There are specific health concerns for refugee communities that are related to their African backgrounds. These include certain diseases and health conditions that exist in Africa that are not of concern in Australia, as well as the health consequences of conflict and living as a refugee.218
The increasingly indoor-oriented lifestyle of Africans in Australia, and specifically African women, contributes to less exposure to sunlight in their daily lives. This can lead to Vitamin D deficiency, which often presents asymptomatically. This deficiency has been found to be present in 40-80% of refugee patients and up to 100% in some sub-sets of the African refugee population. It is mostly prevalent in the elderly, women who veil, people with darker skin and children who spend a lot of time indoors.219
Vitamin D is important in calcium metabolism, bone growth, immune function, gene stability, muscle functions and brain development. Though commonly asymptomatic at its onset, Vitamin D deficiency can lead to rickets, leg bowing, seizures and bone and muscle dysfunction. Furthermore, the deficiency is linked to diabetes, schizophrenia, prostate cancer and Multiple Sclerosis. Infants of mothers who were deficient during pregnancy will be born deficient, leading to a failure to thrive and delayed walking.220
Other health concerns of African refugees are often related to a change in lifestyle and diet upon their settlement in Australia, such as increased rates of obesity, diabetes, hypertension and anaemia. Many of these are longer-term issues that have on-going effects for the broader African community in Australia. There are also concerns related to their experience in Africa (such as shistosomiasis or other intestinal parasites) or their experience as refugees (such as high rates of TB and other communicable diseases).
Furthermore, African refugees may experience high rates of ongoing mental health concerns due to experiences of torture and trauma.221 Food shortages in many places in Africa, and prolonged food insecurity resulting from conflict, has led to high levels of malnutrition among refuge populations, which can have lasting effects that medical services must consider and address.222
TB rates, similar to rates in Africa, remain high among the refugee population. One study found that only one in three refugees was screened for TB. Of those screened, 25% were found to be positive, making TB the second most common health issue for this group after Vitamin D deficiency.223
Refugees often face difficulties in accessing diagnostic facilities for TB. Given the relatively low rates in Australia, diagnostic facilities are not widespread and the usual method of diagnosis – the Mantoux screening – requires multiple visits, which is often logistically and financially out of reach of the refugee population.224
Primary health care doctors participating in a Melbourne-based study discussed selectively referring refugee patients for TB testing based on where the person lived, knowing that only those residing close to the testing site would follow through.225 However, this course of action, while seen as pragmatic by the doctor, takes personal choice away from refugees and deprives them of the right to make their own decisions about their health and care.
There is a need to increase immunisation levels in the African refugee population as a whole. Much of the older population has been shown to be immune to most vaccine-preventable diseases, most likely from childhood exposure. However, “[w]ithout improving the vaccination status of refugees, there is a risk of outbreaks of disease such as measles. Children are especially at risk, with low immunity and close contract [sic] through schools. Vaccinating this population should be considered a priority area.”226
Many of the health problems identified in African refugee communities reflect the effects of entrenched poverty in their home country, as well as the results of torture and trauma. Health assessments upon arrival in Australia must go beyond simple lab tests. A more thorough examination must be mandated by government to ensure that their health issues are identified and addressed early on.
20.10Shortcomings of the Australian health care system (especially GPs) to manage complex refugee health concerns
Australian health care providers, especially general practitioners (GPs), are often unfamiliar with and untrained to handle many of the conditions with which refugees present.227 Health facilities and health personnel are not equipped to handle their myriad and complex health concerns. Furthermore, they can assume a level of understanding of health issues and the health care system that refugees should not be expected to know. Indeed they may not consider that when they treat a refugee it might be the person’s very first encounter with a formalised health care system.
Refugee populations in Australia receive primary health care almost exclusively from GPs and have little knowledge of other alternative or specialised health services. Many GPs have little, if any, training in tropical medicine or cross-cultural competency, have limited knowledge of the cultural and conceptual issues affecting their interactions with refugees, and little understanding of the health issues unique to refugee communities.228
It is critical that GPs receive adequate training in these areas, as they are usually a refugee’s first point of contact with the health system. While GPs might not be qualified to handle management of some diseases, they should be trained in proper identification of potential issues and know where to refer patients for follow-up care.
Refugee families are often referred to, or assigned, a GP upon arrival. However, because they receive little other orientation to the health care system, they are unaware of how to switch to another health care provider or how to access specialist care if necessary. Refugees often feel ‘locked in’ to a particular GP and do not know how to investigate other options if they are uncomfortable with the care they are receiving.229 As a result, when problems arise, they may decide not to seek out care.
More broadly, provision of health care services must be holistic and acknowledge that employment, housing, family circumstances and education all influence a person’s overall health and well-being. Health cannot be considered in isolation from other settlement needs.230