Refugee and Asylum Health - Healthy Inclusion · Introduction: Asylum Seekers and refugees are a...

Refugee and Asylum Health

Nisha Guram 200506571 3rd year medical student University of Liverpool

“I look to a day when people will not be judged by the colour of their skin, but by the content of their character.” (1)

Martin Luther King

Contents Page

Abstract...............................................................................................Page 1

Acknowledgments..............................................................................Page 2

Learning Objectives............................................................................Page 3

Introduction........................................................................................Page 4

Statistics..............................................................................................Page 7

Media Portrayal of Asylum Seekers....................................................Page 8

Method................................................................................................Page 10

Literature Review................................................................................Page 11

Discussion............................................................................................Page 12

Conclusion...........................................................................................Page 17

Recommendations...............................................................................Page 17

Reflection............................................................................................Page 18

References...........................................................................................Page 19

Appendix 1 GMC Duties of a Doctor................................................Page 22

Appendix 2 Case History....................................................................Page 23

Appendix 3 Article used for Journal Club..........................................Page 24

Appendix 4 Presentation for Journal Club..........................................Page 28

Appendix 5 Poster for Conference......................................................Page 29

Appendix 6 Presentation for Conference............................................Page 30

Appendix 7 Global Health Perspective...............................................Page 31

Appendix 8 Key Resources.................................................................Page 33

Appendix 9 Timetable.........................................................................Page 34

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Nisha Guram 200506571

Abstract

Introduction: Asylum Seekers and refugees are a vulnerable group of people, whose

healthcare needs are often ignored or insufficiently met. The British government’s

current strategy is to place thousands of asylum seekers in detention centres, which

can worsen their physical and mental health.

Method: NHS and Cochrane library were used to search for relevant literature

sources. The internet was also used to search for information: the UN and Home

Office websites provided some useful statistics.

Discussion: Detention centres have often been compared to prisons, where asylum

seekers are treated as if they have committed a crime. As there is no legal limit on

the length of time kept in detention, asylum seekers could potentially remain there

indefinitely.

Conclusion: Detaining asylum seekers affects their already fragile mental health, yet

the health care provided in detention centres is insufficient to deal with their physical

health care needs.

~ 2 ~


Acknowledgements

Partaking in this SSM has provided valuable insight into a topic that previously I had

little prior knowledge of. The complex nature of asylum seekers and their health

related problems is often ignored or misunderstood. This SSM has given the

opportunity to correct some of those misconceptions surrounding asylum seekers and

realise that post migration trauma can sometimes have a more damaging effect on

their health than pre migration trauma.

Kieran Lamb and all the staff at Fade Library were incredibly helpful in providing

assistance with searches. Dr O’Neill and Siobhan Harkin organised many of the

placements that were undertaken supplying us with a basic understanding of asylum

seekers. They were also helpful in providing assistance with any queries that we

might have had.

I would also like to thank Asylum Link, Star Women’s Group and all the placements

that we visited for their invaluable information that they passed on to us.

~ 3 ~


Learning Objectives: Asylum Health

1. To understand the causes and consequences of seeking sanctuary, and to be up to

date with current literature in this area.

2. To learn about the main clinical problems of asylum seekers, especially mental

health (depression, PTSD, enduring change of personality), the diagnosis and

assessment of victims of torture and other severe ill treatment, management if

sexual assault victims with poor maternal child bonding.

3. To explore the best ways to provide NHS and other services for asylum seekers,

in a suitable fashion.

Core Learning Activities

1. SLV = Service Learning Visits

2. Case Histories

3. Journal club presentation

~ 4 ~


Introduction

In 1951 delegates of the United Kingdom of Great Britain attended a United Nations

(UN) convention held in Geneva. The convention clarified the definition of a refugee

and the rights that they were entitled to under the protocol; furthermore the

responsibilities that the countries have towards those who have been given leave to

remain in said States (2). 147 countries are signatories of the convention as of August

2007, of which the United Kingdom (UK) is one (2).

It would be useful at this point to clarify the distinction between an asylum seeker

and a refugee. The latter term is explained as a person “owing to well founded fear of

being persecuted for reasons of race and religion, nationality, membership of a

particular social group or political reason, is outside the country of his nationality

and is unable, or owing to his fear is unwilling to avail himself of the protection of

that country” (2) by the 1951 Geneva convention. An asylum seeker on the other hand

is someone who has “lodged an application for protection on the basis of article 3

(explained below) of the Human Rights Act” (3) and is waiting for leave to remain.

The two terms are often incorrectly used interchangeably.

Asylum seekers arrive in the UK by a variety of methods depending on their personal

circumstances. The journey is often difficult and emotionally exhaustive as families

are frequently separated and forced to suffer cramped and dangerous transportation.

Application for asylum can either be submitted at point of entry into the UK or at one

of three screening units located at Liverpool, Croydon and Solihull. The Home

Office interviews each applicant in what is dubbed a “screening interview” (4) to

identify each applicant; alarmingly applicants are not questioned as to the reasons for

claiming asylum. The 1999 Immigration and Asylum Act ensures the dispersal of

asylum seekers throughout the UK; in areas with whom they have little experience (5). This is often to the detriment of their health as they can be subject to racial abuse

and isolation from family and friends.

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Figure 1 (6): Overview of asylum process

Asylum seekers are prohibited from working whilst awaiting a decision despite often

being “highly skilled and [having] previously enjoyed a high standard of living” (5).

To aid with living expenses the UK border and immigration agency (BIA) introduced

a scheme: the National Asylum Support System (NASS) whilst asylum seekers are

awaiting a decision. In order to qualify for these benefits asylum seekers are required

to sign an agreement stating that you will abide by the conditions the Home Office

states, which include agreeing to remain in the location of your case workers choice (7). An adult over 18 claiming asylum would be entitled to £35.52 a week (7)

compared with an adult claiming jobseekers allowance who would be paid £64.30 a

week (8). Clearly the amount paid to asylum seekers is not enough to live on

especially when coupled with the fact that they are prohibited from employment. A

report commissioned by the Home Office in 2007 revealed a disturbing attempt at

coercing asylum seekers to leave by “ensuring that living illegally [in the UK]

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becomes ever more uncomfortable and constrained until they leave or are removed” (9).

The 1998 Human Rights Act was brought in to enforce our basic liberties that were

cited in the European Convention 50 years previously. The Act sanctions British

courts to try human rights cases; whereas formerly, people who felt that their rights

had been infringed “had to go to the European Court of Human Rights in Strasbourg” (10). The Human Rights Act encompasses 16 different articles that initially were

mentioned in the European Convention of Human Rights of which the most relevant

with reference to asylum seekers are articles 2, 3 and 5. Article 2 declares that

everybody has “an absolute right to life” (10), article 3 states “you have the absolute

right not to be tortured or subjected to treatment or punishment which is inhuman or

degrading” (10). Article 5 asserts that “you have the right not to be deprived of your

liberty i.e. arrested or detained except in limited cases” (10) that are specifically

specified in the article itself.

What does this mean for asylum seekers? It signifies that neglecting or dismissing

the absolute human rights under any circumstances is illegal. Public authorities (for

example the UK Border Agency) are legally bound by these rights when taking into

consideration any decisions that can affect asylum seekers.

Aim

Due to the vast topic of refugee and asylum health, it is necessary for this SSM to

pick a more focused subject matter. After speaking with several asylum seekers, who

had spent time in detention centres I decided to examine specifically the healthcare

needs of those who were interned. The research question chosen is: What are the

health care needs of asylum seekers kept in detention centres?

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Summary of Statistics

Currently there are over 42 million people who have been displaced

worldwide because of persecution and conflict (11).

The UK hosts on average 3% of total asylum seekers (11).

Only 13% of applicants were granted asylum by the UK in 2009 (11).

3 out 4 applicants are refused refugee status (11).

In the third quarter of 2009 the number of deportations (forced or voluntary)

was in the region of 17,055 persons (4).

Liverpool houses approximately 4,000- 5,000 asylum seekers (12).

Detention centres do not hold data on the number of asylum seekers that

they hold; therefore finding data on this is difficult.

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Media Portrayal of Asylum Seekers

Asylum seekers are often depicted negatively in the media as evidenced by the

headlines above. Due to media headlines and to some degree comments by

politicians, a member of the British public’s first impression of asylum seekers

would be that of terrorism or health tourism (13). This bias stems from ignorance of

the public of the traumatic experiences that asylum seekers endure both pre

migration and post migration.

Recently the media has cultured this stereotypical attitude that asylum seekers are to

be regarded as terrorists. Worryingly this belief can lead to assault and abusive

behaviour on asylum seekers. There is no substantial truth to these claims; it seems

that the ability to sell newspapers these days matters more than printing favourable

reports of asylum seekers.

There is an irrational fear that asylum seekers come to the UK for health tourism

causing a financial burden on an already taxed National Health Service (NHS).

Governmental policy panders to this propaganda, as evidenced by the Department of

Health’s decision to refuse failed asylum seekers free secondary healthcare on the

NHS (14). What the public fail to realise however, because the media neglects to

inform them, is that many asylum seekers have no prior knowledge of the NHS

~ 9 ~


before arriving in the UK. For many asylum seekers who arrive in the UK had no

choice in their destination, rather it was the decision of their trafficker.

At a recent hearing at the Court of Appeals, the Lord Justice Ward made a

controversial comment that has gained much attention in the press. He stated that

“the purpose of the NHS Act is to provide the people of England and that does not

include people who ought not to be here, failed asylum seekers ought not to be here.

They should never have come here in the first place” (14). This further potentiated the

negative attitudes towards asylum seekers.

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Method

A literature search was conducted using the NHS library and Cochrane library to find

information pertaining to asylum seekers and their healthcare. The articles found

were then used for background reading. These combined with various placements

that were undertaken during the SSM period helped to gain an insight into refugee

and asylum health.

A manual search of the University of Liverpool and Donald Mason Library was also

conducted to search for any useful books or publications.

Once the research question had be chosen, explicit searches were then performed

again using the NHS library and the Cochrane library using specifically chosen

keywords that were relevant to the question. The list of keywords used to search the

databases, along with the results that they produced are detailed below:

Keyword Results

Refugee 2356

Asylum Seeker 46

Detention Centres 47

Detainees 409

Healthcare needs 105

From the results produced the searches were combined to remove any duplicate

articles. Criteria were then applied to exclude articles which were not relevant to this

topic. The exclusion criteria included those which did not focus on detention and

those published before 2000. Two articles were then chosen for the literature review.

These include:

Article 1: A Comparison of the mental health of refugees with temporary

versus permanent protection visas. (15).

Article 2: Mental health of detained asylum seekers (16).

The CASP tools (17) were used as an aid for critical appraisal.

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Results of Literature Review

Article 1 compares the mental health of asylum seekers granted temporary visas with

refugees granted full leave to remain in Australia. The immigration policy differs

from the UK’s in that asylum seekers, without “valid travel documents” (15) (which,

is often impossible) are mandatorily detained. In this particular study those granted

temporary protection visas (TPV) had on average spent a minimum of 12 months in

detention.

The aims of this study were clearly stated in the introduction. The goal of the

research was mentioned as providing “the first systematic documentation of the

mental health of refugees in Australia who have experienced detention”. The

relevance of this is clearly important as the author claims that since this report was

publicised immigration policies in Australia have been amended “limiting mandatory

detention” significantly.

One of the strengths of this article is that it used those with permanent protection

visas (PPV) as a comparison group, and thus the direct effect that detention can have

on asylum seekers can be seen. The results included a list of 23 living difficulties that

people normally encounter and the percentage of the two groups that suffered from

them. A considerable number of TPV holders (76%) had difficulty accessing

emergency health care compared with only 1% of PPV holders. From looking at this

list of criteria TPV holders experience more stress and suffering than PPV holders, as

evidenced by the fact that a greater percentage of them experience difficulties in their

post migration living conditions.

A possible flaw in the study design is the way in which participants were recruited:

researchers approached a social supportive group where all asylum seekers are

legally required to be referred to and obtained a list of recent entrants from which

they invited people to participate. This could introduce bias because it is probable

that the people who agreed to participate are less likely to have as severe depression

and anxiety compared with those that refused. This would make the findings more

positive than had a randomised sample been taken. So in actuality it is probable that

the health of asylum seekers kept in detention in worse than illustrated.

~ 12 ~


Article 2 examines the effect of detaining asylum seekers post migration on their

mental health in the United States of America (USA). Unlike the former study,

researchers interviewed participants whilst they were still currently detained.

Although the aims of the study are clearly pointed out, no mention is made of why

the study was undertaken or the relevance of the conclusions found.

All participants were accounted for and patients were followed up to assess changes

in their symptoms. Differences between psychological symptoms at baseline and

follow up were markedly different among those released and those kept in detention.

Due to the fact that these interviews were conducted at detention centres,

randomisation of interviewees was not allowed. Instead participants were invited to

participate through local organisations providing free legal representation. This could

potentially introduce bias, because the population interviewed mental health

characteristics might not be a true representation of the asylum seeking population.

Another potential weakness of this study was that no comparison group was used,

when analysing the health of detained asylum seekers, it is difficult to ascertain

which influences are down to the trauma experienced pre migration and what impact

the detention centres themselves can have on their health.

Limitations

There is a limited amount of information and studies looking at asylum seekers’

healthcare needs available, particularly in the UK. These studies were chosen

because they looked at Western countries that were the most similar to the UK

and therefore comparisons could be drawn.

Eliminating selection bias is always going to be difficult when investigating

detained asylum seekers’ mental health because to do so would involve using a

randomised sample, which is virtually improbable in this situation. Making

assumptions of the whole population of detained asylum seekers based on these

reports is therefore likely to introduce inaccuracies.

~ 13 ~


Discussion

Under the Immigration Acts, immigration officers are given the power to detain

asylum seekers “at any stage of their claim” (18) at detention centres. Presently there

are ten removal centres (formally known as detention centres) in the UK (19), of

which Yarl’s Wood is one of the more well known. Removal centres have been

criticized by various agencies as being glorified “prisons run on behalf of the Home

Office” (18). The BIA revealed plans for an extensive expansion of the centres

increasing the total capacity in the UK to 3000 detainees (4). From this it can be

inferred that the immigration department’s policy on asylum seekers is that detention

is the solution.

Immigration Officers are provided with guidance on determining who qualifies for

detention. The criteria include: “evidence of absconding, likelihood of removal from

UK and previous history of non-compliance with requirements of immigration

control” (18) to name a few. The same document states that “there is a presumption in

favour of release rather than detention” (18). In reality these criteria are repeatedly

ignored as evidenced by various ex-detainees’ narratives, that they have “committed

no crime” (20). It is difficult to obtain statistics on the number of people detained

annually due to the fact that “there are no centrally available figures” (20). Similarly

there is no information available on the “average length of detention (20).

There is currently no limit upon the period of time that a person can be detained for,

meaning that some asylum seekers can be held indefinitely. Perhaps what is more

shocking is that a report commissioned by Maternity Alliance found that “pregnant

asylum seekers [as well as] mothers with their newborns” (18) were amongst those

detained when there was no prospect of them being released. The rationale behind

this decision is not made clear to these women, only that they pose a flight risk. One

of the women interviewed astutely questioned: “How can I run away when I have no

baby and no money? Where can I go?” (18)

The United Nations High Commission of Refugees (UNHCR) criticises the BIA over

this practice as this contradicts their advice that “as a general rule the detention of

pregnant women in their final months and nursing mothers, both of whom have

special needs should be avoided” (18). The planned capacity increase of the centres

~ 14 ~


specifically for families, however, portrays that the immigration service plans to

ignore this advice. The number of pregnant women and new mothers in detention is

therefore anticipated to increase in the foreseeable future (18).

What the BIA has not taken into consideration, however, is the impact that this will

have on already inadequate antenatal services. The detainees interviewed by

Maternity Alliance found the health care provision at “best useless and at worse

colluding with the detention centre regime” (18) to the detriment of the patients.

Communication is worsened by the lack of adequate translators provided. Pamphlets

are sometimes provided in local languages, yet a substantial number of asylum

seekers are illiterate (13).

It is a requirement of the removal centres to provide monthly reasons for their

detention to asylum seekers, in reality however, this rarely occurs. Asylum seekers

rarely are given reasons for their detention or explanation for their removal to

another centre. This can lead to damaging emotional consequences, particularly as

families are often broken up with family members not be told where they are going (18).

Research undertaken in the UK examining the health of asylum seekers has

publicised that anxiety and depression disorders are experienced by approximately

two thirds of asylum seekers (13). This is hardly surprising when you consider the

emotional suffering that they must have experienced in the first place, which made

them flee their home country, coupled with the traumatic effect that forced detention

can have on asylum seekers this could seriously inflict long term mental health

problems.

The World Health Organisation (WHO) defines health as “a state of complete

physical, mental and social well being and not merely the absence of disease or

infirmity” (21). From this it can be inferred that just providing access to health care

services is not sufficient, rather the basic determinants of health for example clean

water, nutrition and appropriate housing conditions need to be supplied.

~ 15 ~


Yarl’s Wood Immigration Removal Centre has recently gained a lot of media

exposure for its poor treatment of its detainees particularly young children. The

biggest concerns involve the separation between parents and young children during

the arrest (22). Lack of clear information is also cited as being one of the more

distressing aspects of the arrest (23). Until recently there were reports that Yarl’s

Wood standards of healthcare were terrible. The Children’s Commissioner for

England sanctioned a study recently examining conditions at the centre: it was

revealed that “a child’s arm had been left untreated for more than 24 hours despite

the nurse being informed of the injury”. A doctor from Medical Justice also

complained of an incident where a child with a sickle cell crisis, “was not given

adequate analgesia and was expected to walk” (24) to the treatment facility by the

officers.

This is quite clearly inhumane treatment and is in violation of absolute human rights.

Ultimately the Government needs to realise that these are young children who have

been treated inexcusably by public authorities that the Government themselves have

sanctioned. Asylum seekers are here in this country because a great injustice has

been done to them and for the BIA to turn around and treat them in a similar

degrading manner is deplorable.

Medical Justice published a report; ‘Outsourcing Abuse’ (24) in 2008 highlighting the

appalling medical treatment that detained asylum seekers are forced to endure. The

paper describes in the region of 300 cases of “alleged assault” (25) that has occurred in

removal centres. Immigrants complained of injuries that had “been due to [the] use

of serious and unwarranted force” by the officers. This behaviour contradicts with

the UK’s universal health strategy; Health is Global (24), which stresses the

importance of “improving the health of people across the world and in particular

people in the UK” (24).

The inverse care law was first described in 1971 by Julian Tudor Hart and draws

parallels between the inaccessibility of “good medical health care and [how it is

directly proportional to] the need for it in the population served” (26).

~ 16 ~


Various literature sources complain that the healthcare services provided to asylum

seekers in removal centres are insufficient (24, 25). It is alleged that contracted doctors,

in particular General Practitioners (GPs) have to see detainees in such a short amount

of time that it compromises their medical care (24). Long term care for chronic

illnesses is virtually impossible to maintain due to erratic movement of detainees

from centre to centre, along with misplaced medical records. It is likely that

scheduled childhood immunisations for young asylum seekers are missed due to poor

continuity of care (24). Asylum seekers are amongst a population where the

prevalence of infectious diseases is probably quite high; if children are deported

without receiving these vaccinations it can put them at high risk of contracting

diseases which ultimately can be prevented.

The National Health Service (NHS) Act of 2006 restricts free health care under the

NHS to persons who “are ordinarily resident” (27) in the UK. Whilst trusts are not

allowed to deny emergency care or treatment, they are not required by law to provide

treatment for chronic conditions. This law, however immoral was intended to prevent

failed asylum seekers from claiming free health care. Although it does not apply to

those seeking asylum (i.e. those who are awaiting a decision on their refugee status)

many fall through the gaps and are unable to access health care services. A lack of

clear guidance on providing treatment to asylum seekers by the Department of

Health has meant that it is at the discretion of individual GPs. GPs “have no legal

expertise” (27) in situations such as these consequently leading to inconsistent patterns

of treatment.

The NHS was pioneered as a service providing health care that was “free for all” (28)

in 1948. Its core principle is that a “universal service for all [would be provided]

based on clinical need, not ability to pay” (29). Unlike previously those who were

more underprivileged in society would be able to benefit from health care. Sixty

years later, it seems that this key point has been forgotten and once again society

seems to condemn those who are less fortunate.

~ 17 ~


Conclusion

Asylum Seekers should be treated with dignity, and afforded the same level

of care that other citizens of the UK take for granted. Healthcare services

provided in removal centres are inadequate for the needs of asylum seekers.

Detaining asylum seekers affects their mental and physical health, once

released from detention most see an improvement in their mental health

symptoms. Clearly it is obvious that detention only has negative influences

on asylum seekers.

By not providing statistics on vulnerable groups of people, it means that the

government can potentially keep asylum seekers in detention for a lengthy

amount of time without the public being aware of it.

Recommendations

Nationally:

Studies need to be conducted in the UK looking at the effect that detention

can have on asylum seekers health.

Legislation regarding the maximum amount of time that asylum seekers can

spend in detention should be introduced; and data available on the number of

asylum seekers and the length of time that they spend in detention.

Children should not be kept in detention centres; where this is unavoidable or

cannot be put into place immediately considerable care should be taken to

ensure that physically and mentally that they do not suffer.

Locally:

Since Liverpool is an area where asylum seekers are frequently housed in,

there needs to be more support facilities available to them. Especially as

asylum seekers are forbidden from working, it can become quite isolating for

them, having a centre where they can meet and interact with others can

prevent anxiety and depression.

There should be more free heath care clinics specifically catering for Asylum

Seekers, like the specialist clinics run at the Liverpool Women’s Hospital.

Asylum Seekers have different health care needs from other patients, such as

language barriers. Having interpreters present at these clinics would help

overcome this barrier.

~ 18 ~


Education courses providing asylum seekers with the opportunity to

improve their skills, or convert their degrees into ones that are recognised

by the UK, so that should the opportunity arise where they are allowed to

work they are able to do so.

Reflection

Prior to undertaking this SSM I had no real knowledge of the complexity of

the health of asylum seekers. This project has provided me with a basic insight

into health inequalities, which I hopefully will be able to utilize in my future

medical practice. Perhaps what I found was the most shocking, was how easily

the Government and their policies are influenced by the media.

~ 19 ~


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~ 21 ~


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2009;338:b1614. (http://www.bmj.com/cgi/content/full/338/may01_1/b1614)

[Accessed 1st March 2010].

28. Portillo M. The Bevan legacy. BMJ 1998;317:37-40.

29. Department of Health. NHS core principles. Publications policy and

guidance.

(http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsands

tatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4936325)

[accessed 14th April 2010].

30. General Medical Council. Good Medical Practice: Duties of a doctor.

(http://www.gmc-

uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp) [Accessed 1st

May 2010].

http://www.bmj.com/cgi/content/full/338/may01_1/b1614

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4936325

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4936325

http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp

http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp

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Appendix 1 GMC Duties of a Doctor (30)

Patients must be able to trust doctors with their lives and health. To justify that trust

you must show respect for human life and you must:

Make the care of your patient your first concern

Protect and promote the health of patients and the public

Provide a good standard of practice and care

Keep your professional knowledge and skills up to date

Recognise and work within the limits of your competence

Work with colleagues in the ways that best serve patients’ interests

Treat patients as individuals and respect their dignity

Treat patients politely and considerately

Respect patients to confidentiality

Work in partnership with patients

Listen to patients and respond to their concerns and preferences

Give patients the information they want or need in a way they can

understand

Respect patients’ rights to reach decisions with you about their treatment

and care

Support patients in caring for themselves to improve and maintain their

health

Be honest and open and act with integrity.

Act without delay if you have good reason to believe that you or a colleague

may be putting patients at risk

Never discrimate unfairly against patients or colleagues

Never abuse your patients’ trust in you or the public’s trust in the

profession.

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Appendix 2 Case History

Jack (not his real name) left Africa with his family in 2002 because of political

persecution and came to the UK. He and his wife initially applied for student visas

and were given leave to remain to study. Initially Jack did not want to claim asylum

due to the stigma surrounding asylum seekers, and he and his family had the view

that they would one day return to Africa. They remained on a student visa for 5

years, till they graduated. In September 2008 he applied for asylum and was told that

he would have to appear in person every week to sign a document; this was firstly

done in Liverpool, until he was told he would have to make the weekly trip to

Manchester to sign this paper.

Without receiving notification of any kind, immigration officers came to his house

and told Jack and his family to pack their belongings. Despite never missing a

signing Jack, his wife and two children were taken to a detention centre in Dover.

Initially Jack was separated from his family, later at Tinsley House they were

reunited. The emotional anxiety and stress his children suffered is paramount, one of

the children started wetting the bed having never previously done so.

Jack described a constant feeling of anxiety and distress whilst in detention, he was

particularly afraid that at any given moment they would be separated again. Health

care access, whilst in detention was poor; Jack described an instance where his

children developed rashes that were not taken seriously by the healthcare providers,

in the end they were only administered a small dose of paracetamol.

At the first Court Hearing the Judge declined their release due to the fact they were

not present despite being unable to attend as they were detained. After spending 50

days in detention, his wife and children were released. 3 weeks later Jack had his

next Court Hearing, and was taken to London for it; he was given temporary leave to

remain in the UK as long as his case for asylum is ongoing.

Since being in the community, Jack and his family have received a lot of support

particularly from his child’s school. It was the school that provided psychological

support for the children, whereas accessing help through the GP was difficult.

~ 24 ~


Appendix 3 Article used for Journal Club (14)

Raw deal for Refused Asylum Seekers in the UK by Nayanah Siva

A recent UK ruling that restricts the number of failed asylum seekers who can receive free secondary care has caused concern among campaigners and clinicians. Nayanah Siva reports.

As Refugee Week (June 15—21)—a series of events to dispel negative perceptions of refugees—came to a close in the UK, humanitarian organisations, health professionals, and campaigners remained worried about the fate of failed asylum seekers who fall ill in the country.

In May, the UK Court of Appeal decided that refused asylum seekers were not entitled to free secondary health care in the National Health Service (NHS), enraging many groups who have been fighting for the rights of vulnerable migrants.

Under this new law, doctors and hospitals should charge patients who have failed asylum status; care within accident and emergency departments is free but otherwise free care can only be given when doctors deem cases to be urgent, and for non-urgent cases, it is under the hospitals discretion to provide treatment to patients if they are unable to pay.

In the hearing, Lord Justice Ward said: “the purpose of the National Health Service Act is to provide a service for the people of England and that does not include those who ought not to be here. Failed asylum seekers ought not to be here. They should never have come here in the first place and after their claims have finally been dismissed they are only here until arrangements can be made to secure their return.”

The implications of the court's decision for frontline clinicians in the NHS are complex and the Department of Health is currently working on new guidance. Overall, there seems to be a general consensus of hope among campaigners for an appeal against this recent court ruling.

Hannah Ward, media relations manager at the Refugee Council emphasises that many asylum seekers are not here by choice and that “many people [asylum seekers] are here through no fault of their own, either they can't go home or they are waiting to go home. And there is no reason, that in this time, they [refused asylum seekers] should not be entitled to health care”.

Tom Yates—a medical student who campaigns on the issue of health care for asylum seekers and is currently lobbying for an amendment to the health bill that would restore access to NHS services for refused asylum seekers—reiterates the point and

~ 25 ~


says that “many refused asylum seekers remain in the country whilst they await documentation or because the journey home would be unsafe either for security reason or for health reasons”.

Ward also points out that the number of failed asylum seekers in the country is a “tiny number”. She says there were around 25 000 applications for asylum last year, and the few people whose asylum claims were rejected are not all accessing the NHS anyway. “There may be issues with rich Texan oil barons coming over from the US and getting treatment on the NHS, and how can that be right?…But it has always been baffling to us [the Refugee Council] that refused asylum seekers are included in this group.”

Graham Cooke, a lecturer in infectious diseases at Imperial College London and a practising doctor who has spent most of his clinical time with migrant populations, agrees. He has found that the health system is not “overburdened at the moment by people seeking care to which they are not entitled”. Cooke thinks that hospitals' discretion to treat failed asylum seekers should be used appropriately. “This…is important as doctors, in their role as patient advocates, need to be aware that they can argue for their patients.”

Another concern about this new law is that immigration status is not fixed and it is left to health-care workers to ascertain the immigration status of their patients. Susan Wright, director of Médecins du Monde UK, a medical humanitarian organisation, and manager of Project London—a health-care scheme that provides information and advice to vulnerable people and helps them access NHS and other services—is disappointed by this recent decision by the Court of Appeal. “If the government wants to restrict the number of migrants entering the UK, it has every right to do so. But immigration policies should be enforced at the borders, not in the hallways of our hospitals and the waiting rooms of our GP [general practice] surgeries.” Despite discretion being held by health care providers when it comes to failed asylum seekers, Wright is confident that hospital trusts will understand and recognise that “the earlier the treatment is given, the greater the chance of avoiding costly inpatient treatment and undue burdens on A&E departments”.

Many experts are also concerned about health tourism being unduly tangled up with the issue of failed asylum seekers. Ward points out that the recent decision by the Court of Appeal will not affect those people who have been given asylum because they are entitled to free health care anyway. “Using HIV as an example, if people were coming here and claiming asylum because they were HIV positive and they

~ 26 ~


wanted to claim treatment, they could still do that”, says Ward, “so the health tourism argument is really defunct when it comes to people who have claimed asylum”. Additionally, there does not seem to be any evidence that asylum seekers come here for health care, and the few people who are HIV positive “often do not know and find out once they are here”, says Ward. “A lot of asylum seekers do not know what country they are going to when they leave their own country.”

Wright talks about what she has observed at the London clinic she manages. “Rather than being health tourists, the average patient was here for 3 years before coming to see us.” Katherine Sladden, communications officer at the UK's National AIDS Trust, says, “it is a myth that free treatment for HIV will create a rush of people coming to the UK to access it”. A report written by the charity, The Myth of HIV Health Tourism, published in October, 2008, addresses and clearly refutes any allegations of HIV health tourism to the UK.

Ward is also concerned about the precarious situations that many people who have been turned down for asylum may be in, many “have experienced torture, have experienced rape, and many have mental health needs. These are things we really need to take into account when dealing with this small number of people”. Yates also points out that not treating or assessing patients who may have infectious diseases can also be a risk to the community, “patients present with symptoms rather than diagnoses and it is during investigation [in secondary health care] that communicable diseases are diagnosed. Limiting access [to secondary health care] leads to delayed diagnosis and hence increased periods of infectiousness.”

Even those asylum seekers who would have to pay for secondary health care do not always receive adequate care. Kate O'Donnell, a senior lecturer in primary care research and development at the University of Glasgow, Scotland, UK, thinks there are still “issues about access to interpreters in secondary care and sometimes access to urgent care”.

“Asylum seekers found it more difficult to understand the role of GPs in the system—eg, as gatekeepers and referrers onto secondary care services—mainly because they were unused to this type of system in their own countries.” But despite these difficulties, O'Donnell says that her past research showed that “in general, asylum seekers were pleased with the care they received from the NHS, particularly general practice”.

Ward, however, expresses concern about administrative staff not fully understanding the regulations for asylum seekers' entitlement to health care. The new Court of

~ 27 ~


Appeal ruling applies only to secondary care. But, “there are often GP surgery staff who do not understand the entitlements of people and wrongly turn them away, or they are not allowed to register”, says Ward.

Despite all the negative effects of this recent court ruling, Wright does think there are a few aspects of the decision that are positive. “It is now perfectly clear that treatment which is immediately necessary cannot be withheld, even where a patient is not ordinarily resident. And it is clear that this is a clinical determination that must be made by doctors, not administrative staff.”

Phillip Cotton, a practising GP and senior lecturer in general practice and primary care at the University of Glasgow, is deeply concerned about the new ruling and its effect on patients. “I don't like being taken advantage of, I don't like floodgates, I'm not a good Samaritan, and the practice I work in is not a registered charity, yet I cannot deny people medical care because the law tells me I can't help them.”

~ 28 ~


Appendix 4 Presentation for Journal Club

~ 29 ~


Appendix 5 Poster for Conference

~ 30 ~


Appendix 6 Presentation for Conference

Appendix 7: Global Health Perspective

~ 31 ~


The beginning of the 21st Century marked the beginning of a campaign by the world

leaders to eradicate poverty. The 189 Heads of State that were present at the UN

Millennium Summit in 2000 pledged themselves to target 8 specific goals by 2015,

which when achieved would end poverty worldwide.

These 8 goals have been named The Millennium Development Goals, and are set out

as follows:

The UN Secretary General Ban Ki-moon’s report ‘Keeping The Promise’ declares

that “our world possesses the knowledge and resources to achieve the Millennium

Development Goals, falling short of the goals would be an unacceptable failure,

moral and practical”.

Promoting both Child and Maternal Health amongst vulnerable groups such as

asylum seekers are two such targets that can immediately be implemented here in the

UK. It is a common misperception that many of these goals do not apply to

developed countries such as the UK, as opposed to developing countries such as

Kenya. Every country should look to their national health systems with a view to

elevating the health needs of their populations. Further assistance in the form of a

global partnership can then be provided to lower income countries to assist them.

Another key concept relating to asylum seekers is that of universal education. When

children are shunted around or kept in detention centres it negatively impacts their

~ 32 ~


schooling. Ensuring that children particularly those from poor backgrounds are able

to progress through the school system is vitally important. It is well known that those

with a better education are more likely to do well for themselves later in life.

Ensuring a quality education for ALL children would prevent them from falling into

poverty later on in life.

With the deadline rapidly approaching it is imperative that local communities and

national agencies work in partnership to improve conditions and tack these 8 goals in

the hope of achieving something as momentous as the eradication of poverty

amongst all individuals.

UN Secretary General Ban Ki-moon: “We must not fail the billions who look to the international community to fulfil the

promise of the Millennium Declaration for a better world”.

Appendix 8 Key Resources

~ 33 ~


Key Contacts:

Kieran Lamb Fade Library Regatta House. Brunswick Place. L3 4BL. 0151 285 4493

Dr Carmen Camino LATH Liverpool Associates In Tropical Health 0151 291 7526

Julia Taylor STAR Women’s Group Refugee Action

Sue Robinson HMP Kennet Maghull Liverpool Merseyside L31 1HX

Key Websites:

1. www.unhcr.org

2. www.medsin.org

3. www.refugee-action.org.uk

4. www.refugeecouncil.org.uk/practice/basics/facts.htm

5. www.who.int/

6. www.msf.org

7. www.medicaljustice.org.uk

Books:

1. What Are They Doing Here? A Critical Guide to Asylum and Immigration.

By Peter Fell and Debra Heys

Appendix 9 Timetable

Date Activities undertaken

http://www.unhcr.org/

http://www.medsin.org/

http://www.refugee-action.org.uk/

http://www.refugeecouncil.org.uk/practice/basics/facts.htm

http://www.who.int/

http://www.msf.org/

http://www.medicaljustice.org.uk/

~ 34 ~


Monday 4th January I had my initial meeting with Dr O’Neill, where the outline for this SSM was discussed.

Monday 11th January I visited the Fade library, where I received advice on searching the internet for articles. I spoke to an asylum seeker about his experience of claiming asylum and the effect that this had on his children.

Monday 18th January I met with Dr Camino, who gave a talk on issues surrounding Global Health.

Monday 25th January I visited Asylum Link in Liverpool, where I was given a rundown on how the centre provides support to asylum seekers.

Monday 1st February Visited the School of Tropical Medicine Library to do search for an article to present at a Journal club.

Monday 8th February Attended the Link Asylum Clinic at the Women’s hospital, where I saw several asylum seekers receiving antenatal care.

Monday 15th February I had a meeting with Dr O’Neill, where we gave a short presentation on an article that we had found of interest.

Monday 22nd February I visited STAR women’s group. Monday 1st March I visited HMP Kennet. A tour of the grounds particularly the

medical department was given. I had the opportunity to sit in one of the clinics with the GP.

Monday 8th March I searched the internet for relevant information. The UN and Refugee Council websites contained the most helpful information.

Monday 15th March I visited Asylum Link again to talk to some asylum seekers. Saturday 20th March I attended the Liverpool Conflict and Health conference. Monday 22nd March I read around the subject. Monday 29th March I started doing searches to find journal articles of interest that

could be used in this review using various databases. Monday 5th April I carried out further searches using internet databases, and read

around the subject. I started writing the SSM. Monday 12th April I continued writing the SSM. Monday 19th April The morning was spent writing the SSM. I met up with Laura to

produce a poster for the Health inequalities conference in the afternoon.

Monday 26th April The morning was spent writing the SSM. I met up with Laura to prepare a presentation alongside the poster, this was then practiced.

Tuesday 27th April I attended a conference on Health Inequalities at the Liverpool Medical Institution, where I gave a short presentation on a poster that I had produced.

Monday 3rd May I continued writing. Monday 10th May I continued writing. I had a meeting with Dr O’Neill in the

evening to discuss any problems with the SSM. Monday 17th May I finished the SSM, and then proof read the essay. Monday 24th May I made some last minute changes, and then printed it off and

bound it ready to hand in.

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