eMJA: Harris & Telfer, The health needs of asylum seekers living in the community

Asylum seekers and healthcare

The health needs of asylum seekers living in the community

Mark F Harris and Barbara L Telfer

MJA 2001; 175: 589-592

Abstract - Health needs of asylum seekers - Access of asylum seekers to healthcare - Caring for refugee patients - The role of healthcare workers - Competing interests - References - Authors' details Register to be notified of new articles by e-mail - Current contents list - More articles on Social issues

Abstract

Asylum seekers living in the Australian community, and awaiting the outcome of applications for protection visas, may require medical treatment for a range of illnesses, and are likely to have psychological or musculoskeletal problems as a consequence of traumatic experiences in their own countries. Many require specialist treatment.

Some asylum seekers living in the community are denied access to Medicare and can not afford basic medical treatment. This creates suffering in the short term and complications in the long term.

Healthcare professionals have an ethical responsibility to provide basic medical care for asylum seekers in Australia.

Under the offshore component of its Humanitarian Program, Australia offers 4000 places for refugees each year. In addition, Australia offers places under its Special Humanitarian Program for people in refugee-like situations who have links to Australia. There is also provision for granting refugee status to applicants who apply from within Australia (onshore asylum seekers). In total, the program assists 12 000 people per annum.¹

In 1999-2000, the Department of Immigration and Multicultural Affairs (DIMA) received 12 713 applications for refugee status from people onshore.¹ In that year, 2458 onshore asylum seekers were granted protection visas: 1684 of these were granted at the completion of the primary stage of processing (which is handled by a DIMA staff member).¹ More than 70% of those unsuccessful at the primary stage appealed to the Refugee Review Tribunal, but, in 1999-2000, only 679 protection visas were granted after this second stage of processing.¹ The number of protection visas granted as outcomes of successful appeal to the Federal or High Court is not specified on the DIMA website. In the year 1999-2000, 76 protection visas were granted through ministerial discretion, the final stage of appeal.¹ (Because of the time delay involved in the various stages of the visa process these figures do not all apply to the same group of applicants.)

According to DIMA, at 30 June 2000 there were 6500 applications for protection visas at the primary stage and 7828 at the Refugee Review Tribunal stage.¹ With 3622 asylum seekers in mandatory detention at 23 March 2000,² we estimate that there were over 10 000 asylum seekers living in the community in Australia in 1999-2000. While embroiled in the multistage application and appeal process (which can take from three months to over three years) community-based asylum seekers must remain in Australia. During this period, however, many must survive with no right to work, and no Medicare cover, no pharmaceutical benefits and no welfare support.^3,4

Health needs of asylum seekers

Several studies have assessed the health needs of refugees. In the United Kingdom, one in six refugees have a physical health problem severe enough to prevent them from going about their daily life and two-thirds have experienced anxiety or depression.⁵ Not surprisingly, a past history of torture, or the feelings of insecurity experienced by refugees, amplify and extend the duration of their illnesses.⁶ In addition, postmigration factors such as discrimination, lack of social support and unemployment have been identified as major contributors to anxiety and depression in refugees.⁷ Children, in particular, appear to suffer prolonged psychological distress after resettlement.⁸

Some asylum seekers present with the physical sequelae of torture or other violent trauma which may not have received adequate medical attention in their countries of origin. These sequelae include malunited fractures, osteomyelitis, epilepsy or deafness from head injuries, or non-specific musculoskeletal pain or weakness.⁹ In rape victims, in addition to the psychological sequelae of rape, there may be a risk of HIV or other sexually transmitted diseases.

The incidence of infectious and nutritional diseases varies between refugee groups according to their country of origin.¹⁰ The presence of HIV, hepatitis A and B, tuberculosis or immunisable diseases is of major public health concern.¹¹ However, severe parasitic and intestinal infections are also common. Helicobacter pylori infection is particularly common in refugees from developing countries or those who have spent time in refugee camps.¹²

In Sydney, a study in 1994 of 40 asylum seekers attending the Asylum Seekers Centre, a charitable organisation which provides education and support for asylum seekers, suggested that most were suffering from psychological and physical symptoms sufficiently serious to warrant medical assessment.¹³ Thirty reported exposure to premigration trauma, 10 had been subjected to torture, 10 reported gastrointestinal disease, nine musculoskeletal complaints, six gynaecological problems and one had an infectious disease (hepatitis).

Smith has described the similarity between the health of asylum seekers and that of refugees resettled in Australia from overseas.⁴ Their general health problems are complex and compounded by the socioeconomic disadvantage they experience in Australia. Likewise, in the United Kingdom, studies have found that many of the diverse and manifold health needs of asylum seekers overlap with those of "deprived or excluded groups, ethnic minorities or new entrants to the country".¹⁴

Access of asylum seekers to healthcare

UK and Europe

In the United Kingdom, asylum seekers have free access to the National Health Service. They can register with a general practitioner and are exempted from charges for prescriptions and dental and optical care.¹⁵ However, many refugees encounter problems registering with a GP,¹⁶ with GPs' concerns ranging from the demands on their time to communication difficulties.¹⁷ Low consultation rates with primary care doctors have also been reported in Switzerland.¹⁸ Apart from GPs' attitudes, other barriers to healthcare access for asylum seekers in the UK include practitioner inexperience with uncommon and complicated health problems; a lack of relevant cultural, health and health service educational material for both asylum seekers and healthcare staff; language difficulties; misunderstandings; and inadequately resourced interpreter and advocacy services. Importantly, a scarcity of government-funded health services for asylum seekers is overburdening non-governmental and voluntary organisations and community groups.^16,19 In the words of the Chairman of the British Medical Association Medical Ethics Committee:

There has been no real NHS planning for the health needs of asylum seekers . . . No thought has been given to their health needs or the social infrastructure around them and it is possible to see the whole process as an abuse of human rights in itself.²⁰

The outcome of these "system based" shortcomings is "false economy", where many asylum seekers "end up requiring hospitalisation for conditions which could have been easily treated at an earlier stage".²¹

Australia

In Australia, to be eligible for essential medical services through Medicare and the Pharmaceutical Benefits Scheme, asylum seekers with a valid visa must apply for asylum within 45 days of their arrival in Australia. As a result of this "45-day rule" and other governmental restrictions, about 40% of asylum seekers are denied Medicare and work rights.³If they appeal their case to the Refugee Review Tribunal or the courts (as most asylum seekers do who are unsuccessful), these restrictions can persist for many months to years. Asylum seekers experience a greater burden of ill health, lower socioeconomic status and greater problems accessing affordable and appropriate healthcare.^4,13

In exceptional circumstances asylum seekers who are denied Medicare and work rights can receive help from the Asylum Seekers Assistance Scheme (ASAS). ASAS is a Commonwealth Government scheme administered by the Red Cross which provides financial assistance and healthcare to a small proportion of eligible asylum seekers.²² In 2000-2001, the scheme assisted 2641 ASAS-eligible asylum seekers. However, the number of community-based asylum seekers "unable to meet their most basic needs" exceeds the scope of the scheme. For example, in 2000-2001, the Red Cross assisted an additional 1475 asylum seekers who were officially ineligible for the ASAS scheme, but unable to meet their most basic needs (ASAS, National Office of the Red Cross, Melbourne).

The NSW Health Department charges patients who are ineligible for Medicare for inpatient and outpatient care. At a metropolitan referral hospital, these charges are $695 per day for inpatient care and $80 for outpatient care.²³ An assurance of payment is required before treatment is provided (cash, credit card or guarantee from an Australian citizen) (Box 1). When such an assurance of payment is not forthcoming, the patient is to be informed that he or she will receive only the minimum and necessary medical care to stabilise their condition. Persons admitted to a public hospital under ASAS are exempt from paying these fees, but this does not apply to the many asylum seekers who do not qualify for this scheme or fee exemption.

In Australia, there have been few studies of access to healthcare of asylum seekers. In the 1994 study of 40 asylum seekers,¹³ 27 expressed concerns about not obtaining treatment for general health problems over the previous 12 months, with 25 citing lack of access to Medicare as the main reason; 21 reported poor access to emergency care and 19 to long term medical care; and 27 reported difficulty accessing dental care.

Caring for refugee patients

The Victorian Foundation for Survivors of Torture and the West Melbourne Division of General Practice have produced a guide to the care of refugee patients in general practice.²⁴ This emphasises the importance of engaging a professional interpreter and providing adequate education and information to refugee patients, including the cost of prescriptions, investigations and referrals. Key issues to be considered in the assessment include preventive care, chronic conditions for which management may have been delayed or inadequate, dental care, developmental problems, mental health problems, injuries and infectious diseases.

The aims in managing refugee patients who may be survivors of torture or other trauma associated with refugee status are:²⁵

To identify patients who may have experienced torture and/or traumatic experiences.
To understand the context in which torture and refugee trauma may have occurred, and the impact on the individual, family and community.
To assess the physical and mental health problems of torture and refugee trauma survivors.
To work with patients to develop a management plan.
To be aware of and confident in referring patients to appropriate services.
To be aware of the impact of these issues on health professionals.

For many refugee patients who were tortured, the torturing was done by medical practitioners, who were forced to do so by the authorities. Not surprisingly, these patients often find it difficult to trust practitioners, especially when there are also language and cultural barriers.

The role of healthcare workers

Healthcare workers have an ethical responsibility to provide life-saving care for asylum seekers in Australia. However, this responsibility is not always clear cut, and clinicians, in their attempts to provide care in a timely way, are often frustrated by State and Commonwealth health department policies. Patients with physical conditions requiring investigations (such as possible malignancy), subacute conditions (such as extrapulmonary tuberculosis), or those with chronic conditions which may result in acute complications (such as diabetes), face significant barriers to accessing healthcare (Box 2). Very often they rely on charitable organisations and the ingenuity of volunteer healthcare workers to "bend the system". This is becoming increasingly difficult. A case study illustrating the problems of access to healthcare is given in Box 3.

Competing interests

None declared.

References

Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed September 2001).
Department of Immigration and Multicultural Affairs. DIMA Fact Sheet 82: Immigration detention. http://www.immi.gov.au/facts/82detain.htm (accessed September 2001)]
Mares P. Borderline: Australia's treatment of refugees and asylum seekers. Sydney: UNSW Press, 2000.
Smith M. Desperately seeking asylum: The plight of asylum seekers in Australia. New Doctor Summer 2000-2001; 74: 21-23.
Carey Wood J, Duke K, Karn V, Marshall T. The settlement of refugees in Britain. London: HMSO, 1995. (Home Office research study 141.)
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Pernice R, Brook J. Refugees' and immigrants' mental health: association of demographic and post-immigration factors. J Soc Psychol 1996; 136: 511-520.
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Blochliger C, Junghanss T, Weiss R, et al. Asylum seekers and refugees in general practice: problems and possible developments. Soz Praventivmed 1998; 42: 18-28.
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Murshali H. Refugee Council, UK.
Australian Red Cross. Asylum Seeker Assistance Scheme. http://www.redcross.org.au/ourservices_acrossaustralia_asas_default.htm (accessed October 2001, updated February 2006).
NSW Health Department. Health Services Act 1997. Scale of fees for hospital and other health services. Circular No 99/64.
Caring for refugee patients in general practice. Victorian Foundation for Survivors of Torture, on behalf of the Western Melbourne Division of General Practice, 2000. Canberra: Department of Health and Aged Care, 2000. ISBN 0 9585657 4 0. Available at: http://www.racgp.org.au/downloads/20000831refugeevic.pdf (accessed November 2001).
Managing survivors of torture and refugee trauma. Guidelines for general practitioners. NSW Service for Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS), General Practice Unit, South West Sydney Area Health Service, Centre for Health, Equity, Research and Evaluation (CHETRE), NSW. Sydney: Refugee Health Service, 2000. ISBN 1 876056 12 6.

Authors' details

University of New South Wales, Sydney, NSW.
Mark F Harris, FRACGP, MD, Professor of General Practice,
School of Community Medicine.
Barbara L Telfer, BPhysiotherapy, MPH Student.

Reprints: Professor M F Harris, School of Community Medicine, University of New South Wales, Sydney, NSW 2052.
m.f.harrisATunsw.edu.au

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1: A Medicare card is required for all hospital attendances

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2: An audit of primary care needs of asylum seekers at the Asylum Seekers Centre, Sydney, 2001

Objective and methods: To describe the health problems and access to health services of community-based asylum seekers, we audited the records of 102 consecutive asylum seekers attending the general practice clinic at the Asylum Seekers Centre in Sydney over a 12-month period in 2000-2001. These asylum seekers, whose mean age was 33.5 years (SD, 15.9; range, infancy to 68 years), did not have access to Medicare. Sixty-one per cent were men. Results: Most patients were from Africa, the Middle East and South America. Their diagnoses, in order of frequency, are listed below. There was a history of torture or trauma in 45 of these patients. Psychological, musculoskeletal and cardiovascular problems were the most common. Sixty-seven were prescribed medication, 32 required a pathology test and 20 were investigated by imaging. Twenty-eight patients were referred (most frequently to physiotherapy, eye clinic, gynaecologist, psychologist, diabetes centre, gastroenterologist, urologist, breast clinic or family planning). For several patients there were problems with providing care because of cost or access. This resulted in a significant delay in care over and above what would normally be expected, or in the care not being provided. This included patients requiring hospital admission (5), complex investigation including magnetic resonance imaging, bone scan, angiography (3), subacute or elective surgery (5), dental care (3), referral to allied health (3), specialist medical care (6) and drugs on the Pharmaceutical Benefits Scheme, which are expensive to purchase at full price (6). Arranging bookings for confinement was difficult in most cases — especially so in two. Conclusions: This pattern of morbidity is not surprising given their frequently reported history of torture and trauma. A significant proportion required specialist care and experienced problems accessing hospital-based services, especially inpatient care, as well as difficulty paying for expensive drugs (such as triple therapy for Helicobacter pylori infection, and antipsychotic drugs).

Psychological and medical conditions of asylum seekers

Psychological, including depression, anxiety, post-traumatic stress disorder	26%
Musculoskeletal, including previous injuries/trauma	24%
Circulatory, including hypertension, heart disease	18%
Digestive, including peptic ulcer	16%
Infectious diseases, including TB, HIV, hepatitis B	12%
Urological, including urinary tract infections, prostatitis	9%
Neurological, including headache, epilepsy	8%
Endocrine, including diabetes	7%
Pregnancy	6%
Female genital conditions	6%
Ophthalmological conditions	6%
Skin conditions	5%
Dental problems, including dental abscess, gum disease	3%
Anaemia	2%
Ear problems	2%

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3: Case study

A 27-year-old man whose case was before the Refugee Review Tribunal had experienced trauma during imprisonment in his country of origin and had sleep problems as a result.
He had had abdominal pain, diarrhoea and fever for 3-4 months. He felt constantly tired and lethargic and had lost 9 kg (down to 43 kg). He had been unable to get medical attention because he was not eligible for Medicare.
On examination, his right abdomen was very tender and he had an enlarged liver. His haemoglobin level had fallen to 86 g/L (normal range, 120-160 g/L), and he had a lowered white cell count and a raised erythrocyte sedimentation rate of 60 mm/h (normal range, 5-15 mm/h). The provisional diagnosis was tuberculosis or malignancy.
He was referred to a senior gastroenterologist, who tried to admit him to hospital for further investigation. However, the hospital would not authorise his admission as he did not have a Medicare card. After multiple entreaties by the doctors involved, the Red Cross lodged an application with the Department of Immigration and Multicultural Affairs for financial coverage of his health costs in a public hospital. This took 5 days to organise, during which time he suffered repeated blackouts at home.
He was eventually admitted to hospital a week after the original recommended urgent admission date and investigations confirmed a diagnosis of tuberculosis. He was treated with antituberculosis chemotherapy and has made a slow recovery over 6 months.

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