Transcript Refugee Health

Refugee and asylum seeker health
Georgie Paxton
Immigrant Health Service
March 2015
Outline
• Policy context
• Access to health care
• Practical issues
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.
REFUGEE APPLICANT
OFFSHORE
ONSHORE
Humanitarian entrant
Asylum seeker
AIR ARRIVALS*
‘ILLEGAL’/UNAUTHORISED/IRREG
ULAR MARITIME ARRIVALS
“(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.”
United Nations High Commissioner for Refugees Antonio Guterres, 17 June 2014
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
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some
240
~9600
1189
?
4000
1800 ASRC
Offshore – 1746
Held – 1994
BVE – 26,586
CD – 2995
TPV – ltd THC, no new TPV yet
Offshore – 13,750 annual
Non IMA– 8000 2012/13
http://www.immi.gov.au/About/Pages/detention/about-immigration-detention.aspx
Asylum
seekers
(non IMAs)
AS in
review
process
Asylum seekers in
community
Asylum seekers
in community
detention
(IMA - Bridging visas)
Offshore
arrivals
Refugee
background
Detention
centres
Born in Australia to refugee parents
Access to health care
Community detention
Bridging Visa
Offshore
Assessment & care by GP
+/- Refugee Health Nurse
+/- Triage
+/- Assessment & care by GP
+/- Refugee Health Nurse
+/- Assessment & care by GP
+/- Refugee Health Nurse
Funded by IHMS
Not Medicare eligible
Screening completed varies
Hospitals
Medications: through IHMS
letter and selected
pharmacies
(or ?hospitals)
Medicare Eligible
(50-100% expired)
All Medicare services
(inc. CHC & hospitals)
Medicare Eligible
All Medicare services
(inc. CHC & hospitals)
Medications:
Medicare – PBS but not HCC
ASAS – HCC rate/OTC full
(selected pharmacies)
CAS – funded (case by case)
(or ?hospitals)
Medications:
Medicare
HCC
Am I seeing this group? In theory…
In practice…
Asylum seeker
identification
Resources
Community detention
Bridging Visa
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
Offshore/status granted
Support to find housing
Case manager 6 -12 months
Centrelink – full access
Work rights
Full access education
http://refugeehealthnetwork.org.au/wp-content/uploads/Red-Cross-SRSS-overview1.pdf
Clinical red flags
Mental health
concerns
Depression, anxiety, self-harm, suicidality,
pain/somatisation, sleep issues, full range
TB (active vs latent)
Prolonged cough, fever, night sweats,
LOW/poor growth, other depending on site
Fever recent arrival
Malaria endemic area
Typhoid, Ebola!
GIT Sx
Bacterial/Parasite infections, Helicobacter pylori,
sickle crisis
Vit D deficiency
Bone pain, muscle pain all ages
Rickets, low Ca seizures children
Child protection
issues
Behavioural disturbance, irritability, overt
concerns, sexualised behaviour
Has my patient had a refugee health check?
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(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
Critical challenges – mental health
Refugee experience
Trauma, torture
Forced migration
Asylum experience
Uncertainty
De-personalisation
Dependency
Loss family function/parenting
Irritability – tension – conflict
Vicarious trauma
Offshore
Held
CD
BVE
Mental health consequences
PTSD
Depression – self harm – suicidality
Anxiety
Grief
Other
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
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Policy – profound uncertainty
Poverty
Mental health
Service access
Be aware of people in held detention
Practical points
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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-fellows2014/
• Refugee health network http://refugeehealthnetwork.org.au/engage/
• RCH http://www.rch.org.au/immigranthealth/clinical/Clinical_resources/