British Medical Journal would be a good start. But there is no scope to ask peo- ple to do significantly more—consultants are already working at least 50 hours a week for the NHS, beyond the legal...

British Medical Journal
would be a good start. But there is no scope to ask peo-
ple to do significantly more—consultants are already
working at least 50 hours a week for the NHS, beyond
the legal limit. This is one reason why the government’s
ill conceived seven year prohibition on private practice
has been so widely condemned—it would not affect the
amount of NHS work done. Nor do I agree that bonus
payments for meeting targets are the way forward. We
have all experienced the distortions in good clinical
decision making caused by undue emphasis on reduc-
ing waiting lists. What motivates professionals is quality
of care; the remuneration system should underpin that
motivation, not introduce incentives to pervert it.
The Central Consultants and Specialists Com-
mittee believes that a new contract can deliver bette
quality of care for patients, ensure a reasonable life fo
future consultants, and enable managers to plan and
deliver services more effectively. The committee has
ecently published some proposals for such a contract
and is calling on the government to enter into discus-
sions about it.
Competing interests: None declared.
Asylum seekers and refugees in Britain
Health needs of asylum seekers and refugees
Angela Burnett, Michael Peel
People who are seeking asylum are not a homogene-
ous population. Coming from different countries and
cultures, they have had, in their own and othe
countries, a wide range of experiences that may affect
their health and nutritional state. In the United
Kingdom they face the effects of poverty, dependence,
and lack of cohesive social support.1 All these factors
undermine both physical and mental health. Addition-
ally, racial discrimination can result in inequalities in
health and have an impact on opportunities in and
quality of life.2
Refugees’ experiences also shape their acceptance
and expectations of health care in the United
Kingdom.3 Those from countries with no well
developed primary healthcare system may expect hos-
pital refe
al for conditions that in Britain are treated
in primary care. This can lead to disappointment fo
efugees and i
itation for health workers, who may
also feel overwhelmed by the many and varying needs
of asylum seekers, some of which are non-medical but
nevertheless affect health. Addressing even a few of
these needs may be of considerable benefit.
Previous studies in the United Kingdom have
found that one in six refugees has a physical health
problem severe enough to affect their life and two
thirds have experienced anxiety or depression.4 5
Disentangling the web of history, symptoms—which
may be minimised or exaggerated for a range of
easons—and cu
ent coping mechanisms requires
patience and often several sessions. Medication should
e as simple as possible.
Physical needs
In a study ca
ied out in the United States, 5% of
Koreans and 15% of Cambodians were found to be
positive for hepatitis B surface antigen.6 In Spain, 21%
of migrants from sub-Saharan Africa were chronic
ca
iers of hepatitis B7; hepatitis A and meningitis may
e more prevalent, depending on country of origin.8
HIV prevalence is likely to mi
or that in the country of
origin, although some refugees may have been placed
at particular risk. (HIV/AIDS will be covered in the last
paper in this series.) Benign tertian malaria may not be
seen until several years after a
ival.6
In 1988, 3.4% of refugees a
iving in the United
States had tuberculosis.6 In Britain, new a
ivals
should be screened for tuberculosis at the port of
entry, but in practice only a small proportion is
screened, and tuberculosis in those who apply for asy-
lum after a
ival will not be identified until later. Cur-
ently no screening is ca
ied out at the channel ports
(P Le Feuvre, S Montgomery, personal communica-
tion, 2000), or at cargo ports, where some asylum
seekers may a
ive (P Matthews, personal communica-
tion, XXXXXXXXXXSome areas with large numbers of
efugees have set up screening programmes, but thei
coverage varies. A study in Blackburn of a sample of
1085 immigrants found 11 cases of tuberculosis at the
Summary points
Asylum seekers and refugees are not a
homogeneous group of people, and have
differing experiences and expectations of health
and of health care
Symptoms of psychological distress are
common, but do not necessarily signify mental
illness
Trained interpreters or advocates, rather than
family members or friends, should be used
wherever possible if language is not shared
Community organisations provide invaluable
support and can reduce the isolation experienced
y so many refugees
Particular difficulties which face women are often
not acknowledged
Support for children, especially unaccompanied
minors, needs to be multifaceted, aiming to
provide as normal a life as possible
Education and debate
This is the
second in a
series of three
articles
Medical Foundation
for the Care of
Victims of Torture,
London NW5 3EJ
Angela Burnett
senior medical
examine
Michael Peel
senior medical
examine
Co
espondence to:
A Burnett
a.c.burnett@qmw.
ac.uk
BMJ 2001;322:544–7
544 BMJ VOLUME 322 3 MARCH 2001 bmj.com
port, and a further 40 cases subsequently, of which
seven (17%) were lost to follow up.9 The process is
stigmatising, however, and seems to focus more on
protecting the native population than benefiting the
health of the new a
ivals.10 Refugee health in many
areas in Britain has become the responsibility of com-
municable diseases departments, giving the impres-
sion that refugees are vectors of infection, but refugees
with infectious diseases needing care and treatment
are the minority.
Parasitic diseases may also be found.11 Gastro-
intestinal symptoms were reported by 25% of a group
of asylum seekers in Australia12 and are common in
asylum seekers in Britain, particularly young men.
Helicobacter pylori is commoner in people from poore
countries6; high rates of diabetes, hypertension, and
coronary heart disease are found in people from East-
ern Europe.8 There is also a risk of substance misuse as
a coping strategy.13 Some may have experienced
episodes of malnutrition and poor hygiene and sanita-
tion. Headaches, backache, and non-specific body
pains are common; they may be of musculoskeletal
origin, as a consequence of trauma, muscular tension,
or emotional distress.
Children and adults may be incompletely immu-
nised, from lack of opportunity, and which immunisa-
tions they have received may be unclear (P Le Feuvre,
S Montgomery, personal communication, XXXXXXXXXX
Access to dentists is important, as dental problems are
common.8
Psychological needs
People may show symptoms of depression and anxiety,
panic attacks, or agoraphobia.14 Poor sleep patterns are
almost universal but may not be described spontane-
ously. Some may be anxious and nervous or may
develop behaviours to avoid stimuli that remind them
of past experiences. Problems with memory and
concentration may hinder learning. Many will have
een forced to leave other members of their family
ehind and may not know their whereabouts, or even if
they are alive or dead. The Red Cross or Red Crescent
can help with the tracing of relatives (see box on “use-
ful information”).
Such symptoms are often reactions to refugees’
past experiences and cu
ent situations. Social
isolation and poverty have a compounding negative
impact on mental health,15 as can hostility and racism.2
If medication is indicated, it should be kept to a
minimum. Reducing isolation and dependence, having
suitable accommodation, and spending time more
creatively through education or work can often do
much to relieve depression and anxiety. Positive
changes can be seen as immigrants adjust, are reunited
with families, and take up educational and employ-
ment opportunities.16 But there are many ba
iers pre-
venting people from rebuilding their lives.
Many refugees wish to tell their story, which in itself
may be therapeutic,17 but it should not be assumed that
people must go through this in order to recover,18 as
some find it extremely distressing. Every culture has its
own frameworks for mental health and for seeking
help in a crisis.19 Mozambican refugees describe forget-
ting as their usual cultural means of coping with
difficulties. Ethiopians call this “active forgetting.”20
Counselling
Counselling may be an unfamiliar concept for many
efugees who are not accustomed to discussing thei
intimate feelings with a stranger outside the close family
circle.21 Counselling is cu
ently a Western-orientated
concept; its usefulness depends on an individual’s socio-
economic background and cultural orientation (V
Nguyen-Gillham, personal communication, 2000), and
for it to work, a trust building and befriending
elationship must develop first. Informed consent is the
first step to building trust, and clinicians need to explain
their way of working and the rationale for using talking
as a medium for potential healing (N Patel, personal
communication, XXXXXXXXXXAssistance with practical matters
may also help to develop trust. Counselling can be help-
ful if it is culturally sensitive to the needs of ethnic
minorities; in this respect it can be useful if members of
efugee communities develop counselling skills.22
Isolation
Refugee community organisations are invaluable in
supporting refugees and acting as advocates. They can
provide information and orientation and reduce the
isolation experienced by so many refugees.23 In a study
of Iraqi asylum seekers in London, depression was more
closely linked with poor social support than with a
history of torture.24 Informal groups, structured in a cul-
turally familiar way, can be a useful way of sharing expe-
iences and ways of coping and making sense of past
experiences.25 It is important for refugees to develop
ongoing links and friendships with people in the host
community as well as making contact with people from
their own countries,26 and the best mental health
outcomes may be achieved in this way.27 Many
community and religious organisations have welcomed
efugees. Recent hostile media headlines and comments
from politicians, however, have not nurtured good
elationships, and there has been an increase in negative
feelings towards refugees and consequent racist attacks
on them.28
Communication
It is important to for the services of a trained advocate
or interpreter to be available unless patient and
Mental health projects for refugees, such as this one in east London, help reduce social
isolation and stress
K
A
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N
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B
IN
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F
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Education and debate
545BMJ VOLUME 322 3 MARCH 2001 bmj.com
health worker speak the same language. Refugees may
ing a family member or friend to interpret. Though
this may help in obtaining background information, it
may result in inaccurate interpreting and also make it
difficult to discuss sensitive issues such as sexual health,
gynaecological problems, sexual violation, domestic
violence, or torture. Using children to interpret may
place inappropriate responsibilities on them.
Using the same interpreter for all consultations can
help the development of trust, but exiled communities
may polarise into groups reflecting conflicts in the
home countries and not every interpreter will be
universally trusted. Interpreters and advocates can
provide valuable information for health workers on
cultural and other relevant issues. Telephone interpret-
ing can be useful when there are no local interpreters.
Also, health workers may need training in working with
interpreters.
Information on health
Information about health services needs to be in
elevant languages, and some culturally appropriate
examples are available