Healthcare for refugees
For one section of society the difficulties they face looking after their health can be enormous and the health service is straining to respond to their needs. Ireland's burgeoning refugee community face many difficulties in adapting to their new life in a strange society, not the least of which is the growing threat of racism, according to a recent report by Amnesty International.
It is a common pastime to find fault with the health service these day and not without reason. Few question the dedication and skill of doctors, nurses and GPs, but a lack of funding and organisation over the years has led to a situation where the service is not as responsive to the needs of patients as it ought to be. This can be particularly the case when dealing with the special needs of refugees.
Despite Amnesty's criticism, official Garda figures suggest that racist attacks in Ireland are few and far between. There were 15 racially motivated attacks reported last year, a small rise on the 12 reported for the previous year. However, much low level abuse and assault goes unreported. Refugees are reticent to involve the police in such incidents, often because they have adverse experiences of police in their native country. There is also the language barrier and an ignorance of how to engage productively with Irish bureaucracy. These issues affect refugee relations with the health service as much as with the Gardai.
It is not racist attacks but the problems involved in adapting to a new society that adversely affects the health of asylum seekers. Iwa Sebit, who works with ARASI, the Association of Refugees and Asylum Seekers in Ireland, believes that the system currently in place for assisting refugees in Ireland actually damages rather than improves the physical and mental health of people in his community.
'Much low level abuse and assault goes unreported. Refugees are reticent to involve the gardai in such incidents, often because they have adverse experiences of police in their native country'.
"The biggest issue that our community faces is the culture difference", he explains. "Many find it difficult to learn how to cope with interacting with new people and a new society. Language can be a barrier as many people come from Eastern Europe or parts of Africa where they do not speak English".
While there is a translation service, known as Rotext, available to public health nurses, doctors and casualty departments, there seems to be only patchy knowledge at best of this service among health professionals. There are anecdotal reports of asylum seekers being asked to return to hospitals with an interpreter and health professionals communicating with refugees via primitive sign language.
A spokesperson for the Eastern Regional Health Authority told irishhealth.com that all public health nurses and casualty staff are made aware of how to contact Rotext. However, sources within the health service dealing with refugees on a regular basis confirmed that staff on the ground are not always aware of the service and will often turn to another refugee to provide language assistance. Obviously, such practices infringe upon a person's right to be treated confidentially.
An additional problem for many asylum seekers arises from the food they encounter in Ireland. Our staple diet of meat and two veg, chips and bread lies uneasily in stomachs that might only rarely have tasted meat, potatoes possibly never and are much more used to a range of vegetables that are not widely available in this country.
"Diet is a big issue", agrees Sister Briege Keenan who helps run the Vincentian Refugee Centre attached to St Peter's Church in Phibsboro. "Many asylum seekers may never have eaten bread or potatoes or the other staples of our diet in their lives. A number have been admitted to the Mater hospital with chronic constipation. I saw one child who had lost a dangerous amount of weight because he couldn't tolerate meat and chips and other Irish foods. Also in hostels very often they are not allowed to cook their own food."
While refugees are accommodated in hostels, they are provided with meals by the establishment in which they are accommodated. So refugees often find they are faced with a monotonous diet of foods they are often unable to digest.
"The change from one type of food to another can affect many people", says Iwa Sebit. "Children especially have a very high rate of falling sick because the food given to them is not suitable for their diet. They refuse it and fall ill or they eat it and become sick from eating it".
Most of Ireland's asylum seekers come from Nigeria or Romania. Those two nationalities accounted for almost half of all applications in 1999. In the first five months of last year, Nigerians accounted for 30% and Romanians 28% of the people who applied for asylum in this country. Per capita, Ireland is one of the most popular destinations in Europe for refugees. In 1999, one refugee arrived in Ireland for every 465 people already living in the country.
"Refugees are health conscious, but they don't generally use the system", believes Briege Keenan. "When they arrive they go to hostels for one or two weeks before they are dispersed around the country. They are encouraged not to get a medical card before they are dispersed, so this can be a problem if they fall ill in the meantime. Many come from countries without a medical card or free medical system and because they have never been sick they don't apply for the card. Then they have to pay money they can't afford in order to be seen by a doctor when they do fall ill."
There are three main reception centres for refugees in the Dublin area, based in different health boards. Because of bureaucracy, there can be a lack of uniformity in health provision for refugees.
According to the ERHA, all refugees arriving at the reception centres are offered basic health screening and there is a very high take-up rate for this. A multi-disciplinary team of psychologists is available to assess any psychiatric or mental health difficulties asylum seekers might be experiencing and doctors and public health nurses are on hand throughout the day.
However, a health worker who preferred not be identified told irishhealth.com that the system badly needs a single person to assume responsibility for refugee health. They added that there was a pressing need for more social workers, more child minders and someone other than security staff to stay overnight in reception centres.
There is now a refugee population in Ireland running into tens of thousands of people, made up of individuals from dozens of different countries. Even within these nationalities there are many different cultures represented, as minorities are the most likely to flee from an oppressive state. For this reason, Ireland has received a significant community of Roma gypsies and Ogoni people from Nigeria.
Despite the fact that Ireland is rapidly becoming a multicultural society, there are claims that the Department of Health has been extremely slow in responding to the new pressures that this places upon the health service.
Claims by some people that refugees are importing virulent new diseases into Ireland have proven unfounded, as the vast majority accept health screening at reception centres. Those who do require treatment receive it quickly and very few have transpired to be carrying any form of infectious or transmittable disease.
However, as a result of experiences in their home countries, many of those who come to Ireland arrive with unresolved psychological problems. Others develop low level psychological difficulties after their arrival.
The Eastern Regional Health Authority runs a clinical psychology and counselling service specifically designed to deal with the psychological problems some refugees face. Equipped with interpreters, the service provides asylum seekers and those settled in Ireland with a confidential psychological assessment and treatment at St Brendan's Psychiatric Hospital in Grangegorman.
'Refugees often find they are faced with a monotonous diet of foods they are often unable to digest'.
"We run a specialist service for asylum seekers because they have issues arising from leaving their countries of birth such as family break ups, sexual aggression and trauma that require specialist attention", explains Maeve Stokes, the senior psychologist who heads the unit.
"Once they come to Ireland, there are other psychological issues which arise from social exclusion. We have a clinical psychologist who deals exclusively with unattached minors who arrive in the country. Obviously they have great needs".
Under the 1996 Refugee Act, unaccompanied children who arrive in the country fall under the care of the health boards. The 1991 Child Care Act applies to refugee minors as much as to Irish or European children. The Irish Refugee Council has called for these children to have guardians appointed for them. Asylum seeking children remain a most vulnerable group, especially without an adult to take responsibility for them.
The Refugee Psychology Service employs two counselling psychologists, a psychotherapist and a clinical psychologist who specifically deals with underage refugees who have arrived in Ireland without any adult support. The service is attached to the three refugee reception centres in the capital and provides immediate short-term intervention for refugees newly arrived in the country. It also receives referrals from doctors, psychiatrists, refugee agencies and solicitors. A small number of refugees, on hearing of the service, refer themselves.
For a variety of reasons, refugees are more likely than the rest of the population to face psychological difficulties. Some of these arise from psychiatric problems they may have experienced before travelling to Ireland, or from traumatic experiences attached to their leaving their native country. The counsellors and psychologists who work with the service have treated people experiencing a wide range of mental health difficulties, from torture and rape to depression and bereavement.
There is a psychological condition attached to the act of fleeing one's country itself. This is termed cultural bereavement and is brought on by the realisation that treasured possessions, friends and family, native culture, in fact the very homeland itself are all lost.
"Being forced to flee from one's country represents a major life event for a refugee and is likely to provoke emotional turmoil", says Maeve Stokes. "While a refugee's initial emotional reaction may be a sense of relief, this is usually short-lived. They are then confronted with a bewildering set of demands and challenges, combined with feelings of loss and concern for the welfare of those left behind."
Further difficulties arise once a refugee arrives in Ireland. The culture shock can be enormous, especially for those arriving alone with no support. Imagine arriving in Central Africa with no friends or family, unable to speak the language and unable to draw upon the support of your country and you get an idea of the predicament of many refugees.
"We assume that if someone has come halfway around the world to be here, then they will be able to adapt", says Sister Briege Keenan. "But many of them are shell-shocked by culture shock for the first six months. Even when they have not left a traumatic situation behind, to leave their country for good is difficult in all sorts of ways".
According to Maeve Stokes, many refugees experience depression as a result of their initial experience of life in this country. Socially excluded, sometimes racially abused, refugees are denied the right to work until their case has been decided, a lengthy period of time. In the interim, enforced unemployment can cause many refugees, especially those used to being useful and active, to experience inertia and fear that they will not be able to provide for their families.
Anyone who arrived in the country since 1999 cannot work while their application is processed. They have no right to education and have severe difficulty obtaining accommodation, as they are reliant on health board payments to pay for their rent. As other people experiencing deprivation have found, such payments rarely come close to meeting the going rate for rental accommodation.
'Refugees throughout the world await their fate - another refugee flees their native country every 23 seconds according to Amnesty International'.
Hence many asylum seekers suffer from a lack of privacy and are forced to share accommodation in poor conditions. Because they are not allowed to take up paid employment, despite the need for workers in the current economic climate, they suffer from a raft of poverty related issues, which often result in boredom, depression and trauma. Iwa Sebit of ARASI agrees that it is the situation that refugees enter when they arrive in this country that causes many psychological problems.
"All refugees experience the psychological torture of waiting in limbo to see if their application to stay in this country will be accepted", he explained. "While people are living on handouts of £15 per week and have no access to the jobs market, it stops them from helping themselves. They are under half-arrest, because they are not allowed to do this, not allowed to do that. It all causes enormous frustration, which is very bad for health".
In 1995, nearly half of all asylum applications were approved in the first instance. By 1999, that had dropped to only 4% of applications. The efficiency of the asylum processing system has come in for criticism and rightly so. In 1999, there were 6,400 applications awaiting a decision. With thousands more arriving monthly, the system is becoming swamped and many asylum seekers are left in a limbo, unable to work and living on a pittance with nothing to do. This brings its own problems, including the mental health difficulties that are aggravated by social exclusion.
As the Irish Refugee Council has argued, the process of seeking asylum itself is so convoluted, slow and inconsistent that it leads to depression in many asylum seekers. Up to 40% of refugees whose initial applications for asylum has been rejected are granted asylum on appeal. This implies an inadequacy in the system first time around.
"What's happening here is that people who have suffered terrible things may have no documents to support their argument" says Iwa Sebit. "Their argument may then be disregarded or not believed. So they feel they are not being listened to. This is a great cause of worry for them".
Maeve Stokes has found that there are four groups of refugees who are particularly vulnerable to emotional or psychological problems. As well as unaccompanied minors and the old, she identifies refugees who have pre-existing mental health problems as requiring the help of her service. Perhaps the most in need, however, are those who have witnessed, or been a victim of, extreme violence.
Many refugees arriving in Ireland, especially those coming from places in conflict, may have witnessed or been subject to torture and rape. Some women report being sexually abused en route to Ireland. For these women, feelings of shame, guilt and debasement are extremely difficult to come to terms with in a foreign country.
Careful counselling with a female psychologist, often in the presence of an interpreter, is the only way to attempt to treat the trauma they have experienced. The establishment of a safe refuge for victims of rape and torture by the Holy Ghost Fathers offers some traumatised refugees an additional environment where they can learn to heal.
At Spirasi, the Spiritan Asylum Seekers' Initiative on Dublin's North Circular Road, people who have experienced the effects of witnessing extreme violence or having that violence practised upon them can benefit from alternative healing treatments including aromatherapy and homeopathy. They run clinics three evenings a week for people to learn healing processes designed to help them over their past experiences.
But it is not only the traumatised or mentally vulnerable among the refugee community who suffer psychologically. Briege Keenan has found that many of the people she deals with are experiencing regular insomnia and depression, simply because of their status so far from home, without the support networks that they previously had.
"You have people who are unable to sleep at night. Many suffer from depression. Sometimes we forget that items on the news, such as civil unrest in their native countries, seriously affect asylum seekers. If you were far away from home and didn't know the whereabouts of your family, that would adversely affect you, obviously".
Of course, many refugees arrive in Ireland without their families and are often unable to contact their relatives. Perhaps they too have fled and their whereabouts are unknown, or something worse may have occurred. That fear is a cause of many psychological issues.
"The break-up of families is one of the biggest causes of psychological distress", explains Maeve Stokes. "A most significant and recurring theme for refugees is the intense suffering that parents undergo when separated from their children. There is a strong wish for reunification and a sense of helplessness and sadness when they are unable to gain information about their children's well-being".
Until the language barrier problem can be fully addressed, hospitals and GP consultations will remain difficult for refugees to deal with.
One suggestion has been to make the Rotext phone number a freephone number and promote it heavily within the health system. A free number that is easy to recall would certainly improve communications between patients, the GPs and hospital staff who treat them.
Until the Department of Health complete an examination of refugee health needs, and address those needs by providing proper support to the health professionals who work on the ground, the difficult status of asylum seekers will continue to be lowered still further by risks to their health.
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