Asylum Seekers and Refugees
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Preparation for DRC groupwork
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An asylum centre is due to open near your practice.
As well as this page, our separate Health Needs paper will help you with this. |
There is no greater loss on earth than the loss of one's native land
Euripides
A personal view
"Fifteen years ago I came to the United Kingdom as a political refugee from Eritrea. I remember feeling extremely vulnerable. I had lost my home, my family, my friends, my job, and my social status. I knew nothing about the healthcare or social welfare systems, and, even though I had the advantage of a good education and spoke English, it took me a long time to understand them. I received no information about the health service and was not invited to register with a general practitioner. Despite coming from an area with a high prevalence of tuberculosis I was not offered a health check on arrival." (5)
Yohannes Fassil, community health development manager.
Definitions
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A refugee is "any person, who owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his/her nationality and is unable or, owing to such fear, is unwilling to avail himself/herself of the protection of that country; or who, not having a nationality and being outside the country of his/her former habitual residence, is unable, or owing to such fear, is unwilling to return to it." |
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Asylum seeker: asylum claim submitted, awaiting Home Office decision. |
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Refugee status: (accepted as a refugee under the Geneva Convention) given leave to remain in the UK for four years, and can then apply for settled status (Indefinite leave to remain, see below). Eligible for family reunion for one spouse and all children under 18 years. |
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Indefinite leave to remain (ILR): given permanent residence in Britain indefinitely. Eligible for family reunion only if able to support family without recourse to public funding. |
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Exceptional leave to remain (ELR): the Home Office accepts there are strong reasons why the person should not return to the country of origin and grants the right to stay in Britain for four years. Expected to return if the home country situation improves. Ineligible for family reunion. |
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Refusal: the person has a right of appeal, within strict time limits. (1) |
Immigration and Asylum Act 1999
In the UK, despite much criticism, the Immigration and Asylum Act 1999 became effective in 2000.
Under the legislation up to 2600 people seeking asylum are dispersed each month into regions outside London and the south east. Accommodation is provided for asylum seekers, but they have no choice over where it is located.
Asylum seekers requesting support are given benefits to a maximum of 70% of the state benefit level, which for a single person in 2000 was £36.54 per week.
Asylum seekers are not allowed to work.
There has been concern that the new procedures will increase ill health among an already vulnerable population. (3)
Who are the asylum seekers?
There are over 48 million refugees in the world today.
The majority seek protection in neighbouring countries, largely in Africa and Asia, but an increasing number are coming to western Europe, including refugees from former eastern European countries. (5)
The United Kingdom, as a signatory to the 1951 Geneva Convention, is committed to offer asylum to people fleeing from persecution. (1)
In 2000 there were over 300,000 refugees in the United Kingdom. (5)
Most asylum seekers in Britain are from countries that are in conflict.
Asylum seekers have had varied experiences which may include personal experience of violence as well as assaults on their social, economic, and cultural institutions.
Many asylum seekers are highly skilled and previously had a high standard of living.
Many are being dispersed throughout Britain to areas that have had little experience of working with refugees.
Many are living below the poverty threshold, which poses a threat to their
health.
Most asylum seekers in Britain are single men, under the age of 40, although
worldwide most refugees are women.
Many families in Britain are without one parent, who may be missing or dead, and there is an appreciable number of unaccompanied minors.
Numbers from each country fluctuate principally according to the local human rights situation. For example, much of the increases in 1998 and 1999 were from the former Republic of Yugoslavia. (1)
Previous experiences
Burnett and Peel (2001) point out that the experiences which people may have endured include massacres and threats of massacres, detention, beatings and torture, rape and sexual assault, and witnessing death squads and torture of others; being held under siege, destruction of homes and property and forcible eviction, disappearances of family members or friends; being held as hostages or human shields; and landmine injuries.
Adults and even children may have been conscripted into the army, and women and girls may have been forced to become sexual slaves.
Other forms of persecution are persistent and long term: political repression, deprivation of human rights, and harassment.
In camps refugees may have experienced prolonged squalor, malnutrition, lack of personal protection, and deprivation of education; children may have been deprived of the opportunity to play normally.
These personal experiences are likely to have been accompanied by damage, frequently intentional, to social, economic and cultural institutions. (1)
"Cultural bereavement" and coping with "deeply disruptive change" are widely shared experiences of migration.
Refugees are distinguished from other migrants by their lack of choice. Refugees have had to leave their countries of origin to escape persecution, imprisonment, torture, or even death.
Families may have been physically separated, causing much grief. Refugees are often preoccupied by worry about relatives left behind in their country of origin.
Many refugees, including children, have no other relatives in the United Kingdom. (6)
Health needs
In a BMJ editorial, Connelly and Schweiger (2000) state that the health of refugee communities in the United Kingdom is poor.
Many people who have had to flee their homelands will have suffered physical or mental torture.
Asylum seekers in the United Kingdom now face an uncertain time trapped in poverty and absolute dependence, a situation characterised by the Medical Foundation for the Care of Victims of Torture as humiliating and likely to jeopardise the psychological and physical health of refugees.
Poverty is a cause of ill health, and social dislocation combined with poverty is especially hazardous for mental health.
The health of children is especially sensitive to poor accommodation and the parental stress caused by such conditions.
Asylum seekers will have free access to the NHS, but without interpreters it will be difficult for many to make use of these services.
The situation will be exacerbated by the dispersal of refugees to areas where appropriate services have not been developed and where there are no local communities of people of the same ethnic origin as the asylum seekers.
Asylum seekers can register with a general practitioner, but an exemption certificate for prescription charges, dental, and optical care will only be issued after they have been allocated accommodation.
Local authorities are obliged to provide accommodation for asylum seekers, but these departments are already under pressure.
Much could be accomplished by encouraging the media to present asylum seekers and refugees as resourceful and capable survivors. (3)
People who are seeking asylum are not a homogeneous population, state Burnett and Peel (2001). Coming from different countries and cultures, they have had, in their own and other countries, a wide range of experiences that may affect their health and nutritional state. In the United Kingdom they face the effects of poverty, dependence, and lack of cohesive social support.
All these factors undermine both physical and mental health. Additionally, racial discrimination can result in inequalities in health and have an impact on opportunities in and quality of life.
Refugees' experiences also shape their acceptance and expectations of health care in the United Kingdom. Those from countries with no well developed primary healthcare system may expect hospital referral for conditions that in Britain are treated in primary care.
This can lead to disappointment for refugees and irritation for health workers, who may also feel overwhelmed by the many and varying needs of asylum seekers, some of which are non-medical but nevertheless affect health. Addressing even a few of these needs may be of considerable benefit.
Previous studies in the United Kingdom have found that one in six refugees has a physical health problem severe enough to affect their life and two thirds have experienced anxiety or depression. (2)
See separate Health Needs Document for a more detailed review of health needs of asylum seekers.
Isolation
Refugee community organisations are invaluable in supporting refugees and acting as advocates. They can provide information and orientation and reduce the isolation experienced by many refugees.
In a study of Iraqi asylum seekers in London, depression was more closely linked with poor social support than with a history of torture.
Informal groups, structured in a culturally familiar way, can be a useful way of sharing experiences and ways of coping and making sense of past experiences.
It is important for refugees to develop ongoing links and friendships with people in the host community as well as making contact with people from their own countries, and the best mental health outcomes may be achieved in this way.
Many community and religious organisations have welcomed refugees. Recent hostile media headlines and comments from politicians, however, have not nurtured good relationships, and there has been an increase in negative feelings towards refugees and consequent racist attacks on them. (2)
Communication
Burnett and Peel (2001) suggest that it is important to for the services of a trained advocate or interpreter to be available unless patient and health worker speak the same language.
Refugees may bring a family member or friend to interpret. Though this may help in obtaining background information, it may result in inaccurate interpreting and also make it difficult to discuss sensitive issues such as sexual health, gynaecological problems, sexual violation, domestic violence, or torture.
Using children to interpret may place inappropriate responsibilities on them.
Using the same interpreter for all consultations can help the development of trust, but exiled communities may polarise into groups reflecting conflicts in the home countries and not every interpreter will be universally trusted.
Interpreters and advocates can provide valuable information for health workers on cultural and other relevant issues.
Telephone interpreting can be useful when there are no local interpreters.
Also, health workers may need training in working with interpreters. (2)
Information on health
Information about health services needs to be in relevant languages, and some culturally appropriate examples are available covering general access to services.
Some areas have produced leaflets describing local services, but not all refugees are literate, particularly women. Somali culture, for instance, focuses more on oral communication: written Somali dates only from 1972.
Health advocates and refugee community organisations are important in increasing awareness about health. Smoking, for example, is a problem it may be useful to address, as it tends to be high in some groups of refugee men. (2)
Access to health care
Asylum seekers often receive poor health care, according to the Audit Commission. (7)
Asylum seekers and refugees, unlike other overseas visitors, are entitled to all NHS services without payment, yet many say they have difficulty obtaining health care, state Burnett and Peel (2001).
Many, in particular young single homeless people, have found it impossible to register with general practitioners at all, while others may be only temporarily registered and not entitled to a health check, screening, or immunisation, and previous notes will not be available.
Mobility may be cited as a reason to register only temporarily, but 70% of responders to a study on refugees in 1995 had not moved in the previous year, although this figure may now be affected by dispersal.
Difficulties that face health workers include language, pressure of time, lack of understanding of cultural differences, and lack of expertise.
Refugees are perceived as having huge needs that are difficult to fulfil and as being very demanding. This may be true for some individuals as it is in the general population but many refugees are actually reluctant to make demands.
The health of asylum seekers is affected by many aspects of their experiences, both past and present, including multiple loss and bereavement, loss of identity and status, experience of violence and torture, poverty and poor housing, and racism and discrimination, and the responses needed are not solely medical.
The effects of poverty on both physical and mental health have been well documented and it is of deep concern that asylum seekers are being forced to live below the poverty threshold.
If not otherwise exempt, those on low income can apply with an HC1 form for an AG2 exemption certificate in order to receive free prescriptions, dental treatment, optician services, and hospital travel costs. The form, however, is 16 pages long and available only in English, and the certificate itself is valid for only six months.
Some have experiences of abuse which they have previously never described, and the process of giving testimony in itself can be therapeutic. (1)
GPs' experiences
In a letter to the BMJ in 2000, Montgomery and Le Feuvre said that their east Kent practice had cared for many resident asylum seekers and for many more who arrived at the Channel ports. Since February 1999 they had tried to meet the medical needs of people from 43 different countries.
In their part of Kent there are no trained interpreters, and, indeed, to expect to have an interpreter on hand at a moment's notice for this number of languages is unrealistic.
They found that even commercial telephone translation services are not able to supply some of the languages they require.
However, they suggest that listening to patients, careful body language, and the use of diagrams and written material are all techniques that have enabled us to communicate to a reasonable level.
"It is not difficult to show that you are trying to help, and with encouragement people will often find ingenious ways of expressing themselves", they state.
The main obstacles to providing appropriate care are the inflexibility of the NHS and the delays and bureaucracy inherent in the arrangements for the support of asylum seekers. Many people arrive with no money at all, and it takes time for them to receive vouchers.
"In the meantime, how does a woman who is menstruating buy sanitary protection? How does a mother in bed and breakfast accommodation obtain nappies for her baby? How do they pay for prescriptions?"
An exemption certificate (HC2) comes as part of the support package for asylum seekers, but it can take up to three weeks to be issued.
In their experience, it is solving problems like these that consume time and energy.
They reassure GPs that asylum seekers are resourceful and their needs are not overwhelming; neither are the language barriers insurmountable. (7)
GP perceptions
Jones and Gill (1998) pointed out that, although all refugees are entitled to the full range of NHS treatment free of charge, including the right to register with a general practitioner, there is evidence that some general practitioners are confused about this.
A study in Islington found that 38% of refugees encountered problems registering
with a general practitioner.
Information on general practitioners' perceptions of refugees' health needs is
limited. Perhaps reflecting the low level priority that refugees receive on the
national agenda, most studies are local and small scale, but they suggest that
problems exist.
Ramsey and Turner found that 50 general practitioners identified a diverse range of problems and five practitioners reported their own anxiety in dealing with patients "with special needs who seemed to take up a disproportionate amount of time."
Seventeen general practitioners in this study identified language difficulties as the reason for their associating refugee status with lengthy and time consuming consultations.
Refugee families are not likely to have enjoyed good quality primary care in their countries of origin.
Immunisation rates may be low, and medical records are usually not available.
Language barriers at the reception desk and in the consultation are common.
Interpreter services are generally not available outside working hours and for acute consultations.
Telephone interpreting using "hands free" technology may offer a solution, but this remains underdeveloped.
Lack of adequate professional interpreting services presents a barrier for all non-English speaking patients, but this barrier is larger for those with psychological and emotional difficulties that can only be explored verbally.
If tragic mistakes are made as a result of communication failure does moral responsibility rest with the doctor or with a medical system which expects doctors to communicate well but fails to provide adequate resources? (6)
General practitioners' knowledge of issues relating to asylum seekers is poor,
states Dar (2000).
Although all asylum seekers are eligible for free NHS treatment and have the right to register with a general practitioner, general practitioners are often confused about these people's entitlements.
They often registered patients on a temporary rather than a permanent basis, thereby excluding them from a full package of checks and advice.
Additionally, various forms of identification have been unnecessarily requested before registration. (4)
References
1 Burnett A, Peel M, BMJ 2001;322:485-488. Asylum seekers and refugees in Britain: What brings asylum seekers to the United Kingdom? http://bmj.bmjjournals.com/cgi/content/full/322/7284/485
2 Burnett A, Peel M, BMJ 2001;322:544-547. Asylum seekers and refugees in Britain: Health needs of asylum seekers and refugees. http://bmj.bmjjournals.com/cgi/content/full/322/7285/544
3 Connelly J, Schweiger M, BMJ 2000; 321:5-6. Editorial: The health risks of the UK's new asylum act. http://bmj.bmjjournals.com/cgi/content/full/321/7252/5
4 Dar S, BMJ 2000 Letter. http://bmj.bmjjournals.com/cgi/content/full/321/7265/893
5 Fassil Y, BMJ 2000;321:59. Personal view: Looking after the health of refugees. http://bmj.bmjjournals.com/cgi/content/full/321/7252/59
6 Jones D, Gill P, BMJ 1998;317:1444-1446. Refugees and primary care: tackling the inequalities. http://bmj.bmjjournals.com/cgi/content/full/317/7170/1444
7 Montgomery S, Le Feuvre P, BMJ 2000. Letter. http://bmj.bmjjournals.com/cgi/content/full/321/7265/893
Useful Links
Provides a directory of information and resources concerning the health needs of asylum seekers and refugees
http://www.cre.gov.uk/gdpract/refuge.html#luxury
"Much has been written about refugees and asylum seekers in recent months. Unfortunately, everything said is not always based on fact. This page seeks to clarify the truth."
http://www.refugeecouncil.org.uk/
The Refugee Council is the largest organisation in the UK working with asylum seekers and refugees.
http://www.dh.gov.uk/assetRoot/04/05/09/15/04050915.pdf (274k)
Caring for Dispersed Asylum Seekers - the DoH Resource Pack
Collated by: Michael Harris
Last updated: 29 August 2007