Fifteen years ago I came to the United Kingdom as a political refugee from Eritrea. I remember feeling extremely vulnerable. I had lost my home, my family, my friends, my job, and my social status. I knew nothing about the healthcare or social welfare systems, and, even though I had the advantage of a good education and spoke English, it took me a long time to understand them. I received no information about the health service and was not invited to register with a general practitioner. Despite coming from an area with a high prevalence of tuberculosis I was not offered a health check on arrival.
Eighty five per cent of refugees in the United Kingdom live in London
My experience is certainly not unique. There are over 48 million refugees in the world today. The majority seek protection in neighbouring countries, largely in Africa and Asia, but an increasing number are coming to western Europe, including refugees from former eastern European countries. There are now over 300 000 refugees in the United Kingdom, and there has been an increase in the number of people applying for asylum each year—from fewer than 2000 in the mid-1980s to more than 40 000 in 1997.
In common with most western European countries and the United States, the United Kingdom requires asylum seekers to demonstrate that they have been personally targeted for persecution in order to quality for refugee status. This strict interpretation of the 1951 United Nations convention on the status of refugees is reflected in a high refusal rate. In 1997, 76% of applications were rejected.
Refugees face health problems similar to those of other deprived and ethnic minority communities, as well as specific health problems from the physical and mental after effects of displacement and social isolation, war, and sometimes torture, and communicable diseases, of which tuberculosis is the most important. The growing scale of the problem has prompted the European Commission to look at refugees' health needs, and its report will be released in the autumn.
It is estimated that 85% of refugees in the United Kingdom live in London, but local services are often poorly equipped to meet their health needs. From the moment they apply for asylum, refugees are eligible for health care under the NHS. However, poor knowledge of the system and language barriers limit their access to services. Interpreters are often unavailable, and even when they are present it can be impossible for refugees to explain complex health and social problems during a brief consultation.
More than half of the cases of tuberculosis in London occur in people born outside the United Kingdom, but the current screening system reaches only a small minority of new entrants. About a half of asylum seekers declare themselves on entry and are given a medical examination and a chest x ray examination. Only a quarter of these are notified to the consultant in communicable disease control in the health authority of intended residence, and only a small fraction are followed up to rule out tuberculosis.
Not only is this process flawed, it is also stigmatising. It has more to do with protecting the indigenous population from an infectious hazard than promoting the health of new arrivals. What is needed is a better way of identifying them and a more comprehensive health assessment that includes an introduction to health services and an explanation of their rights and responsibilities.
Although the arrangements in London are far from ideal, the city does have the advantage of a long history of settlement by new immigrants. Health and social care providers have made efforts to develop services to meet the health needs of refugees, and there is a network of informal support among the diverse cultures in the city. The 1999 Asylum and Immigration Bill, which is going through parliament at present, proposes to disperse refugees to other parts of Britain and to substitute income and housing benefits for vouchers and support in kind.
Although income and housing are priorities for refugees, a sense of community is also important. There is a risk that they will choose to return to London even at the expense of living outside the official welfare support system, which would compound the effects of deprivation and leave health and social services to deal with the resulting poverty, unemployment, overcrowding, and homelessness.
Refugees' health is discussed in a report from the Health of Londoners Project which was published earlier this year. This makes recommendations about facilitating registration with primary care, strengthening translation and advocacy services, and improving initial health assessments.
As long as there are conflicts in the world and as long as the divide between the rich and poor countries exists, people will continue to flee persecution and poverty. I hope that we are able to treat them with care and dignity.