Alien nation
The health of asylum seekers actually declines in the first two years after they arrive in the UK. Jearelle Wolhuter investigates the impact of poverty, language and cultural differences on refugee health care.
They arrive in huge numbers. They drain our resources. They spread disease. They are a huge financial burden and they are almost impossible to get rid of.If public opinion polls and media reports are to be believed, this is the way many people see asylum seekers and refugees - as human rats. Negative stereotypes about asylum seekers abound. In a MORI poll published in June 2002, 64 per cent of respondents said that the media most used the term "illegal immigrant" when referring to asylum seekers. Other words commonly associated with them include "desperate", "foreigner", "bogus" and "scrounger". The poll also showed that the public grossly overestimates the number or refugees coming to Britain - the UK only hosts about 1.98 per cent of the world's asylum seekers, but it is perceived to host nearly a quarter. The Refugee Council points out asylum seekers are portrayed as criminal, illegal, desperate to get to England in large numbers and a huge drain on the NHS.
This negative image is not helped by the real problems posed by asylum seekers' healthcare needs. A report by the British Medical Association (BMA) published in October 2002 states that the few studies on the health problems of asylum seekers in the UK suggest that one in six refugees (17 per cent) has a physical health problem severe enough to affect their life, and two-thirds have experienced significant anxiety or depression. As a group they are especially vulnerable to certain diseases and psychological conditions. Some health conditions, those linked to poverty and overcrowding, are common to asylum seekers, and some, such as psychological and physical problems associated with war and torture, are specific to them.
From a humanitarian and ethical perspective, anyone who is ill or suffering deserves to be treated. From a public health perspective, the high levels of communicable diseases such as HIV / Aids, hepatitis (inflammation of the liver) and tuberculosis among asylum seekers are of particular concern. On February 23 The Times reported that the government is planning to introduce compulsory HIV tests for immigrants after the number of new cases rose by 26 per cent in one year. In each of the last four years, there has been approximately 6,500 cases of chronic hepatitis B imported via immigration. This compares to approximately 600 to 700 cases of endogenous acute hepatitis B per annum in the country, according to the British Liver Trust. The London Borough of Newham is the tuberculosis capital of the developed Western world. As the New Scientist reported on July 7, 2002, Newham's 108 cases per 100,000 of its population put it ahead of India and Russia in terms of prevalence. Around half of all TB cases are asylum seekers.
Many refugees come from regions where these diseases are common. However these conditions are not common in Britain - and this has a number of implications. Firstly the local population is at risk of infection. Due to the low local incidence, they have probably not been immunised and they don't have a natural resistance. This means the disease can spread rapidly. Secondly doctors may be unfamiliar with these diseases and may not recognise the symptoms. These illnesses can have serious long term complications. The longer they are left untreated, the more difficult and expensive they are to treat.
Despite reports like the one in The Times, HIV / Aids is probably not the UK's biggest health problem among refugees. Diseases such as tuberculosis and hepatitis are much more contagious and prevalent. HIV is spread through sex, the sharing of needles and contact with blood, but not through sneezing or coughing. This means it could be very hard for someone who is HIV positive to find a dentist willing to treat them, but the disease might be more contained within that person's own social group than tuberculosis, which is an airborne disease that spreads like the common cold, or hepatitis, which spreads through contact with infected blood, body fluids and sex. However people who have HIV are more susceptible to infection, so they have a higher risk of acquiring TB and hepatitis.
If left untreated a person with tuberculosis can infect 10 to 15 people in one year. According to the World Health Organisation, overall, one third of the world's population is currently infected with TB and as many as 50 per cent of the world's refugees could be infected with TB. Infected people do not necessarily become sick though. TB is an opportunistic disease, which can lie dormant for years and become activated when someone's immune system is weakened.
Three quarters of the world's population live in areas where there are high levels of hepatitis B infection. "Ultimately as more people suffer from the end-stage liver disease associated with chronic hepatitis B we will see more pressure for treatment and in some cases transplantation. Between 1996 and 2000 there were 125 liver transplants for hepatitis B-related cirrhosis at an average cost of £55,500 per transplant, not including long-term immuno-suppression and follow-up. Inevitably this may well go up," says Nigel Hughes, Chief Executive of the British Liver Trust.
Despite the scary statistics and headlines, the BMA's report notes that the average physical health status of asylum seekers on arrival is not particularly poor compared to the average fitness of UK residents. New entrants' health only decline in the first two or three years after arrival in the UK. Living in poverty - in damp, mouldy accommodation - and suffering from bad nutrition is not basically conducive to physical well-being.
The biggest barriers to healthcare are language and cultural differences. Among refugees men are more likely to be literate and speak English than women, but women are more likely to suffer from poor health and depression. In term of psychological problems, the Western concept of counselling may be alien to refugees. Psychological problems can be exacerbated by prejudice concerning physical health: many HIV positive women will have acquired the disease through rape during wars or campaigns of intimidation. Now they not only face the psychological trauma of the rape, the psychical complications of the disease, but also the fear of passing it to their partners or children.So what is to be done? The BMA advocates better health assessment on arrival and then treatment as needed. For example screening for TB through a chest X-ray on arrival is patchy. Interpreters are not always on hand when medical services are provided and as asylum seekers are moved, their medical records don't always follow them. Screening should not be intended to keep people out, but whether asylum seekers are granted leave to remain or not, they could pose a public health risk. If they do stay and they are ill, early detection and treatment could save the NHS millions of pounds down the line and help make them able-bodied productive citizens.
Hepatitis B can be prevented by an inexpensive jab - indeed, the British Liver Trust would like to see everyone vaccinated as a child. Tuberculosis can be treated fairly inexpensively with antibiotics, but once it becomes resistant, treatment can be futile and very much more expensive. People tend to become resistant when they do not finish their first course of antibiotics. HIV / Aids cannot be cured, but providing treatment can extend someone's life, thus enabling them to work.
Asylum seekers are not allowed to work at the moment, enhancing their status as an uneducated, lazy, poor and ill underclass, parasitically preying on the UK's resources. Yet, in at least one aspect, allowing them to work would solve two problems at once. There are many doctors and nurses among asylum seekers who are currently not allowed to work. They represent an untapped resource. As Dr Nayeem Azim, a refugee from Afghanistan who is a medical doctor puts it: "We need doctors who are multilingual. We need doctors with experience of diseases such as TB. Most of all, we need more doctors." It costs around £250,000 to train a doctor from scratch, but only £5,000 to retrain one to work on the NHS. In 2001 there was an estimated 800-1,200 asylum seeker and refugee doctors in the UK.
NHS nursing shortages could be filled by the "hidden army" of refugee nurses rather than overseas recruitment says immediate past President of Royal College of Nursing, Roswyn Hakesley-Brown. "The shortage of qualified nurses, especially in London, has been well documented. There are obvious ethical considerations around actively recruiting from developing countries which may have their own problems with public sector staff shortages."
A MORI poll published in February 2003 shows that while 85 per cent of Britons of every colour believes the government does not have immigration under control, most of them (70 per cent) view multi-culturalism as a good thing. If asylum seekers' health problems can be addressed and if refugee doctors and nurses can be allowed to work, they may be seen as less of a threat and more of an asset to the community.
