1. Refugees and Asylum Seekers in Australia
This presentation outlines background demographics and information about refugee and asylum seeker health.
Refugee Health Fellow Program
Nov 2015 – do not use after June 2016

2. Legal status Refugee: Asylum seeker:
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.”.
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.
It is helpful to start with a definition for who a ‘refugee’ or ‘asylum seeker’ is and to know the difference
A refugee is someone who:
Has a well founded fear of being persecuted (according to grounds stated)
Are outside of their country of nationality
Are unwilling/unable to return
An asylum seeker:
A person who is seeking protection and is still waiting to have his/her claim assessed
Australia has international obligations to protect the human rights of all asylum seekers and refugees regardless of how and where they arrive, or whether they arrive with/without a visa.
See for more specific details on obligations under various international treaties.
UNHCR 1951 ‘Convention Relating to the Status of Refugees’ and 1967 ‘Protocol relating to the status of refugees’

3. UNHCR Global Trends 2014 59.5 M forcibly displaced (incr 8.3M)
19.5 M Refugees
38.2M Internally Displaced
1.8M Asylum Seekers
34,300 Unaccompanied Children
10M stateless
2013 Just surpassed > 50M with war in Syria, first time in the post-World War II era, exceeded 50 million people
2014 increased 8.3M and number of unaccompanied children – largest jumps in a year ever

4. UNHCR numbers – end 2014 Origin Destination 86% developing world
<1% resettled

5. Australia ranks 50th for number of refugees hosted
67nd for refugees as a share of the population
70th in ranking for refugees proportional to GDP
UNHCR 2014
See interactive version:

6. “Humanitarian Entrant”
REFUGEE APPLICANT
OFF SHORE
ON SHORE
“Asylum seeker”
Offshore applicants who are recognised as refugees arrive in Australia with a Humanitarian Visa (200)
On-shore applicants are asylum seekers – and arrive by boat or plane.
At various times, the boat arrivals have been referred to as “Unauthorised” “Illegal” “Irregular Maritime Arrivals” by DIBP. This language is depersonalises children and families.
Fleeing persecution is not a crime. Seeking asylum is a human right. It is not illegal to seek asylum without a visa. Around 80 percent of asylum seekers who come to Australia by boat are found to be refugees
“Humanitarian Entrant”
AIR ARRIVALS*
UNAUTHORISED/ILLEGAL/
IRREGULAR MARITIME ARRIVALS

7. Australian Humanitarian Intake
Humanitarian Programme grants by category 2008–09 to 2012–13
Category
2008–09
2009–10
2010–11
2011–12
2012–13
Refugee
64992
6003
5998
6004
12 012
Special Humanitarian (offshore)
4511
3233
2973
714
503
Onshore1
2492
4534
4828
7041
7504
Temporary Humanitarian Concern 5 -
Total3
13 507
13 770
13 799
13 759
20 019
These numbers represent Australia’s intake – annual intake (refugee category) set to increase to 18,750 in next four years.
1 Includes protection visas and onshore humanitarian visa grants that are countable under the Humanitarian Programme. 2 This figure included a one-off allocation of 500 refugee places for Iraqis. 3 Data in this table is reported as at the end of each programme year.
DIBP Fact sheet 60

8. 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
No family sponsorship
19 July 2013
Offshore processing, no resettlement
Prolonged held detention
If stayed in Australia – included in legacy
caseload
These are the key dates in legislation affecting asylum seekers arriving by boat.
Note the change in path to held detention, community detention or bridging visa sine 2012 and path to offshore processing and no resettlement in Australia since The changes in 19 July 2013 resulted in prolonged periods of held detention.

9. Numbers (30th September)

10. Pre-departure health screen (offshore)
DHC - Humanitarian
(Voluntary – 3 d prior to travel)
Exam, parasite check
RDT and Rx if positive
CXR and HIV if PHx TB
Albendazole
MMR 9m – 54y
+/- YF vaccine
+/- OPV
Ax local conditions
+/- Repeat visa medical
Visa health assessment - all
(Compulsory, 3–12 m prior to travel)
Hx/Exam
CXR ≥ 11 yrs
HIV ≥ 15 yrs
VDRL
FWTU ≥ 5 yrs
Character requirement
AUSCO
Outcomes
+/- Visa
Alert (Red. General)
HU +/- delay travel
Outcomes
Fitness to fly assessment
Alert (Red, General)
+/- HU
Children, particularly younger children, receive very little pre-departure screening.
VHA for all and extra DHC for Humanitarian, and also that kids get very little screening (animated red circles)
YF details - All people > 1 yr old who have stayed 1 night+ in YF country within 6 days of flight to australia need YF certificate
OPV – All people departing from Pakistan, Cameroon and Syria will need to have a full course of polio vaccinations certified before they can leave the country.  OPV added in 10 countries - Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel, Kenya, Nigeria, Pakistan, Somalia and Syria
The Australian Cultural Orientation (AUSCO) program is provided to refugee and humanitarian visa holders over the age of five who are preparing to settle in Australia. The program provides practical advice and the opportunity to ask questions about travel to and life in Australia. It is delivered over five days before the visa holders begin their journey to ensure that all topics are covered in sufficient detail.
Australia
Post arrival health screening Voluntary

11. Onshore refugee health assessment
There is a refugee health assessment guide available for each state:

12. Suggested screening tests
Baseline
Consider
FBE
Ferritin
Vit D, Ca, PO4, ALP
Malaria (endemic)
HB sAg, sAb, cAb
HCV
Schistosoma
Strongyloides
Syphilis EIA
STI screening (sexually active)
HIV
QFT-IT (13 and older) TST (< 13 yrs)
Faecal specimen
PTH (kids; rickets, low Ca intake)
B12/folate (food restriction, COB)
Vit A (food restriction)
Pb (development, pica, exposure)
H pylori (Sx)
These are the recommended screening tests in children. More details can be found here:

13. Prevalence (Australian data)
Anaemia Iron deficiency Low Vitamin D Low Vitamin A Hepatitis B Hepatitis C HIV Schistosoma Strongyloides Malaria Faecal parasites Mantoux test + STI screen, inc syphilis Helicobacter pylori Inadequate immunisation
10 – 20% all groups, 23 – 39% < 5 years 11 – 34% all groups % African, % Karen 40% African sAg 2 – 21%, sAb 26 – 60% 1% <1% 7 – 24% African and South Asian 2 – 21%, higher South Asian 4 – 10% African, (still get cases) 14 – 42% all groups 20 – 55% Ltd data 82% African 100%
These numbers reflect compiled prevalence data in Australian cohorts of patients, with regards to the conditions screened for.
These conditions are common and prevalence varies according to country of origin.
The prevalence of these conditions emphasizes the need for appropriate screening in refugee and asylum seeker background children

14. Mental health - consider
Country of origin situation
Migration journey
Detention experience/uncertainty
Torture/trauma
Sexual violence
Family separation/loss
Depression
Anxiety
PTSD
Self harm/suicidal ideation
Adjustment/grief/other
Developmental/behavioural impact (children)
Mental health is a significant issue and needs to be considered in all refugee background children.
Note that the mental health concerns may arise from various causes, including the detention experience as well as country of origin situation.
Children should be screened for mental health concerns at their appointments.

15. Violence & persecution Social & Psychological Effects
Core Components of Trauma Reaction
Recovery Goals
Killings, assaults
Life threats, threats of harm to family, friends
‘Disappearances’
Chronic fear & alarm
Disruption of connections to family, friends, community, & cultural beliefs
Destruction of central values of human existence
Humiliation
&
Degradation
Anxiety
Feelings of
helplessness
Loss of control
Relationships changed
Grief
Depression
Shattering of previously held assumptions:
Loss of trust
Meaning, identity & future
Guilt
Shame
Restore safety
Enhance control
Reduce the disabling effects of fear & anxiety
Restore attachment & connections to others who can
offer emotional support & care
Restore meaning & purpose to life
Restore dignity & value
Reduce excessive shame & guilt
Death
Separation
Isolation, dislocation
Prohibition of traditional practices
Deprivation of human rights
Killing on mass scale
Boundless human brutality on mass scale
An overview of the trauma pathway from violence and persecution to recovery goal.
Invasion of personal boundaries
No right to privacy
Impossible choices
Insults

16. Full plan: http://www.health.vic.gov.au/diversity/refugee.htm

17. A useful screening tool “ASK” when meeting with refugee families

18. For more information: Refugee Fellow Program Contacts:
RCH Immigrant Health:
Foundation House (VFST):
DIBP Fact Sheets: