Issues in palliative care for refugees and asylum seekers

Refugees and asylum seekers are forced migrants. [1] The United Nations High Commissioner for Refugees (UNHCR) estimates that in 2012 there were 23,000 people on average a day forced to leave their homes and seek protection as a result of conflict or persecution, with 46% of these, children. [2]

A refugee is defined by the 1951 United Nations Convention as a person who 'owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside of the country of his nationality and is unable or owing to such fear is unwilling to avail himself of the protection of that country'. [3]

Refugees have a lawful right to enter a country for the purposes of seeking asylum, regardless of how they arrive or whether they hold valid travel or identity documents. [4] An asylum seeker is a person whose application for asylum or refugee status is pending in the administrative or legal processes. [5] Australia received 13,770 humanitarian entrants in 2009-10. Refugees may have been granted permanent residency with free access to services, whereas those claiming asylum in Australia (after arrival) may have restricted entitlements dependent upon visa categories. [6] These regulations are changing.

Literature on the health of Asylum Seekers and Refugees may not be easy to find. The relevant literature may be found using terms such as ‘multicultural’ rather than their immigration status.

Considerations when providing care

Asylum seekers and refugees will differ in their country of origin, their reasons for leaving, their socio-economic status and healthcare needs. [7] There are many reasons why people flee their home country. Some will have been exposed to violence, threats, conflict, natural disasters, war or political instability. [8] They may have been subject to human rights violations such as torture (physical or psychological), rape or persecution.

There are many challenges faced by refugees and asylum seekers. Some will have spent many years in refugee camps or have spent time in detention. Often they have had little or no healthcare access, either in their country of origin or in the country they subsequently fled to, an experience shown to have negative health outcomes. [9,10] Many will have come from low-income countries, with high prevalence of diseases such as TB, HIV/AIDS and Hepatitis B. [11]

Asylum seekers and refugees have also lost their housing, income and position in society, employment, social support systems, cultural norms, religious customs and language. Many will have suffered psychological trauma through the death or separation of family. They may not know the whereabouts of family or friends, or even if they are alive. [5] Many will find it difficult to adjust to life in a new country after a prolonged period as a refugee. They may also face hostility when trying to re-settle into new communities. [12] Loneliness and grief are often key issues. [13]

Common issues in practice

High priority conditions for refugees and immigrants have been found to be abuse and domestic violence, anxiety and adjustment disorder, depression, diabetes, torture and PTSD, intestinal parasites, and dental caries. [14] Some refugees are educated middle-class people, where higher rates of obesity, hypertension, coronary artery disease, diabetes and anaemia have been found. [4,7]

Asylum seekers and /or refugees may therefore suffer from both long and short term health sequelae. This could be in the form of increased risk of mental illness, PTSD, anxiety and depression or complicated grief. [15] Psychological distress may also be increased if their immigration status is uncertain. Those who have been subjected to torture may also have ongoing medical conditions, disabilities and pain. [16]

Implications for health professionals include acute illness and disease that may need to be addressed. There is likely to be a lack of medical history or records, and the health screening that occurs prior to arriving in Australia is focused on public health screening rather than individual risk factors and the harsh conditions of deprivation that many have been exposed to. During the determination process, access to Medicare and the PBS may be absent or restricted. The costs of medication in the community may therefore be an issue. Hospital and hospice admissions are covered.

For health professionals there may also be a lack of familiarity with some of the health issues of refugees and asylum seekers and the diseases that they are presenting with. Across Australia, each state and territory has responded slightly differently to address the health needs of newly arrived refugees. In some states there are specialised primary health care refugee clinics performing comprehensive health checks on all newly arrived refugees, while in others they are referred directly to General Practitioners who may refer to specialists at public hospitals as appropriate. There are Medicare Benefits Schedule health assessment items for refugees and other humanitarian entrants. [17]

Language barriers create communication difficulties which may mean delays in diagnostics and in timely care. The use of interpreters in very important and cultural competency and sensitivity training can help in part to improve the needs of increasingly diverse populations. [1,17]

In the longer term, there are health promotion and prevention implications. Monitoring of chronic diseases such as Hepatitis B may be required, and for those such as torture survivors, referral to a specialised mental health service may be needed for ongoing care. The literature demonstrates that those with a history of torture may continue to have pain or psychiatric disorders years or even decades following their migration to Australia. [18-19]

Refugees and Asylum Seekers usually lack knowledge of the Australian health care system. They may have unrealistic expectations of the health system based on their previous experience. [20] The effect of the migration determination process within Australia and the uncertainties of this process may in itself have major psychological and psychiatric impact on wellbeing.

There may be issues of trust with people in authority, including health professionals, as they may have been involved in the administration of torture in their country. If they have been tortured or raped in the past they may not tolerate medical examinations or procedures. [5]

  1. Wahoush EO. Reaching a hard-to-reach population such as asylum seekers and resettled refugees in Canada. Bull World Health Organ. 2009 Aug;87(8):568. doi: 10.2471/blt.08.061085.
  2. United Nations High Commissioner for Refugees (UNHCR). Displacement, the new 21st Century Challenge: Global Trends 2012 (2.41MB pdf). Geneva: UNHCR; 2013.
  3. United Nations High Commissioner for Refugees. Refugees [Internet]. 2014 [cited 2014 June 10].
  4. Mehrab N. Understanding the ‘boat people'. Psychotherapy in Australia. 2011 Feb;17(2):62-3.
  5. Harris M, Zwar N. Refugee Health (193kb pdf). Aust Fam Physician. 2005 Oct;34(10):825-9.
  6. Correa-Velez I, Johnston V, Kirk J, Ferdinand A. Community-based asylum seekers’ use of primary health care services in Melbourne. Med J Aust. 2008 Mar 17;188(6):344-8.
  7. Dookeran NM, Battaglia T, Cochran J, Geltman PL. Chronic disease and its risk factors among refugees and asylees in Massachusetts, 2001-2005. Prev Chronic Dis. 2010 May;7(3):A51. Epub 2010 Apr 15.
  8. Stige SH, Sveaass N. Living in exile when disaster strikes at home. Torture. 2010;20(2):76-91.
  9. Sweet M. Call for action on asylum seekers’ health. Aust Nurs J. 2007 Apr;14(9):16-8. (102kb pdf)
  10. Davidson GR, Carr SC. Forced migration, social exclusion and poverty: Introduction. J Pac Rim Psychol. 2010 May;4(1):1-6.
  11. Pottie K, Janakiram P, Topp P, McCarthy A. Prevalence of selected preventable and treatable diseases among government-assisted refugees Implications for primary care providers. Can Fam Physician. 2007. Nov;53:(11):1928-34.
  12. Pieper HO, Clerkin P, MacFarlane A. The impact of direct provision accommodation for asylum seekers on organisation and delivery of local primary care and social care services: A case study. BMC Fam Pract. 2011 May 15;12:32.
  13. Strijk PJ, van Meijel B, Gamel CJ. Health and social needs of traumatized refugees and asylum seekers: an exploratory study. Perspect Psychiatr Care. 2011 Jan;47(1):48-55. Epub 2010 Aug 12.
  14. Swinkels H, Pottie K, Tugwell P, Rashid M, Narasiah L. Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions. CMAJ. 2011 Sep 6;183(12):E928-32. Epub 2010 Jun 14.
  15. Rauchfuss K, Schmolze B. Justice heals: The impact of impunity and the fight against it on the recovery of severe human rights violations’ survivors. Torture. 2008;18(1):38-50.
  16. Bandeira M, Higson-Smith C, Bantjes M, Polatin P. The land of milk and honey: A picture of refugee torture survivors presenting for treatment in a South African trauma centre. Torture. 2010;20(2):92-103.
  17. Smith M, Lo W, Bindr J. Prescribing for refugees. Aust Prescr. 2013;36(5):146-7.
  18. Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental Health of Cambodian refugees 2 decades after resettlement in the United States. JAMA. 2005 Aug 3;294(5):571-9.
  19. Prip K, Persson AL, Sjolund BH. Self-reported activity in tortured refugees with long-term sequelae including pain and the impact of foot pain from falanga – a cross-sectional study. Disabil Rehabil. 2011;33(7):569-78. Epub 2010 Jun 8.
  20. O’Donnell CA, Higgins M, Chauhan R, Mullen K. Asylum seekers’ expectations of and trust in general practice: a qualitative study. Br J Gen Pract. 2008 Dec;58(557):e1-11.

Last updated 20 August 2021