Calling Australia Home

Over the past two years the Australian Government increased its refugee intake by an additional 12,000 places for refugees fleeing the Syrian crisis. Around half were actually Iraqi refugees, many of whom were residing in Syria but had to relocate due to the conflict.

Between January 2016 and late 2017, over 15,000 refugees have been permanently resettled in NSW alone. Almost 7,000 were part of the additional Syrian intake. Greater Western Sydney has always been the most common NSW location for refugee settlers. For the current cohort, the Fairfield area has been a particular hot spot, mainly because the majority of arrivals were sponsored by family members already living there.

The Australian Government funds Humanitarian Settlement Services (HSS) programs that provide early practical support to refugees on arrival and throughout their initial settlement period. HSS clients are assisted to register with Centrelink, Medicare and health services. Sponsors, however, take on the bulk of these responsibilities for those that they support to travel here.

The NSW Refugee Health Service’s role in dealing with this influx

The NSW Refugee Health Service is funded by NSW Health to provide a range of services and programs to assist those of refugee backgrounds, in particular newly-arrived refugees. As well as teaching, advocacy and research, the Service partners with various agencies to provide health education and health programs for community members, especially those settling in Sydney. NSW RHS also has a clinical role, providing a Refugee Health Nurse Program (RHNP) across metropolitan Sydney, and a limited General Practitioner service. In other parts of NSW, local responses are in place to assist refugee settlers.

Refugee nurses undertake initial health assessments and screening for conditions not detected overseas, at several locations and in selected schools. Part of the rationale of the RHNP is to facilitate care by mainstream health services, including GPs. Also, the program has been shown to reduce impact on emergency departments by providing a responsive first point of contact, and advice on health issues in new arrivals. However, the RHS only sees a proportion of all refugees, given that many sponsors, in particular, take their newly arrived family members direct to their own local doctor.

The NSW Ministry of Health provided a significant funding enhancement from 2016 to assist with the increase in refugee numbers. As well as enlarging the NSW RHS, funds also went towards the statewide torture/trauma counseling service (known as STARTTS), to healthcare interpreter services, chest clinics following up past TB and latent TB infection, and refugee paediatric clinics at Sydney Children’s Hospital, Children’s Hospital Westmead and Liverpool. Catch-up vaccines also received an initial boost.

RHS expanded its nurse-led assessment team and conducted over 3,000 assessments last financial year. The nurse-led model is based on referral to GPs for ongoing care, to mainstream services such as dental clinics and women’s health, and to specialised services for those with complex conditions.

In March last year, we launched an Early Childhood Nurse Program, the first dedicated just to children of refugee backgrounds, which has already seen over 200 children under five years old, mostly through home visits. Some of these preschoolers and babies are asylum seekers without Medicare.

An interesting program getting underway is called the Health Navigation Program, which is recruiting a team of volunteers to help newly arrived refugees get to their various health appointments in that overwhelming period of early settlement. This was successfully trialled in the past in northern Sydney, assisting Tibetan refugees there.

Main health issues, and some challenges

Refugees undergo health screening prior to being granted a visa. Nevertheless, not all conditions are sought at that stage. Additionally, the criteria refugees need to meet are now less stringent than for other migrants – an excellent policy decision from a humanitarian perspective, but one that has thrown up some challenging service provision issues in recent years.

The main health issues among this Middle Eastern cohort are:

• Psychological health – significant loss and grief affecting most families;
• Chronic diseases – hypertension, CVD, diabetes – often under-managed in recent times (access to medication is difficult when in exile, especially when one has to pay), or in some cases, undiagnosed prior to arrival;
• Risk factors for CVD are also common: high lipids, smoking, overweight;
• Child and youth overweight and obesity, with limited dietetics referral options;
• Frail aged new arrivals – a new phenomenon, with 6% of arrivals in the past two years being over 65 years old; MyAgedCare services are needing to adapt to this new cohort;
• Under-immunisation, with documents often lacking, and GPs not surprisingly confused about catch-up needs;
• Disability (physical and intellectual) in children and adults has been a very significant issue; these individuals sometimes arrive with no formal diagnosis, and have had minimal or no intervention overseas (such as one adult with cerebral palsy, bed-bound with severe limb contractures); the National Disability Insurance Scheme (NDIS) rollout has been an unfortunately-timed complicating factor; access to timely assessment services such as occupational therapy has been a struggle, and psychometric testing for adults with intellectual disability remains a particular challenge.

This last issue has led to the creation of a small disability team within our service, including a nurse and social worker to facilitate access to disability equipment, occupational therapy assessments and enrolment in the NDIS. Bilingual educators are used to better inform patients and their carers about available services.

Other conditions identified in some resettling refugees include oral health (with good public dental clinic access for children, but long waiting lists for adults), vitamin D deficiency, iron deficiency anaemia and thalassaemia trait, and in a small number, chronic infections such as hepatitis B and strongyloides. Outreach to high schools has identified hearing impairment and vision problems in a proportion of adolescents. Low health literacy in some means that much explanation needs to be given about preventive health such as cancer screening.

The good news

Raising awareness about possible health issues in refugees always runs the risk of over-pathologising. Most people of refugee background are basically well and are raring to go in terms of resettling here, improving their education levels and contributing to the society. Many stories emerge of doctors and dentists sitting and passing their exams; wheelchair-bound children delighting in the freedom of mobility, and school attendance, in their newly acquired, re-conditioned electric wheelchairs; mothers of such children now acting as support to other parent carers; 4 year olds who can’t hold a pencil rocketing ahead with their fine motor skills once they and their parents are shown what to do.

What can medical professionals do?

Being informed about refugee health issues is a good start. There are many relevant resources including websites and national guidelines (e.g: www.asid.net.au/products/refugee-guidelines-2016). A number of Primary Health Networks (PHNs) have created HealthPathways on refugee health.

Last year’s Commonwealth Budget included funding for catch-up vaccines for all humanitarian entrants. GPs can now ensure all recent arrivals, be they children, adolescents or adults, have the same protection against vaccine-preventable diseases as those born here.

The Australian Government funds the Doctors Priority Line (phone 1300 131 450), a free phone interpreting service for GPs and specialists in private practice, available 24/7. An on-site interpreter can be booked in advance. Health care interpreter services are available to doctors and others working in the public health system across NSW. Practitioners can avail themselves of a large range of translated patient education materials.

Barriers to healthcare, including gap fees, should always be taken into account. We also need to remember that there is a minority of people living in the community as asylum seekers, without Medicare, who need our advocacy and support to maintain their health whilst waiting for their refugee status determination.

Finally, how to approach healthcare for those who have suffered persecution and psychological trauma: respect is a good starting point. “Compassionate listening” is a lovely concept – just letting people tell some of their story can help their healing. In these ways we can all contribute to helping our patients of refugee background who now call Australia home.