Bug Breakfast^* in the Bulletin: refugee health

Refugees are people living outside of their country of nationality because of a well-founded fear of persecution for reasons of race, religion, nationality, membership of a certain social group or political opinion.¹ Asylum seekers are people who have applied for recognition as refugees and are awaiting a decision on their application.² If their application is successful they receive refugee status.

There are two components to Australia’s humanitarian migration program: the first and largest component is the resettlement in Australia of people who have been given refugee status elsewhere (‘offshore resettlement’ of refugees); the second component is for people applying for refugee status while already in Australia (‘onshore protection’ of asylum seekers).³ Asylum seekers are either ‘authorised arrivals’ who enter Australia on a valid visa such as a visitor’s or student visa or ‘unauthorised arrivals’ who enter Australia by boat or plane without a visa.⁴ Unauthorised arrivals are detained in various immigration detention centres across Australia while their refugee claims are processed.

Asylum seekers who arrive in an unauthorised manner receive health screening in the detention centres. Authorised asylum seekers, who are generally allowed to remain in the community while their applications are processed, may have received health screening in their country of origin as part of their visa requirements, and will undergo further checks.

Refugees, on which the remainder of this article will focus, have to undergo the same health checks as other migrants before receiving humanitarian visas to travel to Australia, including tests for tuberculosis and, depending on age, HIV. Since mid-2005, a proportion also undergo health checks immediately predeparture, organised by the Australian Government. These include an assessment of their fitness to fly and rapid malaria testing when appropriate. They are given antiparasitic treatment and, for those under 30 years of age, measles, mumps and rubella vaccination.

Refugees normally arrive in Australia in family groups. Health screening processes after arrival differ between and within the States and Territories. In NSW, screening varies depending on where in NSW the refugees are settled by the Department of Immigration and Citizenship. The NSW Refugee Health Service, funded by NSW Health, runs assessment clinics in Sydney, where the majority of refugees settle. The Children’s Hospital Westmead has also established a dedicated clinic. Area Health Services have set up clinics for assessing refugees settling in Newcastle and Coffs Harbour. These people are offered a link to mainstream health services such as General Practitioners (GPs) and dental clinics or to the specialised NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors.

Some refugees arriving in Australia have infectious diseases, including malaria, schistosomiasis, hepatitis B and Helicobacter pylori. Sometimes unusual tropical diseases are diagnosed, such as Chigoe flea in refugees from a Tanzanian camp.⁵ A number of refugees are under-immunised, for example for measles and rubella.⁶

In early 2005, the Australian Government arranged several charter flights to bring large groups of refugees to Australia. In February, a group of 300 Burundian refugees arrived, of which 30 came to Fairfield in Sydney. These people had lived in Tanzanian refugee camps for up to 10 years. The General Practice Unit at Fairfield Hospital was asked to provide screening and immunisation. The refugees were screened for Hepatitis B, malaria, schistosomiasis, strongyloides, hookworm and Giardia, and where necessary, they were vaccinated.

The challenges posed by the newly arrived refugees were: ascertaining past medical history; collecting blood and stool specimens; and explaining test results. With the cultural and language barrier, the availability of an interpreter was critical. Organising follow-up tests or treatment was difficult as it was not easy for the refugees to get to the hospital in a city environment that was completely new to them. They also had to negotiate the social security system, enrol their children in school, start to learn English and perhaps seek a job. Consequently, for recently arrived refugees, their health may not always be the first priority.

For resettled refugees medical care is relatively good but there are still some important concerns such as: difficulties in completing immunisation schedules where immunisation histories are unclear and where refugees have passed the age at which certain vaccines are normally given; the provision of certain medications (e.g. Praziquantel for schistosomiasis) that are not covered by the Pharmaceutical Benefits Scheme; and the debate across different jurisdictions with regards to the degree of additional tuberculosis screening that may be warranted.

A positive initiative is the development of protocols and guidelines for the screening and treatment of resettled refugees. Recently, a new Medicare item number was introduced to remunerate GPs who undertake health assessments for newly arrived refugees. These and other issues are under discussion through a national Multi-Jurisdictional Working Group on refugee health issues.

For asylum seekers, medical care in detention centres as well as in the community has been criticised for not meeting adequate standards.^4,7–9 Recent attention has been given to those asylum seekers living in the community without access to Medicare, with discussions taking place nationally about how to facilitate access to primary health services and hospital care.