Refugee and asylum seeker health Refugee Health Fellow Program March 2018 – do not use after June 2018
Legal status 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. ” . 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. UNHCR 1951 ‘ Convention Relating to the Status of Refugees ’ and 1967 ‘ Protocol relating to the status of refugees ’
UNHCR Global Trends 2016 • 65.6 M forcibly displaced • 22.5M Refugees • 40.3M Internally Displaced • 2.8M Asylum Seekers • 75,000 Unaccompanied Children • 10M stateless • 51% of refugees are children <18yo
UNHCR numbers - 2016 UNHCR Global Trends Forced Displacement in 2016, UNHCR, Geneva. 2017. www.unhcr.org/5943e8a34.pdf
UNHCR pathways – end 2015 • Destination • 84% developing world • <1% resettled
REFUGEE APPLICANT ONSHORE OFFSHORE ORPHAN RELATIVE ONSHORE 837 OFFSHORE 117 HUMANITARIAN ENTRANT ASYLUM SEEKER ‘ILLEGAL’/UNAUTHORISED/IRREG AIR ARRIVALS* ULAR MARITIME ARRIVALS
Australian and Victorian numbers Category Australia Victoria Offshore intake 13,750 in 2015-16 ~ 4000/year 18,750 by 2018-19 ~ 6000/year Syrian/Iraqi 12,000 (across 2016 -2017) ~ 40% AS, boat, BVE 19,129 (1/2018) 6882 ( 1/2018 ) 11,237 finalised grants (1/2018) 3599 finalised grants (1/2018) Held detention 1287 (1/2018) 167 (1/2018) Community 447 (1/2018) 164 (1/2018) detention
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, Nauru) – processing halted (until 4/15) • No work rights • No family sponsorship • 19 July 2013 • Offshore processing, no resettlement • Prolonged held detention – detention releases stopped (until end 2014/early 2015) • If stayed in Australia – included in legacy caseload • 15 December 2014 • Migration Act amended – legacy caseload By December 2017 – 9396 finalised of ~24,684 fast track
Asylum seekers and detention
Pre-departure health screen (o (offshore) Immigration Medical Exam - all (Compulsory, 3 – 12 m prior to travel) DHC - Humanitarian Hx/Exam (Voluntary – 3 d prior to travel) TB screen 2-10y Exam, parasite check CXR ≥ 11y Malaria RDT and Rx if positive (location) HIV ≥ 15y CXR and HIV if PHx TB FWTU ≥ 5 yrs Albendazole ≥ 1 y HBsAg (preg/URM/HCW) MMR 9m – 54y HCV (HCW) +/- YF vaccine Syphilis (Humanitarian) ly) Character +/- Polio vaccine requirement Ax local conditions +/- Repeat IME AUSCO Outcomes +/- Visa Outcomes Alert (Red. General) Fitness to fly assessment Health Undertaking +/- delay travel Alert (Red, General) +/- Health Undertaking Australia Post arrival health screening Voluntary
Pre-departure health screen (o (offshore) Immigration Medical Exam - all (Compulsory, 3 – 12 m prior to travel) DHC - Humanitarian Hx/Exam (Voluntary – 3 d prior to travel) Syrian cohorts TB screen 2-10y Exam, parasite check Combined IME and DHC CXR ≥ 11y Malaria RDT and Rx if positive (location) Hx/Exam HIV ≥ 15y CXR and HIV if PHx TB TB screen 2-10 y FWTU ≥ 5 yrs Albendazole ≥ 1 y CXR ≥ 11 y HBsAg (preg/URM/HCW) MMR 9m – 54y HIV ≥ 15 y HCV (HCW) +/- YF vaccine HBsAg Syphilis (Humanitarian) ly) Character +/- Polio vaccine FWTU ≥ 5 y requirement Ax local conditions Albendazole Full 1 st dose catch-up immunisations +/- Repeat IME AUSCO Mental health screen Development screen (<5 y) Outcomes +/- Visa Outcomes Alert (Red. General) Fitness to fly assessment Health Undertaking +/- delay travel Alert (Red, General) +/- Health Undertaking Australia Post arrival health screening Voluntary
Chaves NJ, Paxton G, Biggs BA, Thambiran A, Smith M, Williams J, Gardiner J, Davis JS; on behalf of the Australasian Society for Infectious Diseases and Refugee Health Network of Australia Guidelines writing group. Recommendations for comprehensive post- arrival health assessment for people from refugee-like backgrounds.
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)
Social & Core Components Violence & Psychological of Trauma Recovery Goals persecution Effects Reaction Restore safety Killings, assaults Anxiety Life threats, threats Enhance control Chronic fear & alarm Feelings of of harm to family, Reduce the helplessness friends disabling effects of Loss of control ‘Disappearances’ fear & anxiety Restore Death Disruption of Relationships attachment & Separation connections to changed connections to Isolation, family, friends, others who can Grief dislocation community, & offer emotional Prohibition of Depression cultural beliefs support & care traditional practices Deprivation of Shattering of human rights previously held Destruction of Killing on mass scale assumptions: Restore meaning & central values of Loss of trust purpose to life Boundless human human existence Meaning, identity brutality on mass & future scale Invasion of personal Restore dignity & boundaries Humiliation Guilt value No right to privacy & Reduce excessive Shame Impossible choices Degradation shame & guilt Insults
Access to health care Offshore TPV or SHEV Asylum seeker boat Community detention Post claim (negative Permanent Residency Temporary Residency arrival on BVE, or (now mostly offshore decision) or FDBVE plane arrivals on BVE medical transfers) Allocated GP GP access varies Most linked with GP Usually no RHN Referred to GP on Most linked with GP No RHN Usually no RHN arrival No RHN Not Medicare eligible +/- RHN May have Medicare, All services (inc. Medicare eligible Medicare eligible may be short duration (~10% expired now) community health and Medicare eligible All services (inc May rely on AS All services (inc. hospitals) All services (inc. community health & primary care services GP, meds, specialists community health and community health & hospitals) Hospitals – access if hospitals) and hospitals funded hospitals) FASSTT appealing decision by IHMS FASSTT FASSTT No NDIS eligibility No FASSTT No NDIS eligibility FASSTT NDIS eligible NDIS – EI likely No NDIS eligibility NDIS – EI likely No NDIS eligibility NDIS – EI unclear NDIS – EI likely Medications: through Medications: Medications: IHMS letter and Medications: Medications: Medicare – PBS rate Medicare – PBS cost, Medicare – HCC rate Medicare – HCC rate selected pharmacies HCC rate if SRSS(?) otherwise full price (or hospitals)
Community supports Offshore TPV or SHEV Asylum seeker boat Community detention Post claim (negative Permanent Residency Temporary Residency arrival on BVE, plane (now mostly offshore decision) or FDBVE arrivals on BVE medical transfers) No housing support Housing support No housing support Housing and utilities No housing support Case Mx up to 18m Band 5 complex case No caseworker provided Can have case Mx if No income support (AMES) Mx, DHA case Mx Fixed location complex (AMES) (loss SRSS) Tier system Band 6 – min case Mx, Contracted case Mx Employment support 1=min no DHA case Mx No funded legal DHA case Mx 2=?most SRSS stopping No funded legal Centrelink – access, 3=complex No funded legal No Centrelink inc family/childcare Urgent Victorian 60% Special Benefit and HCC/Carers support package Centrelink – full No Centrelink equiv SHEV provisions access, inc HCC/Carers 89% Newstart equiv available till 30 June No Centrelink (1.5/5 yrs welfare) 2018 Code conduct Code conduct Work rights Most work rights from Work rights Kinder 2015 (if BVE valid) Work rights Kinder No work rights School to 18y (none 2012-2014) Full access education, Kinder (2015) Kinder Tertiary – Int student Kinder School to 18y recently difficult (no Austudy or Youth School to 18y School to18y Tertiary education Allowance) Tertiary – Int student Plane arrivals often retain conditions of their substantive entry visa (e.g. tourist/student), and remain eligible for permanent protection visas
For more information: Refugee Fellow Program Contacts: • http://refugeehealthnetwork.org.au/engage/refugee-health-fellows/ RCH Immigrant Health: • http://www.rch.org.au/immigranthealth/ Foundation House (VFST): • http://www.foundationhouse.org.au/ Department of Home Affairs Fact Sheets: • http://www.homeaffairs.gov.au/about/corporate/information/fact-sheets
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