meeting the health needs

of refugee and asylum seekers in the uk

an information and resource pack for health workers

Angela Burnett & Yohannes Fassil

 “I believe that future historians will call the
twentieth century not only the century of the
great wars, but also the century of the refugee. It
has been an extraordinary period of movement
and upheavals. There are so many scars that
need mending and healing and it seems to me
that it is imperative that we proclaim that asylum
issues are an index of our spiritual and moral
civilisation.
How you are with the one to whom you owe
nothing, that is a grave test and not only as an
index of our tragic past. I always think that the
real offenders at the half way mark of the
century were the bystanders, all those people
“Understand that it is not simple or easy
who let things happen because it didn’t affect
Avoiding past memory
them directly.
I can’t remove from my mind
My traditional culture I believe that the line our society will take in this
My sentimental torture matter on how you are to people to whom you
The folktales of my childhood owe nothing is a signal. It is the critical signal
Never old, never dead that we give to our young and I hope and pray
Stamped in my mind that it is a test we shall not fail.”
I have normal feelings
Rabbi Hugo Gryn, a Holocaust survivor
I suffer for dignity
(from a Moral and Spiritual Index, published by
Please do not kill my broken heart”.
the Jewish Council for Racial Equality and the
Yilma Tafere, a refugee from Ethiopia Refugee Council, 1996

“When you’re a refugee your life is never

complete. There is always part of your life that is
missing, and that part is home”
Adil, a child refugee from Somalia
From Off Limits - Refugee Voices, Double
Exposure for C4Learning

How would refugees like to be treated?

“Lots of smiles if possible, it could make a big
difference to our health”
Asylum seeker, dispersed to the North West

page 3
 Foreword

Every day healthworkers provide a wide range of

care and support to refugees and asylum seekers.
Frequently these people have left their homes in
pursuit of safety and a better quality of life. Their
circumstances are difficult and their needs are
often highly complex.
We commend this comprehensive and clearly
presented Information and Resource Pack. The
authors have adopted a style which means the
pack can be used as an education resource or as
a reference point. Building on the skills and
experience of health workers, the pack contains
practical information, details of useful contacts
and resources and includes examples of good
practice from around the United Kingdom.
The prime aim of this Information and Resource
Pack is to support and enhance individualised
care for each refugee and asylum seeker. Its
success in achieving this aim was expressed by a
GP in Birmingham.
“This is an incredibly useful and well laid out
document. It has made me realise that I need
to adopt a new approach to caring for refugees
and asylum seekers and this pack will be an
invaluable resource for me.”
Pippa Bagnall,
Head of Primary Care
London Directorate for Health and Social Care
Dr. David Colin-Thomé
National Clinical Director for Primary Care -
Department of Health

page 4
Table of Contents
Page
1) Introduction and background
1.1) Using this resource pack and who it is for 8
1.2) About the authors 8
1.3) Acknowledgements 9
1.4) Methodology 9

2) Background to the Situation of Asylum Seekers and Refugees

Key Points 10
2.1) The experiences of asylum seekers and refugees 10
2.2) Definitions of immigration status 11
2.3) The procedure for asylum application 12
2.4) Asylum and Immigration Legislation, dispersal and the
National Asylum Support Service (NASS) 12

3) Culture, Language and Communication

Key Points 14
3.1) Culture and health 14
3.2) Communication – working with interpreters and advocates 15
3.3) Speech and language difficulties 18
3.4) Information on access to healthcare and on health 18

4) Health Services Summary

Key Points 20
4.1) Eligibility for health care 21
4.2) How to find a GP and dentist 21
4.3) Planning health services 22
4.4) Funding support for primary care services caring for asylum seekers 24
and refugees
4.5) Asylum seekers’ expectations of healthcare 27
4.6) Information for receptionists and practice managers 28
4.7) Health assessment, including registration checks and screening 28
4.8) Hand-held records 29
4.9) Community development and health 30
4.10) Linking with refugee communities and community organisations 30
4.11) Consultation with asylum seekers and refugees 30
4.12) Feedback, complaints and compliments 30
4.13) Multi-sectoral working and partnerships with other organisations 31
4.14) Training for health workers 32
4.15) Support for health workers 32
4.16) Health networks 32
4.17) Occupational health issues 33
4.18) Refugee health workers 33

page 5
 5) Key Clinical Areas
Key Points 34
5.1) General health status 35
5.2) Prescribing and dispensing 35
5.3) Psychological well-being 36
5.4) Psychological therapies and counselling 39
5.5) Discussing distressing events 39
5.6) Physical expressions of distress/somatisation 40
5.7) Sleep problems 40
5.8) Physical health 40
5.8.1) Gastro-intestinal symptoms 40
5.8.2) Chronic diseases: diabetes, hypertension, coronary heart disease, stroke 41
5.8.3) Rheumatic heart disease 41
5.8.4) Haemoglobinopathies 41
5.8.5) Dermatology 41
5.8.6) Respiratory illnesses 41
5.8.7) Musculo-skeletal 41
5.8.8) Eyes 41
5.9) Immunisations 42
5.10) Tuberculosis (TB) 42
5.11) Other communicable diseases 42
5.12) HIV/AIDS 42
5.13) Sexual health and family planning 44
5.14) Health promotion 45
5.15) Oral health 45
5.16) Nutrition 46
5.17) Drugs and alcohol 46
5.18) Physiotherapy 47
5.19) Role of complementary therapies 48
5.20) Traditional healthcare 48
5.21) Arts therapies and creative arts 48

6) Torture and Violence

Key Points 49
6.1) Survivors of torture and organised violence 49
6.2) Psychological health following torture and violence 51
6.3) Physical effects of torture and violence 53
6.3.1) Musculo-skeletal, fractures and soft-tissue injuries 53
6.3.2) Head injuries and epilepsy 53
6.3.3) Ears and eyes 53
6.3.4) Effects of chemical attack and nerve gas 54
6.4) Children who are survivors of torture and violence 54
6.5) Sexual violence 55
6.6) Sex trafficking 56
6.7) Domestic violence 56

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7) Needs of Specific Groups
Key Points 57
7.1) Health of women 57
7.2) Maternity care 58
7.3) Female Genital Mutilation 59
7.4) Health of men 61
7.5) Health of older people 61
7.6) Health of families 62
7.7) Health of children and adolescents 63
7.8) Unaccompanied minors/separated children 65
7.9) Age Assessment 66
7.10) Child Protection 66
7.11) Disability and Special Needs 67
7.12) Carers 69

8) Other Related Issues

Key Points 70
8.1) Socio-economic issues and support 71
8.2) Spiritual support 71
8.3) Tracing missing family members 72
8.4) Housing 72
8.5) Schooling and education 73
8.6) Learning English 73
8.7) Training and employment for refugees 73
8.8) Work permits 74
8.9) Legal support 74
8.10) Medico-legal reports and letters of support 75
8.11) Detention of asylum seekers 75
8.12) Racism, discrimination and hostility 75
8.13) Media contact 76
8.14) Contact with the police 76
8.15) Linking with local communities and befriending 76

9) Resources
Key Points 78
9.1) One Stop Services and national agencies working with refugees 78
9.2) Local resources 82
9.3) Background in-country information 82
9.4) Useful websites 82
9.5) International Human Rights Conventions 82

Appendix 1 - Guide to languages by country 83

Appendix 2 - Welcome Pack 85
Appendix 3 - TB screening protocol 86

page 7
 1. Introduction and
background
1.1) Using this resource pack and section 2.4). Changes in immigration policy affect
who it is for both the health of refugees and the ways in
which their health care is delivered. As a result,
This resource pack is for health workers in both services need to be flexible. It is important that
the statutory and the voluntary sectors, health workers connect with the full range of
particularly those with less experience of working agencies charged with responsibilities in this field.
with asylum seekers and refugees. It is for both We have written the pack so that different
clinicians and service planners. sections can be used on their own, according to
We have not divided the pack into different needs and interests. Each chapter is summarised
sections for particular health workers as many as a box containing key points. The pack is
health workers in this field, especially Health available on the Internet on the following site:
Visitors and nurses, are expanding their roles and www.doh.gov.uk/london/index.htm. We strongly
taking on new responsibilities. recommend that a nominated person in each
Many of the issues discussed are standard good area should be responsible for adding
practice for any person, whether or not a information about local services, organisations
refugee. Health workers already possess many of and resources.
the necessary skills for working with asylum We have tried to address the important issues
seekers and refugees. However, some areas may which affect the health of asylum seekers and
be unfamiliar, such as torture. refugees, although not all are directly the
While it raises issues and offers some practical responsibility of health workers. The information
suggestions, it should not be taken as a blueprint. provided is the most accurate available at the
The most important approach is to treat people time of writing and reflects the experiences of
as individuals, taking into account their views, health workers who responded. If you feel there
cultural beliefs and practices, and not making are inaccuracies in the text, do contact us so that
assumptions. Although refugees and asylum we can update and amend future editions. In
seekers are often grouped together they, like all addition, if you have any comments or suggestions
of us, have varying experiences, needs and as to how this pack can be improved, we would
aspirations and are not a homogenous group. welcome emails to [email protected] .
The terms refugee and asylum seeker denote a
situation rather than an identity. Issues facing
1.2) About the authors
those newly arrived are often very different from Yohannes Fassil, a pharmacist and health planner
those more settled in the UK. by training, came to the UK as a refugee from
Eritrea and now works for Kensington, Chelsea
“There is no one best solution for all refugees”
and Westminster Health Authority as head of
Refugee health advocate, London
Diversity and Community Development Strategy.
The pack was compiled following consultation He has been responsible for refugee health and
with refugees, asylum seekers, health workers community development programmes in
and others working in this field. Some of the Kensington, Chelsea and Westminster, and
present difficulties appear to arise from different nationally, for over 15 years. Angela Burnett is
expectations between users and providers of the descendant of refugees. She was a GP in East
services. This pack aims to try to bridge the gap. London for 10 years and is currently developing
Immigration policy is currently under revision (see the Sanctuary Practice, for asylum seekers and

page 8
refugees in Hackney, East London. She is also Asylum Seekers and Refugees, parts of which
working at the Medical Foundation for the Care have formed the basis for this pack and
of Victims of Torture since 1995 and the Refugee Kensington, Chelsea and Westminster Health
Education and Training Advisory Service (RETAS). Authority for supporting Yohannes in this work.
She runs training workshops in the care of
refugees and torture survivors and has worked 1.4) Methodology
with Primary Care Trusts and Health Authorities Initial interviews were held with 24 asylum
on the development of health services for seekers and refugees, in London and in three
refugees. Both are involved in careers advice and dispersal areas – Leeds, Manchester and
support for refugee health professionals, in order Liverpool. These were open discussions, based on
to enable them to work in the UK. a loose framework, and enabled interviewees to
raise issues they felt to be important. Some
1.3) Acknowledgments interviews were carried out individually in the
We would like to acknowledge and thank all person's own language. A group discussion was
those asylum seekers, refugees and health held in London, comprising refugee health
workers who gave up their time and contributed workers and refugees working as advocates.
their views and experiences for this study. We are Based on these discussions, questionnaires were
unable to acknowledge everyone individually by compiled for health workers working clinically
name, but in particular we would like to thank: with refugees and asylum seekers, and for
Dr. David Colin-Thomé and Pippa Bagnall at the administrative staff (receptionists and managers).
London Directorate for Health and Social Care These were sent to a number of health workers,
(previously the London Regional Office of the with differing experiences of working with asylum
NHS Management Executive), for funding the seekers, using a snowballing technique. Fifty-five
work, Lydia Yee, Veena Bahl and Alison Beedie at health workers responded from throughout
the Department of Health, Sally Hargreaves from England and Scotland, including refugee
community workers, nurses, midwives, health
Kensington, Chelsea and Westminster Health
visitors, GPs, consultants, psychologists,
Authority, Jane Anderson, Jocelyn Avigard, Pennie
psychiatrists, receptionists, practice managers,
Blackburn, Bill Bolloten, Sherman Carroll, David
researchers. Their background included primary
Chappel, Naaz Coker, Jane Cook, Judy Cook, Tim
care, mental health, child health, women’s health,
Cowan, Susan Donnelly, Tim Dowson, Workneh
maternity care, infection control, sexual health,
Dechasa, Seble Ephrem, Gosaye Fida, Rachael
public health and service planning. Contact was
Gosling, Kate Harris, Liz Hart, Amina Hassan, Iona
made with services in Wales and Northern
Heath, Caroline Hyde-Pryce, Marina Iaverdino, Ireland. A search was also conducted of both
Bobby Jacobson, Dubravka Janekovic, Rachel published and unpublished literature concerning
Jenkins, Valerie John-Charles, Mark Johnson, Pip the health of refugees.
Kemsley, Peter Le Feuvre, Helen Lester, Ann Lorek,
A draft was circulated to all those who had
Sue Lukes, Rhona MacDonald, Joan MacFarlane,
originally given their views, in order to check that
Rebecca MacFarlane, Annabel Mascott, Ghrimay their views were fairly represented, as well as to
Mebrahtu, Philip Matthews, Helen Montgomery, further interested people. The pack reflects issues
Sarah Montgomery, Helen Murshali, Michael Peel, important to the respondents, and their quotes
Linda Penny, Asefa Qayyum, Melinda Rees, have been used to illustrate points.
Refugee Support Service, Carmen Rojas-Jaimes,
Sana Sadollah, Martin Schweiger, Sam Selikowitz,
Cheikh Traore, Peter von Kaehne, Natalie
Warmen, Adrian Webster, Melba Wilson, Ruth
Wilson, Masoume Zellipour, colleagues at the
Medical Foundation for the Care of Victims of
Torture who assisted in the preparation of the
Guidance to Health Workers providing Care for

page 9
 2. Background to the
situation of asylum seekers
and refugees
2.1) The experiences of asylum 2.1) The experiences of asylum
seekers and refugees seekers and refugees

2.2) Definitions of immigration status “When you’re a refugee your life is never
complete. There is always part of your life that
2.3) The procedure for asylum is missing, and that part is home”
application Adil, a child refugee from Somalia
Nearly 22 million people throughout the world
2.4) Asylum and Immigration are estimated to be asylum seekers or refugees,
Legislation, dispersal and the with a further 21 million internally displaced
National Asylum Support Service within their own countries (www.unhcr.ch).
(NASS) Numbers of asylum seekers from each country
fluctuate, principally according to the local
Key points human rights situation. The vast majority remain
in neighbouring countries, most of which have
• Britain, as a signatory to the 1951 Geneva
scarce resources to provide for their needs.
Convention, is committed to offer asylum to
United Nations estimates suggest that Iran
people fleeing from persecution
currently hosts 1.9 million refugees and Pakistan
• Most asylum seekers and refugees in Britain hosts 2 million, for example1.
are from countries that are in conflict
Only those with access to significant resources
• Most asylum seekers in the UK are young travel to industrialised countries. In 2000 the UK
men, although worldwide the majority of ranked 9th amongst EU countries and 78th in the
refugees are women world2 in terms of asylum seekers per head of
• Asylum seekers and refugees have great population, with 1.7 asylum seekers per 1,000
courage, resourcefulness and resilience national population. This compares with the
• Asylum seekers are being dispersed largest host countries, Armenia, Guinea and the
throughout the UK, to areas that may have Federal Republic of Yugoslavia, who host 80,
had little experience of working with refugees 59 and 46 refugees per 1,000 national
population respectively1.
• Planned changes to the asylum process and
support arrangements include Some have been detained and tortured in their
own countries, and exposure to violence is
• ID smart cards
widespread. Some people have been persecuted
• New systems of financial support to replace
because of their political or religious beliefs and
vouchers
activities, others because they belong to a
• Use of induction and accommodation centres minority ethnic group, or due to their gender or
• Improved consultation with local agencies sexual orientation. Some have had to leave
• A commitment to accepting UN- nominated because of an environmental disaster or an
refugees directly engineering project. Many people migrate due to
1 Home Office Secure Borders, Safe Haven, Integration with Diversity in
Modern Britain White Paper on Immigration and Asylum 2002 (Figures
from United Nations High Commisioner for Refugees (UNHCR)
2 Refugee Council Website
http:// refugeecouncil.org.uk/news/myths/myth001.htm
page 10
poverty as disparities between rich and poor, both such fear, is unwilling to avail himself of the
between and within countries, continue to widen. protection of that country...”
United Nations 1951 Convention relating to the
Those leaving their country to seek asylum
Status of Refugees (Geneva Convention)
experience many losses. As well as losing family
members, through death or separation, they lose The various definitions of refugee status are
their home, family, friends, money, job and explained below:
identity, and may lose dignity and hope. It is the Asylum seeker
multiple loss and, most importantly, the loss of A person who has submitted an application
their role, status and usual support network that for protection under the Geneva Convention
may make it difficult for people to cope. and is waiting for the claim to be decided by
Most of those seeking asylum in the UK are single the Home Office
men under the age of 40, although worldwide Refugee status
most refugees are women. Many families in the Accepted as a refugee under the Geneva
UK are without one parent, who may be missing Convention and granted Indefinite Leave to
or dead, and there are a significant number of Remain (ILR) – permanent residence in the UK.
unaccompanied children. Eligible for family reunion (one spouse and any
Those making the often arduous and dangerous child of that marriage under the age of 18).
journey to exile are courageous, resourceful and Exceptional Leave to Enter or Remain
resilient, and these qualities can assist them to (ELE or ELR)
rebuild their lives. After the initial relief of arriving The Home Office accepts there are strong
frustration and disillusionment may ensue, as the reasons why the person should not return to
reality of life becomes apparent. It is important to the country of origin. ELR grants the right to
enable people to develop independence, acquire stay in the UK for 4 years. (S)he is expected to
language, and have access to education and return if the home country situation improves.
employment. Integration requires support from Ineligible for family reunion.
the local community. (see section 8.15 Linking
Refusal
with local communities and befriending)
The person’s application for refugee status is
Most refugees understandably hope that one day rejected but (s)he has a right of appeal, within
they will be able to return home, when the strict time limits
situation becomes safer. During 2000 almost
Family reunion
800,000 refugees throughout the world returned
Spouse and children under the age of 18 of a
to their home country. person who is given refugee status. They are
Further reading given Indefinite Leave to Remain (ILR) -
permanent residence in the UK.
Burnett A and Peel M
What brings asylum seekers to the In order to fulfill the terms of the Geneva
United Kingdom? Convention an asylum seeker must demonstrate
BMJ 2001; 322:485-8 that (s)he is personally at risk of persecution were
(s)he to be returned to his/her country of origin,
2.2) Definitions of immigration status
This is not always easy to prove.
In order to be recognised as a refugee, an asylum
In this pack the term refugee may sometimes be
seeker must fulfil the terms of the 1951 Geneva
used to include asylum seekers and people at all
Convention and demonstrate that:
stages of the asylum process, as detailed in the
“...owing to a well founded fear of being table above.
persecuted for reasons of race, religion,
nationality, membership of a particular social
group or political opinion, is outside the country
of his nationality and is unable, or owing to

page 11
 Provision of essential living needs is made in
vouchers, which can be exchanged for goods at a
variety of supermarkets, and a small amount of
cash (£14 per adult from 2002) each week to
cover expenses such as bus fares or phone calls.
Pregnant women supported by NASS can receive
a maternity grant worth £300. The application
must be made between 36 weeks gestation and
2 weeks after the birth.
Asylum seekers are not dispersed from London if
receiving care from the Medical Foundation for
the Care of Victims of Torture. If an asylum
seeker is receiving specialist health care and
dispersal is considered inadvisable, NASS should
2.3) The procedure for asylum be contacted via their lawyer or local One Stop
application Service (See Section 9.1 One Stop Services and
An application for asylum may be made at the National agencies working with refugees)
port of entry (port applicant) or after entry to the In February 2002 the Government announced
UK (in-country applicant). With a couple or family proposed amendments to the asylum process and
one application is made; the man is usually the support arrangements in a new White Paper,
main applicant. Unaccompanied children make Secure Borders, Safe Haven, including:
their own application. An asylum seeker may be
• Issuing all new asylum seekers with a new ID
detained if an immigration officer believes (s)he
smart card (the Application Registration Card,
may abscond, to establish identity or the basis of
or ARC) that will include photographic and
the claim, or prior to removal. (See section 8.11)
fingerprint details. This will be issued to all
Currently, asylum seekers complete a Statement
new asylum applicants from January 2002,
of Evidence Form (SEF) in English, which must be
with all asylum seekers registered in this way
returned within two weeks. If a claim is refused
by the end of 2002. From July 2002, Post
the applicant can appeal. It is essential that
Offices will issue cash via the ARC.
asylum seekers have access to a specialised
immigration lawyer. (See section 8.9 - Legal • Vouchers will be superseded by early autumn
support). 2002 by new systems of financial support,
including the setting up of induction and
2.4) Asylum and Immigration accommodation centres, where asylum
Legislation dispersal and the seekers will be housed. Those choosing to live
National Asylum Support with family or friends may no longer be
Service (NASS) entitled to any support.

Before the Immigration and Asylum Act 1999 was • It is planned that all new arrivals will spend
implemented, the Benefits Agency and local between 1-7 days in new induction centres,
authorities provided support to asylum seekers. where they will receive information about the
From April 2000 this became the responsibility of asylum process and their obligations.
the new National Asylum Support Service (NASS), Accommodation centres are also planned to
administered by the Home Office. be piloted, where some asylum seekers will be
NASS are responsible for providing support for all housed while their claims are determined.
destitute asylum seekers until the Home Office • The principle of dispersal from London and
determines their asylum application. Asylum the South East will remain for most new
seekers can be provided with both support and arrivals, with NASS given a regional structure
accommodation (on a no choice basis), or if they and promising improved consultation with
have accommodation already, support alone. local authorities and other agencies.

page 12
 • A commitment to explore taking United Audit Commission
Nations nominated refugees directly into the Another Country. Implementing Dispersal under
UK, ultimately as part of a Europe-wide the Immigration and Asylum Act 1999 Abingdon:
agreed scheme. Audit Commission Publications 2000.
• A requirement for most immigration
Wilson R
applicants to demonstrate a knowledge of
Dispersed: a study of services for asylum seekers in
English and citizenship education, and the
West Yorkshire Dec1999 – Mar 2001, The Joseph
introduction of a citizenship ceremony and
Rowntree Charitable Trust, 2001.
pledge as part of the naturalisation process.
Available from the Joseph Rowntree Charitable
• Measures to combat people trafficking, illegal Trust, The Garden House, Water End, York, YO30
entry and illegal working. 6WQ Tel: 01904 627810 Price £10.
National Asylum Support Service, Home Office
Voyager House, 30/32 Wellesley Road, Secure Borders, Safe Haven – Integration with
Croydon CR0 2AD Diversity in Modern Britain
Helpline: 0845 602 1739 (local rates) Immigration and Asylum White Paper and Bill 2002
Voucher enquiries: 0845 600 0914
NASS policy bulletins are available on:
www.ind.homeoffice.gov.uk/default.asp?
pageid=2056.

Further reading
Connelly J and Schweiger M
The health risks of the UK's New Asylum Act
BMJ 2000; 321: 5-6.

page 13
 3. Culture, Language and
Communication
3.1) Culture and health • The intepreter may be mistrusted
• Information on health and access to health
3.2) Communication – working with
should be available in relevant languages
interpreters and advocates
• Not all asylum seekers and refugees
3.3) Speech and language difficulties are literate.
• Use different ways of communicating
3.4) Information on access to health messages
care and on health • Provide a welcome pack for newly arrived
asylum seekers
Key Points
• Some translated materials are available
• Health is affected by cultural issues
• Asylum seekers and refugees are not a 3.1) Culture and health
homogenous group
Health-related behaviour and health care are
• Individuals may not follow assumed norms of both affected by culture. How, when and what
culture or religion – check with the person people present to health workers will be
• If you can, offer a choice of gender of health influenced by culture and beliefs. We need to be
worker and interpreter (may not be possible) aware of our own assumptions, stereotyping and
• People may be unfamiliar with the concept interpretations. Interpreters, health advocates and
of ‘mental illness’ as we define it, which for health workers from a displaced background can
them may be linked to spirit possession or assist with details of cultural background.
divine punishment and carry great stigma “The interpreters provide most of my
• Access to trained interpreters is crucial for information” GP Gateshead
all staff There are however both individual beliefs and
• Advocates and linkworkers can provide health values and those that are collective and shared
promotion and health needs assessments with others from the same culture. Knowledge of
• Using a family member or friend to interpret their culture’s beliefs and values needs to be
may have limitations balanced against the individual’s perspective,
• Avoid using children to interpret which may differ, especially after spending some
time in the UK. Individuals interpret differently
• Majority of respondents prefer face-to-face
values current in their culture and may not follow
interpreting
assumed norms of culture or religion. It is
• Telephone interpreting should supplement for therefore important to discuss and understand a
emergencies, out-of-hours and languages not person’s own values and wishes. Some people
covered by face to face interpreters may observe certain rituals and customs
• Allow double the time when working with an associated with birth and death. In some cultures
intepreter a post mortem is forbidden unless absolutely
• Try to spend a few minutes briefing and de- necessary (e.g. Islam). Cultural, religious and
briefing the intepreter (if time permits) dietary needs of patients should be addressed. If
• Emphasise confidentiality possible, offer a choice of gender of the health
worker and intepreter.

page 14
Every culture has its own frameworks for mental Algeria) and also the language with which they
health and for seeking help in a crisis; individuals feel comfortable (e.g. many Kosovars speak
within the same culture may exhibit different Serbo-Croat, but may feel uncomfortable doing
degrees of resilience and vulnerability. so, given the history of persecution in Kosovo).
Mental illness carries marked stigma in many Advocates have further training in addition to
cultures, which may deter people from seeking interpreting skills, enabling them to deliver health
help. Culture affects interpretation of behaviour promotion, carry out health assessments and
and may influence diagnosis of mental illness. improve access to health care.
When visiting someone’s home, remove your “Advocacy services seem to be more
shoes if other family members have done so. In appropriate than basic interpreting services”
many cultures great store is placed on providing Nurse team leader, London
hospitality to visitors, and people may feel upset
For information on the Health Advocacy Network
if you refuse what is offered. It also provides an
run by the Council for Ethnic Minority Voluntary
opportunity for those so often dependent to offer
Organisation (CEMVO), see Section 4.16 –
something in return.
Health Networks.
3.2) Communication – working with
interpreters and advocates Minority Ethnic Health Inclusion
Project (MEHIP)
Access to high quality translation and interpreting
services is a basic requirement for all agencies Contact: Sana Sadollah,
involved in providing services to refugees. Refugee Linkworker, MEHIP, Springwell House,
Ardmillan Terrace, Edinburgh, EH11 2JL
“We can’t do any of this without interpreters” Tel: 0131 537 7561
GP London
MEHIP links minority ethnic individuals and
The majority of health workers who responded communities with health services, to improve
prefer face-to-face interpreting, feeling it to be the accessibility and appropriateness of services
more personal and reassuring, and enabling across Lothian.
verbal and non-verbal cues to be picked up. Linkworkers:
‘I feel I have a greater rapport with the refugee • provide advocacy to increase patient
and with the interpreter with face-to-face participation in their own health care.
interpreting. Refugees appear more at ease” • support professionals to enable them to work
Health visitor, Bedford more effectively with all minority ethnic
Access to telephone interpreting is useful, individuals and groups
particularly for emergencies and out-of-hours. A • Support people from minority ethnic
hands-free or 2-way phone will make this more communities to access primary care services
and relevant community resources
practicable.
“At least the telephone is quick, efficient and • Bridge communication difficulties and assist
always available” Community practitioner, London in overcoming cultural barriers between
professionals and individuals
However, telephone interpreting is more limited
• Promote the development of information
when working with psychological issues and for
resources for minority ethnic groups
picking up non-verbal cues. Face-to-face
interpreting allows more interaction. If possible, The linkworker can see a person before their
offer a choice of gender of interpreter, particularly appointment with a health worker, discuss
if working with survivors of torture or sexual their situation and assess where they can most
violence. Receptionists and managers should also appropriately find help, so that the time with
have access to interpreting support for their the health worker can be spent more
work, if needed. Details will be required both of effectively. She can also provide follow-up.
the language spoken by a refugee (e.g. Arabic
spoken in Sudan differs from Arabic spoken in

page 15
 If possible, offer a professional interpreter or • arrange seating appropriately in a triangle, so
advocate. People may bring a friend or family that everyone can see each other
member to interpret, and this may be their • both health worker and interpreter should
preferred choice. Be aware, however, that introduce themselves
inaccurate interpreting may result, and issues such
• emphasise confidentiality, covering yourself
as gynaecological problems, sexual health,
and the interpreter
psychological health, family relationships, domestic
• maintain eye contact with the client rather
violence, child protection, sexual violation or
than the interpreter
torture may be difficult to discuss using a family
member or friend. Asking children to interpret may • address the client directly as “you” rather than
place inappropriate responsibilities on them, speaking to the interpreter and referring to
disrupt family dynamics, and cause them to miss the person as “she” or “he”
school. Although people may appear to choose to • speak slowly and clearly, using straight-
bring their own interpreter, this may not be the forward language and avoiding jargon, one or
case. If a trained interpreter is not available, they two sentences at a time
fill the gap but may feel this is unsatisfactory1. A • ensure that everything you say to the
recent survey in Barnet showed that the interpreter in front of the client is interpreted
satisfaction of refugees with local health services – if you and the interpreter have a private
was closely linked with the level of provision of conversation, this can alienate the person and
interpreters at GP appointments, if they did not can be uncomfortable for them
speak English themselves2. • when the client is talking, watch and listen.
Continuity of interpreter can help both with You may pick up important cues
development of trust for a refugee and also • try to have a short de-briefing with the
between interpreter and health worker. interpreter after the session. The interpreter
“ My working relationship with the interpreters may be able to offer additional feedback on
has improved enormously as we have got to cultural issues. Check how the interpreter
know each other better” feels – distressing events similar to the
GP Gateshead interpreter’s own experiences may have been
However, communities in exile may continue to be discussed, and (s)he may need support
divided along similar political lines as those • the interpreter should be respected as a
determining the conflict in the country of origin. professional colleague
For this reason the interpreter may be viewed with Most asylum seekers are keen to learn English,
suspicion if (s)he is seen as a member of another which will increase independence and likelihood
group, or as being politically opposed to the of gaining employment. As they gain language
refugee patient. skills, they may require an interpreter only
intermittently; but an interpreter may be needed
When working with an interpreter:
if you know that you are going to address
• allow more time for appointments (if possible particularly difficult issues. (See section 8.6 -
double the time, although without extra Learning English).
resources, this will be hard to achieve)
Provision should be made in each locality for the
• if possible, spend a few minutes explaining organisation and funding of interpreting services.
and discussing with the interpreter each of Interpreters could be shared across different
your ways of working. You should arrange services e.g. health and social services, leading to
how the interpreter should intervene if better co-ordination and continuity. Initially there
anything is done or said that is culturally may be hesitancy in using interpreters, even if
unacceptable, or is misunderstood readily available, and work may be needed to
ensure take-up of services. Training in working
1 Shackman J The Right to be Understood 1984 (see resources) with interpreters will be needed for staff - most
2 Cowen T Unequal Treatment – Findings from a Refugee Health Survey
in Barnet, Refugee Health Access Project, London, 2001 health workers have had none in this area, and

page 16
many would welcome this. Community As Good as Your Word. A guide to community
interpreters covering a large geographical area interpreting and translation in public services,
need access to transport. In some areas, Sanders M
interpreting services are limited and are only able Available from the Maternity Alliance, 45 Beech
to cover a fraction of the need. St, London, EC2P 2LX
Tel: 0207 588 8583
Considerations when recruiting
Fax: 0207 588 8584
interpreters
Email: [email protected]
In addition to accurate interpreting, interpreters
working in this situation should be able to: Telephone interpreting
Understand and be sensitive towards other (both offer contracts throughout the UK)
people and their needs and difficulties Newham Language Shop
Have active listening and interpersonal skills Tel: 0208 430 3040 or 0208 230 0800
Deal with strong emotions (administration)
Appreciate the importance of boundaries Language Line
Match the tone of the health worker Swallow House, 11-21 Northdown St,
Understand and cope with cultural and other London N1 9BN
conflicts that may arise in the work Tel: 0207 520 1400 or 0800 783 3503
Be self-confident and withstand pressures
Phrasebooks
from either side
Working with Kosovar/Albanian Patients A
Work in a team
Medical Phrasebook and Resource.
Based on The Right to Be Understood
Dr Philip Matthews and Dr Fahri Seljmani,
Shackman J et al, (see Resources)
South Essex Mental Health and Community Care
Phrasebooks have been prepared in some NHS Trust 2000.
languages (see below). Available from Tel: 01268 366052 or fax: 01268
366076 and on the internet on http://www.fam-
Further reading english.demon.co.uk/albanian.pdf
Phelan M and Parkman S
Working with Czech/Slovak Patients
How to do it – Work with an Interpreter.
Dr Peter Le Feuvre
BMJ 1995 311: 555-557
Enquiries to Pippa Barber, East Kent Community
Tribe Rachel
NHS Trust, Queen Victoria Memorial Hospital,
Bridging the gap or damming the flow? Some
King Edward Ave, Herne Bay, Kent CT6 6EB or
observations on using interpreters/ bicultural
Dr P Le Feuvre, Mill Lane Surgery, Mill Lane
workers when working with refugee clients,
House, Margate, CT9 1LB
many of whom have been tortured.
Tel: 01843 220881
British Journal of Medical Psychology (1999),
Fax: 01843 231713
72. 567 – 576
Standard letters in various languages
Resources:
Developed in Newcastle by Susan Donnelly,
The Right to Be Understood – A handbook and
Specialist Health Visitor for Asylum Seekers,
training video on working with, employing and
2 Jesmond Road West, Newcastle NE2 4PQ,
training community interpreters,
Tel: 0191 245 7319
Shackman J, Reynolds J, Greenwell S and
Chin R 1984 Copies in other languages are planned on
ISBN: 0 86082 469 1 websites: www.medact.org and
Available from Jane Shackman: 28 The Butts, www.harpweb.org.uk
Chippenham, Wilts, SN15 3JT
[email protected]

page 17
 3.3) Speech and language difficulties Health advocates and refugee community
For both children and adults, speech, language organisations can increase health awareness.
(including both understanding and use of Group outreach sessions in hostels can effectively
language) or communication difficulties in the disseminate information both on health and how
mother tongue may be helped by referral to a to access health services. Information can also be
Speech and Language Therapist. Interpreters or made available in English language classes in
advocates may assist with assessment and local colleges, community settings such as cafes
therapy. and restaurants (predominantly reaching men)
and shops catering for particular cultural groups.
Turkish Phonology Screening Health information may need to be targeted for
Assessment (version 1) special groups e.g. by gender, age.
By Francesca Buxton and Ed Hooke, London
Translated Materials
Speech and Language Therapy Special Interest
Group (SIG) Bilingualism 1996 The following materials can be obtained from
Dr Sarah Montgomery, Guildhall St. Surgery,
Price £16.00.
Folkestone, Kent. Tel: 01303 851411
Contact Francesca Buxton on 0208 210 3751
• Health Screening Questionnaire: Czech,
This assessment is intended for use by speech
Albanian, Farsi, Sorani, Arabic, Romanian
and language therapists to obtain a broad yet
concise sample of Turkish-speaking children’s • About your doctor (information about being
pronunciation. It contains: registered with a GP): Czech, Albanian, Farsi,
Sorani, Arabic, Romanian
• explanatory notes including information on
Turkish phonology • Advice and information for children
(Vaccination programme and basic medical
• 31 photocopied pictures for test items
care that parents can do) Czech, Albanian,
• assessment form with target response in Romanian
Turkish, phonemic transcription of target
• Immunisation Schedule: Russian
response and English equivalent;
phonologically similar forced–alternatives • Information and instructions for various
are also provided. contraceptive methods (Oral combined and
progesterone, Depo-Provera): Czech,
3.4) Information on access to Albanian, Romanian
health care and on health • How to stay healthy in England (information
on diet, smoking etc): Czech, Slovak, Farsi,
“From my experience, for new arrivals,
Arabic, Sorani, Russian
information is important”
Female asylum seeker • Standard Hospital Appointment Letters (fill in
basic information from the hospital letter on
“ What is important is helping people, perhaps translated sheet): Czech, Albanian, Sorani
only recently arrived in the UK, how to find
• The role of the Health Visitor: Czech
their way around the health care maze, how
things work, and how to gain access to the • The role of the Midwife Czech
various services” • Aspects of Antenatal Care: Czech and
Health visitor, London Aspects of Postnatal Care: Czech
Information on health and on health services • Stress symptoms: Czech
needs to be available in relevant languages, • Healthy Eating (British Hypertension Society
although not all refugees, particularly women, are Leaflet): Czech
literate. Many cultures, e.g. Somali, communicate • Preparing baby milk feeds: Czech and
effectively by word of mouth, story-telling being Sterilizing equipment for baby feeds Czech
an important way of disseminating information,
• Sleep Problems in young children: Czech
and this has been used in health promotion,
using video and audiotapes.

page 18
Resources indicate when medication should be taken.
Medact, 601 Holloway Road, London N19 4DJ They are available in various languages. In
Tel: 0207 272 2020 addition, standard letters for appointments have
Fax: 0207 281 5717 been translated into various languages.
Email: [email protected] See Appendix 2 for information on welcome packs
website: www.medact.org
The refugee section of the website has Lambeth, Southwark and Lewisham
information about translated material and other Refugee Health Team
resources. Carmen Rojas, Team Leader,
Masters House, Dugard Way (off Renfrew Rd),
Refugee Council: 3 Bondway, London SW8 1SJ
London SE11 4TH
Tel: 0207 820 3000
Tel: 0207 414 1507 Fax: 0207 414 1513
Produces booklets covering legal, support and
access to services including health and education. E-mail:
Separate booklets are available “Information for [email protected]
asylum seekers” available in English, Albanian, Welcome pack with information about local
Arabic, Chinese, Czech, Farsi, French; Kurdish services, available in French, Somali, Chinese,
(Sorani), Romanian, Russian, Somali, Tamil and Farsi, Amharic, Spanish, Tamil, Arabic, Russian,
Turkish and “Information for refugees and people Kurdish, Turkish and Albanian.
with ELR”, available in English, Albanian, Farsi, British Red Cross Information Pack for Newly
French; Kurdish (Sorani), Somali, and Turkish. Arrived Refugees.
Available from the Information Team on Available in English, French, Spanish, Farsi,
0207 820 3085. Kurdish, Somali and Russian and planned in
Portuguese, Pashto, Czech, Arabic and Tigrinya.
The Terrence Higgins Trust publishes leaflets on
Aimed particularly at refugees in the London
HIV awareness, HIV prevention and safe sex and
area, but may also be useful for other areas in
relationships in English and French, and also has
the UK. Topics include sources of help and advice
tapes in Swahili.
for refugees, rights to basic services like health
African Health Team, Terrence Higgins Trust,
and education and how to access these services.
52-54 Grays Inn Road, London WC1X 8JU
Tel (Admin): 0207 831 0330 Refugee Unit, British Red Cross London Branch,
54 Ebury St, London SW1W 0LU
Email: [email protected]
Tel: 0207 730 7674 Fax: 0207 730 5089
website: www.tht.org.uk
The Red Cross Refugee Orientation volunteers
It is planned to centralise translated information carry out home visits and help with accessing
leaflets on the websites www.harpweb.org.uk services and provision of clothing, kitchen
and www.medact.org. utensils, bedding, dictionaries etc.
3.5) Welcome Packs: Signposts - Information for asylum seekers
Produced primarily for newly arrived asylum seekers, and refugees
these contain information about local services: Available in English only. May in future be
available in other languages. Covers how to get
Welcome Packs: support, legal representation, health care,
Susan Donnelly, specialist health visitor for housing and education, the political system
Asylum Seekers, in the UK, UK laws, making phone calls, travel
2 Jesmond Road West, Newcastle NE2 4PQ and shopping.
Tel: 0191 245 7319 National Information Forum, BT Burne House,
In Newcastle, Welcome Packs have been Post Point 10/11, Bell St London NW1 5BZ
developed for asylum seekers which explain Tel: 0207 402 6681 Fax: 0207 402 1259
how to access health services, information on Email: [email protected]
prescriptions and information on local services. Website: www.nif.org.uk
Pictures are used, e.g. a clock, in order to

page 19
 4. Health Services

4.1) Eligibility for health care Key Points

4.2) How to find a GP and dentist • All asylum seekers and refugees are entitled
to full NHS care
4.3) Planning health services • HC1 form needs to be completed for free
4.4) Funding support for primary care prescriptions, dental treatment, optician
services and travel costs to hospital
services caring for asylum
seekers and refugees • Permanent rather than temporary registration
is preferable
4.5) Asylum Seekers’ expectations of • NHS Direct can assist with finding and
health care registering with a GP or dentist

4.6) Information for receptionists and • Information systems are needed in order to
plan and monitor services
practice managers
4.7) Health screening, incl registration • Health services for refugees should be of
similar range and quality to those of the
checks and needs assessment local community
• A dedicated service may enable appropriate
4.8) Hand-held records
support to be provided
4.9) Community development and • Include refugees in strategic planning and
health policies
• Additional funding may be available
4.10) Linking with refugee
• People may have different expectations
communities and community
of health care
organisations
• The NHS and how it works needs to be
4.11) Consultation with asylum explained
seekers and refugees • A health assessment should be offered

4.12) Feedback, complaints and • Uptake screening such as smears and

mammography can be increased by the
compliments
availability of female health workers and
4.13) Multi-sectoral working and advocates
partnerships with other • Hand–held records can facilitate
organisations communication in a mobile population
• Link with refugee community organisations
4.14) Training for health workers
• Multi-sectoral working and partnerships with
4.15) Support for health workers other organisations are important
• Training should be made available for staff
4.16) Health networks
• Health workers need support
4.17) Occupational health issues • Avoid making people more helpless in exile by
rescuing or creating dependence
4.18) Refugee health workers

page 20
 • Do not get isolated Anyone who has come to the UK under family
reunion (see section 2.2) will not have made an
• Networks for health workers can provide
asylum application but will have a passport stamp
valuable support.
for Indefinite Leave to Remain. They also have full
• Refugee health workers are a valuable entitlement to health care.
resource for the NHS and need assistance to
People on low income without benefits should
revalidate their qualifications.
apply with an HC1 form for an HC2 or HC3
certificate, giving full or partial exemption
4.1) Eligibility for health care
respectively from charges for prescriptions, dental
“Health workers know the system, refugees are treatment, optician services and travel costs to
blinded to the system. They need help to access hospital. The HC1 form is available from
the system” pharmacists, Primary Care Trusts or from the
(male doctor with refugee status) Department of Health, Sandyford House,
All asylum seekers, refugees and their Newcastle-upon-Tyne NE2 1DB Tel: 0191 203
dependents, at whatever stage of their 5555. Travel to and from hospital for treatment
asylum claim, are entitled to all NHS care is reimbursed by the hospital to HC2 certificate
without payment. holders at the time of the visit. Certificates are
‘Overseas visitors exempt from charges: valid for 6 months, after which a new application
No charge shall be made in respect of any must be made.
services forming part of the health service Permanent rather than temporary registration
provided for an overseas visitor, being a person, with a GP is preferable, as it will facilitate a health
or the spouse or child of a person – check, screening, health promotion,
who has been accepted as a refugee in the immunisation, continuity of care and access to
United Kingdom, or who has made a formal previous records, if in existence. Practices with
application for leave to stay as a refugee in the large numbers of refugees and asylum seekers
United Kingdom...’ may have the possibility of applying for extra
Statutory Instrument no. 306: The National funding (see section 4.4 – Funding support for
Health Service (Charges to Overseas Visitors) primary care services).
Regulations 1989. Asylum seekers and refugees are entitled to
The British Medical Association (BMA) secondary and tertiary health care if indicated.
recommends that doctors should not be obliged Many people may come from countries where
to check the immigration status of people before they have had direct access to hospitals. They
treating them. Where a hospital needs to verify may be unfamiliar with referral and waiting lists,
that a patient is an asylum seeker or refugee, one and will need these explained. Waiting lists may
of the following should suffice: also pose problems when asylum seekers have
i) an Application Registration Card (ARC), ID been moved or dispersed.
smart card (see section 2.4)
4.2) How to find a GP and dentist
ii) a travel document issued in accordance with
Some people may be having difficulties
the Convention on the Status of Refugees
registering with a GP or dentist. In many areas
iii) a letter from the Home Office stating that the lists are closed due to recruitment problems,
patient is a refugee or has been granted
which are particularly acute in urban and
refuge in the UK
deprived areas (where many asylum seekers are
iv) a letter from the Home Office confirming an placed). Under the Race Relations Act, health
application for asylum services cannot discriminate on racial grounds. It
A passport should not be required. would infringe the Act to deny registration to an
(adapted from BMA guidance Access to Health asylum seeker or refugee living in the practice
Care for Asylum Seekers and the BMA’s response catchment area whilst registering other patients
to Secure Borders, Safe Haven: Integration with (for further information on the Race Relations Act
Diversity in Modern Britain 2002 ) see www.cre.gov.uk).

page 21
 The process to follow for registration with a GP Outreach services may result in improved access,
or dentist is detailed below: particularly initially for new arrivals. The issue of
1) Check the person’s address whether to provide a dedicated service for asylum
seekers needs to be considered. There is a
2) Ring NHS Direct on 0845 4647 (who access
concern that separate services may
interpreters via Language Line), for
marginalise refugees.
information on local services. Primary Care
Trusts (PCTs) have details of languages spoken “Refugees should be dealt with by mainstream
by GPs and local access to interpreting. services – there should not be separate services,
3) If all local lists are closed, the registration thus further stigmatising these people”
department will arrange allocation to a practice Psychiatrist, London
for 3 months, most probably the nearest A dedicated service may, however, be able to
practice to where (s)he is living, with no provide more specialised support, including
choice. After 3 months (s)he may be taken off language support, more time available for
the list and have to reapply. appointments and a more comprehensive and
4) Some areas have Primary Care Walk-In Centres. specialist multi-disciplinary team, and may be the
Details can be obtained from PCTs. These are best solution for those in emergency
good for emergencies, but cannot offer accommodation. Ultimately, the aim should be
continuity of care. to integrate people into mainstream services. In
some areas (such as Newham in East London)
5) People can change practices, as long as they
asylum seekers register initially with a specialist
live within the catchment area of the new
practice and after a period of 12-18 months are
practice. They do not require permission from
expected to register with a local practice.
their GP to register with another practice.

4.3) Planning health services Newham Transitional Primary

Care Team
We recommend that a named person leads and
Church Road Health Centre, 30 Church Road,
acts as co-ordinator within each area. High
London E12 6AQ
quality information systems are required in order
Tel: 0208 218 7625
to plan and monitor services. The population of
email:[email protected]
asylum seekers is dynamic, with constant changes
in circumstances. Information systems to include The team, comprising a GP, nurse practitioner,
all asylum seekers, with comparable data in all practice nurse, health visitor, clinical
regions, should be established as part of the psychologist, reception staff and a practice
initial infrastructure. At present the Home Office manager, provides transitory quality primary
does not provide information on the number of care services to people currently unable to
asylum seekers resident in a particular area. register with a GP in their local area. It assesses,
treats and monitors health problems, referring
“ We need notification systems from NASS and
to other specialist agencies as necessary.
the council as to where people are placed.”
People are normally registered for between
Nurse, London
6 - 18 months. At an appropriate time during
When planning services, ensure that refugees this period the team will enable the client to
have access to a similar range and quality of register with a GP locally.
health services as the local community. If services
for asylum seekers are perceived to be better, Asylum seekers and refugees should be included,
resentment and hostility may ensue. Every effort as part of the local community, in district-wide
should be made to improve resources for the planning, including strategic policies of Trusts and
whole community. Services should reflect the Primary Care Trusts (PCTs), Strategic Health
standards contained in National Service Authorities, Health Improvement and
Frameworks (NSFs). Modernisation Plans (HIMPs) and voluntary
organisations. For those areas where schemes
are applicable, Health Action Zones (HAZ),

page 22
Education Action Zones (EAZ) Sure Start (children diversity of the local population.
aged 0-4), the Children’s Fund (children aged • Race equality and diversity work will be
5-12) and Connexions (young people aged integrated in the Trusts’ and PCTs’ Clinical
13 – 19) should address the needs of asylum Governance work.
seekers and refugees.
• A Local Development Scheme facilitates
Facing up to Difference - meeting permanent GP registration for refugees and
the health needs of a diverse asylum seekers.
community • Commissioning refugee support services,
Kensington and Chelsea and Westminster interpreting and advocacy, training and
Health Authority’s Health Improvement family support
Programme for commissioning services for • A refugee health workers’ support scheme is
Black and Minority Ethnic Communities - being developed.
“Facing Up to Difference” - is based on equity • Members of the community are encouraged
of access and provision of care. Focussing on to actively participate in the health
the impact of ethnicity and cultural diversity, it improvement initiatives, programmes and
aims to develop partnerships between the NHS partnership forum.
and Black and Minority Ethnic Communities
locally. It aims to improve health and reduce Further reading
adverse impacts linked to ethnicity on people’s
Levenson R and Coker N
access to and experience of health services.
The Health of Refugees – A Guide for GPs
• A Social Mapping project draws together London: King’s Fund, 1999
information mapping, needs assessments and
provides audits to agree priority areas for Trafford P and Winkler F
implementation. Voluntary organisations and Refugees and Primary Care
community groups have contributed to a London: Royal College of General
database. Practitioners 2000
• The Black and Minority Ethnic (BME)
Communities Health Forum, an independent
health partnership forum, is facilitating
communication between the PCT, NHS Trusts,
BME groups and individuals.
• Ethnic recording of all NHS in-patient service
users is aiming to meet a 95% performance
target.
• Trusts and PCTs are improving access to
written/audio-visual materials, interpreting
services, staff training on anti-discrimination
practices and tackling racial harassment in
the NHS.
• Community groups will be supported to
effectively participate in service planning
and monitoring.
• Improve advocacy services for refugees and
asylum seekers with mental health problems.
• A recruitment and selection strategy aims to
increase the local health service staffing
profile, to reflect the ethnic and cultural

page 23
 4.4) Funding support for primary care Personal Medical Services (PMS)
services caring for asylum Practices can bid for extra resources to support
seekers and refugees their work in looking after asylum seekers and
refugees
Many health workers have emphasised the
Three PMS pilots in Westminster include asylum
importance of proper resourcing for this
seekers and refugees, and specific quality
important work, which can be very demanding in
standards are built into the contract. These
time and energy, both physical and emotional.
include offering full registration, identifying and
Support for primary health care services caring for addressing health needs, engaging in learning
large numbers of asylum seekers and refugees opportunities, and referring to mother tongue
can be structured and resourced in a variety of and/ or specialist counselling services if
ways: appropriate. For further details contact:
Local Development Schemes (LDS) can provide Anna Barnes, Westminster PCT,
extra funding for practices registering refugees. The Medical Centre, 7e Woodfield Road, W9 3XZ
Hammersmith PCT, Brook Green Medical Centre, Tel: 020 8451 8169
Bute Gardens, London W6 7EG Fax: 020 8451 8162
Tel: 0208 237 2805 Dedicated primary care services provided under
Fax: 0208 237 2804 Personal Medical Services Schemes (PMS).
Website: www.hammerpcg.org.uk Examples of these include:
Hammersmith Primary Care Trust Local PMS Service for newly-arrived
Development Scheme (LDS) asylum seekers
Tel: 0208 237 2805
Dr Peter Le Feuvre, Mill Lane Surgery,
Practices taking part receive a joining payment Mill Lane House, Margate, CT9 1LB
per 1000 patients on their list and an additional Tel: 01843 220881
one-off payment for each refugee or asylum Fax: 01843 231713
seeker given permanent registration. They are
A one-stop service run by a GP, a full-time
expected to undertake the following key tasks:
nurse, attached health visitor, receptionist and
• Full, rather than temporary, registration of all manager, offering all new arrivals a health
asylum seekers and refugees assessment and preventative health screen,
• Each newly registered patient receives an including immunisation and cervical smears.
extended health check People are subsequently allocated to local
• Use of formal, rather than informal, general practices, where their details are faxed
interpreting services and the patient receives a hand - held record.
• Practice staff (GPs, nurses, managers and The Sanctuary Practice for asylum
receptionists) attend training, the aim of seekers and refugees in Hackney
which is to raise awareness about the
Valerie John-Charles/Dr Angela Burnett,
experiences and needs of refugees and
John Scott Health Centre, Green Lanes, N4 2NU
asylum seekers
Tel: 0208 210 3766
• Data collection (e.g. ethnic mix, language Fax: 0208 210 3769
needs) so that the PCT can build up a profile email: [email protected]
of the refugee population of Hammersmith,
Newly established, the practice will provide
in order to plan and develop services in the
health care to asylum seekers living in
future
emergency accommodation, prior to dispersal.
Working closely with interpreters and advocates,
it will assess their health needs, provide
appropriate screening and ensure this

page 24
 information is passed on to practices in dispersal feed the experiences of agencies in meeting
areas where they subsequently register. It will these needs into service development and policy
provide support to other practices throughout networks, and have piloted a model of support
the district in developing best practice working which enables GP practices to effectively work
with refugees, enhanced by a Local with this population in a culturally sensitive way.
Development Scheme, to facilitate the (from Hinton T. Working with Refugees and
registration of refugees who are settled within Asylum Seekers in Lambeth Southwark and
the district. The practice will develop strong Lewisham, Health Action for Homeless
partnerships with local voluntary sector People, 2001).
organisations, which play an important role in
the health and social care of refugees. A The Asylum Seekers’ Health Support
linkworker will provide outreach to hostels. Team (ASHST) - Glasgow
Brian Moss, Staff Nurse, Asylum Seekers’
Refugee health teams, primarily nurse-led,
Health Support Team,
working across GP practices.
Cowglen Hospital, 10 Boydstone Road,
Lambeth, Southwark and Lewisham
Glasgow G53 6XJ
Refugee Clinical Team, provides nurse-led primary
Tel: 0141 211 9222
care services, working with local GP practices
Fax: 0141 211 9305
Jane Cook, Team Leader, Moffat Clinic, 65 Email: [email protected]
Sancroft St, London SE11 5NG
Greater Glasgow Primary Care Trust employs
Tel: 0207 411 5689
the Asylum Seekers’ Health Support Team
Fax: 0207 411 5667
(ASHST) in the greater Pollok and greater
Email: [email protected]
Govan areas of Glasgow. Two team members
Lambeth, Southwark and Lewisham Refugee visit a newly arrived asylum seeker at home, to
Health Team identifies and addresses difficulties assess immediate health problems and
preventing refugees from accessing health accommodation, and identify any interpreting
services and aims to improve their access. needs. The team undertakes an initial health
Carmen Rojas, Team Leader, Masters House, assessment and then, in conjunction with local
Dugard Way, Renfrew Road, London SE11 4TH GPs, identifies a suitable practice with which
Tel: 0207 414 1507 to register.
Fax: 0207 414 1513
Specialist health visitors work in some areas
E-mail: with refugees and asylum seekers and support GP
[email protected] practices. For information on the UK Health
Visitor network, contact:
The Three Boroughs Team, Lambeth,
Susan Donnelly,
Southwark and Lewisham
Specialist health visitor for Asylum Seekers,
Tel: 0207 411 5689 (Clinical Team)
2 Jesmond Road West, Newcastle NE2 4PQ
0207 414 1507 (Health Team)
Tel: 0191 245 7319
The Refugee Clinical, the Refugee Health and
the Homeless Teams have developed a model
of working which fills many of the gaps in the
provision of information and awareness-raising
to refugees and asylum seekers, agencies which
work with them and health practitioners.
Through the provision of clinical services, the
production of written materials and health
promotion and awareness raising sessions, the
teams support front line services to better meet
the health needs of this population. They also

page 25
 Other Possible Sources of Funding for Children’s Fund
Developing Services The Children’s Fund addresses the needs of
Health Action Zone (HAZ) children aged from 5-12 years

Health Action Zone funding to The Children’s Fund in Newham

improve psychological well-being Contact details:
of families [email protected]
Irene Sclare Tel: 0208548 5023/5094
tel: 020 7919 2683
In Newham a range of projects has been
email: [email protected]
grouped together for networking and
In Lambeth, Southwark and Lewisham, the co-ordination purposes in a Refugee and
Health Action Zone is developing a service for Homeless Delivery Team. Projects include an
troubled refugee children and their parents, access to schooling outreach worker, art
teachers and carers. It aims to help to resolve therapy, play and focussed work with the Roma
emotional and behavioural difficulties, increase community. They are underpinned by
child and parent support, and improve capacity developing preventative work, accessing
to access mental health services. Child mental mainstream provision and supporting well
health specialists, clinical psychologists and a being through creative activities. Projects
family therapist will work jointly, offering ensure that children are actively involved in
services in schools, clinics, and community developing and implementing services.
organisations. Training and group work will be
carried out in partnership with health workers, Further information on the Children’s Fund at:
teachers and social workers http://www.cypu.gov.uk/corporate/childrensfund
/index.cfm
Sure Start
http://www.go-london.gov.uk/educationskill
Sure Start aims to improve the health and well-
/childrens_fund_in_london.asp
being of families and children before and from
birth to 4 years old. Sure Start programmes are Connexions
concentrated in neighbourhoods where a high
proportion of children are living in poverty and
Connexions in Lewisham
where new ways of working can improve Lewisham is piloting the new Connexions
services. Local programmes will work with parents service, offering a range of guidance and
and parents-to-be to improve children's life support for 13–19 year olds, scheduled to go
chances through better access to: ‘live’ across the London East area from April
2002. Locally, the service has seen work with
• Family support
young asylum seekers and refugees as an
• Advice on nurturing
integral part of the programme. It has formed
• Health services close links with the Lewisham Asylum team
• Early learning and the Lewisham Refugee Network, as well as
Further information from: having Personal Advisors in Schools, Lewisham
http://www.surestart.gov.uk/text/info.cfm College and in the local community. Examples
of areas of work with Refugees and Asylum
Seekers have been: support in finding school,
college, or training places, group work,
personal development & volunteering
opportunities, advice and support in gaining
accommodation, access to benefits, and access
to education for those who have recently
obtained ELR/Refugee Status. Connexions has a
firm commitment to all young people, including

page 26
 asylum seekers and refugees. There may, in the The Buttle Trust, Audley House, 13 Palace Road,
future, be the possibility of some funding to London, SW1E 5HX. 0207 828 7311 administers
voluntary organisations offering specific services Child Support Grants for clothes, bedding,
to targeted groups of young people within the essential furniture and household equipment.
Connexions framework. Connexions is Children must have refugee status or Exceptional
committed to involving young people in the Leave to Remain, or have lived in the UK for 2
design and running of the service. years or more, and not be subject to a
For further information: removal/deportation order.
www.connexions.gov.uk
4.5) Asylum seekers’ expectations
main Connexions website
of healthcare
Lewisham Connexions Pilot website:
Asylum seekers from countries where primary
http://communities.msn.co.uk/Connexions
care is not well developed may expect hospital
Lewishampilotsite/_whatsnew.msnw?f=0
referral for conditions which, in the UK, are
The European Refugee Fund and the treated in primary care. This may result in
disappointment for them, irritation for health
Challenge Fund
workers and frustration for both. Careful and
Projects relating to the integration of people with repeated explanation of how the NHS functions
refugee status or Exceptional Leave to Remain, may be needed. In some areas (e.g. Newcastle)
and for voluntary repatriation are eligible for information packs have been developed in
funding. Projects can cover areas such as learning different languages for newly arrived asylum
English as a second language, seekers. In others, (e.g. Lambeth, Southwark and
mentoring/befriending, health, housing, Lewisham) outreach workers conduct health
education and employment, addressing specific sessions in hostels, providing information about
social needs amongst refugee communities, e.g. how local health services can be accessed (See
women, children and vulnerable groups. Section 3.4 Information on access to health care
Guidelines are available on the website, and on health). However, clinicians may need to
http://www.ind.homeoffice.gov.uk or by post or explain again when referring to hospital.
e-mail from the address shown below, marked
Some people may come from countries with
'ERF project guidelines'.
technologically developed health care systems.
Refugee Integration Unit, Asylum and Appeals They may expect investigations for conditions that
Policy Directorate, Home Office, 5th Floor in the UK are managed more conservatively. In
Voyager House, 30 Wellesley Road, many countries injections are a preferred method
Croydon CR0 2AD of drug administration.
Tel: 020 8633 0065
Some may not have had access to health care
E-mail: [email protected] services in their own country, due to disruption by
or [email protected] conflict, gender (e.g. Afghanistan where women
could not be seen by male health workers, nor
Other sources of funding for
themselves work), or ethnic group (e.g. Kosovars
individuals of Albanian heritage). Health workers and others
The Family Welfare Association helps families with in authority may be viewed with mistrust, as they
grants for household items and for holidays for may have been part of the system of oppression
children with a disability. Applications must be in the person's home country. Confidentiality
made by a professional on behalf of a family. needs to be emphasised, and trust may take a
Family Welfare Association while to develop. People may have fears about
501 - 505 Kingsland Road, London, E8 4AU interpreters maintaining confidentiality,
Tel: 0207 254 6251 particularly in small communities.

page 27
 4.6) Information for receptionists and would describe her as12 years old. Some3
practice managers may record only the year when they
were born.
The role of receptionists, as the first point of
contact, is very important. • Time may be expressed differently in
some cultures4
• Receptionists and managers should have
access to telephone interpreting services, as 4.7) Health assessment, including
needed. Receptionists in a Glasgow practice registration checks and screening
are piloting videophones. For information, The new patient check provides an important
contact: opportunity to establish health needs, language
Margaret Hanlon, Practice Manager, needs, and social circumstances.
Fernbank Medical Centre, 194 Fernbank St,
“Carrying out a thorough initial health
Glasgow, G22 6BD.
assessment is critical”
Tel: 0141 589 8000 Fax: 0141 589 8004
Nurse team leader, London
• Many people will be unfamiliar with
In addition to the usual health check, consider
appointment systems, which will need
adding the following. It is unlikely to be feasible,
explaining. This can be done through
nor appropriate, to carry out everything at the
outreach sessions in hostels or written
initial visit:
information (see section 3.4 - Information on
health), but some flexibility is likely to be Ethnic origin
required. Check that appointments do not fall Language needs – whether an interpreter is
on religious days of worship. If possible, try required and, if so, which language/dialect
and enable people to make use of cheap Social history – accommodation/family/whether
travel arrangements when booking separated, how travelled to the UK
appointments. People with sleep problems Experiences of torture/violence
may find early morning appointments difficult Disability/special needs
to keep.
Diet/Nutrition
• There may be a need to liaise with people Immunisation as appropriate
about hospital appointments, in order to
Screening as appropriate – breast, cervical,
explain the content of letters written from
testicular
the hospital. This is particularly important for
Sexual health advice and screening /family
patients who do not have any relative or
planning – as appropriate
contact in the local community to translate
for them, and it can reduce anxiety and TB screening (see Appendix 3)
misunderstandings. HIV and Hep B/C screening as appropriate
• Check how a person would like to be Sickle cell/thalassaemia
addressed and how they wish to be If bowel symptoms are present, check stool for
registered. Do not assume the name order is ova, cysts and parasites
the same as in Western European usage. Assessment of psychological well-being (See
• In the UK, date of birth is frequently used as a section 5.3)
form of identification. This is not the case in Oral health
many countries and some people may not Recently arrived asylum seekers may have run out
know their date of birth, or there may be of essential medication for a chronic illness and
differences in how people describe their date need urgent assessment and resupply. Check if
of birth and age1. Some people2 may express an HC1 form is needed (see section 4.1)
their age as one year older than European
1 In Ethiopia the Julian calendar is used, which is roughly 7.5 years
convention. So a child born in January 1990 “behind” the Western Gregorian calendar. The year 1994 in the
would in November 2001 be considered in the Ethiopian calendar began during September 2001 in the European
calendar.
UK to be aged 11; but her family would 2 e.g. including people from Turkey, Iran and Afghanistan
3 including Tibetans
measure her age as being her 12th year and 4 in Ethiopia, time is measured with a 12-hour day starting at daybreak
(12 o’clock in the morning or 6am European time), and ends at 12
o'clock in the afternoon, or 6pm European time. 10 am European
time is 4 o'clock in the morning Ethiopian time. 5pm European time
page 28 is 11 o’clock in the evening Ethiopian time.
Screening, such as smears and mammography,
“The Red Book”, used in England. The pages are
has tended to have low uptake amongst refugee in triplicate – one copy remains with the client in
women. Access can be significantly increased the hand held record, another is kept with the
through the availability of female health workers Health Support Team and the third is for the GP
and advocates. Translated leaflets have also been and primary care team.
found to be useful, but not all women are
The advantages of the system are that it
literate. Women who have experienced sexual
improves continuity of care and reduces
abuse, sexual violence or female genital
duplication. Information from the initial health
mutilation (FGM) may have particular difficulties
assessment carried out by the Health Support
with cervical screening.
Team can be useful for the GP’s registration
Health Assessment for asylum check. The client can choose whether to share
seekers in Belfast information with other agencies such as
housing or benefits offices. The record gives
At a local church-based drop-in clinic, health
an in-depth analysis of health needs and makes
visitors offer basic health assessments and
it clear who is working with the client, the
information on how to access health services.
health needs that have been identified and the
Free condoms are available. It is planned to
future care plan.
expand the service to offer blood pressure
checks, urinalysis, Heaf testing, BCG Information about local services, how health
vaccinations and health promotion sessions. services work and breast and cervical screening
Information will be passed on to GPs, programmes is available at the back of the
highlighting the findings of the health record. This has been translated into Arabic
assessment, with onward referral to other and Albanian.
services if required. A health link worker is Hand held records have also been developed in
planned, to act as a an advocate for asylum many other areas, including Lambeth, Southwark
seekers and a resource for health workers, and Lewisham, Luton and Sheffield
raising awareness of the health needs of asylum (contact names and details below).
seekers and improving their access to services.
Jane Cook, Nurse Practitioner and Team Leader,
4.8) Hand-held records The Refugee Clinical Team
Hand–held records may be useful for asylum Moffat Clinic, 65 Sancroft St, London SE11 5NG
seekers, who are often moved around frequently. Tel: 0207 411 5689
Our experience is that asylum seekers are very Fax: 0207 411 5667
reliable with carrying papers, but cramped living
conditions and lack of privacy may make it Linda Penny, Nurse Practitioner,
difficult to maintain information as confidential. Health Care for the Homeless, Asylum Seekers
People should be given a summary of what is and Travellers (HHAT),
written in the record. Offering people a copy of The Lodge, 4 George St West, Luton, LU1 2BJ
their health record can be a way of enhancing Tel: 01582 511000
their autonomy and building trust. Fax: 01582 511001

Hand Held records Joan MacFarlane, Primary Care Nurse Consultant,

Asylum Seeker Health,
Health Support Team, The Medical Centre,
7E Woodfield Road, London W9 3XZ Park Health Centre, Duke St, Sheffield S2 5QQ
Tel: 0208 451 8175 Tel 0114 2261739
The Health Support Team in Parkside developed Fax 0114 2261742
hand held records for those who are homeless, Email: [email protected]
asylum seekers and refugees, due to the
mobility of these groups of people. The records We hope to develop a standard hand-held record,
are based on the child development record, to be used nationally.

page 29
 They may assist people to register with GPs and
accompany them to outpatient appointments, or
visit them in hospital. Some employ health
workers, many of whom have health
qualifications from their own country (See section
4.18 - Refugee health workers) whose skills and
experience can contribute greatly to the health of
their community. They may be involved with
health promotion activities and may organise
sessions to raise awareness about particular
health issues. Although many provide services on
a voluntary basis, this cannot be assumed and
health workers should wherever possible try to
4.9) Community development seek funding to pay workers for the time they
and health offer as interpreters, translators or advocates,
unless they are being funded specifically to do
Community development approaches to improve this work.
health have been widely used since the 1960s,
However, political divisions may exist within
particularly in areas of deprivation and poverty.
refugee communities and this may deter some
They offer a framework for health workers and
people from contact with such organisations
other agencies to involve local communities in the
promotion and development of good health. Continued funding remains a problem for many
of these organisations, and part-time staff or
The King’s Fund Primary Care Group has produced
volunteers carry out much of their work. There is
a series of publications to support health care
a need to support the creation and development
teams. For more information refer to:
of refugee groups and organisations in dispersal
Community Development in Primary Care – a areas.
guide to involving the community in Community
Orientated Primary Care (COPC) by Richard 4.11) Consultation with asylum
Freeman and Stephen Gillam. King’s Fund 1997. seekers and refugees
www.health-activist.net contains details about
Involving users in planning, developing and
training in community development.
implementing services is likely to contribute
towards their appropriateness and acceptability.
4.10) Linking with refugee
We have already highlighted the fact that asylum
communities and community
seekers and refugees are not a homogenous
organisations group and have varying needs and expectations.
It is therefore important that consultation is wide,
Refugee community organisations (RCOs) provide
and that care is taken to include those whose
advice and support to asylum seekers and
views may not ordinarily be heard, such as
refugees. Some work with specific communities
women, older people, young people, people with
(by country or ethnic group) or groups, e.g.
disabilities, those with mental health problems.
women or people with a disability; others work
Evaluation of services should also include the
with all groups. They may provide immigration,
views of users.
housing and benefits advice, interpreting and
translating. They can act as advocates, reducing 4.12) Feedback, complaints and
isolation, providing orientation, social support compliments
networks, information in people’s own language Asylum seekers and refugees should have access
and a connection with their own culture. to feedback and complaints procedures.
Depression amongst refugees is closely linked with Information needs to be available in relevant
poor social support. Some organise education - languages, and assistance given to enable people
English and computer classes, mother-tongue to participate, e.g. through making an interpreter
classes and homework clubs for children. available.

page 30
4.13) Multi-sectoral working and Partnerships between Health and
partnerships with other Education in Westminster
organisations
Health Support Team, 7E Woodfield Road,
Communication is crucial between the range of London W9 3XZ
different agencies involved in providing services Tel: 0208 451 8175
for asylum seekers and refugees. These include
Joy Stanton, Refugee Support Co-ordinator
refugee community organisations, groups and
to Schools,
individual displaced people, local and national
Tel: 020 7641 6391 Fax: 020 7641 6330
voluntary organisations, social services, health
email: [email protected]
workers and health organisations, education
departments, housing departments, The Health Support Team based in Kensington
accommodation providers, National Asylum Chelsea and Westminster works closely with
Support Service (NASS), lawyers, advice agencies, the Education Department in Westminster. The
the police, interpreting services, religious groups, Health Support Team does outreach work to
local residents’ groups and anti-racist groups. refugees in Bed &Breakfast hotels, carrying out
Systems need to be established to ensure that an in-depth assessment and helping people to
information is exchanged efficiently and access mainstream services. The Refugee
appropriately. Many areas have developed a Liaison Worker in the Education Action Zone
multi-agency Refugee Forum, which facilitates arranges school places, interpreters, admissions
meetings and contact between agencies. interviews and induction in school. Education
services refer children with health care needs
A list of agencies working nationally with asylum
to the Health Support Team. Both contribute
seekers and refugees is included (Section 9.1 One
to educational sessions. TB screening sessions
Stop Services and national agencies working with
form part of a one-stop Community Health
refugees). Information on local agencies can be
initiative at the Bayswater Family Centre, also
obtained from your nearest One Stop Service
incorporating Education, Housing,
(Section 9.1 as above).
Environmental Health and Benefits advice.
“Working with other agencies prevents
fragmentation, makes it easier to meet the Refugee and Asylum Seeker
breadth of needs and provides an opportunity Participatory Action Research
for consultation and supervision.” (RAPAR)
Psychologist, London c/o Faith and Justice Commission,
Resources such as interpreters, translation, Cathedral House, 250 Chapel St, Salford,
advice, advocacy and training can be shared M3 5LL
across agencies within a district. Supporting Cath Maffia: 0161 212 4452
services with longer-term funding, if shown to be Rhetta Moran: 0161 295 5277
successful, is preferable to the insecurity of short- RAPAR is bringing together health, social
term funding. services, education, youth and leisure series,
housing, community safety, community
development workers, advocacy agencies,
church groups, the police, local residents’
groups and the Red Cross. Current work is
focussing on issues of communication, mental
well-being, community gynaecology, group
health promotion, community safety, and
employment opportunities.

page 31
 4.14) Training for health workers It is easy to feel impotent when faced with so
many problems. You may feel a huge pressure to
Clinical and reception staff in all agencies require meet all needs yourself, while feeling that you do
training, to include awareness of issues facing not have the information, skills or time to do so.
asylum seekers and refugees and of the If possible, build networks with others involved in
available services. this work, both within and outside your own
Many health workers who responded to the discipline and within the statutory and voluntary
questionnaire requested training. Postgraduate sectors, so that you are not working in isolation.
tutors and others responsible for training can Some problems may have no solution, but it may
arrange courses and study days. Training should help to listen.
be multi-disciplinary, bringing together the
“I realise it’s not just me who doesn’t always
voluntary and statutory sectors, in order to share
know what to do’”
information and to develop skills and networks.
Health visitor, London
Organisations offering training on working with Managers need to be aware of the time demands
asylum seekers and refugees: placed on workers by interpreting, multiple and
complex difficulties and multi-agency liaison.
Medical Foundation for the Care of Victims of
Torture, 96-8 Grafton Road, London, NW5 3EJ
Tel: 0207 813 7777 4.16) Health networks
(Training on working with survivors of torture and Medact, 601 Holloway Road, London N19 4DJ
organised violence against adults and children) Tel: 0207 272 2020
Fax: 0207 281 5717
Refugee Council, Breathing Space, Refugee
Email: [email protected]
Council: 3 Bondway, London SW8 1SJ
website: www.medact.org
Tel: 0208 210 3766
The Refugee Health Network comprises a
(Training on access to health care and on multi-disciplinary group of health workers from
psychological health) throughout the UK, whose aims are to share
Dr Angela Burnett information and lobbying for improved conditions
email: [email protected] for asylum seekers and refugees.
Tel: 07960 860 266
(Training on access to health care, physical and
psychological health for adults and children)

4.15) Support for health workers

“As with all new ventures, staff pressure and
stress have been big issues.”
Practice Manager, Glasgow
Working with refugees is both rewarding and
challenging. It is important not to set up
unrealistic expectations, nor to make promises
that cannot be fulfilled. Encourage independence,
although refugees may need more help to access
services. Health workers may be exposed to a
high degree of distress whilst listening to people’s
accounts of their experiences and may need
support themselves. Administrative staff may
also be affected. It is important not to
become isolated and to recognise limitations
and vulnerabilities.

page 32
Network of Health Visitors working with asylum Jewish Council for Racial Equality (JCORE), 33
seekers and refugees. Seymour Place, London W1H 6AT
Susan Donnelly, Specialist Health Visitor Tel: 0208 455 0896
for Asylum Seekers, Fax: 0208 458 4700
2 Jesmond Road West, Newcastle NE2 4PQ Email:[email protected]
Tel: 0191 245 7319
The Postgraduate Centre for Refugee Doctors
Council for Ethnic Minority Voluntary runs courses for refugee doctors preparing for the
Organisations (CEMVO) Health Advocacy Network PLAB exam, both by attendance and through
Tel: 020 8432 0409, distance learning.
E-mail: [email protected] Dr Nayeem Azim, Postgraduate Centre for
Website: www.emf-cemvo.co.uk Refugee Doctors, 67 Elliot Road, London NW4 3EB
Provides health advocates with access to Tel: 0208 203 4466
information, support and resources. Fax: 0208 203 1682
Mobile: 07950 644956
4.17) Occupational health issues Email: [email protected]
The usual precautions should apply. It is Website: www.plabisgood4u.com
recommended that clinical healthworkers should
check their immunity for TB and Hepatitis B. RETAS
(Contact details see Section 8.7) offers careers
advice and support for monitoring for
4.18) Refugee health workers
refugee doctors.
It is estimated that there are 1-2 000 doctors and
Nurses
a similar number of nurses amongst refugees and
asylum seekers, as well as dentists and Helen Watts, Praxis, Pott St, London E2 0EF
professionals allied to medicine. Schemes exist in Tel: 0207 749 7601
many cities, offering careers advice and support Email: [email protected]
to assist them to be able to work within the NHS. Website: www.praxis.org
They must pass English language exams and a Offers career advice and support with the
revalidation process, specific to their discipline. revalidation process for nurses

Doctors The Royal College of Nursing,

Regional Postgraduate Deans are local points of 20 Cavendish Square, London W1M 0AB
contact. A refugee doctors’ database is being co- Tel: 0207 409 3333
ordinated by the British Medical Association Offers support for nurses including career advice,
(BMA) and the Refugee Council. Doctors on the workplace representation, educational
database are notified about any events or new opportunities, immigration and visa advice
developments and receive a newsletter with
Professions Allied to Medicine
information about local groups offering support
in preparing for the exams and in gaining clinical Helen Watts, Praxis, Pott St, London E2 0EF
attachments and work. Information is available Tel: 0207 749 7601
on www.refugeecouncil.org.uk and Email: [email protected]
www.bma.org.uk or telephone Deng Yai on Website www.praxis.org
0207 820 3138. The BMA (tel: 0207 383 6680) Offers career advice and support with
offers a free benefits package to refugee and the revalidation process for professions allied
asylum seeking doctors. to medicine
An updated “Guide for Refugee Doctors”,
outlining the procedures to gain registration and
the sources of help and support that are available
will shortly be available from:

page 33
 5. Key Clinical Areas

5.1) General health status 5.10) Tuberculosis (TB)

5.2) Prescribing and dispensing 5.11) Other communicable and

tropical diseases
5.3) Psychological well-being (see
also section 6.2 - psychological 5.12) HIV/AIDS
health following torture and
5.13) Sexual health and family
violence
planning
5.4) Psychological therapies and
5.14) Health promotion
counselling
5.15) Oral health
5.5) Discussing distressing events
(see also section 4.15 – Support 5.16) Nutrition
for health workers)
5.17) Drugs and alcohol
5.6) Physical expressions of
5.18) Physiotherapy
distress/somatisation
5.19) Role of complementary
5.7) Sleep problems
therapies
5.8) Physical health (see also Section
5.20) Traditional healthcare
6.3 - Physical health following
torture and violence) 5.21) Arts therapies and creative arts
5.8.1) Gastro-intestinal symptoms Key Points
• Take a holistic approach to health
5.8.2) Chronic diseases: diabetes,
• Practical issues may need to be addressed
hypertension, coronary heart
• Social isolation and poverty have a negative
disease, strokes
effect on physical and psychological health
5.8.3) Rheumatic heart disease • Many people’s health deteriorates after arrival
• Immunisations may be incomplete
5.8.4) Haemoglobinopathies
• Consider alternatives to drugs, such as
5.8.5) Dermatology massage, if available, for chronic pain
• Consider cultural factors when assessing
5.8.6) Respiratory illnesses health, particularly for psychological health

5.8.7) Musculo-skeletal • Symptoms of psychological distress

are common
5.9) Immunisations • Carefully consider before pathologising
what may be natural responses to highly
abnormal situations

page 34
 • Physical presentations of distress are common
Fassil Y
• Drugs and alcohol may be used as a coping
Looking after the health of refugees
strategy
BMJ 2000; 321: 59
• Offer voluntary counselling and testing for HIV
if appropriate Burnett A and Peel M
• People living with HIV/AIDS need specialist The health needs of asylum seekers and refugees
legal advice BMJ 2001; 322: 544-7

• Offer information on sexual health and family 5.2) Prescribing and dispensing
planning
“When I tell my GP my worries with my broken
• Oral health may be poor
English, he tells me everybody has worries and
• People may be undernourished gives me tablets”
• Complementary therapy, art therapy, music Male asylum seeker, dispersed
therapy, and creative support may be helpful Although some health conditions are amenable to
medication, prescribing may not help many of the
5.1) General health status
problems which refugee’s experience. Consider
The health of asylum seekers and refugees, as alternatives to drugs such as massage for pain, if
with anyone, is affected by physical, psychological this can be made available. One refugee is
and environmental factors. In order to make the quoted:
pack easier to follow, health issues are classified
into different sections. However, in practice “We are probably going to develop an anti-
physical and psychological health issues are paracetamol antibody because we have been
interwoven requiring a holistic approach. taking it so much”
Attention is drawn to the special circumstances of Taylor G. Amnesty conference proceedings
Sept 2001
this group of people, but their health is more
likely to be affected by commonly occurring Muslims observing Ramadan may fast between
medical problems. sunrise and sunset and may not wish to take
medication orally between these times. Fasting is
The physical health status of asylum seekers on
not recommended for patients who have
arrival is not perceived to be a major problem.
significant renal disease, heart failure, during
The majority of people seeking asylum are
pregnancy and for diabetics, who are insulin-
relatively young. However, previous surveys and
dependent or poorly controlled. Diabetics well-
our own research have found that many people
controlled on short-acting oral hypoglycaemics
perceive that their health deteriorates after arrival.
(e.g. gliclazide, glipizide, and metformin) can fast
“The health of asylum seekers often deteriorates if they split their total daily calorific intake into
after their arrival in the UK. Mental health also two meals and take their tablets with the meals.
deteriorates.” Short-acting meglitinides such as repaglinide
Health visitor, Salford should be taken immediately prior to food. Blood
People with serious illnesses who would not have glucose should be regularly monitored, and
access to treatment in their home country may treatment should not be omitted.
seek to stay in the UK on compassionate grounds Information developed in Newcastle for asylum
They should seek specialist legal advice. seekers includes a clock, on which the times for
medication may be drawn. (note that Ethiopians
Further reading use a different time system) (see Welcome Packs
Aldous J et al in section 3.4 and Appendix 2). Some
Refugee health in London - Key Issues for Public pharmacists have access to telephone
Health interpreting.
London: the Health of Londoners Project, East For identification of differently named medicines
London and the City Health Authority 1999 from abroad the pharmacy department at your

page 35
 local hospital may be able to help. Some people Assessment
may receive medication from abroad, but may be Expressions of distress and the ways in which
having only intermittent supplies. people cope differ both between and within
Asylum seekers not on social security benefits cultures, which makes assessment and treatment
need to complete an HC1 form in order to access of psychological health problems of refugees
free prescriptions. (See section 4.1) People who complex. It is important to maintain an open
do not yet have an exemption certificate should mind over a longer period of assessment. Check
complete form FP57, so that they can claim back how the client makes sense of psychological
prescription charges when they have obtained a distress from within their culture; and also what
certificate. culturally appropriate responses to distress may
be. When making a psychological assessment,
5.3) Psychological well being include an assessment of risk of suicide and
(see also section 6.2 - psychological health issues of child protection (see section 7.10) if
following torture and violence, Section 7.6 - indicated. There may be cultural and religious
health needs of families, section 7.7 – children taboos regarding talking about self-harm.
and adolescents, section 7.8 – unaccompanied Cultural differences and difficulties with language
minors/separated children, section 8.2 - spiritual and communication may increase the possibility
support) of a misdiagnosis of mental illness. The questions
“Because of my worries my doctor gives me used to diagnose mental illness may not be
reliable when used in translation or cross-
tablets, but my worries are due to my
culturally. Black and minority ethnic people in the
immigration status and my loneliness”
UK have been shown to be disproportionately
Female asylum seeker, dispersed
diagnosed with schizophrenia, sectioned under
Presentation the Mental Health Act1 and given high doses of
Psychological distress is common amongst asylum anti-psychotic drugs rather than talking therapy.
seekers and refugees. People commonly “I worked with an asylum seeker who had been
experience: labelled as having mental health problems, but
• extreme sadness the client herself had not been involved (in the
assessment) nor was she aware of many of the
• anxiety, depression and panic attacks
discussions that had taken place. It illustrated to
• problems with memory, concentration and me some of the difficulties when an assessment
disorientation is made in a way that does not match the
• poor sleep patterns (almost universal) client’s needs. She was not listened to.”
These may result from: Health visitor, London
• the atrocities and multiple losses that people Language
have experienced
Bilingual health workers or interpreters are
• displacement and their current situation in essential. Interpreters and advocates may need
the UK additional training in mental health issues and
• social isolation, poverty, hostility, loss of status may find therapy sessions confusing and
and racism, which have a compounding upsetting. If possible, try to spend some time
negative effect on psychological health. with the interpreter at the beginning and end of
• the uncertainty of a life in limbo and the fear a session, discussing ways of working. (See
section 3.2 - Working with interpreters and
of being sent home
advocates). Some mental health workers have
• loss of their friends, family and community, as
expressed concerns about working with
well as their home, job, culture and country
interpreters, and may require training. Our
• mental illness, which may be long-standing, experience is that psychological work is effective
or which may be linked with their experiences. through interpreters (and would be impossible
1 Minnis et al Racial Stereotyping: Survey of Psychiatrists in the United
without them, where language is not shared).
Kingdom BMJ 2001 323: 905-6

page 36
Addressing psychological distress • contact with family/family reunion (See section
For many people, restoration of their normal life 8.3 - Tracing missing family members)
as far as possible can be the most effective • social support – links to integrated community
promoter of mental health and can do much to groups (see section 4.10 - Linking with
relieve feelings of sadness and anxiety. On the refugee communities and organisations)
part of health workers, supportive listening is very • strong religious or political ideology (see
valuable in order to acknowledge injustice, both section 8.2 - Spiritual support)
past and present and to help people to cope both • having a proactive problem solving approach
with their memories and with their current
situation. Many people find that talking helps, a
bearing of testimony. However, some people may
Waltham Forest Refugee Mental
be suspicious of health workers, as they may have
Health Project
been identified with the ruling state in their home
country, and even been involved in oppression. Kate Thompson, Refugee Support Psychologist,
Trust needs to be earned and may take some Larkswood Centre, Thorpe Coombe Hospital,
time to develop. In addition, many people may Forest Road, London E17 3HP
experience guilt or shame regarding their Tel: 0208 520 8971
experiences. Fax: 0208 535 6850
Prior to setting up the service, a thorough
“Refugees are looking for safety – after some
needs assessment was conducted with local
time, if we feel safe, we will open up”
refugee community groups, individuals and
Male Doctor with refugee status
support organisations. The main difficulties
“ The catharsis of being listened to for long and concerns described were:
enough and patiently enough can be all that • Isolation/cultural bereavement
is needed to restore health to a nearly
• Boredom/confounding of expectations of life
normal level”
in the UK – anxiety about immigration status,
GP Glasgow
financial worries and a feeling of not being
Working with asylum seekers and refugees has wanted in the UK,
particular challenges, because people are
• Changing roles in the family/clash of values
dislocated, have lost their usual support systems
and, especially in the case of asylum seekers, • Residual effects of traumatic events (although
have an uncertain future. Build on a person’s less mention of this than might be expected)
strengths, giving them as much control over the • Physical illness
pace and content of your meeting as possible – • Risk of substance abuse, connected with
overall they are in control of very little and this worry, sleeping difficulties or boredom
can be very debilitating. A psychologist in London • Suicide
described the importance of “being a witness”
Community suggestions for intervention were:
and of “politicising rather than pathologising
anger”. He had arranged for one of his clients to • Counselling
record his experiences for an Oral History Project • Awareness raising
at the Museum of London, which had • Activities/keeping busy
strengthened his sense of identity and had been • Traditional healers/traditional community or
very therapeutic1. religious leaders
For many people, psychosocial support, reducing
their isolation and accessing help with practical
and social issues may help to improve mood. The 1 Webster A Personal Communication
2 Watters C Refugees and Asylum Seekers- needs and service
factors outlined below have been shown to development issues. Presentation to a conference on ‘Developing
effective Mental Health Services for a multi-ethnic society’ London
protect against mental illness for people in exile2, 1997 Cited in Harris K and Maxwell C A Needs Assessment in a
and interventions should aim to enhance these. Refugee Mental Health Project in North-East
London: Extending the Counselling Model to Community Support,
Medicine , Conflict and Survival 2000, 16, 201-215

page 37
 mental well-being needs of refugees and asylum
The psychologist has placed great importance
seekers across the UK. Its main working areas are
on supporting those people and organisations
case work, capacity building for Refugee
helping refugees to rebuild social and
Community Organisations, advocacy and training
community links. Her work comprises
For further details, contact:
• community mobilisation, with existing groups
The Refugee Council, 3 Bondway,
or finding a link person, if none exists, giving
London SW8 1SJ
assistance to obtain funding for community
Tel: 0207 820 3000
initiatives
Fax: 0207 582 9929
• raising awareness of mental health issues with
both refugee groups and with health workers. Emma Williams, The Medical Foundation for the
• Networking and liaison Care of Victims of Torture, Star House,
104-8 Grafton Road, London NW5 3EJ
• individual clinical work, working flexibly and
Tel: 0207 813 9999
with a wide holistic perspective, with referral
Fax: 0207 813 0033
to a counsellor from a particular background,
an elder or healer if indicated. Further reading
A Turkish speaking counsellor has joined the Burnett A and Peel M
project, working with individuals and groups. The health needs of asylum seekers and refugees
BMJ 2001; 322: 544-7
However, those whose ability to function remains
impaired may need additional intervention. CVS Consultants and Migrant and Refugee
Communities Forum.
Treatment and support
A Shattered World - The Mental Health Needs of
Psychological therapies and counselling are
refugees and newly arrived communities
discussed in section 5.4. If prescribing ensure
London, Lavenham Press, 1999.
that information about the drug and anticipated
Available from CVS Consultants,
side effects is clearly understood.
27-9 Vauxhall Grove, London SW8 1SY
Mental health services Fernando S.
“Why are mainstream mental health services Mental Health in a Multi-Ethnic Society
unable to deal with refugee mental health as London: Routledge 1995.
part of their services?” Watters C
Nurse practitioner, London The Mental Health Needs of Refugees and
Mental health services, for those who need them, Asylum Seekers: Key Issues in Research and
should aim to be accessible, flexible and Service Development in Nicholson F Current
appropriate, reflecting the standards in the Issues of Asylum Law and Policy Avebury 1998
Mental Health National Service Framework, The
Webster A and Rojas Jaimes C
Journey to Recovery 2001. Services have a
The Mental Health Needs of Refugees in Lambeth
statutory responsibility to provide care. In many
London, 2000
societies mental illness carries significant stigma,
Available from Refugee Health Team,
which may deter people from accessing services.
Master House, Dugard Way, off Renfrew Rd,
Offering services within the community may be
London SE11 4TH
more acceptable and close links should be
Tel: 0207 582 5247
established with community mental health teams
and the voluntary sector, including refugee
community organisations.
Resources
The Breathing Space Project
This initiative between the Refugee Council and
the Medical Foundation aims to address the

page 38
5.4) Psychological therapies and In many cultures, problems are talked over with
counselling an older member of the family, an elder or
religious leader. There may be people who fulfill
Counselling may be an unfamiliar concept for these roles within communities in the UK.
some people, who may be more accustomed to Further reading
discussing problems with family and community,
Guidelines for providers of counselling training to
rather than with a stranger, and may be
refugees and Guidelines for refugee community
concerned about confidentiality. Some members
organisations providing counselling services.
of refugee communities are trained in counselling
Available from:
skills, which can be used in culturally appropriate
The Evelyn Oldfield Unit, 356 Holloway Road,
ways. Story-telling and narrative may be helpful.
London N7 6PA
Group work can offer support and reduce Tel: 020 7700 0100
isolation. Groups may be primarily therapeutic, or Fax: 020 7700 8136
may be more social and practical in nature. Adult Email: [email protected]
and child psychotherapy, family therapy and
cognitive behavioural therapy may also be 5.5) Discussing distressing events
considered. (see also section 4.15 – Support for health
workers)
Somali Counselling Service, Tower
Hamlets Many people wish to talk about their experiences
and find the process of testimony itself to be
Amina Hassan, Somali Counsellor, Steels Lane
therapeutic. However not everyone needs nor
Health Centre, 384 Commercial Road,
wants to do this and some find telling their
London E1
stories extremely distressing. If psychological or
Tel: 0207 790 7171
physical difficulties persist, acknowledging
Email: [email protected]
possible causes may be important through
The bilingual counsellor is trained in several establishing trust and gentle questioning.
techniques, including Cognitive Behavioural
It may be possible to ask about experiences of
Therapy, psychodynamic and systemic family
torture and violence, but if direct questioning
therapy techniques, using these in ways
appears to be too uncomfortable, the subject
appropriate for the Somali community with
may be introduced indirectly:
whom she works. The community in East
London is long established, with merchant “I know that some people in your situation have
seamen first arriving from Somalia towards the experienced torture and violence. This is
beginning of the 20th century, some of whom something that I may be able to help with. Has
chose to settle in London and other parts of the this ever happened to you?”
UK. Subsequently the civil war in Somalia This sort of work is best done when the client’s
resulted in many people fleeing to the UK as social situation is relatively stable and they are
refugees. feeling ‘safe’. If this is not the case, it may be
The counsellor has written leaflets in Somali on better to focus on improving their social situation
psychological health issues. She carries out and strengthening their coping skills to help with
training for health workers and gives the distressing memories. If you do address such
information and education on health issues memories it is important that the client feels in
relevant to Somali people. The service is part of control of the process. Keep checking whether
the Primary Care Psychology team. The the pace and content feels comfortable.
Counsellor works with the Somali Advisory Sometimes a person who has previously disclosed
Group in Tower Hamlets, composed of health a painful past event becomes unwilling to talk
workers in both the voluntary and statutory about it. It may be more helpful in such cases
sectors, whose focus is to address health issues to talk about current concerns rather than
faced by Somali people pressing them.

page 39
 With a child, additional considerations need to be population admit to a “serious” sleep
taken into account, including age, level of problem, and 35% of over-65’s)
understanding and the context in which (s) he • May be associated with depression, stress,
is living. fear, grief and nightmares
It is also important that the health worker feels • Keep prescribing to a minimum, and only for
safe and confident about being able to manage a limited period. Because of tolerance and
the disclosures that might be made. dependence, most hypnotics should not be
The client may be searching for the meaning of taken for more than 4 weeks. Give
an apparently meaningless event. It may be information about the medication and
helpful to locate this within their political or expected side effects.
religious belief systems, if present. There is some • The following advice may be helpful:
evidence that survivors of torture who have a Usual advice about exercise, alcohol,
political understanding of what happened to smoking, caffeine etc.
them are less troubled than those who have no Avoid napping during the day
such understanding. Try to go to bed and wake up at the same
time every day
5.6) Physical expressions of Allocate a limited time each day to focus
distress/somatisation specifically on worries/concerns
“Sometimes refugees express emotional distress Practice relaxation, meditation or prayer
or depression as physical symptoms, such
Insomnia is a symptom not a condition, and
as back pain, and this can be very difficult
treatment should address the underlying
to address.”
problem. Many people do not feel safe where
Community practitioner, London
they live. In hostels, some people may feel
Stressful circumstances may manifest as uncomfortable sharing a room with someone
weakness, headaches, abdominal, neck or back whom they do not know well, and this may
pain, with no apparent physical basis. People may affect their sleep. This may be particularly an
experience their distress physically or they may issue for survivors of torture. Bedwetting may be
only describe physical symptoms, believing that a problem, particularly for children.
health workers are more interested in physical
problems. They may be experiencing 5.8) Physical health
psychological symptoms but may not describe (see also Section 6.3 - Physical health following
them, perhaps due to lack of appropriate torture and violence)
language or due to the stigma of mental health The list below is not exhaustive, but highlights
problems. Although people may expect some of the more important issues, drawing
investigations and treatment, they are often attention to the special circumstances of this
aware of the interrelations between physical and group of people.
psychological symptoms.
5.8.1) Gastro-intestinal symptoms
Symptoms commonly last for some time. It may
be useful to chart the variability of such These are commonly experienced, particularly by
symptoms alongside mood states. If symptoms young men, and may result from gastritis, peptic
persist, consider ways of support, perhaps ulceration, unfamiliar food or stress. H. Pylori is
through counselling or complementary therapies commoner in people from poorer countries.
such as massage, if available. People may have consumed contaminated water
or food en route to the UK and parasitic diseases,
5.7) Sleep Problems gastroenteritis and more rarely, cholera, bacillary
“They just give me tablets to help me sleep” dysentery and typhoid, may occur, although
male asylum seeker dispersed to Leeds gastro-intestinal infections are usually due to
common pathogens and pose little risk to public
• Sleep problems are very common amongst
health. The usual principles of infection control
refugees (in fact 20% of the overall adult
and hygiene apply.

page 40
Routine stool screening in the absence of 5.8.5) Dermatology
symptoms is not indicated, unless it is known that Fungal infections and scabies are common, often
asylum seekers are arriving from an area where related to poor conditions of hygiene during
there is a known outbreak of, e.g. cholera. travel or whilst in temporary accommodation.
5.8.2) Chronic diseases 5.8.6) Respiratory illnesses
Eastern Europeans experience high rates of There may be an increase in both upper and
diabetes, hypertension and coronary heart lower respiratory illnesses, which may be
disease. High rates of diabetes, coronary heart associated with poor living conditions, poor
disease and stroke are found amongst people of nutrition and smoking.
South Asian and E African origin.
5.8.7) Musculo-skeletal
5.8.3) Rheumatic heart disease
Pain in muscles and joints and backache are
This is more common in poorer countries and common. As well as analgesia, consider
may not have been detected previously. physiotherapy or massage or other
5.8.4) Haemoglobinopathies complementary therapies, if available.
(See section 5.6 - Physical expressions of
Sickle cell disease and A and B thalassaemia are
distress/somatisation)
more common in people of Black African, Indian,
Pakistani, Roma, Middle Eastern or Eastern 5.8.8) Eyes
Mediterranean heritage. Some practices People of African and Afro-Caribbean heritage
opportunistically screen for haemoglobinopathy in may have a higher incidence of glaucoma.
people in affected groups. Pregnant women from Eastern Europeans, South Asians and E Africans
affected groups should be offered screening and, have a higher incidence of diabetes.
if positive, offered genetic counselling. People exposed to nerve gas (e.g. in Halabja in
Iraq) may have visual problems. (See section 6.3
– Physical effects of torture and violence).
Asylum seekers need to complete an HC1 form
in order to access a free eye check (see section
4.1 Eligibility for Health Care for details).
Those with visual impairment are entitled to a
Community Care Assessment and to be registered
blind or partially sighted (see section 7.11
Disability and special needs).

Further reading
Burnett A and Peel M
The health needs of asylum seekers and refugees
BMJ 2001; 322: 544-7

page 41
 5.9) Immunisations screening for TB and discuss with a
Country immunisation schedules are available on Communicable Diseases Consultant
http://www-nt.who.int/vaccines/GlobalSummary/ (see section 5.12 HIV/AIDS).
immunization/CountryProfileSelect.cfm. Conflict Information sheets produced by the British Lung
may have disrupted immunisation programmes, Foundation are available in English, Somali,
or the family may have left before completion. Turkish, Urdu, Punjabi, Bengali and Gujerati on
Refer to standard immunisation protocols. More http://www.phls.co.uk/facts/TB/Index.htm
detailed advice can be obtained from your local Consider neonatal BCG vaccination for babies at
Consultant in Communicable Disease Control risk of TB (discuss with your local Communicable
(CDC). Diseases Consultant).
Offer HiB and Meningitis C vaccines to those in
5.11) Other communicable and
the appropriate age groups.
tropical diseases
Offer rubella screening for women of
Malaria, meningitis, hepatitis A, B and C, and
childbearing age
measles may be more common, depending on
It may be worth screening for hepatitis B/C the country of origin. Chronic hepatitis B
(discuss with CDC as above) infection increases the risk of liver cancer.
Consider offering neonatal BCG vaccination Filariasis and leprosy and other tropical diseases,
(see section 5.10 - TB) although rare, may occur. HIV/AIDS is discussed in
more detail in section 5.12
Immunisations
Further information can be obtained from:
Hammersmith Primary Care Trust includes a list
Hospital for Tropical Diseases Grafton Way
of immunisations in the following languages in
London WC1E 6AU
their resource pack, compiled by Rachel
Manolson: Albanian, Amharic, Arabic, Tel: 0207 387 4411
Armenian, French, Farsi, Polish, Romanian, Liverpool School of Tropical Medicine,
Russian Somali, Spanish, Turkish. Pembroke Place, L3 5QA
Parsons Green Centre, 0151 705 3205
5-7 Parsons Green, 5.12) HIV/AIDS
London
HIV/AIDS is a significant issue for many refugees
SW6 4UL
and asylum seekers, but is often hidden and
5.10) Tuberculosis (TB) difficult to address. Situations of risk include
Although asylum seekers and refugees should not unprotected sex in a situation of high prevalence,
be stigmatised as vectors of infection, those paid sex, (which refugee women in particular
coming from areas where TB is prevalent carry a may have been forced to use during their flight in
heightened risk of infection. Living conditions in order to survive), through a blood transfusion,
the UK may be over-crowded, promoting contaminated needle, intra-venous drug use, or
transmission of TB. Maintain an increased index of mother-to-child transmission. Some may have
clinical suspicion. If you are planning screening, been placed at risk of HIV as a result of sexual
see Appendix 3 for TB screening protocol. violation, particularly as in many countries the
Community TB outreach services may increase incidence of HIV is higher among the military,
screening uptake, such as the outreach service who are often the perpetrators of sexual
based at West Beckton Health Centre, 90 Lawson violence.
Close, West Beckton, London E16 3LU Tel: 0207 People may be concerned about the possibility of
445 7088. Only a small proportion of new arrivals HIV infection, but may not raise it due to fear,
is screened for TB at the port of entry. and to concerns about confidentiality and stigma,
Concurrent HIV infection increases the false and mistrust of interpreters. Those at risk should
negative rate of the tuberculin test. If there is be offered information, confidential voluntary
reason to suspect HIV, check status before counselling and testing for HIV and other sexually

page 42
transmitted infections (STI’s) and the availability of SAC consultancy line for professionals
treatment explained. It can be difficult to raise the (Fridays 2:00 - 5:00 pm):
issue of HIV/AIDS when it is not clear whether a 0207 816 46 05
person feels that they have been at risk. The THT Direct - Service users
following questions may be helpful in initiating (service also available in French):
discussion: 0845 12 21 200
“What do you know about HIV/AIDS? Do you Information on HIV/AIDS can be obtained from:
think that you have been at risk?”
The African Health Team,
People may feel very concerned about being Terrence Higgins Trust,
recognised as being HIV positive. Services which 52-54 Grays Inn Road,
can be provided in a setting that does not identify London WC1X 8JU
people by their diagnosis may be preferred. Tel (Admin): 0207 831 0330
Some may prefer to travel to a clinic further from Tel Helpline: 0207 242 1010
their home. The specialised confidentiality of (Noon – 10pm daily)
genito-urinary clinics, where no information is
disclosed without the patient’s express Regional offices:
permission, may enable people to feel more Coventry 02476 229292
secure, but this may be problematic if GPs do Birmingham 0121 694 6440
not have full information about a person’s Oxford 01865 243389
condition or medication. Brighton 01273 764200
Asylum seekers and refugees are eligible for all Bristol 0117 955 1000
available treatments, although people may not be Bath 01225 444 347
aware of this, as treatment is often unavailable in Leeds 0113 295 1921
their home countries. Asylum seeking women are Email: [email protected]
not however currently eligible for milk tokens. Website: www.tht.org.uk
Some women who are HIV positive may continue
Terrence Higgins Trust offers support and
to breastfeed, in order to conceal their HIV status
information through a telephone helpline, for
within the community.
people affected by HIV/AIDS. Offices nationwide
People may be at risk of transmission in the UK and an African Team based in London, publish
and information should be given on prevention. leaflets in English and French and also have tapes
Health outreach teams (e.g. Lambeth Southwark available in Swahili. They have published a good
and Lewisham) have carried out education practice guide for health professionals.
sessions (See section 3.4 – information on health
and healthcare for contact details). People who Refugee Council Information Team
are HIV positive are at increased risk of TB Tel: 0207 820 3085
(See section 5.10 – TB). Produces leaflet “Advice on HIV/AIDS”, giving
basic advice, information and useful organisations
Access to specialist legal advice is important.
in the following languages: English, French,
Those who, if deported, would lose access to
Somali, Arabic and Albanian.
treatment may seek compassionate grounds to
remain. A list of specialist solicitors is available African Aids Helpline
from Terrence Higgins Trust’s Specialist Advice Tel: 0800 0967 500
Centre (SAC): (Freephone Tues - Sat 2 – 10pm.)
Offers telephone support, advice and information
in English, French, Luganda, Swahili and Shona.
Check time availability for different languages.

page 43
 National AIDS helpline hesitant to attend. Advocates and outreach
For free telephone advice and information about health workers can explain the importance of this
HIV/AIDS in different languages: and may be able to increase uptake.
English 0800 521 261 There has been a recent increase in syphilis in
(24hours) countries of the former Soviet Union, attributed
Arabic 0800 917 2227 to the rapid growth of the sex industry, increasing
(Wed 6 - 10pm) homelessness, poor diagnostic facilities and
Bengali 0800 917 2227 limited access to treatment. People may be at risk
(Mon 6 - 10pm) of chlamydia, trichomonas, and gonorrhea. The
Cantonese 0800 917 2227 incidence of hepatitis B and C is higher amongst
(Sun 6 - 10pm) people from Africa, Asia and Eastern Europe.
Gujerati 0800 917 2227 Sex education and effective outreach work are
(Thur 6 - 10pm) important. Teenage refugees are asking for
Hindi 0800 917 2227 information about sexual health. They often feel
(Fri 6 - 10pm) caught between two cultures – that of their
Punjabi 0800 917 2227 parents and that of their peers. Relevant
(Sat 6-10pm) information should be made available, including
Urdu 0800 917 2227 where to obtain contraception.
(Tue 6- 10pm)
As in any other situation, the news of pregnancy
Positively Women, may be welcomed or dreaded. Although in many
347-349 City Road, London EC1V 1LR cultures abortion is unacceptable, do not make
Tel helpline: 0207 713 0222 assumptions about what the woman or couple
(Mon – Fri 10am - 5pm) might wish to do.
Asylum seekers and refugees are entitled to
National organisation offering counselling and
access fertility services.
support for women with HIV/AIDS. Runs support
groups, including one for African women. In many cultures homosexuality is a taboo issue
and it is often denied that it exists, making it
5.13) Sexual health and difficult for gay men and women to discuss
family planning sexual health, and increasing their isolation.
This is an area where refugees, and in particular Reading:
young people, would like more information. Layzell S and England R What do Turkish-
People may not use family planning due to
speaking women want to know about sexual
religious or cultural reasons, but this should not
health? A study to inform the production of
be assumed. Offering choice of gender of health
Turkish language information leaflets. Health
worker and interpreter may enable discussion to
Education Journal 1999 58 (2), 130-8
take place. Children should not be used to
Organisations:
interpret. Domiciliary family planning services may
be appropriate for those who cannot access Women’s Health,
clinics or GP surgeries. Information on 52 Featherstone St London EC1Y 8RT
contraception should be made available in Tel (office): 0207 251 6333
appropriate languages. Fax: 0207 608 0928
The Refugee Outreach Team in Lambeth, Tel (helpline): 0207 251 6580
Southwark and Lewisham distributes condoms (Mon – Fri 9.30am – 1.30pm)
amongst refugee communities (See Section 3.4 Email: [email protected]
for contact details). Website: www.womenshealthlondon.org.uk
Be aware that many women and some men are Help and information on a wide range of issues
survivors of sexual violence, including rape (see concerning women’s health.
section 6.5 - Sexual violence). Infection screening
should be offered, although many people may be

page 44
Blackliners, Unit 46, Lambeth, Southwark and Lewisham Refugee
Eurolink Business Centre, 49 Effra Road, Health Team
London SW2 1BZ Carmen Rojas, Team Leader,
Tel (Admin): 0207 738 7468 Masters House, Dugard Way,
Tel (Helpline): 0207 738 5274 Renfrew Road, London SE11 4TH
Website: www.blackliners.org Tel: 0207 414 1507
Offers sexual health and HIV support to people of E-mail:
Asian, African and Caribbean origin and a [email protected]
support service for men who are gay or who are
questioning their sexuality. Health Promotion for
Asylum Seekers
5.14) Health promotion Lambeth, Southwark and Lewisham Refugee
Translated written information on health can be Health Team (contact details above)
useful, but other methods will be more effective
The team organises health promotion sessions
for those who are not literate. Oral traditions are
at colleges, Refugee Community Organisations,
strong among many refugee communities and
hostels and the Refugee Council One Stop
story-telling is an important way of disseminating
Shop. They work closely with the health
information, which has been used in health
promotion unit of the community dental
promotion. Community organisations can raise
services, reproductive health and the
issues in group and individual settings. Video and
Community Drug Education Project to organise
audio-cassettes have also been used successfully.
sessions covering family planning, dental
Peer educators can offer information and advice
awareness, drug awareness, sexual health and
about health services and about health
access to services. They have also worked with
promotion. Word of mouth plays an important
the African Well Women’s Clinic to facilitate
role in disseminating information and publicising
sessions addressing female circumcision. This
services. Health services in many countries have a
work entails either working with specialists to
curative rather than a preventative focus, so many
develop training sessions, delivered by the
people may not understand the relevance of
team, or specialists facilitate the sessions, with
health promotion and this may need to be
the team providing language support. There
explained. Sexual health promotion (see Section
has been much use of role play and visual
5.13 Sexual health and family planning) and
techniques. For many health promotion
mental health promotion
agencies this represents their only work with
(see Section 5.3 Psychological well-being) should
this population.
be included.
Group health promotion activities provide Further reading
opportunities to: Clark C et al
• break down social isolation and in the process Promoting the Health of Refugees
improve mental health and wellbeing London: Health Education Authority 1998
• share information about health needs and 5.15) Oral Health
how to address them
Several studies have indicated that refugees and
• efficiently use the time of health workers and asylum seekers are at risk of poor oral health,
interpreters. reflecting the conditions and time span of
Smoking is high amongst some groups of migration, and oral health and access to dentists
refugees (e.g. men from Eastern Europe). This in countries of origin. The availability of refined
may be a reflection of their culture, but may also sugar in the form of soft drinks and sweets may
reflect the stress under which many refugees live. be high in refugee camps. Oral health may have
Examples of translated leaflets for health low priority compared to the more immediate
promotion are on the Medact website problems of resettlement.
www.medact.org

page 45
 • Access to interpreters is crucial for clinical Some, including pregnant and breast-feeding
care, information and health promotion. women, have been found to be
• Lack of awareness of cultural factors and under-nourished. Those living in hostels,
health beliefs can lead to difficulties with where all meals are provided, may have
compliance and misunderstanding. In some difficulties with unfamiliar food.
cultures, e.g.Vietnamese, deciduous teeth are Children may suffer from chronic under-nutrition,
not normally conserved if they are diseased, so with stunting of growth. Rickets, scurvy and
there may be barriers to children accessing thiamine deficiency are more commonly seen. UK
dental care. It may be difficult for a man to centiles charts are not standardised for all ethnic
treat an orthodox Muslim woman. groups, but children should be referred for
• Written oral health information is obviously further assessment where there is more than a
not useful where illiteracy is a factor. two-centile discrepancy between height and
weight, or where serial measurements of growth
• Recruiting and training health personnel from
fail to show adequate weight or height gain.
the same country as asylum seekers and
refugees may address cultural barriers, but 5.17) Drugs and alcohol
other barriers may exist, e.g.class.
There is little information currently about the
• Dental and facial trauma could be a result of prevalence of drugs and alcohol use amongst
violence, torture or even carried out by health refugee communities. However, it is known that
personnel people under stress may use alcohol and drugs as
• Conditions such as soft tissue malignancies a coping mechanism; the risk factors for drug
and oral manifestations of HIV/AIDS can be use, such as poor housing, poverty, less access to
detected early through screening procedures. education and unemployment are prevalent
(See section 5.12 - HIV/AIDS) amongst refugee communities.
• Oral cancer is on the rise in many continents Drugs and alcohol services need to have an
due to an increased use of tobacco. understanding of the issues facing refugees, both
• Culturally relevant oral health promotion past and present, and they need to have access
should be developed. to interpreters. There is significant stigma around
drug use amongst refugee communities and, in
When treating or giving advice on oral health, the
addition, families feel a great responsibility if a
following should be taken into account:
family member is using drugs. There is a need to
• Expressions of pain involve and support families and to stress
• Differences in the interpretations of symptoms confidentiality.
• Expectations of dental care due to different or
Khat/kat/chat
no previous health care experiences
These leaves are chewed predominantly by
Asylum seekers must complete an HC1 form to people of East African, Middle Eastern and Arab
access free dental treatment (section 4.1 – heritage. Taken socially to dispel hunger and
Eligibility for Health Care). For information on fatigue and for relaxation, users may become
how to find an NHS dentist, see Section 4.2. euphoric initially and then depressed as the
effects wear off. Use can cause dizziness,
5.16) Nutrition
lassitude, tachycardia, epigrastric pain and
“Because of my language problem, I don’t know psychiatric manifestations similar to the effects of
what to order. I always say bread and spaghetti. other stimulants. It can lead to psychological
That is the few things I know. So my diet is not addiction, but no physical dependence has been
so good” female asylum seeker, dispersed reported. It is a common social activity amongst
Limited finances, language difficulties and a lack of men of Somali, Ethiopian and Yemeni heritage,
choice mean that diet may be restricted. Culturally and taken in small amounts is unlikely to be
familiar and acceptable food (e.g. Halal meat harmful. However there is concern amongst the
eaten by Muslims) may not be locally attainable. Somali community about young men frequently

page 46
chewing khat in large amounts. There is also fitting centres and wheelchair services, or may
concern that there is a potential for khat to be have experienced torture. Some of those with
replaced by other drugs and alcohol. long-standing polio may be coping well
functionally and may not need intervention. Many
Drugs awareness refugees have poor housing and little money and
The Refugee Health Team in Lambeth, Southwark exercise on prescription may be more accessible
and Lewisham has carried out outreach work in than joining a gym or doing exercises at home
hostels on drugs awareness, in conjunction with (although some may feel uncomfortable with
the community drugs education service. They prescribed exercise). Groups teaching relaxation
have also translated information and worked to techniques may be useful. Many people feel
increase drugs awareness in community uncomfortable taking their clothes off, especially
organisations working with refugees (See section if they had had them forcibly removed. In a
3.4 on Information on health and health care for hospital gym people may feel acutely
contact details). embarrassed stripped down to their underwear in
front of others.
Orexis, an organisation in Deptford, South
London, offers support to users of khat and has Physiotherapy for survivors of torture
carried out a study of khat in the Somali Torture survivors may be sensitive about being
community. touched. Be aware of the position that the person
Tel: 0208 691 1233 is placed in, which may be reminiscent of the
torture situation and of your own and the
Telephone helplines
interpreter’s positioning. Some may feel
Drinkline uncomfortable about mixed sex hydrotherapy
Tel helpline: 0800 917 8282 (Freephone) sessions and some torture methods may have
Mon – Fri 9am – 11pm, weekends 6-11pm involved the use of water. If tortured using electric
Offers advice, information and suport to anyone shock, some may be sensitive to electrotherapy.
concerned about their own or somebody else’s
Further reading:
drinking. Uses Language Line
Franklin C (2001)
National Drugs Helpline
Physiotherapy with torture survivors Physiotherapy
Gives information and advice for drugs users and
87, 7, 374-377
their families in the following languages
Contact:
English 0800 776600 (24hours)
Elizabeth Carrington,
Bengali 0800 917 6650 (Mon 6 - 10pm)
International Development Adviser,
Cantonese 0800 917 6650 (Sun 6 - 10pm)
Chartered Society of Physiotherapists.
Hindi 0800 917 6650 (Fri 6 - 10pm)
Tel: 0207 306 6694
Punjabi 0800 917 6650 (Sat 6 - 10pm)
Urdu 0800 917 6650 (Tues 6 -10pm)

5.18) Physiotherapy
Many people may be unfamiliar with
physiotherapy and it is helpful to establish the
person’s beliefs concerning the problem, what
they feel may help them and realistic goals and
outcome measures. Pain patterns may not
conform to the familiar, particularly for a survivor
of torture.
The problems which people present will be
broadly similar to the host population, but some
conditions may be more prevalent. Many come
from war zones and may have had amputations
or may be paraplegic; requiring referral to limb-

page 47
 5.19) Role of complementary in combating isolation, communicating meaning,
therapies enhancing self-esteem and strengthening identity
Therapies such as massage, physiotherapy, and belonging.
osteopathy, relaxation and herbal medicine may For more information contact:
lessen chronic pain, anxiety, insomnia, stress and Artists in Exile, The Riverside Studios,
some of the physical and psychological effects of Crisp Road, London W6 9RL
torture.
Tel: 0208 237 1115
“I would like to see the introduction of a Fax: 0208 237 1001
massage therapy service, to alleviate musculo- Email: [email protected]
skeletal pain, reduce stress, improve self-esteem
The Comfrey Project in Newcastle
and reverse issues associated with negative
touch such as torture.” c/o The Rights Project, 292 Wingrove Ave,
Nurse, London Newcastle upon Tyne, NE4 9AA
Tel: 0191 273 1838
5.20) Traditional healthcare Fax: 0191 272 1114
Refugees may use traditional health care remedies Established with Health Action Zone funding
or consult traditional healers within their own and practical support from the Rights Project,
communities. Traditional practices include this allotment-based scheme aims to promote
scarification (cuts made in the skin by African mental and physical well-being among refugees
traditional healers, usually in a regular pattern, and asylum seekers in the West End of
into which herbs may be inserted). Some herbal Newcastle. A small group of asylum seekers
remedies may interact with prescribed from different countries meet once a week
medication, so it is worth checking if people are with the project co-ordinator. The emphasis is
using these. on creating a safe, pleasant and friendly place
for people to meet, rather than on maximizing
5.21) Arts therapies and creative arts horticultural output, but they have cultivated a
The arts therapies (art, dance movement, drama good selection of vegetables and flowers.
and music) offer a variety of different channels of Clients enjoy the opportunities for learning,
communication in which to engage with freedom, joy, relaxation and meeting
psychological issues. Therapists, who have a new people.
professional training, may combine one or more
psychological framework (e.g.psychodynamic,
systemic) with the creative dimension of their art
form. Creative therapies have been shown to
offer benefits to people who have lived through
situations of political conflict, in conjunction with
practical support and healthcare.

Further reading
Kalmanowitz D and Lloyd B
The Portable Studio – art therapy and political
conflict: initiatives in former Yugoslavia and South
Africa, London, Health Education Authority 1997

Pavlicevic M
Music Therapy in Context,
London, Jessica Kingsley Publishers 1997

In addition, other art-related projects, including

acting, music, writing and poetry may be helpful

page 48
6. Torture and Violence

6.1) Survivors of torture and • Many women and some men are survivors of
organised violence sexual violence, including rape
• Many people feel deep shame
6.2) Psychological health following
• Some women and children are trafficked to
torture and violence
the UK for the purposes of working in the
6.3) Physical effects of torture and sex industry. They are a very vulnerable group
violence • Domestic violence may be hidden

6.3.1) Musculo-skeletal, fractures and 6.1) Survivors of torture and

soft-tissue injuries organised violence
Torture is “.. the intentional infliction of severe
6.3.2) Head injuries and epilepsy
pain or suffering, whether physical or mental,
6.3.3) Ears and eyes upon a person in the custody or under the
control of the accused.“
6.3.4) Effects of chemical attack and Article 7.2 (e) (excerpt) of the Rome Statute of
nerve gas the International Criminal Court 1998

6.4) Children who are survivors of Organised violence is considered to have a

torture and violence political motive. Survivors of torture or organised
violence may have been ill treated by government
6.5) Sexual violence agents such as the army, police or security forces,
or rebel groups perpetrating organised violence.
6.6) Sex trafficking Estimates of the proportion of asylum seekers
who have been tortured vary from 5 - 30%,
6.7) Domestic violence depending on the definition of torture used and
Key Points their country of origin.

• Torture and violence have been experienced Many people do not initially admit to their
by many asylum seekers and refugees in experiences of torture. This may be through
the UK shame or embarrassment. It may be difficult to
disclose sensitive information of, for example,
• Much can be done by health workers to
sexual violation to an immigration officer of the
alleviate the physical and psychological
opposite sex. Health workers may be in a better
difficulties that face survivors
position to build trust and empathy and to ask
• Survivors of torture may not volunteer about experiences of torture or ill treatment. If
their history due to feelings of guilt, shame direct questioning appears to be too
or mistrust uncomfortable, it may be possible to introduce
• Consideration must be given to building a the subject indirectly.
relationship of trust
“ I know that some people in your situation
• Children may have experienced torture have experienced torture or ill treatment or
themselves or have witnessed others being rape. This is something that we may be able to
tortured help with. Has this ever happened to you?”

page 49
 People have commonly been beaten, kicked and Medical Foundation for the Care of
slapped. Many women and some men have Victims of Torture,
experienced rape or other sexual violence (see 96-98 Grafton Road, London NW5 3EJ
section 6.5 - sexual violence). Some methods are Tel: 0207 813 7777
typical of certain geographical areas: falaka in the Fax: 0207 813 0011
Middle East and Turkey (beating on the soles of Email: [email protected]
the feet), and in India the ghotna, (a pole placed Website: www.torturecare.org.uk
across the legs, on which the torturer stands).
Provides services for survivors of torture and
People may be burned with cigarettes, or given
other forms of organised violence and their
electric shocks. Finger or toenails may be forcibly families, providing case work, counselling, advice
extracted and fractures inflicted. People may be regarding welfare rights, physical and mental
forced to witness visually or aurally others being health care, individual and group therapy,
tortured, or may be forced to participate in physiotherapy and complementary therapy, family
torturing others, and mock executions may be therapy and child and adolescent psychotherapy.
performed. More detailed information on the Care is provided for individuals, for families and
prevalence of torture methods can be found on in groups.
the Amnesty website (Campaign to Stop Torture)
Medico-legal reports may be written, by referral
www.stoptorture.org
from solicitors, in support of asylum claims.
General Considerations Advice and help with access to health care
The effects of torture are an accumulation of throughout the country.
physical violence, detention (unhygienic cells, Staff run training sessions and workshops for
inadequate diet), and the psychological professional groups working with refugees and
consequences of one’s own and witnessing survivors of torture and can discuss issues with
others’ experiences. A survivor of torture may health care workers.
have a preoccupation that his or her body has The Medical Foundation is no longer able to see
been irreparably damaged and may experience clients without an appointment. Details of how
chronic pain, leading to repeated consultations. to refer can be found on the website
The essentials are time, a sympathetic approach, (http://www.torturecare.org.uk/refer).htm)
and, if language is not shared, a trained
The Traumatic Stress Clinic, Camden & Islington
interpreter who is not a family member or friend.
Mental Health NHS Trust,
The continuity gained by using the same
73 Charlotte St, London W1T 4PL
interpreter and health worker for each session
Tel: 020 7530 3666
may help to engender feelings of trust and safety
Fax: 020 7530 3677
for the client. However, be aware that this work is
Email: [email protected]
stressful for interpreters and may re-stimulate
Website: http://www.traumaclinic.org.uk
feelings about similar experiences of their own. If
possible, it is helpful to spend some time with the Provides specialised multi-professional NHS
interpreter, both at the beginning of a session to mental health services for adults, children and
discuss both your ways of working, and after the families in this country as refugees or asylum
session is over, in order to address any issues seekers. Interventions include individual (child,
which have arisen. adolescent and adult) and family assessment and
If a referral is made, ensure that the complexity of therapy services. Consultation, advice and/or
the person's situation, including their social supervision are offered to other services working
circumstances, is clear. (S)he should be seen by an with refugees. Referrals may be made by
practitioners in secondary care, primary care and
experienced member of the team.
social services – chiefly from across north London.
The family of a survivor of torture may also need
Referrals should be made to the address above,
support. Children may feel additional pressures
specifying if they are directed to the child &
and should be given an opportunity to talk about family service or to the adult refugee service in
their feelings. the Clinic.

page 50
Expert witness reports may be prepared on Anxiety
instruction from solicitors in relation to asylum panic attacks, pain, headaches, psychosomatic
applications or appeals. Training sessions are symptoms, poor concentration and memory, sleep
offered in conjunction with other services. Advice disturbance, flashbacks (distressing memories of
on refugee-related research is also available traumatic events), worries, anticipating the worst,
confusion, avoidance of situations, aggressive
Further reading
behaviour, impulsive behaviour, withdrawal from
Burnett A and Peel M others, passivity.
The Health of Survivors of Torture and Organised
Violence BMJ 2001; 322: 606-9 Hyper-arousal
increased nervous system arousal, sleep problems,
Forrest D and Hutton F excessive anger, irritability, memory and
Guidelines for the examination of survivors concentration problems, hypervigilance,
of torture jumpiness.
London, Medical Foundation for the Care of
Victims of Torture, 2000 Loss and bereavement
loss of family, friends, home, social support
Basoglu M network, job, lifestyle. Grief, numbness, anger,
Torture and its Consequences denial, yearning, preoccupation with a lost
Cambridge University Press 1992
person, and the effect of those who have
Amnesty International disappeared. Anxiety, emptiness, apathy and
Take a Step to Stamp Out Torture 2000 despair, anger; altered behaviour in relationships
such as increased dependency, fierce self-
Amnesty International sufficiency, compulsive care-giving and
Broken Bodies, Shattered Minds - suspiciousness; fear about relationships such as
Torture and ill-treatment of women 2000 fear of intimacy, ready devaluation and
idealisation of others; depression, pessimism,
Amnesty International
sleep disturbance, appetite disturbance, poor
Hidden Scandal, Secret Shame -
Torture and ill-treatment of children 2000 concentration, self blame, hopelessness, suicidal
thoughts and plans.
British Medical Association (Sommerville A ed.)
The Medical Profession and Human Rights: a Shattered core beliefs
handbook for a changing agenda, loss of trust and meaning, capacity to trust
London, British Medical Association and Zed damaged, loss of sense of future, sense of
Books 2001 identity shattered, loss of sense of a just world,
and powerlessness to change society.
6.2) Psychological and mental health
following torture and violence Guilt and shame
(see also Section 5.3 Psychological guilt at having failed to prevent violence,
well-being) particularly if members of family have been
threatened, tortured or killed, survivor’s guilt, self-
Presentation destructive behaviour, avoidance of others due to
Some people experience atrocities without shame, self-blame, ability to experience pleasure
developing any serious psychological symptoms inhibited; inability to disclose experiences, which
beyond a natural increase in anxiety and results in secrets within the family and which may
occasional nightmares. Others show more marked lead to breakdown of family relationships and
signs of anxiety, depression, guilt and shame as a social isolation.
result of their experiences and also due to their
current situation. Intrusions
re-experiencing aspects of the original traumatic
Some may present with symptoms of mental
event in nightmares or as intrusive memories or
illness, which may be long-standing, or which
flashbacks.
may be linked with their experiences.

page 51
 Avoidance Support and treatment
avoiding reminders of the event(s), inability to For many people, the most valuable inputs are
recall parts of the trauma, sense of detachment supportive listening and practical assistance to
from others, flattened affect. rebuild their lives. Community, religious, spiritual
and creative links may be important. Refugees
Low mood
have survived against huge odds, and their
depression, loss of interest, withdrawal, loss of
resilience may be a strength to be tapped into.
self-esteem, social isolation, loss of motivations,
Consider antidepressants for concurrent
loss of interest in activities.
depressive illness. Tricyclics and SSRIs may be
Assessment useful for the treatment of intrusion and
Common expressions of psychological and avoidance symptoms and if drug treatment for
emotional distress do not necessarily mean the depression is indicated.
same in different cultural and social settings. For
Symptoms which may need
a discussion of cultural issues affecting
specialist help include:
psychological health see section 5.3 (Psychological
Consistent failure to function properly with
well-being). It is important to maintain an open
daily tasks
mind over a longer period of assessment.
Carefully consider before pathologising what may Frequently expressed suicidal ideas or plans
be the natural expression of grief and distress Social withdrawal and self-neglect
concerning highly abnormal experiences. Behaviour or talk that is abnormal or strange
Diagnoses such as post-traumatic stress disorder within the person’s own culture
(PTSD) and depression should be used cautiously
Aggression
as they may not address the complex way in
Shackman J, Gorst-Unsworth C
which historical, social and political factors
and Summerfield D
interact and impact on the experiences of
communities1. Further reading
“ We are unfortunately medicalising refugees Harris K and Maxwell C
when their prime needs are non-medical.” A Needs Assessment in a Refugee Mental Health
(Psychiatrist, London) Project in North-East London: Extending the
No psychiatric illness is specific to trauma or Counselling Model to Community Support
torture and PTSD is not in itself a marker for Medicine, Conflict and Survival 2000;
past trauma2. 16, 201-215
Symptoms need to be understood in context and Summerfield D
through the meaning they represent to the The Impact of War and Atrocity on Civilian
person experiencing them3. Someone politically Populations: Basic Principles of NGO Interventions
active and familiar with the use of torture may be and a Critique of Psycho-social Trauma Projects
able to make more sense of their experiences and London: Relief and Rehabilitation Network,
feelings than someone for whom detention and Overseas Development Institute 1996
ill treatment appear more arbitrary.
Bracken P and Petty C (Eds.)
Risk of suicide and issues of child protection (see
Rethinking the Trauma of War
section 7.10 Child Protection) should be assessed.
London and New York: Save the Children Fund
There may be cultural and religious taboos
and Free Association Books 1998
regarding talking about self-harm.
However the description of psychological state is 1 Bracken P Hidden agendas: deconstructing post traumatic stress
disorder. In Bracken P, Petty C Eds. Rethinking the trauma of war.
formulated, care for survivors of torture and London, New York, Save the Children and Free Association Books,
1998
violence is paramount. Using an approach wider 2 Hutton F Psychological assessment of torture survivors. In Forrest D,
than a biomedical base may offer more Guidelines for the examination of survivors of torture. London, The
Medical Foundation for the Care of Victims of Torture 2000
appropriate treatment models. 3 Summerfield D Addressing human response to war and atrocity. In
Kleber R et al eds. Beyond trauma. New York: Plenum, 1995

page 52
Bracken P, Giller J, Summerfield D post-traumatic head injuries. Post-concussion
Psychological responses to war and atrocity: syndromes may present with problems of memory
the limitations of current concepts and concentration, but these symptoms can also
Soc. Sci. Med. 1995; 40: 1073 - 82 be stress-related.
6.3.3) Ears and eyes
Watters C
The Mental Health Needs of Refugees and Slapping around the ears is common during
Asylum Seekers: Key Issues in Research and interrogations. There is usually a history of pain,
Service Development in Nicholson F Current Issues bloody discharge from the ears, and persistent
of Asylum Law and Policy hearing loss. Otitis media may result from
Avebury 1998 traumatic perforation. Scarring of the eardrum
may be present.
Webster A and Rojas Jaimes C
People who have been detained in darkness for
The Mental Health Needs of Refugees in Lambeth
long periods often complain of soreness and
London, 2000 Available from Refugee Health
watering of the eyes in bright light. This finding
Team, Master House, Dugard Way, off Renfrew
has not yet been fully documented or
Rd, London SE11 4TH Tel: 0207 582 5247
investigated. Occasionally on a very bright day
6.3) Physical effects of torture and redness of the eyes can be observed, but it is
violence rarely bright enough in the UK for this to
be overt.
6.3.1) Musculo-skeletal, fractures and soft-
tissue injuries
Torture, landmines, shrapnel and other violent
trauma may result in injuries, which may have
received inadequate medical attention, resulting
in a high prevalence of limb injuries, including
malunited fractures, osteomyelitis or amputation.
Wounds and burns may be infected or
inadequately treated. Pain, weakness and other
non-specific symptoms are common, and these
may be helped by physiotherapy, non-steroidal
analgesics, complementary therapy such as
massage, relaxation and techniques to
manage symptoms.
Prolonged suspension by the arms can lead to
neuropathies and muscle weakness, much of
which recovers subsequently, but which can lead
to permanent disability. In the Indian
subcontinent, techniques such as the ghotna tear
and crush muscle, sometimes permanently. Keloid
scars from burns and cuts may be distressing to
the individual. Electric shocks are a very painful
method of torture, and equipment for this
purpose is still exported to countries in which
torture is common.

6.3.2) Head injuries and epilepsy

Many people subjected to violence have been hit
on the head, sometimes resulting in epileptiform
convulsions. These should be managed as for all

page 53
 6.3.4) Effects of chemical attack and nerve gas See section 6.1- Survivors of torture and
Chemical warfare agents were used in World War organised violence, for organisations and further
1 and have been employed or allegedly employed reading.
in approximately 12 conflicts since. The most
6.4) Children who are survivors of
recent large-scale use of these weapons was by
Iraq in its war with Iran in the late 1980s and by
torture and violence
Saddam Hussein against the Iraqi Kurds, notably Children may have experienced violence or
in Halabja in 1988. The chemical arsenal torture themselves, or may have witnessed
comprises mustard gas, which causes blistering of members of their family being tortured. Some
the skin and lungs, and several types of nerve gas may have been abducted to become child
- tabun, sarin, soman and VX. soldiers and forced to commit violent acts
themselves. They will also have suffered multiple
All of these, with the possible exception of VX,
loss.
were used at Halabja. During the attack 5,000
people are thought to have died. The major long- Children react to such experiences in different
term effects of mustard gas include1 ways (See section 7.7 - children and adolescents).
In order to assess their needs, time and trust are
• respiratory disorders including asthma,
needed. Children may feel under pressure to
bronchitis, bronchiectasis and pulmonary
keep secret both information and their feelings.
fibrosis
Providing an opportunity for children to talk
• respiratory cancers (nasopharyngeal, laryngeal
about their experiences over time and imparting
and lung)
to them a sense of belonging will enable them to
• pigmentation abnormalities of the skin develop confidence in their new surroundings. It
• chronic skin ulceration and scar formation is vital that children are able to join mainstream
• skin cancer, including rapidly advancing basal schools as quickly as possible as it has been
cell carcinoma found that this may be the most therapeutic
event for a refugee child3. However, they may
• chronic conjunctivitis
experience bullying and racial abuse at school.
• recurrent corneal ulcerative disease (may result
Family and Children Consultation Services may be
in blindness)
able to offer support. Children may benefit from
• delayed recurrent keratitis, causing soreness
both individual and group work. The latter gives
and itching of the eyes.
them an opportunity to be with other young
• Leukaemia people from similar circumstances, who
• Bone marrow depressions resulting in understand the impact of war and conflict,
immunosuppression multiple loss and the difficulties of adjusting to
• Psychological disorders (mood and life in a new environment and with family
anxiety disorders) pressures. It is important to take a multi-
disciplinary approach, where all those who have
• Sexual dysfunction as a result of scrotal and
responsibility for different aspects of the child’s
penile scarring
welfare work in partnership.
The incidence of birth defects such as harelip, See section 6.1 – Survivors of torture and
cleft palate, spina bifida, congenital heart defects, organised violence, for organisations and
Downs Syndrome and other major chromosomal further reading.
disorders have been found to be more common
in Halabja since the attack, as have miscarriages
and unexplained infant deaths. Infertility,
childhood leukaemia, lymphomas and
1 Sidell F and Hurst C Long-term Health Effects of Nerve Agents and
neurological disorders have been noted in the Mustard Gas, in Medical Aspects of Chemical and Biological Warfare
2 Gosden C http://www.oneworld.org/ips2/mar98/iraq2.html
population2. 3 Melzak S and Kasabova S Working with children and adolescents
from Kosovo London: Medical Foundation for the Care of Victims of
Torture, 1999

page 54
6.5) Sexual violence Referral to a Sexual Health Clinic should be made,
Many female, and some male, asylum seekers are to exclude infection. Women who have
survivors of sexual violence including rape. This experienced sexual violence may experience
has throughout history been used as a weapon of difficulties with internal examination, but may
warfare to degrade and humiliate an enemy. In however be reassured by being examined. Some
many cultures, sexual violence and rape are taboo clinics run a sexual assault service with
subjects, and survivors may feel very experienced doctors, health advisers and
uncomfortable discussing their experiences. If psychologists.
possible, offer a choice of gender of the health Although some people may benefit from talking
care worker and interpreter. A relative, and about their experience of sexual violence, others
particularly children, should not be used to may feel very uncomfortable. It may be more
interpret. Persistent unexplained distress and effective to help people to develop their own
anxiety may be due to a history of sexual support networks by facilitating the development
violation. Women who have experienced sexual of meetings and activities and by addressing
violence may have particular difficulties with current practical difficulties that they are facing. It
cervical screening. is important to address sexual violation in the
context of the many traumas and losses
It may be possible to ask directly about
experienced.
experiences of sexual violation, but if direct
questioning appears to be too uncomfortable, it Organisations that can take referrals and
may be preferable to introduce the subject offer assistance:
indirectly:
Medical Foundation for the Care of Victims
“ I know that some people in your situation
of Torture 96-98 Grafton Road, London NW5 3EJ
have experienced sexual violation. Has this ever
Tel: 0207 813 7777
happened to you?”
Fax: 0207 813 0011
Sexual violence is motivated by a wish to Email: [email protected]
dominate and degrade and is a very powerful Website: www.torturecare.org.uk
weapon against individuals, families and See section 6.1 Survivors of torture for
communities. For both male and female survivors, further details.
the dominant emotion following is usually that of
deep shame. Women may be shunned by their Victim Support:
community and family as having been defiled, Provides practical help and emotional support
and are no longer accepted. to victims and witnesses of crimes.
Rape and other sexual violation, including electric Tel: 0207 735 9166 (Office)
shocks applied to the genital area, rarely leave Tel: 0845 3030 900 (Victim support line)
any long-term physical signs, particularly for
women. Absence of physical signs does not mean 9am – 9pm weekdays, 9am –7pm weekends
that sexual violation has not taken place. For
and 9am – 5pm Bank Holidays
men, objects forced into the meatus may lead to
scarring of the distal urethra, and sometimes
Rape Crisis Centres
thickening can be felt. It should not be assumed
Branches throughout the UK. For further
that dysuria is due to a STI. Men tend to under-
information ring
report their experiences of sexual violence. They
Tel: 0207 916 5466 (office)
may have doubts about their sexuality and fear
infertility. Both men and women commonly
experience sexual difficulties following sexual
violence and may need reassurance about
sexual function.

page 55
 6.6) Sex trafficking for them to leave. In some cultures, domestic
Some women and children are trafficked to the violence is tolerated or is kept within the family,
UK for the purposes of working in the sex and women may be unaware that help is
industry. They may not have made an application available. Their partner’s violent behaviour may be
for asylum but may have a case and may need tolerated because of the violence that he may
legal advice. They have a wide range of physical have experienced himself. Physical punishment of
and psychological health needs but may be hard children may be common within families and a
to reach, as they may be fearful of contact with distinction needs to be made between discipline
statutory services. Outreach healthwork has been and physical abuse.
initiated in London to provide health services.
Organisations
For further information contact:
Refugee Women’s Resource Project,
Cathy Zimmerman, Health Policy Unit, London
Asylum Aid, 28 Commercial St, London E1 6LS
School of Hygiene and Tropical Medicine,
Keppel Street, London, WC1E 7HT Tel: 0207 377 5123
Tel: 0207 927 2490 / 2412 Fax: 0207 247 7789
Fax: 0207 637 5391 E-mail: [email protected]
email: [email protected] Website: www.asylumaid.org.uk
Provides advocacy on the rights of refugees and
Further Reading advice on individual asylum claims, legal advice
Reports of trafficking of children to the UK, and representation, outreach work, research,
publicity and campaigning, sharing expertise and
www.antislavery.org/homepage/resources/Children
promoting good practice. Current work is looking
www.immigrationindex.org/human-trafficking
at the issue of domestic violence.
6.7) Domestic violence Victim Support:
Women experiencing domestic violence are
Tel: 0845 3030 900 (Victim Support line)
particularly vulnerable because they may lack
Open 9am – 9pm weekdays, 9am –7pm
family and community support. Their access to
weekends and 9am – 5pm Bank Holidays
accommodation, and sometimes to asylum, may
Provides practical help and emotional support to
be linked with their partner, so it may be difficult
victims and witnesses of crimes.

page 56
7. Needs of specific groups

7.1) Health needs of women • Support for children needs to be multifaceted,

aiming to provide as normal a life as possible
7.2) Maternity Care
• Unaccompanied minors are particularly
7.3) Female Genital Mutilation vulnerable
• X-Rays should not be used to assess age
7.4) Health needs of men
• Address issues of child protection sensitively,
7.5) Health needs of older people whilst keeping the child’s needs paramount

7.6) Health needs of families • Disability may be hidden and stigmatised

• Refugee carers are often isolated and
7.7) Health needs of children and unsupported
adolescents
7.1) Health needs of women
7.8) Unaccompanied Displacement is difficult for all refugees, but
minors/separated children women are often the most seriously affected1.
They face additional problems because of their
7.9) Age Assessment lower status in society. They may have to take on
7.10) Child Protection unfamiliar roles and responsibilities, as head of a
household and breadwinner, and be lacking their
7.11) Disability and special needs previously important family and community
supports. Poverty and racial harassment add to
7.12) Carers difficulties. Some women living in hostels have
KEY POINTS experienced sexual harassment2. Women’s
involvement in political activities may have been
• Particular difficulties which affect women are in the form of political activism or may have
often not acknowledged taken a different form, such as providing shelter
• Female Genital Mutilation is illegal in Britain or food to those in hiding.
and carries health risks. Refer to specialist The needs of women may not be identified,
clinics. There may be issues of child protection especially in cultures where men are traditionally
• Men may find lower status difficult to the spokespeople. Women are less likely to have
deal with language skills in English, or to be literate. It is
• Older people are more likely to have chronic important to speak to women directly, using an
health problems and to be undernourished independent interpreter rather than a family
• They may have responsibility for raising member. Women are more likely to report poor
children health and depression. They may be lonely and
• Offer support services for older people and do isolated but, if given the opportunity, welcome
not assume that the family can care for all the opportunity to belong to a group, where they
their needs may benefit from the contact and support.
1 Ferron S, Morgan J, O’Reilly M Hygiene promotion – a practical
• Engage at a family level and offer support to manual for relief and development. London Care International and
both parents and children Intermediate Technology Publications, 2000.
2 Hinton T Working with Refugees and Asylum Seekers in Lambeth,
• Parents may need support with parenting Southwark and Lewisham. London, Health Action for Homeless
People and Crisis, 2001

page 57
 Many are survivors of violence, which may have and women's sections of refugee community
been sexual in nature. In many cultures rape is a organisations; Partnership and network
taboo issue which may not be discussed and development between the refugee women's
which results in the woman being shunned by her organisations; Health and Social Care; Advice and
husband, family and community. She is likely to counselling on mental health; Bi-monthly
feel very ashamed and unclean and may be newsletter - "Refugee Women's News"
unwilling to talk about her experiences. Women
Refugee Women’s Resource Project,
may also have experienced genital mutilation,
Asylum Aid, 28 Commercial St, London E1 6LS
domestic violence and enforced sterilisation.
Tel: 0207 377 5123
Some women may have an unwanted pregnancy,
Fax: 0207 247 7789
which may be a result of sexual violence.
E-mail: [email protected]
Termination of pregnancy may be unacceptable in
Website: www.asylumaid.org.uk
some cultures, but assumptions should not be
made about what a woman may wish to do and Provides advocacy on the rights of refugees and
information should be made available so that she advice on individual asylum claims, legal advice
can make an informed choice. and representation, outreach, research, publicity
and campaigning, especially on gender-related
Screening and health promotion have tended to
have a low uptake amongst refugee women. persecution, casework and outreach services.
However this has been shown to be greatly Refugee Women’s Directory (1998) published by
improved by increasing the availability of female the Refugee Council
health workers and advocates in order to enable
Lists organisations that assist refugee women.
women to discuss their health and choices
more easily, and to address misperceptions of Women’s Health, 52 Featherstone St
health screening. London EC1Y 8RT
Women need to be offered sexual health care, Tel (office): 0207 251 6333
family planning and maternity care that is Fax: 0207 608 0928
sensitive to their cultures. They should be offered Tel (helpline): 0207 251 6580
choice on the gender of health worker and (Mon – Fri 9.30am – 1.30pm)
interpreter. Health workers should be aware that Email: [email protected]
some women may have undergone Female Website:www.womenshealthlondon.org.uk
Genital Mutilation (FGM), which can affect sexual
Help and information on a wide range of issues
health and childbirth (See section 7.3 - FGM).
concerning women’s health.
Some women may have previously been part of
organised or informal women’s groups. In the UK, Further reading
groups can be an important form of support and Hinshelwood G
of information sharing. Shame the Silent Emotion
Organisations working with women refugees: Institute of Psychosexual Medicine Journal,
(1999) 22; 9 –12
Refugee Women’s Association, Print House,
18 Ashwin St, London E8 3DL 7.2) Maternity care
Tel: 0207 923 2412 Pregnant women may be unfamiliar with the type
Fax: 0207 923 3929 of care available in the UK. If possible, offer a
E-mail: [email protected] choice of female health worker and interpreter.
Provides advice, guidance and counselling for Interpreters should also be arranged for antenatal
women refugees on education, training and classes. A hand-held antenatal record should be
employment; English courses with childcare and given, as for other pregnant women, and is
travel expenses; Community business for work particularly useful if women asylum seekers move
placements and employment for refugee women; accommodation.
Capacity building for refugee women's groups

page 58
HIV testing needs to be sensitively handled (see Jenny McLeish,
section 5.12 - HIV/AIDS). Some women may be at Social Policy Officer, Maternity Alliance,
risk of hepatitis B and C. Counselling for 45 Beech St, London, EC2P 2LX
haemoglobinopathies and for antenatal screening Author of report: Mothers in exile
for malformations should be offered. Although in (see further reading)
many cultures abortion is unacceptable, do not Tel: 0207 588 8583
make assumptions about what the woman or Fax: 0207 588 8584
couple might wish to do in the event of a Email: [email protected]
malformation being discovered. They need access [email protected]
to information to make an informed choice.
Website: www.maternityalliance.org.uk
A woman who is pregnant as a result of rape will
need especially sensitive support. She may face Jo Murphy Lawless,
particular difficulties relating to her baby, Centre for Gender and Women's Studies,
although this is not universal. Trinity College, Dublin
Women in many cultures are used to being Co-author of report titled “The Maternity Care
supported by female family members when giving Needs of Refugee and Asylum Seeking Women
birth, and will feel their absence. Husbands and Email: [email protected]
male partners are rarely the major sources of Further reading
support and may be in an unfamiliar role.
McLeish J
Dispersal can increase isolation, with separation
Mothers in Exile: Maternity experiences of asylum
from potential support networks.
seekers in the UK,
“Postnatally women are highly isolated; many London The Maternity Alliance 2002 Tel: 0207 588 8583
described sitting at home crying endlessly –
none had received support for post-natal 7.3) Female Genital Mutilation
depression”. Research officer, London Female genital mutilation (also known as FGM or
Pregnant women supported by NASS can receive Female Circumcision) describes a range of
a maternity grant worth £300 in vouchers. The practices involving the removal or alteration of
application must be made to NASS not less than healthy female genitalia. It is practiced in 28
4 weeks before and not more than 2 weeks after African countries, in SE Asia and the Middle East
the birth. However it has been difficult for and it is estimated that 100 – 140 million women
women in emergency accommodation to access are affected. The highest prevalence rates are
this grant. found in Djibouti, Guinea, Somalia, Eritrea, Mali,
Sierra Leone and Sudan. It is illegal in the UK.
Asylum seekers currently have no access to milk
tokens. Hygienic conditions may be difficult to Affected women may experience problems with
maintain for the preparation of bottles. sexual, reproductive and general health, including
difficulties with passing urine and menstruation,
Milk for babies of women who are recurrent urinary tract and pelvic infections, and
HIV positive fistula and keloid formation. Infections may
Dr Daya Nayagam result in infertility. Childbirth may be problematic,
Tel: 0207 771 5423 with increased risks of stillbirth and haemorrhage.
In Lambeth, Southwark and Lewisham, the Taking a cervical smear may be painful.
Health and Local Authorities fund a scheme Psychological sequelae include anxiety, depression
giving HIV positive women (including asylum and sexual difficulties.
seekers) sterilising equipment, bottles and Ideally, Female Genital Mutilation should be
formula milk. identified as early as possible in the antenatal
period before 20 weeks gestation so that reversal
can be performed before labour, though it can
also be performed in the first stage of labour.
Midwives and obstetric staff need training in

page 59
 identifying and caring for women affected. The A specialist clinic offering midwifery, obstetric,
BMA suggests possible questions to ask: gynaecological care and de-infibulation for
“Are you circumcised?” “Are you closed?” or women who have undergone Female Genital
“Are you open?” Mutilation. It has a wide catchment area.
A child thought to be at risk of Female Genital
Women’s Health Team of Central Manchester
Mutilation is considered to be at risk of child
PCT, Robert Darbishire Practice, Rusholme,
abuse, and steps should be taken to initiate child
Manchester
protection proceedings (see Working together to
safeguard children. A guide to inter-agency Contact Zeinab Mohamed 0161 225 6699
working to safeguard and promote the welfare of [email protected] for further information
children. Department of Health, Home Office, For details of your nearest specialist clinic, see the
Department for Education and Employment FORWARD website: www.forward.dircon.co.uk
London: The Stationary Office 1999). There under the heading Help and Advice.
should be discussion with the family about the
health and legal issues, with a sensitive approach The African Well Women's Advice
to their beliefs and culture, the aim being to find Clinic, Waltham Forest
effective ways of ensuring the protection of the Contact: Jennifer Bourne, The Refugee Advice
child whilst promoting her overall welfare. The Centre, 340 High Road, Leyton, E10 6JP
involvement of social services, community Tel: 0208 558 4077
paediatricians, counsellors, local community Fax: 0208 556 0100
groups and other health workers with experience
Set up to provide advice on women's health
in this area should be sought. A few women have
issues relating to female circumcision, the clinic
been granted refugee status on the grounds that
is held weekly at the Refugee Advice Centre,
they would be at risk of Female Genital Mutilation
Leyton. It is staffed by outreach nurses from
if they were returned to their country, and the
the Community Health Project working
United Nations High Commissioner for Refugees
alongside a Somali gynaecologist, who speaks
(UNHCR) supports this.
English, Somali and Arabic, and who is in the
(Summarised from the British Medical Association
process of revalidating her qualifications.
website - Female Genital Mutilation: Caring for
Additional interpreting services can be
patients and child protection BMA 2001
arranged if needed. The clinic is open access
http://www.bma.org.uk/public/ethics
and the following services are offered:
Organisations working in this area include: • Advice and guidance
Foundation for Women’s Research and • Cervical screening
Development (FORWARD) • Referral to other services
6th Floor, 50 Eastbourne Terrace, London W2 6LX
• Referral for reversal of circumcision
Tel: 0207 725 2606
• Health promotion advice on the menopause
Fax: 0207 725 2796
e-mail: [email protected] • Advice on aspects of women’s health
website:www.forward.dircon.co.uk • Advocacy for clients with other services
The website provides contact details for clinics It provides a service that women find culturally
with experience of caring for women who have and linguistically appropriate and is an
been affected by FGM, under the heading Help extremely effective setting for delivery of a
and Advice. wider range of services, particularly preventive
and promotive services.
Comfort Momoh, FGM Specialist Midwife, African
From Taket A: Health–related services for
Well Woman Clinic,
women: the views of Somali women living in
14th floor, Guy’s and St Thomas’s Hospital NHS
Trust, St Thomas Street, London SE1 9RT Redbridge and Waltham Forest – report of a
Tel: 020 7955 2381 focus group, South Bank University, 2001
Pager: 020 8345 6789 (881018)

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Further reading: 7.4) Health needs of men
Adamson F. Men, who find their changed, usually lower,
Female Genital Mutilation: a counselling guide for status and powerlessness hard to deal with, often
professionals. feel the change in circumstances affecting
London: FORWARD 1992 refugees more acutely. Depression and anxiety are
common. Women may find it easier to gain
Momoh C
employment, be it often low paid, and this may
Female Genital Mutilation - Information for
lead to changed family dynamics. Families in this
Health Care Professionals (available from C
situation may be at a higher risk of domestic
Momoh, Specialist midwife, Guys and St
violence. Levels of smoking, alcohol or drug
Thomas’s Hospital, see above for contact details)
consumption may be exacerbated by boredom.
Hedley R. and Dorkenoo E. Young men may be frustrated by unemployment
Child Protection and Female Genital Mutilation: and have little to fill their day. In addition, they
Advice for health, education and social may not have the requisite cooking skills to
work professionals. eat well.
London FORWARD 1992 “ Men often do not take their health seriously
Mwangi-Powell F (ed.) enough and do not access services”
Female Genital Mutilation: Holistic care for Community Practitioner, London
women. A Practical Guide for Midwives. London “There is less help available generally for men’s
FORWARD, 2001 health issues” Health Visitor, Salford

Royal College of Nursing. Although men may be more reluctant to access

Female Genital Mutilation: The unspoken issue. health care, outreach services, including health
London: Royal College of Nursing, 1994 sessions held in hostels and education colleges by
community workers, can be a good way to
The Royal College of Midwives engage them, such as are carried out in Lambeth,
Female Genital Mutilation (Female Circumcision) Southwark and Lewisham (See section 3.4 –
Position Paper No. 21, London: The Royal College information on access to healthcare and on
of Midwives, 1998 health for contact details). Some clinics have
established good rapport with men, who readily
McCaffrey M, Jankowska A, Gordon H
access their services.
Management of Female Genital Mutilation:
The Northwick Park experience. 7.5) Health needs of older people
British Journal of Obstetrics and Gynaecology Older people are not represented in large
1995; 102:787-790 numbers amongst newly arrived refugees, but
Snow R Female genital cutting: distinguishing the they face particular difficulties and their needs
rights from the health agenda Tropical Medicine are rarely a priority in the planning and delivery
and International Health Vol. 6 No 2 pp89-91 of services.
Feb 2001 Older people have comparatively poor health and
are more likely to have chronic health problems
Video: (as with other older people). Their nutritional
Another form of abuse London, FORWARD 1992. status may be vulnerable due to a poor diet and
A general introduction, discussing health dental problems. Food may not be culturally
implications and including a woman who had acceptable and familiar.
genital mutilation performed on her. They may be grieving for losses already sustained
and may be fearful of death and burial in a
foreign place. Isolation and loss of support
mechanisms on which they have relied in the past
may compound this. Short-term memory loss and
so much change, with few familiar markers, may

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 result in confusion and disorientation, especially 7.6) Health Needs of Families
when familiar patterns and environments are Families may be incomplete, with members
disrupted and they may be less able to cope with missing through death or separation (see Section
activities of daily living. 8.3 for details of the Red Cross Family Tracing
With families disrupted, older people may have Service). Critically important to a child’s health
responsibility for bringing up children, challenged and development is the ability of parents or care-
by poverty and lack of access to social services givers to ensure that the child's needs are being
and compounded by displacement from responded to. Asylum seeking and refugee
traditional homes and the destruction of parents may be struggling with their own needs,
traditional social structures. and this may affect their ability to parent
Although dependent older people from refugee effectively. Parenting capacity should be
communities are more likely to be cared for by considered in the context of the family’s structure
families, there may be an assumption that the and functioning, and who contributes to the
family (if indeed family are present) will look after parental care of the child or children. Children of
all their needs, and services that are available may asylum seeking and refugee families should be
not be offered. considered and assessed as children first, using
Older people are often considered to be less able the statutory framework of the 1989
to acquire new language and skills, and Children Act.
education programmes are rarely targeted An understanding of how the family usually
towards them. In fact a range of coping strategies functions, and how it functions under stress can
and contributions have been identified amongst be very helpful in identifying what factors may
older people. They have a wide range of assist parents in carrying out their parenting roles.
indigenous knowledge and experience, including Of particular importance is the quality and nature
traditional healing and crafts. They preserve and of the relationship between a child’s parents, and
transmit cultural heritage, stories and activities, how this affects the child, and also the quality of
and may play an important role in the resolution relationships between siblings. Account must be
of family or community conflict. taken of the diversity of family structures, who is
considered to be family and who is important to
Further reading the child. The family’s social integration and
Older people in disaster and humanitarian crises: access to community resources are also
guidelines for best practice important, but for many refugee families, these
Available from HelpAge International, may be limited.
PO Box 32832 London N1 9ZN Multi-disciplinary working is important, involving
Tel: 0207 278 7778 whenever appropriate the GP and primary care
Fax: 0207 843 1840 team, health visitor, school nurse, child and
Email: [email protected] family consultation services, social services,
Website: http://www.helpage.org education services, mental health services and
voluntary Sector.
Offer support to both parents and children.
Parents have additional stresses from children
taking on the values of the host country, and may
be concerned about younger generations losing
their cultural identity, language and customs.
Young people often describe their difficulties of
being “caught between two cultures”, that of
their parents and that of their peers. The effects
of displacement and dislocation faced by refugee
families may be passed down to further
generations, long after the original migration.

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Figure 2 – The Assessment Framework (Appendix A from Framework for the Assessment of Children in Need
and their Families 2000 Department of Health, Department for Education and Employment Home Office.

Further reading immature in other situations e.g. when in school.

Framework for the Assessment of Children in They may face exclusion from school due to
Need and their Families (2000) disruptive behaviour.
Department of Health, Department for They may exhibit:
Education and Employment, Home Office. • withdrawal, lack of interest and lethargy

7.7) Health needs of children and • aggression and poor temper-control

adolescents • irritability
Children may be living in fragmented families, • poor concentration
having lost their parents, siblings and other close • repetitive thoughts about traumatic events
relatives. They may be with unfamiliar carers, may • poor appetite, over-eating, breathing
have arrived alone or may live with parents who difficulties, pains and dizziness
have changed under the pressures of torture, • regression (e.g. bed-wetting) and will feel
exile and loss and who are experiencing great humiliated by this
difficulty in parenting. They may feel that their • nightmares and disturbed sleep
parents have failed to protect them. Some may
• nervousness and anxiety
have been abducted to become child soldiers and
• difficulty in making relationships with other
forced to commit violent acts themselves.
children and adults
Young people experience loss of family, friends,
• lack of trust in adults
home, culture etc. and may have difficulty making
friends. They may appear to be mature beyond • clinging, school refusal
their years, and in a caring role with their parents, • hyperactivity and hyperalertness
particularly when they are with them, but be • impulsive behaviour

page 63
 Very few children need psychiatric treatment. safety and stability can go a long way to
Although vulnerable, children are resilient – they restoring the sense of security many refugee
may develop a range of coping strategies and children have lost.”
manage well. Interventions need to be geared to Young Minds Report, War and Refugee
the enhancement of resilience and protective Children, October 1994
factors, which include:
“It is no exaggeration to say that refugee
• A feeling of belonging, with a special children’s wellbeing depends to a major degree
relationship with an involved adult carer on their school experiences, successes and
(ideally a parent) failures ... School policies are a powerful tool for
• Time and space to think about their helping refugee children feel safe and normal
experiences and the feelings connected with again, and begin to learn.”
these experiences, alone and with others. This Naomi Richman, In the Midst of the Whirlwind -
includes the time and space to play and a manual for helping refugee children, 1998
express feelings in a creative way e.g. through
Most refugee children have to live with
art, drama, music, story-telling etc.
enormous uncertainty. This may lead to
• Being able to make active choices - e.g.
noticeable behavioural and emotional difficulties
involving children in decisions about them
and distress. These children may benefit from
• Belonging to their own community and taking supportive listening in schools, and both
part in cultural events
individual relationships with staff and guided
• Belonging to and being part of the local group relationships with other refugee children.
community in the UK. Befriending towards Enabling young people to come together in a
active involvement in youth groups, after group to discuss their situation amongst their
school activities, homework clubs etc.
peers who understand the particular stresses and
Children will have to get used to a new language issues can be helpful. Supplementary mother-
and to learn how to communicate. Expression of tongue schools may encourage cultural identity.
language takes approximately two years to reach
The needs of young refugees in
the equivalent of the indigenous population1.
Lambeth, Southwark and Lewisham
Most children will be behind in their schooling.
The Health Action Zone Young Refugee Project,
Families may not be able to afford toys for
Elizabeth Blackwell House, Wardalls Grove,
children.
Avonley Road, London SE14 5ER Tel: 0207 771
“ Visiting refugees’ homes, an apparent lack of 5282/5105
stimulation in the form of visible toys etc
Aim: to produce a strategy to improve the
emerge as obvious needs.” Midwife, Bedford
health of young refugees and facilitate access to
The most therapeutic event for a child who is a services. Interviews with refugee children,
refugee, whether living with familiar carers or community workers, health workers and policy
strangers, is to become part of the local school officers showed:
community, to learn and to make friends2.
• Refugee children’s perceptions of health relate
However, they may experience bullying and racial
to both their emotional and social well-being
abuse at school.
• Factors negatively affecting health include
“Schools can play a crucial role in promoting the poverty, housing, bullying at school,
well-being of refugee children and can often separation from family, worrying about family,
represent the most important community loneliness, boredom, language barriers and
outside the home. An atmosphere of warmth, lack of interpreters
• More than half the children interviewed felt
1 Levenson R and Sharma A The Health of Refugee Children - their health had deteriorated since arrival in
Guidelines for Paediatricians. London: Royal College of Paediatrics
and Child Health 1999 the UK
2 Melzak S and Kasabova S Working with children and adolescents
from Kosova, London Medical Foundation for the Care of Victims
of Torture, 1999

page 64
 Gosling R
• They want more information about services,
The Needs of Young Refugees in Lambeth,
an advice worker, a telephone hotline and
Southwark and Lewisham
a website
Health Action Zone Lambeth, Southwark and
• Health workers identified nutritional needs
Lewisham, Community Health South London
and a need for health education, particularly
NHS Trust 2000
on sex and drugs for older children
• Health workers had concerns about the Rutter, J
mental well-being of refugee children, mostly “Supporting Refugee Children in 21st Century
in relation to their experiences in the UK Britain - a compendium of essential information”
London, Trentham Books 2001.
• Concerns were expressed about the
vulnerability of unaccompanied minors placed Lynch M
inappropriately, whether in foster placements Health Care for Refugee Children and
or in hostels with other adults. Unaccompanied Minors, Medicine, Conflict
• Some children face long waits for school and Survival 2001; 17: 2
places (up to 8 months)
Melzak S and Kasabova S
• Health workers were keen for training on
Working with children and adolescents from
refugee issues and requested a telephone
Kosova, London, Medical Foundation for the
hotline
Care of Victims of Torture, 1999
• The need for an inter-agency approach was
identified. 7.8) Unaccompanied
As a result of this work, it is planned to develop
minors/separated children
support for young refugees in the following The Asylum Directorate Instructions define an
areas: unaccompanied minor as follows:
• mental health, health promotion, An unaccompanied child is a person who, at
unaccompanied teenagers in adult the time of making his application, is under 18
accommodation, a foster carers resource years of age or who, in the absence of
pack, and bullying. documentary evidence appears to be under
• A training programme for health workers and that age, and who is:
for refugee community workers applying for asylum in his own right
• Inter-agency working, linking relevant without adult family members or guardians to
agencies in the area turn to in this country:
• Employment opportunities for refugee Asylum Directorate Instructions, Chapter 2
health professionals Section 5 www.homeoffice.gov.uk/ind/hpg.htm
Unaccompanied children are especially isolated
Further reading
and vulnerable. Ongoing contact with social
Richman N.
services is important to ensure that they have a
In the Midst of the Whirlwind - a manual for
needs assessment and care plan, which are
helping refugee children,
regularly monitored. Inter-agency working should
City and Hackney NHS Trust and Save the
improve planning and co-ordination.
Children. Trentham Books, UK 1998
Young people aged 15 and below will usually be
Levenson R and Sharma “looked after” by the local authority. They are
The Health of Refugee Children - usually defined as “in need” and services are
Guidelines for Paediatricians. provided under Section 20 of the Children Act
London: Royal College of Paediatrics and Child (1989), including foster care or residential home
Health 1999 placement, an allocated social worker, a care
plan, cash financial support and full leaving-care

page 65
 services. Those aged 16 and 17 usually receive timing of pubertal onset is variable, and is
services under Section 17 of the Children Act. affected by gender and ethnicity2 . Poor
Accommodation may be a bed-and-breakfast or nutritional status and illness may delay puberty. It
hostel and they have no allocated social worker. is inadequate to use only two measurements to
They may be particularly vulnerable. determine a pubertal growth spurt.

“Young separated refugees need help in In the Indian subcontinent, a slightly earlier onset
learning cooking skills as well as other of puberty is common, and boys may develop
independent living skills.” facial and body hair at an earlier age than a boy
Researcher with young people, London of Caucasian heritage3. Dental development may
be part of the examination – estimates of a
Resources: child’s age from dental development are accurate
Refugee Council Panel of advisers for to within 2 years in either direction, for 95% of
unaccompanied refugee children the population4.
240 – 250 Ferndale Road, London, SW9 8BB It is not possible to determine the chronological
Tel: 0207 582 4947 age from bone age, and it is inappropriate for X-
Fax: 0207 820 3005 rays to be used merely to assist in age
Offers support to children and young determination. The Royal College of
unaccompanied minors under the age of 18 Radiologists in 1996 advised that X-rays should
when they arrive, and people 18 –21 years not be requested by immigration officials for
who are the main carers for younger brothers this purpose5.
and sisters. The possible margin of error is wide, and it may
be best to word a clinical judgement in terms of
Further reading:
whether a child is probably, likely, possibly or
Ayotte W and Williamson L unlikely to be under the age of 183.
Separated Children in the UK: An overview of the
Adapted from Levenson R and Sharma A The
current situation, London, Save the Children and
Health of Refugee Children: Guidelines for
Refugee Council, 2001
Paediatricians 1999 Royal College of Paediatrics
Available from Refugee Council, 3 Bondway,
and Child Health, London
London SW8 1SJ Tel: 0207 820 3000
7.10) Child Protection
Stanley K Child protection issues need to be addressed
Cold Comfort: Young separated refugees in sensitively, following procedures outlined in
England, London, Save the Children 2001 Working Together to Safeguard Children – A
Available from: Save the Children Fund London guide to inter-agency working to safeguard and
Development Team, Cambridge House promote the welfare of children6. Issues which
Cambridge Grove, London W6 0LE may give cause for concern may include physical
Tel: 0208 741 4054 extension 124 abuse, including disciplining using excessive
http://www.savethechildren.org.uk/functions force, and female genital mutilation (see Section
/indx_pubs.html 7.3 Female Genital Mutilation), emotional abuse,
sexual abuse, or neglect. Parents may be
7.9) Age Assessment
1 Tanner JM Growth at adolescence, 2nd edition. Blackwell Scientific
Doctors may be asked to give an opinion on the Publications 1962
2 Tanner et al Assessment of skeletal maturation and prediction of
age of a child, in particular as to whether a adult height (TW2 method). Academic Press. New York 1983
3 Levenson R and Sharma A The Health of Refugee Children:
young person is a child under the age of 18, as Guidelines for Paediatricians Royal College of Paediatrics and Child
this age represents a change in NASS support Health, London 1999
4 Miles AEW Assessment of age of a population of Anglo-Saxons from
arrangements. An estimation may be made based their dentitions. Proc R Soc Med 1962; 55: 881-6
5 Watt I Dean of Faculty of Clinical Radiology. Letter ref BFCR (96) 9 to
on serial growth measurements and attainment all clinical radiology fellows and members
of the stages of puberty1, but the margin of error 6 Working Together to Safeguard Children – A guide to inter-agency
working to safeguard and promote the welfare of children London
can be as much as 5 years in either direction. The Department of Health, Home Office, Department for Education and
Employment 2000

page 66
struggling with their own needs and this may
affect their ability to parent effectively. Mental
illness may affect their ability to care for a child.
Parents should be offered as much support as
possible, but the welfare of the child is
paramount and his/her needs given priority.
If the child is suffering or is likely to suffer
significant harm and this harm is attributable to a
lack of adequate parental care or control,
compulsory intervention in family life is deemed
to be justified in the best interests of children
(Concept of significant harm). Concerns should
be discussed with your local child protection co-
ordinator in order to establish what action, if any,
to take. If you think that a child may be
disclosing an act of abuse, ask only what you resulting from chronic ill health, accidents,
need to know to take the next step. Repeated torture, war-related injuries, mine injuries,
investigative interviewing may lead to retraction amputations, infections such as polio, strokes,
of an allegation. cancer, arthritis, visual impairment and congenital
disabilities. Disability may be recent or long-
In the case of refugee families, health workers
standing. The incidence of disability is higher
need to be sensitive to differing family patterns,
amongst survivors of torture or war. Those with
lifestyles and child rearing patterns, as well as the
amputations may not have been able to obtain
broader social factors which discriminate against
prostheses, or they may be ill-fitting. People with
black and minority ethnic people. The effects of
physical disability may have difficulty reaching
racial harassment, racial discrimination,
shops that accept vouchers if they are not nearby.
institutional racism, cultural misunderstandings
Deaf people may not know British Sign Language,
and misinterpretations should be understood.
and a suitable interpreter may be hard to find.
The GP or Community Paediatrician should ensure
Asylum seekers supported by NASS (the National
that there is discussion with the family about
Asylum Support Service) are not eligible for social
health and legal issues. In all cases, the interests
security benefits (including disability benefits). It
of the child should be foremost. Co-ordinated
is worth applying for a Community Care
working with social services and refugee
Assessment, as disabled asylum seekers may be
community organisations is important.
able to get additional support from NASS or from
Further reading the Local Authority. Those with refugee status or
Working together to Safeguard Children – A Exceptional Leave to Enter/Remain can apply for
guide to inter-agency working to safeguard and the full range of social security benefits, including
promote the welfare of children. London Disability Living Allowance and Attendance
Department of Health, Home Office, Department Allowance. Special needs should be identified at
for Education and Employment 2000 the initial claim for NASS support.
“There is a lack of adequate services as support
7.11) Disability and Special Needs
is based on immigration status, I try to offer
Disability amongst refugees is a hidden issue and
people adequate support using voluntary
little relevant information exists. In one study1
services and support groups.” Community
10% of the sample reported “some sort of
Practitioner, London.
disability affecting their daily life” A more recent
study in 20012 has identified some of the
1 Carey Wood et al The settlement of refugees in Britain, London:
demographic characteristics of refugees living HMSO, 1995 (Home Office research study 141)
with a disability. As would be expected, many 2 Roberts K and Harris J Disabled refugees and Asylum Seekers
in Britain: Numbers and Social Characteristics York, University of
different kinds of disability are experienced, York 2001

page 67
 In many cultures, disability is associated with National Holiday Fund for Sick and Disabled
stigma and people may be fearful that their Children, Suite 1 Princess House, Princess Parade,
asylum claim may be jeopardised. Support may New Road, Dagenham Essex RM10 9LB
not have been available in their original country Tel: 0208 595 9642
and may not be expected. Similarly, education for Gives grants for holidays
children with a disability may not be expected.
Visual impairment
Refugee Children with Special Royal National Institute for the Blind
Needs/Disability Tel: 0207 388 1266
The Lambeth, Southwark and Lewisham Health Helpline: 0345 669999 (local rates)
Action Zone Young Refugee Project has a link Website: www.rnib.org.uk
worker dedicated to working with children who
are asylum seekers/refugees with special Hearing impairment:
needs/disabilities. For more information contact Royal National Institute for Deaf People
The Health Action Zone Young Refugee Project, Tel (freephone): 0808 808 0123 (voice)
Elizabeth Blackwell House, Wardalls Grove, 0808 808 9000 (text)
Avonley Road, London SE14 5ER Website: www.rnid.org.uk
Tel: 0207 771 5282/5105
Education
Contacts: IPSEA offers advice for parents of children with
British Council for Disabled People, special educational needs
Tel: 01332 295 581 (text) Tel: 0800 0184 016 (freephone)
Website: www.dlcc.demon.co.uk
Skill gives information and advice to disabled
Disability Scotland, Princes House, 5 Shandwick students about further and higher education
Place, Edinburgh, EH2 4RG Tel (freephone): 0800 328 5050 (voice)
Tel: 0131 229 8632 0800 068 2422 (text)
Website: www.skill.org.uk
Childhood Disabilities:
Policy issues
Contact a Family, 150 Tottenham Court Road,
London W1P 0HA Bharti Patel, Social Policy Adviser, Refugee
Tel: 0207 383 3555 Council, 3 Bondway, London SW8 1SJ
Website: www.cafamily.org.uk Tel: 0207 820 3000
Fax: 0207 582 9929
Provides information and advice to families who
care for children with any disability or special Email: [email protected]
need. Puts families in touch with each other if
Dr Keri Roberts (researcher),
they would like contact.
Social Policy Research Unit, University of York
Family Welfare Association 501 - 505 Kingsland Tel: 01904 433608
Road, London, E8 4AU Tel: 0207 254 6251 Fax: 01904 433618
Email [email protected]@york.ac.uk
Helps families with a child with a disability with
Website: http://www.york.ac.uk/inst/spru/
holiday grants. Applications need to be made by
a professional on behalf of a family. Special needs and learning disability
The Family Fund Trust, PO Box 50, York, YO1 9ZX Consideration needs to be given to how best to
address special needs. Such needs may not
Tel: 01904 621115
initially be evident because of language
Website: www.familyfundtrust.org.uk
difficulties. Lack of knowledge of a person’s
Gives grants for e.g. toys, clothes, holidays,
history may mean that needs are inaccurately
washing machine (if child incontinent)
assessed. Some asylum-seeking children have
been thought to have learning difficulties, when

page 68
in fact they were suffering from the effects of 7.12) Carers
emotional trauma. Refugee carers are often isolated and may not be
Ideally a bilingual assessor should carry out receiving their entitled social support, benefits or
assessments in the child’s first language, but if respite care. The majority of carers are women,
this is not possible an interpreter should be used who are generally unsupported.
for the assessment. Asylum seekers may not be entitled to welfare
Stigma and isolation may affect those people benefits, although it is worth advocating to your
who have a learning disability and their families. local social services office. Language barriers and
They may have a lack of information and a prevailing myth that black and minority ethnic
appreciation of help that may be available to communities “look after their own” also
them, including education for children. contribute to the exclusion of many black carers
Contacts: from support services.

MENCAP (Royal Society for Mentally Handicapped Carers National Association

Children and Adults) Carers line on 0808 808 7777
Tel: 0207 696 5503 10 - 12am and 2 - 4 pm Monday - Friday
Website: www.mencap.org.uk
Information, advice and support services in “Who cares?” report available from the Sheffield
England, N Ireland and Wales Carers Centre, price £6.99
Tel: 0114 278 8942
ENABLE, 6th Floor, 7 Buchanan St,
Glasgow, G1 3HL “We Care Too” Report by National Black Carers
Tel: 0141 226 4541 Workers Network, in association with the Afiya
Information, advice and support services in Trust 2002. Available from:
Scotland Tel: 0207 582 0400

National Autistic Society, 393 City Road,

London EC1V 1NG
Tel: 0207 833 2299

page 69
 8. Other related issues

8.1) Socio-economic issues and racism, discrimination, isolation and lack of

support cohesive social support
• Religion is an important source of sustenance
8.2) Spiritual support
for many refugees and asylum seekers.
8.3) Tracing missing family members Religious groups are playing an important
supportive role
8.4) Housing • The Red Cross may be able to trace missing
family members
8.5) Schooling and education
• Asylum seekers may be moved frequently,
8.6) Learning English making the planning of care difficult
• Schools can play a vital role in providing safety
8.7) Training and employment for and stability for children
asylum seekers and refugees • Be aware of the possibility of bullying
8.8) Work Permits • Demand for English classes outstrips supply in
many areas
8.9) Legal support • People who have been tortured may find it
hard to concentrate, impeding their ability to
8.10) Medico-legal reports and letters
learn
of support
• Refugees have high rates of unemployment or
8.11) Detention of asylum seekers under-utilisation of their skills, impacting
negatively on health
8.12) Racism, discrimination and • Asylum seekers cannot work for the first 6
hostility months, after which they can apply to the
Home Office for permission
8.13) Media contact
• Access to good legal support is important
8.14) Contact with the police • Health workers may be asked to write a report
in support of an asylum application
8.15 Linking with local communities
• Some asylum seekers are held in detention
and befriending
• Torture survivors should not be detained
Key Points • Refugees experience racism in many different
• Anything that health workers can do to forms
alleviate poverty and poor living conditions • Racist behaviour towards asylum seekers and
may be beneficial to the health and well-being refugees needs to be challenged
of asylum seekers and refugees
• Be aware of the implications of the amended
• Other factors impacting on health include Race Relations Act 2001 on the NHS
multiple loss and bereavement, separation
• Use the media to disseminate positive and
from family and friends, exile, loss of identity
balanced messages about refugees
and status, unemployment, poor housing,

page 70
 • Asylum seekers do not contribute to Social Services will inevitably need to provide
increased crime, and are as likely to be the practical or financial assistance to families to
victims of crime ensure that essential items such as clothing for
children can be obtained. Even where mainstream
• Improve services for everyone, not just for
assistance is available it may be discretionary, or
refugees
the help available may not be enough to meet
• Assist integration within the local community
the full costs. Examples include school uniform
8.1) Socio-economic issues and grants and vouchers towards the cost of
support spectacles, milk tokens, etc.

Poverty has a negative effect on both physical 8.2) Spiritual support

and mental health, and anything that health
Religion is very important for many refugees,
workers can do to alleviate poverty and poor
providing much sustenance and strength, and it
living conditions may be beneficial to the health
may provide the framework in which they see
and well-being of asylum seekers and refugees.
their experiences, and derive identity and
Other factors which impact on health include
self-esteem.
multiple loss and bereavement, separation from
family, exile, loss of identity and status, poor “It’s very hard to see your whole life turned
access to education, unemployment, poor upside down without it being your fault. I
housing, racism, discrimination and isolation and honestly can say we couldn’t cope with the
lack of cohesive social support. Diminished self- change of life if it wasn’t for faith in God, as
esteem, and self-confidence and increasing being a Muslim you are preparing for any
dependence on others may result. difficulty that arises in your life and have to be
resilient, accept it and move on.”
“Many problems are social or political in nature”
Hassan Farah L and Smith M, Somalis in London
Psychologist, London
Bow Family Centre, 1999
“There is a need for accessible activities to Religious groups and communities often provide
encourage integration i.e. affordable and much emotional and practical support, as well as
welcoming.” social contact. Consider the possibility of co-
Researcher with young people, London working with spiritual or community leaders.
Sports sessions, particularly football, have been
Further reading
set up in some areas and have proved popular
with young men. Weller P (Ed.)
Religions in the UK – A Multi-faith Directory,
“Sports sessions for young male asylum seekers
University of Derby and Inter-faith Network for
reduce isolation, and introduce asylum seekers
the UK, 1997
into the local community as well as being
healthy exercise“.
Health visitor, Salford
Sports and social facilities that will also appeal to
women are needed.
Asylum seekers often face isolation and confusion
when they first arrive. Systems should be
developed to ensure that people are linked into
basic services when accommodation placements
are made. Referrals should be made to agencies
which are in a position to facilitate access to
services such as education and health services.
Since asylum seekers are on very low incomes and
are excluded from other benefits open to those in
receipt of DSS benefits such as the Social Fund,

page 71
 8.3) Tracing missing family members The White Paper “Secure Borders, Safe Haven”
Many people will have been forced to leave includes plans for accommodation centres for
family members behind and may not know asylum seekers. Initially 4 accommodation centres
whether they are safe or not. The Red Cross with 750 bed spaces each will open on a pilot
basis. Current support and dispersal
Family Reunion Department may be able to trace
arrangements will continue for those not selected
relatives whose whereabouts are unknown.
for an accommodation centre.
For people living in Greater London contact:
Red Cross Family Reunion Department: ` Further reading:
International Welfare Service, 54 Ebury Street, Garvie D
London, SW1W 0LU Far from Home – the housing of asylum seekers
Tel: 0207 730 6179, 0207 235 5454 in private rented accommodation,
Fax: 0207 730 5089 London, Shelter 2001 88 Old St, London EC1V
Email: [email protected] 9HU Tel: 0207 505 2043
Website: www.redcross.org.uk Organisations:
For people living elsewhere in the UK, contact the National Asylum Support Service (NASS),
local British Red Cross Office (in the phone book Voyager House, 30/32 Wellesley Road,
under B) or write to International Welfare Croydon CR0 2AD
Department, British Red Cross, 9 Grosvenor Helpline: 0845 602 1739 (local rates)
Crescent, London SW1X 7EJ
Shelter, 88 Old St, London EC1V 9HU
When families are reunited, support may be
Tel: 0808 800 4444 (Freephone 24hour helpline)
needed to cope with what is a highly emotional
Email: [email protected]
event, including different degrees of adjustment
and integration. Shelter gives advice to anyone in the UK who has
a housing problem and can give information
8.4) Housing about local Shelter Housing Aid Centres. Uses
“I have no-one to talk to most of the time. I just Language Line.
go out and walk about most of the time I hate Praxis, Pott St, London, E2 0EF
to go back to the hostel. I do not feel the hostel Tel: 0207 729 7985
is a home” Fax: 0207 729 0134
male asylum seeker dispersed to Leeds Email: [email protected]
Asylum seekers may be housed in temporary
accommodation. The length of time which they Praxis runs a Hosting Scheme for asylum seekers
spend in one place varies considerably, making in London, placing clients with suitable families in
planning of services difficult. High mobility the community. This is for asylum seekers who
interrupts relationships with health and other are unable to claim welfare benefits and who
have been referred to Praxis by a local authority
workers and disrupts trust-building.
social services department.
A recent report by Shelter (Garvie 2001) showed
that much of the housing in which asylum
seekers are living is substandard, with a high
incidence of overcrowding and fire risk. There
may be lack of room for children to play, and
difficulties for particular ethnic and religious
groups in preparing food in shared kitchens.
Some asylum seekers and refugees may choose to
live with relatives or friends, and may not be
entitled to receive support. They may also be
living in overcrowded situations and homelessness
is becoming more of a problem.

page 72
8.5) Schooling and education circumstances may experience difficulties with
Schools can play a vital role in providing a haven concentration. Although people may not initially
of warmth, safety and stability for children. They seem to get much out of English classes if they
may represent the most important community attend while very anxious or depressed, after
outside the home and thus create a sense of some time they may settle and start to find the
continuity. If difficulties are encountered in classes useful. At the beginning the regular
finding a school place, the local Education routine and the social aspect of classes may be
Authority should be able to help. more crucial than what is being learnt1.

Children benefit greatly from being part of the 8.7) Training and employment for
local school community, but be aware of the asylum seekers and refugees
possibility of bullying. Contact with the school Many asylum seekers and refugees have professional
nurse or school health adviser is important. qualifications, skills and experience, yet many are
Schools may have a designated a support teacher unemployed or are not using their skills in their
for refugee children or an English as an work. Unemployment results in poverty and
Additional Language co-ordinator. For further depression and impacts negatively on health.
information about refugee support teacher Information on training and employment
schemes in operation contact: opportunities are available from the following
Newham Refugee Education Team, organisations:
The Credon Centre, Kirton Road, Refugee Education and Employment Advisory
London E13 9BT Service (RETAS),
Tel: 0208 548 5023/5094 14 Dufferin St, London EC1Y 8PD
Email: [email protected] Tel (general): 0207 426 5800
[email protected] Fax: 0207 251 1314
Tel (advice) 0207 426 5801
Camden Language and Support Service, Medburn (Tues and Thurs 2.30 – 5pm)
Centre, 136 Chalton St, London NW1 1RX Email: [email protected]
Workneh Dechasa, Senior Refugee and Website: www.wusuk.org.
Community Education Adviser
Gives advice on education, training and
Tel: 0207 974 8059
employment for asylum seekers and refugees.
Administration tel: 0207 974 8141
Drop-in service on Tues and Thurs 10am - 12pm.
Email: [email protected]
Runs jobskills courses, preparing people for
Special Educational needs: see section 7.11 looking for and gaining employment – CV writing
Further Education: see section 8.7 and interview skills. Offers one-to-one careers
advice for refugee doctors, to enable them to get
8.6) Learning English
back to work.
Information about local English language classes
should be made available. Demand may outstrip
supply in many areas. Adult and further
education colleges may run classes, some of
which may be free or may have reduced charges
for refugees. Some may offer childcare and help
with transport costs. Information about local
English classes should be available from
public libraries, community centres, refugee
organisations, and adult and further
education colleges.
However, it may not be possible for people to
make use of these immediately. People who have
been tortured or have experienced traumatic 1 Kate harris personal communication

page 73
 Refugee Council, Training and Employment status can work without applying to the Home
Section (TES) Office. Dependents are only given permission to
240 – 250 Ferndale Road, Brixton, work in exceptional circumstances.
London SW9 8BB
Tel: 0207 346 6760 (Careers Advice Line)
8.9) Legal support
Fax: 0207 737 3306 Access to good legal advice is very important.
Website: www.refugeecouncil.org.uk The Immigration Law Practitioners Association
can provide advice on lawyers who can act for
Advice to asylum seekers and refugees over the the asylum claim and for other legal difficulties.
age of 25 on the education, training and Asylum seekers and refugees are entitled to
employment options open to them. Drop-in legal aid.
centre is open Mon –Fri 10am – 1pm. Runs a
range of courses, including English as an Immigration Law Practitioners Association
Additional Language, IT, Business Administration 1st Floor, Lindsay House,
and Health and Social Care. Applicants must have 40-41 Charterhouse Street, London EC1M 4JH
been in the UK for at least 6 months. Gives help Tel: 0207 251 8383
with travel and childcare costs. Maintains directory of solicitors, barristers and
other providers of immigration advice who are
Africa Educational Trust, 38 King St,
members of the association, including those who
London WC2E 8JS
can arrange assistance for the Community Legal
Tel: 0207 836 5075/7940
Service Fund.
Fax: 0207 379 0090
Email: [email protected] Refugee Legal Centre
Offers advice on education and training for Nelson House, 153-157 Commercial Road,
African students, asylum seekers and refugees. London E1 2EB
Grants and scholarships may be available for Tel: 0207 780 3200
those in financial difficulty. An African Refugee Free legal advice for asylum seekers on all aspects
Women’s project gives free training advice to of the asylum procedure and conditions of
young, unemployed African women. staying. Also offers telephone advice for detained
asylum seekers.
Further reading:
Rosenkranz H Immigration Advisory Service
A concise guide to Refugees’ Education and County House, 190 Great Dover Street,
Qualifications London SE1 4YB
RETAS London 2000 Tel: 0208 814 1559 (24 hour helpline)
Tel: 0207 357 6917
Prince B, Rutter J, Kerrigan M
(also has branches in Birmingham, Leeds,
A Handbook on Education for Refugees in the UK
Liverpool, Manchester, Norwich, Oakington
RETAS See RETAS entry above for contact details
Detention Centre, Cardiff and Glasgow)
For information on qualified refugee health Free legal advice for asylum seekers on all aspects
workers, see section 4.17 of the asylum procedure and conditions of
staying. Also offers telephone advice for detained
8.8) Work Permits
asylum seekers:
Asylum seekers are not permitted to work initially,
but after 6 months they may apply to the Home
Office for permission. People with a work permit
may work during the appeals process. Those with
Exceptional Leave to Remain (ELR) and refugee

1 Kate Thompson personal communication

page 74
8.10) Medico-legal reports and letters Further reading:
of support Pourgourides C, Sashidharan S, Bracken P A
Lawyers may request a report. This may be a Second Exile: the Mental Health Implications
report documenting your work with a refugee of Detention of Asylum Seekers in the
client or his/her symptoms. United Kingdom
For those who have experienced torture or North Birmingham Mental Health Trust 1996
violence, a healthworker may be asked to 8.12) Racism, discrimination and
document evidence, although a significant hostility
amount of time may have elapsed. In some
Agencies responsible for supporting asylum
instances, torturers leave gross scarring, fractures
seekers and refugees should be aware of their
and paralyses, but techniques may be used which
potential vulnerability to racism, and ensure that
cause only transient bruising or physical sequelae.
effective policies are in place to deal with any
The absence of any physical or psychological signs
incidents. The prevalence of racist attacks and
is not proof that torture has not taken place.
harassment should be considered when deciding
Training can be provided by the Medical
whether particular locations are suitable for the
Foundation for the Care of Victims of Torture.
placement of asylum seekers.
Contact 0207 813 7777
Refugees face racist taunts, threats, arson,
Further reading bullying at school and physical violence, which
Forrest D and Hutton F has in some instances resulted in death. People
Guidelines for the examination of survivors of who are suffering racial harassment need support
torture, and advocacy in order to report the incident to
London, Medical Foundation for the Care of the police and to access protection.
Victims of Torture 2000 Racist behaviour needs to be challenged. The
amended Race Relations Act 2001(see
8.11) Detention of asylum seekers http://www.cre.gov.uk/duty/index.html) imposes a
Some asylum seekers are detained in detention new statutory duty on public authorities
centres and prisons, although detention in prison (including health services) to eliminate unlawful
should cease from 2002. Such detention is racial discrimination and promote equality of
distressing. For those who have been detained in opportunity and good relations between persons
their own country, the experience of subsequent of different racial groups. It aims to make the
detention can be devastating. The experience of promotion of racial equality central to authorities’
being locked up will generally evoke powerful work, to provide fair and accessible services and
memories and these may persist for a long time to improve equal opportunities in employment.
after release from detention. Public authorities are expected to take the lead in
Organisations promoting equality of opportunity, good race
relations and in preventing unlawful
Bail for Immigration Detainees (BID), 28
discrimination. This would include a General
Commercial St, London, E1 6LS
Practice discriminating against asylum seekers and
Tel: 0207 247 3590
refugees by refusing to register them when their
Fax: 0207 247 3550
list is open to other patients.
Organises bail for immigration detainees
From the responses received from health workers,
Association of Visitors to Immigration it is apparent that many had heard adverse
Detainees (AVID) comments about refugees from other patients
PO Box 7, Oxted, RH8 0YT and from some colleagues.

Co-ordinates visitors' groups to detention centres “One colleague expressed the idea that they
should all be sent back”
Health visitor, Salford

page 75
 It is important to address this issue. Informing liaison officer be appointed in each region, with
people of the situation facing refugees and responsibility for the policing needs of asylum
addressing their issues and misconceptions can seekers and refugees in that area.
help. People are often misinformed about the
level of finance which asylum seekers receive.
Refugee and Asylum Seeker
Participatory Action Research
“ I promote positive images of asylum seekers (RAPAR)
and explain why they come to the UK.”
c/o Faith and Justice Commission, Cathedral
Health visitor, Salford
House, 250 Chapel St, Salford, M3 5LL
“ I have discussions with staff and colleagues, Cath Maffia: 0161 212 4452
trying to provide balanced information, so that Rhetta Moran: 0161 295 5277
they could influence others.” RAPAR initiated a series of discussions/meetings
GP Glasgow with Salford Police Force, creating opportunities
for asylum seekers to communicate with police
For further information about the Race Relations
about their experiences of harassment and
Act and health services’ response to the Act,
abuse. Past experiences of law enforcement
contact your local Primary Care or NHS Trust.
services, both at home and as people have
Further reading: moved to the U.K., have led to a severe lack of
Coker N trust towards such agencies on the part of the
Racism in Medicine – an Agenda for Change overwhelming majority of displaced people
London Kings Fund, 2001 that RAPAR has worked with to date. For this
reason, RAPAR maintains a constant dialogue
European Commission against Racism and with the police over issues of community
Intolerance (ECRI) safety, while recognizing the sensitivity of
Second Report on the United Kingdom, this area of work.
Secretariat of ECRI 2000 (Tel: 00 33 388412964)
Further reading
8.13) Media Contact Association of Chief Police Officers (ACPO)
It may be useful to establish contact with local www.acpo.police.uk
media, who can provide balanced information
within local communities. ACPO Guide to Meeting the Policing Needs of
Asylum Seekers and Refugees 2001
“It would help if the media portrayed some of
the positive achievements and contributions of 8.15) Linking with local communities
refugees to the host society.” and befriending
Refugee health advocate, London It is best to improve services for everyone, not
just for refugees. If there is a perception that
8.14) Contact with the police
refugees are getting better services, this may
The police state that asylum seekers and refugees
result in hostility and resentment. Anything that
do not contribute to increase in crime, and are as
can integrate the community should be
likely to be the victims of crime. Asylum seekers
encouraged.
and refugees are entitled to the same protection
to live free from crime, harassment and “I have reservations about providing different
intimidation as any other person, and the police services for different groups as it does not
share responsibility for their safety with other enhance a community bond – there should be
statutory agencies and the community. However, an attempt to find common ground.”
it can be difficult for people to approach the Nurse, London
police. The language barrier and people’s previous Prior to receiving refugees, ensure that local
negative experiences of uniformed authority may people are aware of the situation. (See section
make them reluctant to involve the police in their 8.12 – Racism, discrimination and hostility).
protection. It has been recommended that a Befriending schemes run by the voluntary sector

page 76
provide support and combat isolation and help to
Leeds Asylum Seekers Support
bridge the gap between refugees and the local
Network (lassn)
community. Befrienders need to make a regular
commitment and should receive training and Gill Gibbons, Project Manager, 233-237
ongoing support. Roundhay Road, Leeds LS8 4HS
Tel: 0113 380 5690
“We frequently see people who seem to need Fax: 0113 380 5691 Email:
more than anything an opportunity to talk.” [email protected]
GP Glasgow
LASSN set up a befriending scheme to help to
“My main problem is loneliness. I have breakdown isolation and also an English at
no-one to talk to” Home scheme, which is aimed at people who
Male asylum seeker dispersed are unable to access English classes and who
“Young people whom we spoke to seemed to would benefit from English tuition at home.
warm to the idea of a personal LASSN offers training, one-to-one suport and
advocate/befriender more than counselling.” supervision and a monthly support group for all
Researcher with young people, London volunteers. It has drawn up a volunteer
agreement, which clearly sets out the roles of
Newham Refugee Link the befriender, and English tutor. It gives advice
The Children's Society East London Network, on Health and Safety and guidelines on
Wesley House (Manor Park Methodist Church), boundaries, in order to prevent over
Herbert Road, Manor Park London E12 6AY commitment and potential burnout. It stresses
Tel: 0208 553 9619 or 0208 514 6602 the importance of confidentiality, and volunteers
Fax: 0208 553 3369 sign a confidentiality declaration.
Email: [email protected]
This befriending scheme is run by Hand-in-Hand
Refugee and Homeless Support Group and the
Children's Society. Volunteers, many of whom
are refugees themselves, are trained to support
newly arrived asylum seekers and those who
are finding it difficult to settle. Help includes
assistance with accessing services, listening to
people’s problems and accompanying them
to interviews.

page 77
 9. Resources

9.1) One Stop Services and national

agencies working with refugees

9.2) Local resources

9.3) Background in-country

information

9.4) Useful websites

9.5) International Human Rights

Conventions

9.1) National agencies working with refugees and One Stop Services (OSSs)
S = Surgery Services
NB. Many OSSs provide a part-time outreach service in their local area –
contact the nearest OSS for information.

MAP REF ORGANISATION ADDRESS TEL/FAX

1 MIGRANT HELPLINE, Room 65, No 1 Control Building T: 01304 203 977
Kent Eastern Docks F: 01304 203 995
Dover CT16 1JA
2 MIGRANT HELPLINE, 17 High Street T: 01304 226 830
Kent Dover, Kent CT16 1DP F: 01304 226 831
S Wed MIGRANT HELPLINE YMCA, The Roundhouse T: 0702 1123 269
11.00-14.00 Kent Overy Street, Dartford
Kent DAI 1UP
S Tues MIGRANT HELPLINE Ashford Christian Fellowship Contact main office
9.30-13.30 Kent Brook House, 25 Norwood Street,
Ashford, Kent TN23 1QU
S Mon MIGRANT HELPLINE The Friends Meeting House Contact main office
9.30-15.30 Kent 6 The Friars, Canterbury,
Kent, CT1 2AS.
S Tues & Fri MIGRANT HELPLINE 53 The Old High Street Contact main office
9.30-15.30 Kent Folkestone, Kent, CT20 1RN.
3 MIGRANT HELPLINE 48 Havelock Road T: 01424 717 011
East Sussex Hastings TN34 1BE F: 01424 717 098
S Mon & Fri MIGRANT HELPLINE Braemar House, Contact main office
14.00-16.30 East Sussex 28 St Leonard’s Road,
East Sussex, BN21 3UT Eastbourne

page 78
MAP REF ORGANISATION ADDRESS TEL/FAX

4 MIGRANT HELPLINE 1 Cecil Street T: 01843 292 921

Thanet Margate, Kent CT9 1NX F: 01843 232 085

5 MIGRANT HELPLINE 7a Church Street T: 01273 671 711

West Sussex Brighton BN1 1US F: 01273 695 830

S Fri MIGRANT HELPLINE Hove Drop – In Contact main office

14.00-17.00 West Sussex Cornerstone Community Centre
Church Road, Hove

S Thurs MIGRANT HELPLINE The Red Cross Building Contact main office
13.00-14.00 West Sussex West Green Drive, Crawley

6 NERS 19 The Bigg Market T: 0191 222 0406

(North of England Newcastle NE1 1UN F: 0191 222 0239
Refugee Service)

7 NERS 3rd Floor, Forum House, T: 0191 200 1109

The Forum, Wallsend F: 0191 200 5929
Tyne & Wear NE28 8LX

8 NERS Ground Floor, Maritime Buildings T: 0191 510 8685

St Thomas Street, Sunderland F: 0191 510 8697
Tyne & Wear SR1 1BL

9 NERS 27 Borough Road T: 01642 217 447

Middlesbrough TS1 4AD F: 01642 210 200

10 NICEM 3rd Floor Ascott House T: 02890 238 645

Belfast 24/31 Shaftesbury Square F: 02890 319 485
Belfast BT2 7DB

11 REFUGEE ACTION International Community Centre T: 0115 910 7418

East Midlands 61b Mansfield Road F: 0115 910 7419
Nottingham NG1 3FN

12 REFUGEE ACTION Melbourne Centre T: 0116 261 4830

East Midlands Melbourne Road F: 0116 262 7162
Leicester LE2 0GU

13 REFUGEE ACTION 34 Princes Road T: 0151 702 6300

North West Liverpool L8 1TH F: 0151 709 6684

S Tues REFUGEE ACTION Toxteth Citizens Advise Bureau Contact Main Office
10.00-13.00 North West High Park Street
Liverpool, L8

S Wed REFUGEE ACTION Anfield Citizens Advice Bureau Contact Main Office
10.00-15.00 North West 36 Breckfield Road North
Liverpool L6

S Fri REFUGEE ACTION Great Homer Street Contact Main Office

13.00-16.00 North West Medical Centre
25 Conway Street Liverpool L5

page 79
 MAP REF ORGANISATION ADDRESS TEL/FAX
14 REFUGEE ACTION 1 Tariff Street T: 0161 233 1215
North West Manchester M1 2HF F: 0161 236 4285
Postal Address
Dale House 4th Floor,
35 Dale Street Manchester M1 2HS

15 REFUGEE ACTION 50 Oxford Street T: 02380 248130

South Central Southampton SO14 3PP F: 02380 632995

16 REFUGEE ACTION Senate House T: 0117 989 2100

South West 36 Stokes Croft F: 0117 924 8576
Bristol BS1 3QD
17 REFUGEE ACTION Virginia House T. 01752 519 860
South West 40 Looe Street F. 01752 519 861
Plymouth PL4 0EB

18 RAP London Airports T: 020 8607 6888

(Refugee Arrivals Project) 41b Cross Lances Road F: 020 8607 6851
Hounslow, Middlesex TW3 0ES

19 REFUGEE COUNCIL 1st Floor T: 01473 221 560

Eastern Region 4 – 8 Museum Street F: 01473 217334
Ipswich IP1 1HT.

20A REFUGEE COUNCIL 240-250 Ferndale Road T: 020 7346 6770

London Brixton F: 020 7346 6778
London SW9 8BB

20B REFUGEE COUNCIL Simpson House T. 020 8603 0880

London 6 Cherry Orchard Road F. 020 8603 0885
Croydon CR0 6BA

21 REFUGEE COUNCIL 1st Floor T: 0121 622 1515

West Midlands Smithfield House, Digbeth F: 0121 622 4061
Birmingham B5 6BS

22 REFUGEE COUNCIL 1st Floor, Wade House T: 0113 244 9404

Yorkshire & Humberside The Merrion Centre F: 0113 246 5229
Leeds LS2 8NG

23 SCOTTISH REFUGEE 94 Hope Street, Glasgow, G2 0800 0856087

COUNCIL (advice line
for asylum seekers)

T: 0141 248 9799

F: 0141 333 1860

S Mon SCOTTISH REFUGEE Women’s Group Contact Main Office

14.30-18.00 COUNCIL Quaker Meeting House Women’s Group
38 Elmbank Crescent, Glasgow

page 80
MAP REF ORGANISATION ADDRESS TEL/FAX
S Fri SCOTTISH REFUGE Sighthill Surgery Contact Main Office
10.00-13.00 COUNCIL Sighthill Community Centre
Fountainwell Square, Glasgow

S Every SCOTTISH REFUGEE Larkfield Centre Surgery Contact Main Office

2nd Wed COUNCIL Govanhill, Glasgow.
Afternoon

S Friday SCOTTISH REFUGEE St David’s Centre Surgery Contact Main Office,

Mornings COUNCIL Boreland Avenue,
Knightswood, Glasgow.

S Thursday SCOTTISH REFUGEE Scottish Refugee Council T: 0131 225 9994

COUNCIL 200 Cowgate,
Edinburgh EHI INQ.

24 WELSH REFUGEE Unit 8, Williams Court T: 02920 666 250

COUNCIL Trade Street, Cardiff CF10 5DQ F: 02920 343 731

25 WELSH REFUGEE 1, The Kingsway T: 01792 301729

COUNCIL YMCA, Swansea SA1 5JQ F: 01792 301721

26 WELSH REFUGEE Suite 5+6, 5th Floor T: 01633 252271

COUNCIL Clarence House F: 01633 252273
Clarence Place, Newport NP9 7AA
27 WELSH REFUGEE Trinity House Trinity Street, T: 01978 363240
COUNCIL Wrexham, LL11 1NL

Scotland

23-Glasgow

6-Newcastle
Wallsend-7
10-Belfast 8-Sunderland
N. Ireland 9-Middlesbrough
Scotland
22-Leeds
14-Manchester
Liverpool-13
27-Wrexham

Wales 11-Nottingham
12-Leicester
Birmingham-21 19-Ipswich
Swansea-25
Cardiff-24
16-Bristol 4-Thanet
Newport-26 Hounslow-18 1+2-Dover
20-London
3-Hastings
5-Brighton
Plymouth-17 Southampton-15

page 81
 The following organisations can offer additional described might not be universal experiences for
information or advice everyone. It is important not to make
assumptions about the person and their situation
Refugee Council without hearing their story.
3 Bondway, London SW8 1SJ
Tel: 0207 820 3000 Fax: 0207 582 9929 9.4) Useful websites
East of England Consortium website
United Nations High Commissioner
www.harpweb.org.uk
for Refugees (UNHCR)
Millbank Tower, Millbank, SW1P 4QP United Nations High Commissioner for Refugees
Tel: 0207 828 9191 Fax: 0207 630 5349 www.unhcr.ch

Joint Council for the Welfare of Immigrants, Refugee Council

115 Old Street, London EC1V 9JR www.refugeecouncil.org.uk

Tel: 0207 251 8708 Medical Foundation for the Care of Victims of
Advice Line Tel: 0207 251 8706 Torture www.torturecare.org.uk
(Tues, Thurs 2 – 5pm) Amnesty International
Advice, information and representation for people www. amnesty.org.uk
with immigration or nationality problems.
Medact
British Red Cross, www.medact.org
9 Grosvenor Crescent, London SW1
Asylum support
Tel: 0207 235 5454 Fax: 0207 245 6315
www.asylumsupport.info
Citizens Advice Bureaux – see phone directory for
Immigration index
number of your local branch
www.immigrationindex.org
Information and advice for asylum seekers and
refugees, particularly in the London area, Immigration news
www.immigrationnews.org
9.2) Local resources
Information on local organisations working with Nottingham and Notts.Refugee Forum
asylum seekers and refugees can be obtained www.nottas.org.uk
from your local One Stop Service (see map). We
Other websites are mentioned in specific
recommend that each area nominate a named
sections throughout the text.
person who has responsibility for compiling,
updating and circulating a list of local resources
to accompany this information pack. 9.5) International Human Rights
Conventions
9.3) Background in-country
information The following international human rights
legislation is important for refugees and
Up to date information on in-country situations,
asylum seekers
past and present, can be obtained from the
following websites: Universal Declaration of Human Rights:
Amnesty International: www. Amnesty.org.uk http://www.un.org/Overview/rights.html

UNHCR UN Convention against Torture: http://

www.unhcr.org www.magnacartaplus.org.uno.docs/c-a-t.htm

U.S. Committee on refugees UN Convention on the Rights of the Child:

www.refugees.org http://www.unicef.org/crc/crc/htm
However, it should be noted that the situations UK Human Rights Act: http://
www.hmso.gov.uk/acts/acts1998/19980042.htm

page 82
Appendix 1

Guide to languages by the major countries from which asylum seekers and
refugees originate
(with acknowledgement to Marsha Sanders)

Some people speak English, and many speak several languages. This list aims to cover the most common
languages used by non-English speakers. English has been included where it is an official language.
Afghanistan Pashto, Dari, Uzbek, Turkmen, Farsi, Balochi, Pashai
Albania Albanian, Greek
Algeria Arabic, French, Berber dialects
Angola Portuguese, Chokwe, Herero, Kongo, Luvale, Ambo
Argentina Spanish
Armenia Armenian, Russian, Assyrian
Azerbaijan Azeri, Russian, Armenian, Aramaic
Bangladesh Bangla, Khasi, Bengali, Sylheti
Belarus Belarussian, Russian
Benin French, Fon, Yoruba, Hausa, Bariba, Gurman, Ewe
Bolivia Spanish, Quechua, Aymara, Guarani
Bosnia and Herzegovina Croatian, Serbian, Bosnian, Romani
Bulgaria Bulgarian, Romani
Burma Burmese, Wa, Jingpho, Karen, Kadu
Burundi Kirundi, French, Swahili
Cambodia Khmer, French, Vietnamese, S Chinese dialects
Cameroon English (official), French (official), Bata, Hausa, Mbum, Ki Lamnso, Ewondo,
Fang, Mungaka, Nyang, Tiv, Yaunde, Bassa, Mbo, Sukur, Oku
Chile Spanish
China Mandarin, Cantonese, Wu, Minbei, Minnan, Xiang, Gan, Hakka, Fukien,
Hsiang, Tibetan, Yao, Mongolian, Jingpho, Min-nan
Colombia Spanish
Congo-Brazzaville French, Lingala, Kigongo
Congo,
Democratic Republic of French, Lingala, Kingwana, Kigongo, Tshiluba
Cote d”Ivoire French, Dioula
Croatia Croatian, Italian, Hungarian, Czech, Slovak, German
Czech Republic Czech, Romani
Ecuador Spanish, Quechua
Eritrea Tigrinya, Tigre, Arabic, Afar, Saho, Bilen, Kunama
Estonia Estonian, Russian, Ukrainian, Finnish
Ethiopia Amharic, Tigrinya, Oromo, Somali, Arabic, Sidama, Harari, Afar
Georgia Georgian, Russian, Armenian, Azeri, Abkhaz, Assyrian
Ghana Twi, Fanti, Ga, Ewe, Dagbani, Asante, Hausa

page 83
 Guatemala Spanish, Quechua, Xinca
India Hindi, Bengali, Tamil, Urdu, Gujerati, Punjabi, Kashmiri, Hindustani, Bihari
Indonesia Malay/Indonesian, Dutch, Javanese, Minangkaban
Iran Farsi, Turkic, Kurdish (Sorani/Kurmanji), Luri, Balochi, Arabic, Turkish,
Armenian, Assyrian, Azari
Iraq Arabic, Kurdish (Sorani/Kurmanji), Assyrian, Armenian, Aramaic
Kazakhstan Kazakh, Russian
Kenya English (official), Swahili, Dhopadhola, Luo, Kikuyu, Masaba
Kosova Albanian
Kyrgystan Kyrgyz, Russian
Latvia Latvian, Lettish, Lithuanian, Russian
Lebanon Arabic, Aramaic, French, Armenian
Liberia English, Kpelle, Gola, Bassa, Kru
Lithuania Lithuanian, Polish, Russian
Macedonia (former Yugoslav Republic of)
Macedonian, Albanian, Turkish, Serbian, Croatian
Moldova Moldovan, Russian, Gagauz
Nigeria English (official), Hausa, Yoruba, Ibo, Fulani, Ido. Abua, Bariba, Efik, Emai, Tiv,
Idoma, Igbira, Oring, Kache, Katab, Bata, Ikwere, Isoko, Idon, Igala, Ora, Oron,
Urhobo
Pakistan Punjabi, Urdu, Sindhi, Siriki, Pashto, Hindi, Kashmiri, Brohi, Baluchi
Palestinian Territories Arabic
Peru Spanish, Quechua, Aymara
Poland Polish, Romani
Romania Romanian, Hungarian, German, Romani
Russia Russian, Abkhaz, Mongolian, Moldovan
Rwanda Kinyarwanda, French, Swahili, Chiga
Saudi Arabia Arabic
Serbia and Montenegro Serbian, Albanian
Sierra Leone English (official), Mende, Temne, Krio, Kono, Limba, Gola, Kisi
Slovakia Slovak, Hungarian, Romani
Slovenia Slovenian, Serbo-Croat, Romani
Somalia Somali, Arabic, Swahili, Italian
Sri Lanka Sinhala, Tamil,
Sudan Arabic, Nubian, Beri. Maidi, Dinka, Nuer
Syria Arabic, Kurdish (Kurmanji) Armenian, Aramaic, French, English
Tajikistan Tajik, Russian, Farsi
Tibet Tibetan
Togo French, Ewe, Mina, Kabye, Dagomba, Dagbane, Gurma
Turkey Turkish, Kurdish (Kurmanji, Zaza) Arabic, Armenian, Greek, German
Turkmenistan Turkmen, Russian, Uzbek
Uganda English (official), Luganda, Swahili, Arabic, Acholi, Kakwa, Lango, Luo, Chiga,
Masaba, Nyoro, Rutoro
Ukraine Ukrainian, Russian, Romanian, Polish, Hungarian
Uzbekistan Uzbek, Russian, Tajik, Turkmen
Vietnam Vietnamese, Chinese, French, Khmer, Tring, Lati
Yemen Arabic
Zimbabwe English, Shona, Ndebele

page 84
Appendix 2

What to include in a welcome pack How to contact the police

for newly arrived asylum seekers Information on dental treatment
Appointment cards
Local map
Complaints procedure
How to register with a GP and dentist
Local organisations offering services to asylum
Information on local interpreting services
seekers and refugees
HC1 form
Leisure facilities
Model prescription
How to register with a school
“When and how to take your medication” card –
Where to get legal advice
using clocks and pictures
Explanation of help with travel costs
Emergency numbers

page 85
 Appendix 3

Interim guidance on screening TB screening protocol

for tuberculosis in refugees and 1. All: ask about past history and current
asylum seekers symptoms of tuberculosis
(cough for more than 3 weeks; fever; night
Aims
sweats; weight loss; loss of appetite;
The aims of tuberculosis screening are twofold:
no energy; coughing blood)
a) to identify promptly those with active, Symptoms compatible with TB: refer for chest
especially infectious, tuberculosis, in the X-ray and/or examination
interests of the individual, but also to prevent
2. Asymptomatic, or chest X-ray negative:
transmission of infection to others;
check for a characteristic BCG scar
b) To identify those (particularly children and Scar present: inform of risk, but no
young adults) for whom BCG immunisation or further action
preventive chemoprophylaxis may be
3. No scar: perform a tuberculin skin test
appropriate in order to prevent tuberculosis
(Heaf or Mantoux)
developing in the longer term.
Positive test
Who to screen?
(Children under 16: Grade 2-4
Many asylum seekers come from areas with a Heaf or equivalent;
high prevalence of tuberculosis; others will be at Over 16 years: Grade 3-4 Heaf or equivalent):
increased risk by virtue of their circumstances refer for chest X-ray and examination
before, and after, entry into the UK. All
4. Positive test (as defined at (3) above), but no
asylum seekers are therefore recommended
signs of active TB:
to be screened.1
Children under 16 or young adult (16-34):
Where should screening take place? offer preventive chemoprophylaxis
For those going to reception centres or known Inform all of TB risk
addresses, it is sensible for screening to take place
5. Tuberculin skin test negative:
from there, as soon as possible after arrival.
Children under 16 or young adult (16-34):
Where an address in the UK is uncertain, the
offer BCG immunisation* Inform all of
minimum level of screening (see below) should
risk of TB
take place at the port of entry.
1,2
* BCG is contra-indicated in HIV infected
The screening protocol individuals. Relevant HIV prevalence rates
See below. Completion of the full protocol should should be taken into account.
be the aim. The minimum screening is that Notes
described in Point 1. This may be appropriate i. Further investigation of patients suspected of
where an asylum seeker is unlikely to stay in the having TB and treatment (including
UK longer than about a month, when the chemoprophylaxis) should be under the supervision
immediate personal and public health risks are of a respiratory physician with experience in TB
the main concern. (normally at the local chest clinic).
ii. All those performing tuberculin skin tests and
References administering BCG should be appropriately trained.
1. Recommendations for the prevention and control of
tuberculosis at local levelThe Interdepartmental Working
Group on Tuberculosis The Department of Health and the Department of Health, Communicable
Welsh Office, June 1996
2. Control and prevention of tuberculosis in the United
Diseases Branch (PH6.3)
Kingdom: Code of Practice 2000 Joint Tuberculosis November 2000
Committee of the British Thoracic Society Thorax 2000;
55:887-901

page 86
London, W2 3QR
Department of Health
40 Eastbourne Terrace
Directorate of Health and Social Care

Further Copies available from 0207 725 5601.

BAINES design & print 01707 876555 Printed on environmentally friendly paper A14273
Photographs by Howard Davies (cover, page 12, 13, 48, 53, 56, 62, 67, 69, 72)
Paula Solloway (page 77) and Martin Salter (page 3, 4, 23, 30, 32, 41, 85)