 
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Journal of the New Zealand Medical Association,
23-August-2002, Vol 115 No 1160
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
The health status of asylum seekers screened by Auckland
Public Health in 1999 and 2000
Mark Hobbs,
Catherine Moor, Tony Wansbrough
and Lester Calder
In addition to the 750 prearranged quota refugees that New
Zealand accepts annually, approximately 1500 to 1800 applications for refugee
status are made to the New Zealand Immigration Service each year by those
spontaneously arriving in the country seeking asylum (personal communication, N.
Wong, New Zealand Immigration Service, 4 March 2002). These asylum seekers have
often fled situations that carry the same risk of physical injury, disease and
psychological trauma as those of quota refugees. Whilst only 20–30% of
these asylum-seekers will eventually gain residency as refugees, New Zealand has
a moral obligation to provide them with adequate health care in the months to
years it can take to process their claims. The majority of asylum seekers
entering the country remain in the Auckland
area.1 In contrast to the quota refugees, who
automatically receive comprehensive medical screening and care at the Mangere
Refugee Resettlement Centre, asylum seekers live in the community and their
health screening is voluntary.
Those who declare their intention to seek asylum at Auckland
airport are invited to attend free health screening with the Auckland Public
Health Service. They are considered high priority for screening because they are
likely to have lived under prolonged conditions of hardship with limited access
to health care. Others enter the country on a visa for some other purpose and
declare to a lawyer in New Zealand their intention to seek asylum. They hear of
the screening service by word of mouth.
Screening is carried out by doctors and includes a medical
history, physical and psychological examination, forensic examination, screening
tests, and referrals to a general practitioner and possibly secondary services.
The screening service is independent from the refugee-status application process
and does not affect it.
We report here key findings from this screening programme
for the period 1999–2000 in the hope that this will allow the complex
health needs of this group to be better understood and met by New Zealand
healthcare providers.
MethodsThe files of patients attending
the Auckland Public Health Protection Asylum Seekers Screening Clinic at Green
Lane Hospital between 1 January 1999 and 31 December 2000 were reviewed. Data on
the stated nationality, age, gender, degree of English spoken, reporting of
psychological symptoms and referrals made, were transcribed onto data sheets.
Results of Mantoux tests, chest X-rays, selected screening blood tests and
faecal testing for parasites were recorded. A Mantoux result ≥ 10 mm was
considered
positive.2
The blood test results included full blood count analysis, haemoglobinopathy
screening, ferritin levels, schistosomal serology, and presence of treponemal
antibodies, hepatitis B surface antigens and antibodies, hepatitis C antibodies,
rubella antibodies, and HIV antibodies. Parental recall of children’s
immunisation status was recorded (full, partial, nonexistent or unknown).
Labplus or Diagnostic Medlab laboratory parameters, as printed with each result,
were used to determine the normality of blood tests. Data were analysed using
Epi Info
2000.3
Relative risks (RR) and 95% confidence intervals (CI) were calculated for
exposures, with corresponding p
values.
ResultsNine hundred people received health
screening at the Auckland Public Health Protection Asylum-seeker Screening
Clinic in 1999 and 2000.
Table 1. Demographic characteristics in screened asylum
seekers, Auckland, 1999–2000
Six hundred and twelve subjects were male (68.1%) and 287
were female (31.9%). Gender was not recorded for one person.
The nationalities and age groups of attendees are recorded
in Table 1.
Clinic doctors felt 243 (27.0%) asylum seekers had a command
of English sufficient for a medical consultation without the aid of an
interpreter, while 561 (62.3%) asylum seekers did not. For 96 (10.7%) asylum
seekers this information was not recorded.
Symptoms, or history of symptoms, of psychological illness
were reported by 345 subjects (38.4%). In comparison to all other nationalities,
Iranians were more likely to report psychological symptoms (RR 1.5, 95% CI 1.2
to 1.7, p=0.001). Those under 20 years of age were less likely than adults to
report such symptoms (RR 0.21, 95% CI 0.15 to 0.30, p<0.001). One hundred and
seventy seven people (19.7%) were referred to some form of continued counselling
or psychiatric care. Men were more likely to be referred than women (RR 1.7, 95%
CI 1.2-2.3, p=0.002).
Rates of positive infectious disease serology in the
screened population are shown in Table 2.
Table 2. Infectious disease serology results in
screened asylum seekers, Auckland, 1999–2000
Ab = antibodies; Anti HBs = antibodies to hepatitis B
surface antigen; Anti HCV = antibodies to hepatitis C virus; HIV Ab = Human
Immunodeficiency Virus antibodies
Eight hundred and sixty nine people (96.9%) had a Mantoux
skin test, of whom 316 (36.4%) had a result of 10 mm or more. Anti-tuberculous
chemoprophylaxis was prescribed for 160 people (18.4% of those Mantoux tested).
Seven hundred and eighteen people (79.8%) had a chest X-ray, of which 4 (0.6%)
were reported to be suspicious for active tuberculosis, 26 (3.6%) showed signs
of old tuberculous infection and 688 (95.8%) reportedly showed no evidence of
tuberculosis. Serial chest X-ray monitoring was arranged for 132 people (18% of
the cohort). Twelve people received full multi-drug treatment for tuberculous
disease, including 4 with active disease on chest X-ray and 8 whose chest X-ray
suggested old tuberculosis but who were considered by a chest physician to
warrant treatment.
Giardia lamblia
infection was detected in 52 people (5.7%).
Ascaris lumbricoides ova were found in
the faecal specimens of 32 people (3.6%). Twenty people (2.2%) were found to be
infected with hookworm, 13 of whom were Sri Lankan (RR 10.3, 95% CI 4.2 to 25.2,
p<0.001). Hymenolepis nana infection
was found in 15 people (1.7%). Blastocystis
hominis was found at pathological levels in the faeces of 7 people
(0.8%). Afghans were found to be at an increased risk of carriage of gut
parasites in comparison with other nationalities: RR 3.0 (95% CI 1.7 to 5.1,
p<0.001) for Giardia lamblia; RR
18.4 (95% CI 8.1 to 41.8, p<0.001) for
Ascaris lumbricoides; and RR 20.7 (95%
CI 5.9 to 72.3, p<0.001) for Hymenolepis
nana.
None of the study subjects was affected by a
haemoglobinopathy to the extent they had a clinical disease. However, the
carrier state for alpha and beta thalassaemia and the heterozygous states for
HbS and HbE were found as recorded in Table 3.
Table 3. Blood-related pathology in screened asylum
seekers, Auckland, 1999–2000
Parents reported for those 18 years and younger, that 94
(36.2%) had been previously “fully immunised” according to the
immunisation schedule for their country of birth, 6 (2.3%) had received no
immunisations, 64 (24.6%) had been “partially immunised”. For 96
(36.9%) immunisation status was unknown.
Five hundred and eighty nine patients (65.4%) were referred
solely to a general practitioner, following health screening, for ongoing
medical care. Eighteen people (2.0%) were not noted to have been referred to any
further services. Two hundred and ninety three people (32.6%) were referred to
services in addition to a general practitioner, as recorded in Table
4.
Table 4. Referrals to services other than a GP for
screened asylum seekers, Auckland, 1999–2000
* Less than 1% of the cohort was referred to each of
the following: Red Cross Family Tracing Service (8 referrals), Ophthalmology (7
), Orthopaedic Surgery (6), Sexual Health Clinic (6 ), Neurology (5), Inpatient
Psychiatry (4), Otorhinolaryngology (4), Obstetrics (3), Orthotics (2),
Paediatric Infectious Diseases (Starship Children’s Hospital) (2),
Paediatric Surgery (2), Urology (2), Auckland City Mission (1), Community Child,
Adolescent, and Family Service (1), General Surgery (1), Neurosurgery (1),
Paediatric Haematology/Oncology Clinic (1), Psychiatric Crisis Team (1), Speech
Language Therapy (1).
DiscussionReview of the asylum-seeking
population that attended the Auckland Public Health Protection Asylum Seekers
Screening Clinic in 1999 and 2000 reveals important demographic characteristics
of this group that may assist service planning.
More than two thirds of attendees were male and greater than
88% of attendees were under 40 years of age, reflecting perhaps the sectors of
society more willing or able to journey to unknown circumstances in a foreign
land. A similar gender distribution was found in applications received by the
Refugee Status Branch of the Immigration Service in the 1998/1999 and 1999/2000
fiscal years, suggesting gender is not a specific barrier to accessing the
clinic screening service.4
In the calendar years 1999 and 2000, 3349 people applied for
refugee status (personal communication, N. Wong, New Zealand Immigration
Service, 4 March 2002), but only 900 people (27%) attended the voluntary
screening clinic. One reason asylum seekers may be reluctant to attend voluntary
screening is due to fears that any findings could adversely affect their refugee
status application.5 Others may not have been
aware of the clinic’s existence; only 627 people declared their intention
to apply for refugee status on arrival at New Zealand airports in the years 1999
and 2000 (personal communication, N. Wong, New Immigration Service, 4 March
2002) and it is at this time that asylum seekers are given details of the
clinic. It is difficult to assess the extent to
which these selection biases may have affected the generalisability of our
findings to all asylum seekers.
Awareness of the major nationalities represented amongst
those seeking asylum in New Zealand is important so that services can be
culturally appropriate and thus more likely to be effective. In the period of
this study, almost half the asylum seekers screened were from countries in the
Middle East. In contrast to the more sizable proportion amongst quota refugees,
only 13.4% of screened asylum seekers were from African countries. Asylum
seekers from Sri Lanka and Czechoslovakia each comprised about 15% of the total
asylum seekers screened in the years 1999–2000.
The significant burden of infectious disease found in asylum
seekers reflects high incidence in their countries of origin. The prevalence of
tuberculosis (TB) in the screened group was equivalent to 1333/100 000 while the
prevalence of active TB in New Zealand (assuming a duration of 12 months for
each case) would be approximately equal to 12.4/100 000 in 1999, and 9.9/100 000
in 2000.6 For this reason screening is
indicated, for the benefit of those seeking asylum and the protection of the
communities in which they settle. Vigilance for TB amongst healthcare
professionals is important, as TB-infected refugees and asylum seekers can
develop active TB disease long after
screening.7,8
HIV infection is an important public health issue. Only 1.1%
of screened asylum seekers tested positive for HIV. However asylum seekers and
refugees contributed 21.1% of new HIV diagnoses in New Zealand in 1999, and
17.4% in 2000 (personal communication, N. Dickson, AIDS Epidemiology Group, 21
June 2002). Education regarding ‘safer sex’ practices for infected
people and their communities is of public health importance.
The non-infectious conditions of alpha- and
beta-thalassaemia traits, sickle cell trait and HbE heterozygosity were also
found at high rates in the screened asylum seekers, in keeping with the
relatively high prevalence of these genetic defects in many of the asylum
seekers’ countries of origin. For this reason screening is important,
particularly for couples planning to conceive, as the homozygous form of many of
these conditions causes significant morbidity. New Zealand healthcare providers
will need to be increasingly mindful of these conditions in their clinical
practice.
Psychological symptoms were reported by 38.4% of those
screened, indicating this is a marked problem faced by the asylum-seeking
community. Reeve reported in his dissertation on quota refugee screening that
14% of those screened described significant psychological
symptoms.9 Psychological symptoms may be more
prevalent in the asylum-seeking community than amongst quota refugees due to a
greater sense of uncertainty about their future. Also, quota refugees often
arrive with their families but asylum seekers often worry about family left
behind. The course of events after refugees and immigrants enter their host
country can have a more profound impact on their mental health during
resettlement than events before migration.10
Nearly one fifth of all those screened were referred to counselling services,
although it must be remembered that counselling is a Western-orientated concept
and may not be accepted by some asylum
seekers.11 Those not referred for counselling
were managed by Public Health in conjunction with Community Mental Health
Services. Social support needs were managed in a variety of ways including
Plunket Society input for families, advice on language courses, provision of
material necessities (blankets, food vouchers, access to benefits), advice on
tracing missing family members, and advice and reassurance about legal
process.
Communication difficulties as a barrier to healthcare for
refugees and the need for accessible interpretation services in primary care
have been previously highlighted in New Zealand
research.12 The majority of asylum seekers in
this group were felt by the screening doctor to require an interpreter in the
consultation setting. This service, however, is not available free of charge to
asylum seekers for any subsequent primary care consultations in the Auckland
region, although it is in other parts of the country. Access to English language
training is important because it can decrease the duration of asylum
seekers’ reliance on interpreter services.
Immigrant communities in New Zealand have special healthcare
needs, as shown by the high prevalence of conditions discussed in this article,
as well as experiencing language barriers, cultural differences and economic
difficulties. Appropriate levels of funding are needed to address these issues
in a timely fashion. Awareness by healthcare providers of the issues addressed
in this article is also necessary, for the provision of better care to this
group.
Author information:
Mark Hobbs, Medical Student; Catherine Moor, Public Health Medicine
Registrar; Tony Wansbrough, Medical
Officer; Lester Calder, Public Health Medicine Specialist; Auckland Public
Health Protection Service, Auckland District Health Board
Correspondence:
Lester Calder, Public Health, Community Services, Auckland District Health
Board, Private Bag 92 605, Auckland. Fax: (09) 630 7431; email: lesterc@adhb.govt.nz
References:
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|