Refugee health

At the end of 2008 there were approximately 42 million people around the world who had been forcibly displaced from their homeland.¹ As a signatory to the United Nations Refugee Convention, Australia resettles over 13 000 refugees each year,² with 4000 settling in New South Wales (NSW). In 2007–2008, most of these people originated from Burma, Iraq, Afghanistan, Sudan and Liberia. The majority coming to NSW settled in the greater west of Sydney, with smaller numbers settling in Wollongong, Newcastle, Coffs Harbour, Wagga Wagga and Goulburn.

Many refugees and asylum seekers have experienced physical and psychological trauma as a result of human rights abuses and protracted conflict. Their displacement can result in loss of family, friends, land and other possessions, disruption of education, employment and erosion of community structures and traditions. Their experiences, combined with anxiety, uncertainty and the lengthy resettlement process, can have long-lasting, detrimental effects on their physical, emotional and mental health.

The Migration Regulation Act stipulates that all people entering Australia must be free of active tuberculosis and refers generally to diseases that pose a threat to public health. Human immunodeficiency virus (HIV) infection and hepatitis B and C are not considered to be a public health risk and do not preclude migration to Australia from a public health perspective. Cases of active tuberculosis must be treated before migrating to Australia. Once treatment is considered complete, people can travel to Australia, having signed a Health Undertaking which is an agreement by the person migrating to report to the relevant state chest clinic for ongoing monitoring and further treatment if required.

Pre-departure medical screening is a voluntary check offered to refugee and humanitarian applicants around 72 hours before departure to Australia. The aim of the screening is to identify health concerns which may affect the individual's fitness to travel to Australia and to ensure follow up of those health needs upon arrival. A full pre-departure medical screen includes a physical examination, tuberculosis evaluation for those at risk, malaria test and treatment if required, treatment for intestinal parasites and measles, mumps and rubella (MMR) immunisation for refugees aged nine months to thirty years. Information is documented on a Health Manifest form which is sent to the Department of Immigration and Citizenship. Health issues that need follow-up are flagged on the manifest. In 2008–09, 3800 humanitarian entrants to NSW, 80% of all refugee entrants to NSW that year, underwent a pre-departure medical screen.

Screening of 220 refugee children settling in NSW has detected vitamin D deficiency, schistosomiasis, positive Mantoux tests, anaemia, parasitic diseases, malaria and chronic hepatitis B.³ Poor oral health, chronic conditions including diabetes and hypertension, injuries from war and torture that have been inadequately treated, psychological disorders and delayed growth and development in children are not uncommon. Guidelines published by the Australasian Society for Infectious Diseases entitled Diagnosis, management and prevention of infections in recently arrived refugees can assist practitioners in their management of refugee health care.⁴ Catch-up immunisation may be required. Specialised services in NSW exist for trauma counselling (STARTTS and the Transcultural Mental Health Centre) as well as the Multicultural HIV/Hep C service and an obstetric service at Auburn Hospital for women affected by female genital mutilation.

Refugees, and asylum seekers who are successful in their claim for refugee status, are eligible for Medicare. Health services are provided by mainstream general practitioners and a number of specialised clinics. Barriers in accessing health services include language, cultural differences, knowledge of available services, transport, and financial costs (particularly for specialist assessments, allied health, dental care and some medications). Many health-care providers in Australia may lack the knowledge and cultural awareness required when providing health care to people from backgrounds of war and trauma.

In the recent past, many asylum seekers were not eligible for Medicare. National policy initiatives in 2009 included increased access for asylum seekers to Medicare, free access to telephone interpreters for all pharmacists, and inclusion within the Pharmaceutical Benefits Scheme (PBS) of some medications (for malaria and schistosomiasis). NSW has developed a policy addressing access to hospital care for asylum seekers without Medicare, and is developing a state refugee health plan for release in 2010.

Refugees migrating to Australia are screened for tuberculosis and active cases are treated off-shore. Individuals are placed on Tuberculosis Undertakings when they are fit to travel to Australia. Most refugees are also screened for other conditions within 72 hours before travelling. People from refugee and asylum-seeker backgrounds experience physical, emotional and mental health problems that can pose a challenge to Australian health-care workers. Guidelines and training can assist in providing high quality, comprehensive care that is culturally sensitive. National and state policy initiatives can assist in promoting better access to health services for all humanitarian arrivals.