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

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 https://www.humanrights.gov.au/asylum-seekers-and-refugees-guide 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’

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

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

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: http://public.tableausoftware.com/profile/iting#!/vizhome/shared/3WDBWY5P9

“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

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 http://www.border.gov.au/about/corporate/fact-sheets/60refugee

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 2013. The changes in 19 July 2013 resulted in prolonged periods of held detention.

Numbers (30th September) http://www.border.gov.au/ReportsandPublications/Documents/statistics/immigration-detention-statistics-31-July-2015.pdf

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

Onshore refugee health assessment There is a refugee health assessment guide available for each state: http://refugeehealthnetwork.org.au/desktop-guide-victoria/

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: http://www.rch.org.au/immigranthealth/clinical/Initial_assessment/

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 60 - 90% African, 33 - 37% 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

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.

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

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

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

For more information: Refugee Fellow Program Contacts: http://refugeehealthnetwork.org.au/wp-content/uploads/Vic-Refugee-Health-Fellows-2015.pdf RCH Immigrant Health: http://www.rch.org.au/immigranthealth/ Foundation House (VFST): http://www.foundationhouse.org.au/ DIBP Fact Sheets: http://www.border.gov.au/about/corporate/information/fact-sheets