyond the diagnosis and management of physical ailments.
A medical consultation can be seen as a gateway to services that can ease the psychosocial pressures on an individual. If a physician is aware of local refugee support groups or advocacy projects they can ease the feeling of abandonment and loneliness that asylum seekers often suffer. A physician can contact social workers if they suspect a patient is falling through cracks in the system. Perhaps most importantly, a physician can make asylum seekers aware that the health services are there if needed. It is in a medical consultation that a doctor can spot an individual falling away into isolation and it is in a medical consultation that a doctor can start to bring them back into society.
Simply put, it may not always be possible to truly understand or even fully support an asylum seeker who has witnessed the very worst side of mankind. The least a physician, or indeed anyone, can do is show them the humanity they have come in search of.
Justin Healy is a 4th year medical student at the University of Manchester, UK.
The author would like to thank Mick Sykes from REACHE in Manchester for all his help with this article.
(1) British Medical Association. Meeting the healthcare needs of refugees and asylum seekers - a survey of general practitioners. 2004. http://www.bma.org.uk/ap.nsf/Content/asylum?OpenDocument&login&Highlight=2,asylum (Accessed 15/09/08)
(2) UNHCR. 2007 Trends: Refugees, Asylum Seekers, Returnees, Internally Displaced and Stateless Persons. http://www.unhcr.org/statistics/STATISTICS/4852366f2.pdf (Accessed 20/10/08)
(3) Lewis M. Asylum: Understanding Public Attitudes. Institute for Public Policy Research Publication. 2005
(4) Independent Asylum Commission Interim Report. Fit For Purpose Yet? 2008. p2
(5) British Medical Association. Asylum Seekers: Meeting their Healthcare Needs. 2002. http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFAsylumseekers/$FILE/Asylumseekers.pdf (Accessed 15/09/08)
(6) Clinical Effectiveness Group at Barts. Working with Refugee and Asylum Seekers in Primary Care
http://www.ihse.qmul.ac.uk/chs/development/ceg/guidelines/docs/Refugees%20&%20Asylum%20Seekers.pdf (Accessed 20/10/08)
(7) Cassidy J. Free for all? BMJ 2008;337:a1111
(8) Social Care Institute for Excellence. The Social Care Needs of Refugees and Asylum Seekers. http://www.scie.org.uk/publications/raceequalitydiscussionpapers/redp02.asp (Accessed 20/10/08)
(9) Independent Asylum Commission Interim Report. Fit For Purpose Yet? 2008. p74
(10) British Medical Association. Meeting the healthcare needs of refugees and asylum seekers - a survey of general practitioners. 2004. http://www.bma.org.uk/ap.nsf/Content/asylum?OpenDocument&login&Highlight=2,asylum (Accessed 15/09/08)
(11) Eisenbruch M. From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Soc Sci Med 1991;33(6):673-80.
(12) Burnett A, Peel M. Asylum seekers and refugees in Britain: Health needs of asylum seekers and refugees. BMJ 2001;322:544-547
(13) Gorst-Unsworth C, Goldenberg E. Psychological sequelae of torture and organised violence suffered by refugees from Iraq. Trauma-related factors compared with social factors in exile. BJPsych 1998;172: 90-94
(14) Bracken P, Giller J & Summerfield D. Psychosocial responses to war and atrocity: the limitations of current concepts, Soc Sci Med, 1995:40:1073-1082
(15) British Medical Association. Asylum Seekers: Meeting their Healthcare Needs. 2002. http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFAsylumseekers/$FILE/Asylumseekers.pdf (Accessed 15/09/08)
(16) Lin EH, Carter WB, Kleinman AM. An exploration of somatization among Asian refugees and immigrants in primary care. AmJPH 1985;75: 1080-1084
Source : The Lancet Student
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