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Asylum seekers and healthcare

The medical profession can assist by reinforcing the principle of healthcare as a right, and opposing policies that contribute to poor health

MJA 2001; 175: 587-589

Other people may come to Australia to be given temporary safe haven, as occurred for the first time in 1999, when 4000 ethnic Albanians from Kosovo were flown in, closely followed by 1800 people evacuated from East Timor. Health professionals from around the country were mobilised to care for these people.²

Another group, termed asylum seekers, are people who are outside their country of nationality or their usual country of residence, and apply to the government of the country they are in for recognition as a refugee (and for permission to stay when so recognised). Their application for refugee status is based on fear of persecution in their own country (for reasons of race, religion, nationality, membership of a particular social group, or political opinion).^1,3

In Australia, asylum seekers form two distinct groups:

• those who arrive in an authorised manner (eg, with visitor's or student visas), and who are generally allowed to remain in the community while their applications are processed; and
• those who arrive in an unauthorised manner by plane or boat. People arriving without authority are confined in detention centres until they are granted a visa to remain in Australia, or they leave the country, voluntarily or otherwise.

In the past, if their application for refugee status was successful, asylum seekers were eligible to receive permanent protection visas. These visas provided permanent residence and immediate access to the comprehensive settlement support arrangements available to refugees resettled from overseas.⁴

However, since October 1999, asylum seekers arriving without authority have only been able to receive a temporary protection visa. If their application for refugee status is successful, they are released from the detention centre, and their three-year temporary visa gives them access to Medicare, but no entitlement to many settlement services, including English language classes. In addition, no family members are allowed to join them here.⁴ There are currently over 3700 people nationally holding temporary protection visas of this type.⁵ Holders of temporary protection visas have previously been able to apply for a permanent protection visa after 30 months, but as of September 2001 this is no longer possible.⁶ Unauthorised arrivals will now only have access to recurrent temporary visas.

Worldwide, there are around 22.3 million "people of concern" to the United Nations High Commission for Refugees.⁷ This figure includes 1.2 million asylum seekers. Australia receives comparatively few applications for asylum. While, in 1999-2000, Australia received about 12 700 applications, in 1999 Germany received 95 000 and the United Kingdom 71 000.^7,8 The origins of people seeking asylum in Australia are diverse. The five major countries of origin for "onshore" applicants for refugee status in 1999-2000 were Iraq (18.5%), Afghanistan (14.0%), the People's Republic of China (6.8%), the Philippines (6.4%), and India (5.3%).⁸

There appears to be a growing trend for recipient Western countries to adopt policies aimed at deterring would-be asylum seekers, policies that make it "as difficult and unpleasant as possible to remain in these countries if one is an asylum seeker".⁹ Measures include offering minimal assistance, increased use of detention, temporary protection as an alternative to refugee status, and limited entitlements for those awarded this time-limited protection.^9-11

The asylum-seeking process in Australia^1,3

• Asylum seekers, both those in detention and those in the community, make claims for refugee status by lodging an application for a protection visa with the Department of Immigration and Multicultural Affairs (DIMA). The application is dealt with by a DIMA officer, who interviews the applicant and decides whether he or she engages Australia's obligations under the UN Convention relating to the Status of Refugees.

• When an application is refused, the applicant can seek a merits review of the decision from the Refugee Review Tribunal. This Tribunal examines the claim against the UN Convention definition, and must give the applicant the opportunity of a personal hearing.

• If the Tribunal rejects the review application, the Minister for Immigration has the power to intervene, if the Minister believes it is in the public interest to do so.

• People refused a visa by the Tribunal may appeal to the Federal Court for judicial review on the grounds of error at law, but not on the merits of the case. Recent Australian legislation⁶ aims to further limit the grounds on which an adverse decision can be successfully challenged in the courts.

The health of asylum seekers
In this issue of the Journal, four articles deal with the mental and physical health of asylum seekers. Harris and Telfer¹² focus on asylum seekers living in the Australian community, while the articles of Sultan and O'Sullivan,¹³ Steel and Silove,¹⁴ and King and Vodicka¹⁵ concern asylum seekers in detention centres.

Asylum seekers in the community
The Migration Regulations currently state that people who apply for asylum within 45 days of lawful arrival in the country receive a bridging visa, which offers them work rights and, as potential tax payers, access to Medicare.¹⁶ Anyone applying after the 45-day time period is denied permission to work and cannot access Medicare. They may have no income support and few means to pay for medical care, dental care or medications. Fear, isolation, unfamiliarity with the health system and poor English language skills may also contribute to their disadvantage in terms of healthcare access.^17,18

Restricted access to health services may impact not just on the individual but on public health as well. People applying for refugee status are not required to undergo a health check until other criteria for a protection visa are met.³ This means that, particularly for those who are initially rejected and then appeal, many months or years may be spent in the community without having had a chest x-ray or other health screening. For example, the average processing time for the Refugee Review Tribunal was over nine months in 1998-99 (and thus considerably longer in many cases).¹⁹

Asylum seekers in detention
Currently, there are six facilities in Australia used for immigration detention purposes. Box 1 shows where they are located and the number of people detained at September 18, 2001. Not all those detained are asylum seekers, as by law all non-Australians unlawfully in Australia must be detained.¹ However, asylum seekers whose applications are initially rejected and are going through the lengthy appeal process are likely to constitute a large proportion of the long-term detainees. As of October 2001, of just under 3000 people in detention, 80% were either in the process of applying for asylum, or had done so and had had their applications rejected (Department of Immigration and Multicultural Affairs, Detention Operations Branch, personal communication).

Healthcare in detention centres is the responsibility of the private company contracted to manage the centres, Australasian Correctional Management. The company employs nurses to work in all detention centres, and contracts general practitioners to work varying numbers of sessions, depending on the size of the centre. The larger centres also employ psychologists.

Clearly, for health professionals, this may be a difficult environment in which to work, with a potentially demanding caseload. Moreover, concerns have been raised that medical staff in detention centres are not necessarily experienced or trained in working with survivors of refugee trauma and torture.²⁰

What the medical profession can do
There are many ways in which doctors can assist asylum seekers. One practical way is to register as willing to accept payment for service provision through the Asylum Seekers Assistance Scheme.²¹ Advocacy on behalf of these patients for access to medical and dental services is vital.

Advocacy on a broader level for marginalised groups is a well recognised and legitimate role for health professionals.¹⁷ This includes reinforcing the principle of healthcare as a right, and opposing policies that contribute to poor health. Advocacy via professional bodies is important, with the recent representation by the federal Australian Medical Association to the Minister for Immigration and Multicultural Affairs being a good example (Box 2).

Health professionals can become better informed and more involved by joining organisations such as Amnesty International, Médecins Sans Frontières and the Medical Association for Prevention of War (Box 3).

Mitchell M Smith
Director, NSW Refugee Health Service, Sydney, NSW
(This unit was formed in 1999 and is funded by the NSW Health Department)

1. Refugee and humanitarian issues: Australia's response. Canberra: Department of Immigration and Multicultural Affairs, 2001.
2. Carrello C, Carr PH, Coleman JA, et al. Operation Safe Haven: the Leeuwin experience. Med J Aust 2000; 172: 502-505.
3. Department of Immigration and Multicultural Affairs. Seeking asylum within Australia. Fact Sheet No. 41. Canberra, DIMA 2000. Available at: http://www.immi.gov.au/facts/61asylum.htm (accessed November 2001).
4. Department of Immigration and Multicultural Affairs. Temporary protection visas. Fact Sheet No. 63. Canberra, DIMA 2000. Available at: http://www.immi.gov.au/facts/64protection.htm (accessed November 2001).
5. Multicultural update newsletter. Issue No. 7, Sep 2001. Sydney: Centrelink Multicultural Services, 2001.
6. Department of Immigration and Multicultural Affairs. New measures to strengthen border control. Fact Sheet No. 90. Canberra, DIMA 2001. Available at: http://www.immi.gov.au/facts/90border-1.htm (accessed November 2001, no longer available).
7. United Nations High Commissioner for Refugees. Refugees by numbers. 2000 edition. Geneva, UNHCR 2001. Available at: http://www.unhcr.ch/un&ref/numbers/numb2000.pdf (accessed November 2001 - no longer available).
8. Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed November 2001).
9. Schuster L. A comparative analysis of the asylum policy of seven European governments. J Refugee Stud 2000; 13: 118-132.
10. Hassan L. Deterrence measures and the preservation of asylum in the United Kingdom and United States. J Refugee Stud 2000; 13: 184-204.
11. Department of Immigration and Multicultural Affairs. Unauthorised arrivals and detention. Information Paper. Canberra: DIMA, 2001. Available at: http://www.immi.gov.au/illegals/uad/uad_paper.pdf (accessed November 2001).
12. Harris MF, Telfer B. The health needs of asylum seekers living in the community. Med J Aust 2001; 175: 589-592.
13. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long-term detention: a participant-observer account. Med J Aust 2001; 175: 593-596.
14. Steel Z, Silove DM. The mental health implications of detaining asylum seekers. Med J Aust 2001; 175: 596-599.
15. King K, Vodicka P. Screening for conditions of public-health importance in people arriving by boat without authority. Med J Aust 2001; 175: 600-602.
16. Department of Immigration and Multicultural Affairs. Assistance for asylum seekers within Australia. Fact Sheet No. 42. Canberra, DIMA 2001. Available at: http://www.immi.gov.au/facts/42assist.htm (accessed November 2001).
17. Silove D, Steel Z, Watters C. Policies of deterrence and the mental health of asylum seekers. JAMA 2000; 284: 604-610.
18. Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ 2001; 322: 544-547.
19. Refugee Review Tribunal. Frequently asked questions. Available at: http://www.rrt.gov.au/faq.html (accessed November 2001).
20. Human Rights and Equal Opportunity Commission. Those who've come across the seas: detention of unauthorised arrivals. Canberra: HREOC, 1998. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/h5_2_2.pdf (accessed November 2001).
21. Australian Red Cross. Asylum Seeker Assistance Scheme. http://www. redcross.org.au/whatWeDo/asas.html (accessed November 2001).

©MJA 2001
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