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/