Refugee and asylum seeker health
Georgie PaxtonImmigrant Health ServiceMarch 2015
Outline
• Policy context• Access to health care• Practical issues
RefugeeSomeone who,“owing to a well founded fear of being 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 such fear, is unwilling to avail himself of the protection of that country, or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.”.
UNHCR 1951 ‘Convention Relating to the Status of Refugees’ and 1967 ‘Protocol relating to the status of refugees’
Asylum seekerA person who has left their country of origin, has applied for recognition as a
refugee in another country, and is awaiting a decision on their application.
REFUGEE APPLICANTREFUGEE APPLICANT
ONSHOREONSHORE
AIR ARRIVALS*
Asylum seeker
OFFSHOREOFFSHORE
Humanitarian entrant
‘ILLEGAL’/UNAUTHORISED/IRREGULAR MARITIME ARRIVALS
United Nations High Commissioner for Refugees Antonio Guterres, 17 June 2014
“(Australia) is a very generous country hosting refugees. It has the most successful resettlement program I can imagine and the community integration is excellent. The combination of civil society, local authorities and central government in that is excellent,”
“The problem is when we discuss boats and there, of course, we enter
into a very, very, very dramatic thing. I think it is a kind of collective sociological and psychological question. They receive, I think, 180,000 migrants in a year. If you come to Australia in a different way, it’s fine but if they come in a boat it is like something strange happens to their minds.”
Arrival dates – policy (boat arrivals)• Before August 2012
• Work rights• Retrospective application temporary visas
• 13 August 2012• Path – held detention -> Community Detention or Bridging Visa
• 2013 Temporary Visas• Subject to offshore processing (Manus Island, Nauru)• No work rights (now changing)• No family sponsorship
• 19 July 2013• Offshore processing, no resettlement• Prolonged held detention• If stayed in Australia – included in legacy
caseload
Legislation changes December 2014• Removing references to Refugee Convention in Migration Act• Extending powers to detain & transfer people at sea• New ‘fast track processing’, restricting/excluding rights of review,
new ‘Immigration Assessment Authority’ process• Clarifying children born in Australia to non-citizen parents have same
immigration status as their parents• Allowing cap on the number of protection visas• Reintroducing TPVs (with work rights)
• 3 year TPVs • 5 year Safe Haven Enterprise
• Increased offshore intake (18,750 by 2018-19)• Babies born < 4/12/14 (Nauru) - stay
28 Feb 2015
The average period of time for people held in detention facilities has slightly
increased from last month to 442 days as at 31 January 2015 (Feb 408 days)
Practically speaking - AS• Releases held detention
• 1182 people Dec – Feb• Mostly onto BVE (12m)• Processing due to start mid year
• Rapid assessment process – ‘one shot’• Likely to take 3 years• Limited legal access
• TPV• SHEV 5 yrs – regional or TPV – 3 yrs
• All AS Medicare expired 31/12/14• Ambulance access uncertain
Key numbers (Feb 2015) Vic
• Offshore – 1746 some• Held – 1994 240• BVE – 26,586 ~9600• CD – 2995 1189• TPV – ltd THC, no new TPV yet ?• Offshore – 13,750 annual 4000• Non IMA– 8000 2012/13 1800 ASRC
http://www.immi.gov.au/About/Pages/detention/about-immigration-detention.aspx
Born in Australia to refugee parents
Access to health care
Assessment & care by GP +/- Refugee Health Nurse
Funded by IHMS Not Medicare eligible
Screening completed varies
Hospitals
+/- Triage +/- Assessment & care by GP
+/- Refugee Health Nurse
Medicare Eligible(50-100% expired)
All Medicare services(inc. CHC & hospitals)
Medications: through IHMS letter and selected
pharmacies(or ?hospitals)
Medications: Medicare – PBS but not HCC
ASAS – HCC rate/OTC full(selected pharmacies)
CAS – funded (case by case)(or ?hospitals)
+/- Assessment & care by GP +/- Refugee Health Nurse
Medicare EligibleAll Medicare services(inc. CHC & hospitals)
Medications: Medicare
HCC
Community detention Bridging Visa Offshore
Am I seeing this group? In theory…
In practice…
Asylum seeker identification
Resources
Housing providedFixed location
60% Special BenefitContracted case Mx (welfare agencies)DIBP case manager
No legal supportCode conduct
Housing not providedCrowded/?homeless
89% Newstart6 weeks case work
3 agenciesComplex – ASASNo legal support
Code conduct
No work rightsNo education past 18
Some releases pending
Most – no work rights, now starting
No education past 18?Temporary visa
Support to find housingCase manager 6 -12 months
Centrelink – full access
Work rights Full access education
Community detention Bridging Visa Offshore/status granted
http://refugeehealthnetwork.org.au/wp-content/uploads/Red-Cross-SRSS-overview1.pdf
Clinical red flags
Prolonged cough, fever, night sweats, LOW/poor growth, other depending on site
Vit D deficiencyVit D deficiency
GIT SxGIT Sx
Fever recent arrivalFever recent arrival
Mental health concerns
Mental health concerns
TB (active vs latent)TB (active vs latent)
Depression, anxiety, self-harm, suicidality, pain/somatisation, sleep issues, full range
Malaria endemic areaTyphoid, Ebola!
Bacterial/Parasite infections, Helicobacter pylori, sickle crisis
Bone pain, muscle pain all agesRickets, low Ca seizures children
Child protection issues
Child protection issues
Behavioural disturbance, irritability, overt concerns, sexualised behaviour
• (Ask for any detention health paperwork)• 3 sets immunisations (~4 needles in each)• Screening blood tests (guidelines available)• CXR• Faecal specimen• Mantoux test (children)• Have they had any counseling
• Check results (i.e. 2 visits)• Treatment of problems
Has my patient had a refugee health check?
Critical challenges – mental health
Refugee experience Trauma, tortureForced migration
Mental health consequencesPTSD
Depression – self harm – suicidalityAnxiety
GriefOther
Asylum experienceUncertainty
De-personalisationDependency
Loss family function/parentingIrritability – tension – conflict
Vicarious trauma
Take home messages• Large numbers• Access to health care varies depending on pathway• There may be asylum seekers in your waiting room
• You might be seeing this group of people
• Consider the challenges – as medical providers• Detention - local, offshore
• Consider the challenges – for these people• Policy – profound uncertainty• Poverty• Mental health• Service access• Be aware of people in held detention
Practical points• Ask!• Become informed, inform others• Let your front of house staff know• Document AS status – IT systems• Work with interpreters• Refugee fellows available for Dept training• Support colleagues working within system• Refer social (and legal) aspects to someone with time• Use the primary care services (Refugee Nurses, GPs, CHC)• Refugee fellows/clinicians can support
Resources• Fellows: http://refugeehealthnetwork.org.au/engage/refugee-health-fellows-
2014/ • Refugee health network http://refugeehealthnetwork.org.au/engage/ • RCH http://www.rch.org.au/immigranthealth/clinical/Clinical_resources/