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06 April 2004

Illness in Africans resulting in referral to hospital in Scotland. What services are available for migrants and asylum seekers?

Introduction

Travel related illnesses affect a large proportion of travellers from Scotland to developing countries1. These events often necessitate diagnosis and treatment by a clinician either abroad or on return. Similarly incoming travellers such immigrants can arrive with existing conditions for which treatment is required.

This report summarises data for African nationals presenting to infectious disease clinics in Scotland and is discussed in the context of health-care provision for asylum seekers, refugees and other immigrants. This is a summary of a recent presentation at the Africa European Conference on Travel Medicine (AECTM) in South Africa.

Methods

Data on attendances at infection or tropical disease units in Scotland have been collected since 1998. Data on those attending who were of African origin was extracted for study, being 55 patients.

Results

Of the 55 attendees of African origin, 38 attended Gartnavel Infectious Disease Unit. Countries of recent travel of the patients included Nigeria (11), Ghana (eight), Kenya (six), Congo (five) and Malawi (five) as well as individuals from the Ivory Coast and Somalia.

Infections diagnosed included falciparum malaria 17 (31%), vivax / mixed malaria infections, four (7%), tuberculosis nine (16%), schistosomiasis six (9%), and HIV infection six (11%). All patients with HIV infections appeared to be ignorant of their status prior to referral. None had been on anti-retroviral therapy and therefore had a more advanced illness than would have been expected for UK residents. There was one death. Of 28 patients with malaria, eight had received treatment in their home countries for the same illness and four had had more than one episode in the previous year. Other concurrent identified illnesses included sickle cell anaemia, intestinal helminths, renal failure, infected arthropathy, cardiomyopathy, abscesses, and infected bites.

The reasons given for coming to Scotland included tourism, employment, education, family as well as refugee/asylum status. Only Glasgow recorded refugee status with eight (21%) of the 38 patients seen over this period being refugees or asylum seekers.
In refugees, persisting psychological trauma and injuries from previous physical violence -manifesting itself in nightmares, distrust and fear- often outweighed the primary reason for referral.

Discussion

As of 2003 there were estimated to be 20 million uprooted persons worldwide of which, 10.4 million were refugees, 1.0 million were asylum seekers and 5.8 million were internally displaced persons*. The number of refugees fell by almost 2 million from 2002 principally because of the return of Afghans from Pakistan and Iran. The major refugee hosting countries were Iran (1.3 million), Pakistan (1.2 million) and Germany (980,000).

Many asylum seekers are families with children fleeing violence and persecution in their own countries2, forced to leave their country illegally, leaving papers and possessions behind (three). On arrival they are moved to one of several locations within the UK of which Glasgow is one. Their stay is limited while their applications are processed on the merit of their individual cases. In Glasgow asylum seekers are housed in properties for which there is no waiting list or in private housing. Until refugee status is granted asylum seekers are not allowed to work and they receive 70% of UK benefits. Upon the granting of refugee status they still have to apply to the Home Office for permission to work.

Historically, Scotland has received immigrants from Russia, Italy and Poland, as well as Ireland. More recently Asian and African migrants have settled in the country, with a current Asian population of 75,000 and an African population of 15,000 persons.

With respect to recent asylum applications, immigrants to the UK are arriving from more than 60 nations, speaking 80 languages. All seek a haven from conflict or persecution by reason of race, religion, nationality, social group or political opinion. Around 10,500 refugees have settled in Glasgow area alone. A survey of 5907 heads of households found that 30% of these came from 33 nations in the African continent, with 26% and 16% of heads of households coming from Europe and Asia, respectively2.
Considering the size of the African migrant population in general, and asylum seekers in particular it was surprising that only eight asylum seekers/refugees were referred to the Glasgow Infectious Disease Unit. Among a variety of contributory factors, this may be explained by the fact that the majority of immigrants are free of severe infections on arrival; while psychological trauma before, during and after the asylum process may also be a more immediate, subjective concern. Alternatively, diagnosis and treatment of infectious disease may be carried out in the community, as opposed to infectious disease clinics, where it is unclear whether there expertise in the primary care setting to diagnose and treat conditions uncommon in the UK.

In Scotland, services are in place to help asylum seekers access specific health services and reduce social exclusion. The Scottish Asylum Seekers Consortium ensures that each refugee is registered with a General Practitioner within his or her local area. At the last count 10434 asylum seekers or refugees were registered with GP practices in Greater Glasgow.

The future

As the national surveillance centre for Scotland, SCIEH hopes to gain an understanding of the prevalence of infectious/other diseases among migrants to ensure that health needs of the migrants are being met promptly and effectively, and are working in collaboration with other agencies, including the National Resource Centre for Ethnic Minority Health, on the development of educational resources and surveillance systems.

This small study was primarily observational. The use of WHO ethnic nomenclature did not prove to be ideal in identifying nationality. While not intended to be a comprehensive study the simple questionnaire used proved unsuitable for in-depth analysis. A more effective process that is compatible with other international systems is being developed.

References

  1. Redman et al. (2004). Adverse events among travelers to Asia, Africa and South & Central America from Scotland. FC 5.3. AECTM, South Africa.
  2. CoSLA Refugee & Asylum Seekers Consortium.Number of Asylum Seekers Living in Glasgow. http://www.asylumscotland.org.uk/media_stats_nationalitygla0308.php. Accessed 02/04/04
  3. UNHCR (2003) Refugees by Numbers. United Nations High Commission for Refugees.
  4. CoSLA Refugee & Asylum Seekers Consortium.Asylum Facts. http://www.asylumscotland.org.uk/media_facts.php. Accessed 02/04/04
  5. CoSLA Refugee & Asylum Seekers Consortium.Asylum Myths. http://www.asylumscotland.org.uk/media_myths.php. Accessed 02/04/04

* Definitions

Asylum seeker: Persons seeking sanctuary in a second state who have yet to be recognised as bona fide refugees

Refugee: Persons outside their own country given refugee status

Internally displaced persons: Persons caught in similar situations to refugees but who have stayed in their own country

Returnees: Refugees returning home

Eleanor Wilson, Chris Redman, Alice Maclennan and Eric Walker SCIEH; Ann McDonald National Resource Centre for Ethnic Minority Health

Author(s): Wilson E, Mcdonald, A, Redman C A, Maclennan A, and Walker E Vol: 38 No: 14 Year: 2004 Page:

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