We are all too accustomed to television images of refugees and asylum seekers. We often hear their stories; of persecution and suffering in their home countries and their struggles to reach the relative safety of the West.
What we do not hear – because it has until now been a largely unexamined problem – is how many of them have suffered traumatic head injuries and have sustained brain damage.
Now, however, a team of medical experts in Glasgow have conducted research among asylum seekers and refugees in the city and have uncovered the problem, which not only adds to the suffering of vulnerable people, but which can also – potentially – harm their chances of a successful asylum application.
The result was a report published in Global Mental Health. The research was conducted using 115 asylum seekers and refugees in Glasgow who had been referred to a community psychological trauma service with moderate to severe mental health problems associated with psychological trauma. Using interpreters where required, the subjects were screened for a history of head injury.
One of the report’s authors, Professor Tom McMillan, explains: “Given their background and the reason why they are seeking
asylum, there’s a likelihood they may have sustained a head injury in a circumstance where it has gone undetected.
“They have not attended hospital, not been detected and on average the head injury was 10 years earlier, so they themselves would not necessarily attribute their current difficulties to brain damage.
He adds: “We had to be careful about going too much into symptom areas because sometimes they were undergoing treatment or were about to undergo treatment for other issues. So, we asked more generally if they thought the head injury had had a long lasting effect.”
Head injuries can result in long term impairments in attention, pre-existing memory and ability to form new memories, word finding and executive function. The Glasgow study revealed similar problems among the refugees. “The kinds of problems were related to cognitive function,” says Prof McMillan.
“Typically people’s memory is poor for new events, for things that have happened recently, and they can’t concentrate or attend as well, while they also can have difficulty with judgement, solving problems and integrating cognitive information.
“Sometimes there can be changes in personality where they can be more irritable, aggressive, more fatigued and tired or just lacking energy and the ability to get up and do things.
“You can see how all of these factors might be difficult for people seeking asylum in the UK who have come here from another country.”
The overall average age of those studied was in the 30s. For those believed to have suffered head injuries, it was about 35; with 59% of the sample being female.
Previous studies had indicated that asylum seekers and refugees are more likely than the general population to have experienced physical assault and injury in their country of origin; and to have been victims of torture, including blows to the head and asphyxiation, which can result in brain damage.
Research revealed that more than three quarters (78%) of Vietnamese ex-political detainees resettled in Boston reported a history of head injury.
The Glasgow study found that the overall prevalence of head injury was 51% and at least 38% of those had a moderate to severe head injury that could cause persisting disability.
The prevalence of head injury of a severity likely to cause persisting disability is estimated to be about 2% in the general population in Western countries. The causes of the original trauma were also different.
“The head injury was certainly different from what you would expect from the general population,’’ says Prof McMillan.
“Among the general population in Glasgow, the most common cause of head injury is fall, then assault, then road tragic accident.
“You would expect an accidental cause, like a fall or a road traffic accident in about 70% of people. Whereas in the asylum seekers it’s the other way around.
“Accidental injuries accounted for a third, with assault in two thirds. The assault was associated with causes you wouldn’t normally find in Western countries – they were domestic violence, torture, violence through sexual trafficking, so a different kind of grouping of causes from what you’d commonly find in the general population.”
One conclusion that might be drawn from this is that, assuming those who make it to the West as refugees and asylum seekers tend to be the fittest and most able, then head injury sufferers among the asylum seekers and refugees would be under-represented and the prevalence of head injury in their home countries would be even greater.
“Logic would tell you that it is,” concedes Prof McMillan, but he points out that many of those suffering head injuries might only have made it to the UK with the help of family members or others.
Another serious potential implication is that the injuries sustained by these people might endanger their chances of getting asylum.
“That’s the hypothesis arising from this study; that they might not be able to form a credible evidence provider because their evidence is unreliable and they can’t remember information that people think they should be able to remember.
“It could be that they had a significant head injury at some point during that time period.” He would like to see a greater awareness of the risk of brain injury in such cases.
He adds: “This could be significant in some cases where an individual may be seen to be being a bit di cult or not remembering things or remembering things differently between interviews.
“Perhaps there should be some consideration as to whether there’s any biological basis to this, like traumatic brain injury.”
Furthermore, head injuries can cause emotional problems which can lead to the breakup of relationships, social isolation and unemployment. This can further complicate the fallout of psychological trauma.
There is also the possibility that clinicians may not be alert to the likelihood of head injuries when recording symptom complaints among vulnerable and often traumatised groups, such as asylum seekers, where there is already a high incidence of mental health problems, including post-traumatic stress disorder and depression.
“At a very basic level, NHS services, and particularly mental health services that deal with asylum seekers and refugees, should be screening for head injury when they are assessing people. Therefore, they could, if necessary, carry out a more detailed assessment and take into account any persisting disability when they are working with them.”
Prof McMillan would also like to see greater liaison between those services which deal with asylum seekers and refugees and the brain injury services which could provide advice.
“I’m not suggesting they should be swamped with referrals but at least they can advise in cases where there might be a concern on how to carry out a screening assessment, a kind of link in the NHS care pathways to brain injury services for any cases that require more detailed investigation.”
People referred onto mental health services would be seen by people qualified to identify brain injury, but those being dealt with at an earlier point in the process could still be identified as potentially having a problem.
“I think just having a link with brain injury services could provide them with some education and some simple screening tools so that, if they had a concern, they could perhaps triage a bit and link through.
“Even these fairly simple contacts could be quite important,” says Prof McMillan. In terms of how screening for head injury might be carried out, he says: “There are some formal tools you can use, but you routinely need to identify whether they’ve been in situations where there have been knocks to the head.
“You’re wanting to know how often this is happening, because it can be fairly mild, but if it’s repeated enough it has a cumulative effect.
“We need to know if it resulted in loss of consciousness and, if so, how long that loss was for and whether they were confused for a time afterwards – and how long that was for. By finding that information you can get a reasonably good idea of how severe the injury was. It can be difficult, especially if somebody was drunk at the time or were tortured and can’t actually remember.”
Now the report has been published, the Glasgow team behind the research is trying to make its findings and implications more widely known both in the UK and in other countries taking in refugees and asylum seekers. It has already made a difference in the city where the research was done.
Prof McMillan says: “In Glasgow the mental health team are now routinely assessing and screening for head injury, so there has been a local impact.”