Inspecting asylum seekers upon entry--a medico-ethical complex

In September 2007, the UN Refugee Agency UNHCR summarized the main asylum application levels and trends during the first six months of the year in 36 industrialized countries, including 26 European Union (EU) Member States. Based on the assumption of unchanged yearly patterns, the total number of new asylum claims lodged in these 36 countries over 2007 is about 300 000. The overall number of claims has decreased continuously over the past few years, but this trend was reversed in the second half of 2006. The current numbers represent the first increase since 2001.1 Asylum seekers are considered a vulnerable group. Many of them leave their country in difficult circumstances and hope to find a new home elsewhere. In many cases they were exposed to poverty, persecution or violence before they left. Their countries of origin are often unstable in economic, political and social respect. The geographical origin of asylum seekers in the mentioned 36 countries is very heterogenous.1 In the first half of 2007, Iraqi applicants remained the largest group, with about 14% of all claims. Iraq was followed by China as the second most important source country, with 6% of the claims. Also Pakistan, Serbia and Montenegro and the Russian Federation belong to the leading countries, each of them with 4–5%. In addition, asylum seekers and other migrants usually cross pronounced interpersonal, socio-economic and cultural boundaries.2 These factors together should be taken into account when planning adequate health screening programmes. Medical reception and screening of asylum seekers upon entry is closely interlinked with fundamental human rights. This medico–ethical complex should reconcile the basic needs and rights of the individuals involved and those of the host country. Psychosocial and psychiatric problems represent a major problem among asylum seekers. Surveys conducted in the United Kingdom have revealed that about two-thirds of refugees including asylum seekers have mental problems. One in six suffers from severe physical disorders including infections. A significant number are survivors of torture and organized violence, with physical and psychological consequences. Physical health problems that asylum seekers are wrestling with are also related to tuberculosis, viral hepatitis, sexually transmitted infections and malaria, besides infections with intestinal parasites, dermatophyts and ectoparasites.3–5 Countries have a different past and this fact determined their different policies regarding reception and medical screening of their arriving immigrants, refugees or asylum seekers, according to the then reigning conditions. It is worthwhile studying these differences and learning from each other's experiences. An analysis of American 20th century opinions and policies, for example, shows a continuous search for equilibrium between inclusion and exclusion, inspired by a multitude of arguments mainly related to economy, labour force, quota, safety and terrorism, infection control and public health. The policy on immigration is still evolving.6 Modern principles medical screening of entering persons is based on, fall into three categories. The first one is the basis of the most common national strategy and aims at protecting the population of the host country by identifying and controlling diseases considered as having crucial public health importance. The second category, which is less common, and applicable to, e.g. Australia and Canada, aims at excluding those with disorders (such as HIV/AIDS) presumed to put too heavy a burden on the national health insurance programmes. The International Health Regulations (IHR) allow countries to apply health screening measures for this purpose.7 A third important category concerns the asylum seekers themselves. Today, medical screening is increasingly viewed as a way of optimizing their health, including checking the vaccination status of children. Considering the introduction of medical screening requires answering the following questions: (i) Will the applied methods help reducing the estimated risk for epidemics? (ii) Will the interests of both migrant/refugee/asylum seeker and host country be met? (iii) Can screening be justified on economic grounds? (iv) Is this screening ethically acceptable?8 It is beyond dispute that screening of asylum seekers should be based on the principles of medical ethics, which in turn are rooting in the fundamental human rights. This implies to respect human dignity and freedom; not doing harm, but instead doing good; to respect cultural susceptibilities; and to act fairly.8 Although many countries introduced screening programmes for tuberculosis (through radiography), HIV infection, and other disorders, such a policy is also internationally criticized, both on epidemiological and on ethical grounds. It is not immaterial to state that systematic screening for HIV infection leads to specific ethical dilemmas. For example, it has been suggested in certain countries to bar HIV-positive persons. This is at the very least a highly debatable matter. Furthermore, a known positive HIV status often leads to stigmatization and discrimination. The confidentiality of test results is liable to be pushed aside and this tends to force health services into an ambiguous role, being both defender of the patient's rights and protector of public health. In principle, testing for HIV infection should only take place based on informed consent.9,10 Mandatory screening of all asylum seekers for HIV infection is against WHO's guiding principles of expanded HIV testing and counselling.4,10 It is obvious that countries that do implement mandatory applicant screening programmes act against the letter and the spirit of such recommendations. WHO has however not the power to enforce them, it can only put in a caveat. The International Organization for Migration (IOM) states that positive HIV testing does not necessarily lead to exclusion. The United States of America for example allows certain applicants testing HIV positive after offshore screening.9 On the other hand, a country screening for HIV infection or other disorders and refusing at least part of those testing positive is faced with an additional dilemma in terms of assisting people in need for treatment or not. It is generally accepted that each country has the right and the duty to protect its population and to control its borders. Against this background public health considerations unquestionably belong to the priorities. It is, however, equally clear that many variants of policies and practical approaches to public health issues are possible. A country's way of behaving regarding medical screening of entering asylum seekers and refugees not only depends on epidemiological arguments, but also on its ‘philosophical’ view on the world, the characteristics and accessibility of its public health service, the general entitlement to healthcare, the rights of minorities and immigrants and the country's beliefs with respect to a multicultural society. The inevitable consequence is that practical regulations regarding reception of asylum seekers and refugees may differ significantly. It is conceivable that a country's attitude and policy with respect to reception of newcomers are partly interconnected with both its past and future. To what extent current-days views and opinions of a society are determined by its historical evolution (including, e.g. a colonial past), its geographical position, its experience with immigrants of different origin and their later health problems, the way it is embedded in international structures, and the path it hopes to travel in the future deserves further exploration. It is both logical and imperative for European countries to contribute constructively to harmonization efforts at international level—and in the first place at EU level. Medical screening of asylum seekers should get its legitimate place in this process, respecting the rights, dignity and interests of all involved parties. The EU currently considers asylum policy as a communal matter and is gradually harmonizing the general lines. Good work has already been done,11 but more needs to be achieved before more transparency and true harmonization materialize. A survey conducted after the extension of the EU to 25 Member States revealed that one or another form of medical screening of new asylum seekers then occurred in all countries but Greece, yet with pronounced mutual differences.12 On January 27, 2003, the Council of the European Union issued a Directive wherein minimum standards for the reception of asylum seekers were laid down. Article 9 concerns medical screening and says ‘Member States may require medical screening for applicants on public health grounds’.13 More advanced harmonization in an EU context could lead to a broader inclusion of ‘best practices’ already applied in individual Member States. Access to these practices would then become enforceable by the European Court. In a less favourable evolution,11 however, national governments and politicians would remain under popular pressure to both restrict the numbers of immigrants and tighten the asylum procedures. The resulting common denominator would seem less just to applicants and would even prevent Member States to set out a more liberal asylum policy. Conflicts of interest: None declared.

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