1. Refugee and asylum seeker health Georgie Paxton Immigrant Health Service March 2015

2. Outline Policy context Access to health care Practical issues

3. Refugee Someone 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 seeker A 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.

4. REFUGEE APPLICANT ONSHORE AIR ARRIVALS* Asylum seeker OFFSHORE Humanitarian entrant ‘ILLEGAL’/UNAUTHORISED/IRREG ULAR MARITIME ARRIVALS

5. 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.”

6. 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

7. 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

8. 28 Feb 2015

9. 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)

10. 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

11. Key numbers (Feb 2015)Vic Offshore – 1746some Held – 1994240 BVE – 26,586~9600 CD – 29951189 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

12. Born in Australia to refugee parents

13. 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 Eligible All Medicare services (inc. CHC & hospitals) Medications: Medicare HCC Community detentionBridging Visa Offshore

14. Am I seeing this group? In theory…

15. In practice…

16. Asylum seeker identification

17. Resources Housing provided Fixed location 60% Special Benefit Contracted case Mx (welfare agencies) DIBP case manager No legal support Code conduct Housing not provided Crowded/?homeless 89% Newstart 6 weeks case work 3 agencies Complex – ASAS No legal support Code conduct No work rights No education past 18 Some releases pending Most – no work rights, now starting No education past 18 ?Temporary visa Support to find housing Case manager 6 -12 months Centrelink – full access Work rights Full access education Community detention Bridging Visa Offshore/status granted

18. http://refugeehealthnetwork.org.au/wp-content/uploads/Red-Cross-SRSS-overview1.pdf

19. Clinical red flags Prolonged cough, fever, night sweats, LOW/poor growth, other depending on site Vit D deficiency GIT Sx Fever recent arrival Mental health concerns TB (active vs latent) Depression, anxiety, self-harm, suicidality, pain/somatisation, sleep issues, full range Malaria endemic area Typhoid, Ebola! Bacterial/Parasite infections, Helicobacter pylori, sickle crisis Bone pain, muscle pain all ages Rickets, low Ca seizures children Child protection issues Behavioural disturbance, irritability, overt concerns, sexualised behaviour

21. (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?

22. Critical challenges – mental health

23. Refugee experience Trauma, torture Forced migration Mental health consequences PTSD Depression – self harm – suicidality Anxiety Grief Other Asylum experience Uncertainty De-personalisation Dependency Loss family function/parenting Irritability – tension – conflict Vicarious trauma

24. 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

25. 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

26. Resources Fellows: http://refugeehealthnetwork.org.au/engage/refugee-health-fellows- 2014/http://refugeehealthnetwork.org.au/engage/refugee-health-fellows- 2014/ Refugee health network http://refugeehealthnetwork.org.au/engage/http://refugeehealthnetwork.org.au/engage/ RCH http://www.rch.org.au/immigranthealth/clinical/Clinical_resources/http://www.rch.org.au/immigranthealth/clinical/Clinical_resources/