Health of Refugee/Asylum Seekers in Australia
Contents
Contents
Introduction
Health Assessment of Asylum Seekers in Australia
Initial Health Assessment
Visa Medical Examination
72 Hour Departure Health Check (dHC):
Health Assessment of Asylum Seekers Without Valid Visas
Post Arrival Health Assessment
Summary
Health Effects of Detention
Mental Health
Statistics
Types of traumatic experiences
Offshore Processing
Mandatory Detention
Asylum Seekers and Refugees residing in the community
Physical Health
Cost To Health Care System
References
Introduction
In this section, we comprehensively discuss aspects of health and how the specific journey of refugees may affect this. We have also included a vast range of resources for doctors, medical students and patients in the next section under ‘Cultural Factors/The Refugee Consultation’.
To start, click here to watch Najeeba’s story (Rethink Refugees):
Health Assessment of Asylum Seekers in Australia
Depending on how asylum seekers arrive in Australia, the process of health assessment differs. Those who enter as part of Australia’s Humanitarian Program undergo an initial and a post arrival health assessment. Those who arrive without a valid visa on the other hand, undergo a different process.
Initial Health Assessment
Most people seeking asylum are processed through Australia’s Humanitarian Program. For those in the offshore program, the initial health assessment is comprised of two parts:
- Visa Medical Examination
- 72 Hour Departure Health Check
Visa Medical Examination
As part of obtaining their offshore Humanitarian Visa to Australia, entrants will have undergone a medical examination to determine if they have any diseases or conditions which would represent a threat to public health in Australia, place an economic burden on the health system, or prejudice the access of Australian citizens to health care and community services. Table 6.1 shows tests performed at these exams.
Source: Australian Government Dept. of Immigration and Citizenship
Key points:
●There are no medical conditions that specifically preclude selection for the Australian humanitarian visa program other than tuberculosis (TB). In the case of communicable diseases (e.g. active TB), an applicant will be expected to undergo treatment before travelling to Australia. In cases where TB is deemed inactive, applicants may be approved for entry to Australia on the condition that they present for follow-up monitoring.
●Following their visa medical examination, some humanitarian entrants will have been asked to sign an undertaking that they will contact the Australian Government Health Undertaking Service for follow-up monitoring within a specified time of arriving in Australia – usually 4 weeks. These include:
-People who had TB detected in the course of overseas medical examinations screening which was subsequently treated
-People whose chest X-ray showed an abnormality suggestive of inactive TB
-People whose chest X-rays conducted as part of the overseas medical examinations were of poor quality
-People who have tested positive for hepatitis B or HIV
-People receiving treatment for leprosy
72 Hour Departure Health Check (dHC):
●The department of immigration and Citizenship offers the dHC to refugee and humanitarian program entrants. It is normally conducted 72 hours prior to departure for Australia and its purpose is to ensure that refugee and humanitarian program clients are fit to travel, to check for communicable diseases, to provide vaccination and treatment for parasites and to facilitate health care after arrival in Australia. The dHC is voluntary although about 90% of refugees and 65% of special humanitarian
Visa Type / Info / Healthcare accessOffshore detention / Current offshore detention centers include Nauru and Manus Island. Main reasons for detention include unauthorized boat arrivals; visa overstayed visa or visa cancellation. / Healthcare is provided by the International Health and Medical Services (IHMS).
Onshore Detention / There are a range of onshore detention centers across Australia. Usually persons detained are unauthorized arrivals. / Access to healthcare is provided by the Red Cross (or its contracted partners) who provide access to GPs. This is co-ordinated by the IHMS.
Bridging Visa E / These visas are frequently held by asylum seekers living in the community. These visas generally last 3 years. Must live at a specified address and subject to curfews and supervision. / Holders have full access to medicare, a basic living allowance (89% of the Centrelink Special Benefit). They do have working rights.
Temporary protection visa (subclass 785) / Allows holder to stay and work in Australia for up to 3 years. Available to people who have arrived in Australia illegally and meet health, security and character checks. / Holders have access to Medicare, short-term counselling, Centrelink, and Adult Migrant English Programme. Limits on access to educational services (particularly tertiary education).
Safe Haven enterprise visa (subclass 790) / Similar to TPV except lasts for 5 years, except requires one member of family unit to declare intention to work/ or study in regional Australia. / Holders have access to Medicare, short-term counseling, Centrelink, and Adult Migrant English Programme. Limits on access to educational services (particularly tertiary education).
Community detention (non-visa holders) / Persons in community detention reside in the community without any visa, instead having a letter of introduction from the Department of Immigration. They can receive financial support through the Asylum Seekers Assistance Scheme distributed by the Red Cross funded by Department of Immigration. / Heath-care is provided through the IHMS and persons within this program are clients of the Red Cross Community Detention program. Contact the Red cross Migration Support Program for assistance 8327 7883
Protection Visa (subclass 866)* / Must be found as a refugee as defined by Migration act 1958 and meet protection criteria. Also available to family members of current Protection Visa holders. / Holders have full access to Medicare, and rights to live and work in Australia as a permanent resident.
●program clients undertake them.
●Tests are currently conducted in Ethiopia, Ghana, Guinea, Kenya, India, Iran, Jordan, Lebanon, Nepal, Sierra Leone, South Africa, Syria, Tanzania, Uganda, Zambia and Zimbabwe. Applicants are counselled and given records about any issues arising from their health screening and treatment.
Asylum seekers who arrive in Australia without a valid visa will not have undergone the overseas medical screening exams conducted with Humanitarian Program entrants. However, once they apply for refugee status they are required to undertake a visa medical examination.
Australian Asylum Seeker Refugee Visas and Healthcare Access
Post Arrival Health Assessment
●A comprehensive health assessment provides a review of past and current health problems, systematic planning of further management and preventative health care.
●This is essential for a number of reasons:
-Humanitarian entrants have relatively poor health status and are likely to have had limited access to health care.
-Some health problems experienced by people from refugee backgrounds are asymptomatic, but nonetheless may have serious long-term health consequences (e.g. intestinal parasitic infection, adult vitamin D deficiency, hepatitis B).
-It optimises opportunity for early intervention.
-If sensitively administered, a thorough medical examination can contribute to a person’s psychological recovery.
●Medicare Item Number: (These items cover taking a history, examination, initiating interventions, referrals and a basic preventative health management plan. The prolonged assessment, item 707 performed over a series of visits, is preferable for refugees, as it includes an assessment of psychosocial functioning and a comprehensive preventative health management plan.)
-Items 701 (brief <30mins)
-Item 703 (standard 30–45 mins)
-Item 705 (long 45–60 mins )
-Item 707 (prolonged >60mins )
●It is important to note that a post-arrival health assessment for refugees and other humanitarian entrants is funded by Medicare once within the first 12 months of arrival or residency in Australia even if clients are from refugee backgrounds who are not eligible for these Medicare item numbers.
Summary
●Asylum seekers have varied access to healthcare and health assessment in Australia.
●An asylum seeker may be reluctant to disclose information about their health, fearing that this may affect their application for permanent residency.
●Doctors and health professionals may be in a position to assist asylum seekers in their application for refugee status or permanent residence on humanitarian grounds. However, the Department of Immigration and Border Protection recommends that doctors do not act as advocates in this regard, but rather provide clear and complete medical reports for consideration.
●Asylum seekers may or may not have access to Medicare depending on their migration status. Asylum Seekers who are ineligible for Medicare may be eligible for the Asylum Seeker Assistance Scheme (ASAS) or the Community Assistance Scheme (CAS) facilitated by red Cross. Consider referral to ASAS or CAS.
Health Effects of Detention
Mental Health
Former director of mental health at IHMS, Dr Peter Young, speaks about the 'inherently toxic' conditions of asylum detention here:
Health is impacted both by detention and the harrowing experiences of torture and war that faced asylum seekers before arriving in Australia. The impacts are manifested primarily as PTSD, anxiety, depression including self-harm and suicidal ideation. In detention it is deep uncertainty, hopelessness, fear for their future and lack meaningful activity that contribute to the high rates of psychiatric illness. Particularly, studies have shown that in some populations, Temporary Protection Visas (TPVs) were the strongest predictor of anxiety, depression and PTSD.1
Statistics
●60-80% of detainees are reported to have some form of mental illness – including: anxiety, depression, post-traumatic stress disorder (PTSD), self-harm and suicidal ideation.2
●95% of children who had been detained on Nauru for between 3 - 17 months were at risk of developing PTSD
●34% of children formally assessed had mental health problems that were considered moderately severe to very severe (compared to an estimated 2% in the general population)
●Suicide rates are up to 10 times higher in detention centres than in the Australian community.3
●During the period of 2011-2013, there were 4,313 reported incidents of actual, threatened or attempted serious self-harm in immigration facilities in Australia.4
●The length of time in detention is proportional to the severity of mental disturbances suffered.5,6
●The rates of adolescents participating in protest and self-harming behaviours occur at rates up to 12 times than that of the general population.2
Types of traumatic experiences
Before resettlement
Refugees’ history of trauma is often an accumulation of traumatic experiences which are repeated in many ways, over many years.8,9 They include:8,9,10
●forced separation, disappearance or murder of family members;
●being subject to, or witnessing torture, physical and emotional abuse;13
●sexual assault;
●imprisonment and solitary confinement and
●illness and death of family members during flight or in refugee camps;
After resettlement
These traumas are only compounded by resettlement difficulties including:9,10,11,12
●Social isolation;
●Challenges of ethnic and religious communities to support them;
●Changes in roles and family structure that lead to domestic tensions;
●Experiences of racism and
●Unfamiliarity with basic activities of daily life, for example in paying bills and public transport which can breed a sense of helplessness, dependency and frustration.
These intermingle with the:12
●Ongoing grief and anxiety over loss and separation of family and
●Pressure to assist with immigration or financially of family in dire situations overseas.
The psychological and physical health of refugees is compromised by the perpetuation of the refugee experience - of uncertainty, flight and fear - which inhibit refugees from healing, grieving and thriving in a new life and community.13
Offshore Processing
Nature of offshore processing detention centres:
●Prolonged and uncertain periods of detention cause a ‘contagion’ effect whereby ‘dysfunctional thinking’ is magnified and shared by groups of people who are frustrated, distressed and/or have mental illness.14
●Processing arrangements are confusing and frustrating for asylum seekers who are not provided with much information.14
●Access to mental health services at offshore sites such as Christmas Island, Nauru and Manus Island is limited at best.15,16
●Concern amongst health professionals working at detention facilities that the substandard health care is jeopardising the lives and well-being of the people detained there.17
●UNHCR’s Regional Representative Richard Towle describes the conditions as “harsh, hot humid, damp and cramped.”17
These conditions breed mental health issues such as:2
●Anxiety
●Depression
●Post-traumatic Stress Disorder
●Self-harm
●Suicidal ideation
Mandatory Detention
●Detention is a negative socialisation experience and exacerbates the impact of past trauma including limiting the potential of recovery from pre migration trauma.19
●A 2003 study estimated that the rates of suicidal behaviours among men and women in Australian detention centres was approximately 41 and 26 times the national average, respectively.
●In a 2004 systematic research study investigating mental health in detention, every adult was diagnosed with a major depressive episode and the majority had PTSD.Most expressed suicidal ideation with one third actually harming themselves while in detention.Prior to detention, only half reported having PTSD, a small number had co-morbid depression and no adults had self-harmed or had experienced suicidal ideation.3
●The length of time in detention is proportional to the severity of mental disturbances suffered.5,6
●More than one third of asylum seekers detained for more than 2 years had new mental health problems. This was 10 times the rate of mental health problems in asylum seekers detained for less than 3 months.7
Asylum Seekers and Refugees residing in the community
The malignant environment faced by refugees in detention continues to pose serious negative health effects years after their release into the community. This consequently affects their ability to thrive and contribute to Australian Society. A 2010 study interviewed participants, on average three years and eight months after their release detention, after being held in immigration detention for an average of three years and two months. All participants reported struggling to rebuild their lives in the years following their release. They reported suffering ongoing difficulties with relationships, a sense of insecurity and injustice, poor mental health and poor self concept. They reported depression and demoralisation, concentration and memory disturbances and persistent anxiety. There were also high rates of PTSD, depression and anxiety.8This suggests that the psychological and interpersonal difficulties that participants were suffering was due to their adverse experiences while detained, producing long-term psychological harm.
Adults and children alike have reported difficulties creating and sustaining relationships in the community due to past psychological trauma. For children, this affects their social health and educational attainment at school.
Asylum seekers residing in the community whilst their applications are processed are not immune to negative mental health impacts. The insecurity of being able to live in Australia and the fear of forced removal from Australia has been found to have significantly compromised the wellbeing of asylum seekers.19
Physical Health
A substantial risk of physical illness has also been reported in the literature. Procter et al. noted a lack of infectious diseases screening in children, in a context where over 50% are likely to be infected with tuberculosis and some likely to have blood borne infections such as hepatitis B.21 The recent death of Hamid Kehazaei due to septicaemia from a foot wound is an example of the poor provision of medical care in an isolated area.22
Refugees and asylum seekers may have been exposed to a range of conditions that may predispose them to poorer health. These conditions include overcrowding, poor water safety, poor sanitation and nutrition, increasing risk of communicable disease with little or no provision of health care (this is particularly true for those who have spent time imprisoned or in refugee camps).23,24
These social determinants of health have a profound impact on health outcomes of individuals. In addition, many refugees and asylum seekers have been exposed to an extensive history of persecution and armed conflict and have experienced the threat of, or actual, physical violence.23,24,25 This may include violence directed towards women and children, and sexual assault resulting in increased risks of sexually transmitted infections, HIV/AIDS, and unsafe abortion. Exposure to these conditions puts refugees and asylum seekers at an elevated risk of a variety of conditions,26 including:
●Under recognised and under managed chronic disease, such as anaemia, asthma, chronic obstructive pulmonary disease, diabetes mellitus, dyslipidaemia, hypertension, vitamin D deficiency
●Infectious diseases including HIV, tuberculosis , chronic hepatitis B, and intestinal parasites
●Poor oral health, due to poor nutrition and diet, poor dental hygiene practices, and limited access to dental care
●Delayed growth or development in children
●Direct physical consequences of armed conflict and torture.
The Government Report on the “Health care for asylum seekers on Nauru and Manus Island” done in 2013 showed that offshore processing could also precipitate physical detriments – for example, in Nauru, a gastroenteritis outbreak could be associated with the fact that there are grossly insufficient toileting facilities and publicly exposed showering facilities.28 Such punitive policies have caused the recent hunger strike in Nauru, clearly indicating the distress detainees are under.27
Furthermore, there is a risk of infections such as malaria and highly multidrug resistant tuberculosis in PNG and this can cause a major impact on long term health outcomes.28 There is limited information available on the capacity of health care in Nauru and PNG.28
Cost To Health Care System
A 2011 study provided a conservative estimate of the lifetime mental health costs associated with people in detention and that was $25,000 on average per person, 50% more than the average.7 Since more than 80% of detained asylum seekers are eventually found to be refugees and successfully settled in Australia, it is the Australian health system and Australian taxpayers that shoulder these extra health costs, which are ultimately avoidable.7