Towards better health for refugee children and young people in Australia and New Zealand: The Royal Australasian College of Physicians perspective

© Royal Australasian College of Physicians, 2007 Copies of the full Discussion Paper are available from:Paediatrics & Child Health, RACP145 Macquarie StreetSydney, New South Wales 2000, AustraliaTel +61 2 9256 5444 Fax +61 2 9252 3310Email: [email protected], website: http://www.racp.edu.au/hpu/policy/index.htm Everyone has the right to seek and enjoy in other countries asylum from persecution. Article 14, Universal Declaration of Human Rights (signed by member countries in 1948, including Australia and New Zealand).1 Children and young people make up around 50% of the humanitarian refugee intake in Australia and New Zealand (over 13 000 people per year) and are arguably the most vulnerable subgroup. Of particular concern are those children and young people who are ‘unaccompanied minors’, who lack the protection and support of their families.2 The health needs of refugee children and young people have been well documented and include high rates of preventable conditions and psychosocial morbidity.3–6 Despite complex health needs, routine health care is not always offered on arrival (in Australia) and service delivery is fragmented.7,8 This is in contrast to New Zealand, where newly arrived refugees spend 6 weeks at a reception centre where comprehensive health assessment and initial care are provided. There is a considerable literature highlighting the difficulties in accessing health services by refugees in Australia and elsewhere.9–11 The health care provided to refugees varies widely and preventive activities known to be highly effective – such as immunisation and early detection of infectious disease – are not routinely provided in many settings.12–14 The demography of refugees has changed over recent decades and continues to do so, as the government targets specific groups and populations. Whereas in the 1980s and 1990s, refugees mainly originated in South-east Asia and Europe, the majority of those currently settling in Australia and New Zealand come from African countries, with a sizeable minority from Burma, Afghanistan and the Middle East. Since 2003–2004, Sudanese refugees have constituted the highest single group of refugees settling in Australia. The countries of origin (and transit) have important implications for the health needs of refugees in terms of their exposure to disease and prior access to services. Contrary to expectations, refugee children have minimal routine health screening before departure. Screening generally includes a chest X-ray in children over 11 years and HIV testing in those over 15 years. Recently, refugees bound for Australia from certain regions undergo a ‘fitness to travel’ check just before leaving, including testing for malaria, treatment for intestinal helminths and measles-mumps-rubella vaccine in those under 30 years. Notably, children are not required to be fully immunised before departure. Despite screening, the experience of children’s health services in Australia has been that many significant and treatable but occult problems are detected, including under-immunisation, latent tuberculosis, parasitic conditions, rickets and iron deficiency. Australian authors have therefore recommended routine comprehensive paediatric assessment for refugee children.15,16 The primary aim of this policy statement is to advocate for timely and high-quality health care for every refugee child and young person living in Australia and New Zealand. It complements existing College policy documents addressing equity,17 cultural competence18 and safeguarding children’s well-being.19 The target audience is primarily individual Fellows but also includes health services, policy-makers and governments responsible for providing health care in Australia and New Zealand. This policy statement was developed by drawing on the scientific literature, international guidelines and policy documents, and the expertise of local field workers. Recent publications highlight recommendations based on the experience of health care delivery to refugee families in Australia.3,8,20,21 The principles underpinning this policy statement are that Refugee and asylum seeker children have the same rights to health care as do other children in Australia and New Zealand, and might require specific services commensurate with their complex needs. Access by refugees to appropriate health assessment and care after arrival is often limited by cultural, language or financial constraints, is not offered routinely and lacks coordination.22,23 The health status of children and their families is only partly dependent on health services and is strongly affected by other factors such as family well-being, education, housing and employment. Therefore, addressing refugee health requires a coordinated whole-of-government approach with a range of agencies involved. Investing in children’s health has been shown to produce sound economic benefits, with favourable cost benefits incurred by the provision of preventive immunisation and early detection and treatment of infectious diseases in immigrants from high prevalence countries.24,25 Intensive support early after arrival appears to be highly beneficial and the resilience of refugee children can be enhanced by appropriate supports.26,27 This policy statement recommends that the following are required in order to deliver the most effective health care to refugee children and young people: (i) health service enhancement; (ii) the promotion of research and the development of an evidence base (iii) dedicated training; and (iv) professional practice. The recommendations range from interventions that involve government leadership to interventions directed at health services and professionals. The RACP believes that health services need to be enhanced in order to address the complex health needs of refugee children, young people and their families. Accordingly, the RACP recommends that the Australian and New Zealand governments* should: Develop services that consistently affirm the dignity of refugees. Develop a whole-of-government approach to best address the health and well-being of refugees settling in Australia and New Zealand. Provide publicly funded health care to all refugees, with a mixture of targeted and mainstream services. Provide high quality, accessible, culturally respectful and affordable health care for refugee families. Offer comprehensive health assessments post arrival (addressing physical and psychosocial needs) and appropriate follow-up care for every refugee who arrives in Australia or New Zealand. Develop services with appropriately trained, multidisciplinary team members, multicultural health workers, refugee workers and readily available professional interpreters. Abolish the differential access to health services based on visa category. Abolish current Australian legislation that allows children to be housed in detention centres. Ensure that previous health records are made available and provide personal health records for refugee children, to allow for improved communication of their health needs. The RACP believes that all agencies involved in refugee health should promote research and the collection of data in order to develop an evidence base for the provision of optimal care. Accordingly, governments, institutions, health service providers and practitioners should: Support and conduct nationally coordinated, clinically relevant and culturally appropriate research that will inform best practice and service development. Develop research methods that encourage participation of refugees (including children and young people). Collaborate to address specific research questions that inform future policy and practice in refugee health, including long-term health outcomes and cost-effective service delivery models. The RACP believes that training in refugee health, multicultural health and human rights approaches to health are key to improving the quality of services for refugee populations. Accordingly, the RACP will work with professional bodies to: Promote the importance of cultural competency, human rights and advocacy training at all levels. Create and facilitate the development of training opportunities that expose trainees to multicultural health, refugee health and related fields. Promote continuing professional development for Fellows in cultural and linguistic competence (including working with interpreters), human rights and advocacy for disadvantaged groups, and provide regular opportunities for professionals to update their skills. Support the establishment of training Fellowships in Refugee and Multicultural Health to build capacity and expertise in the workforce. The RACP believes that individual Fellows have a respected role in the community and an important voice in advocating for their refugee patients and for refugee communities. Accordingly, Fellows should continue to: Be aware that financial, linguistic, cultural and social factors can prevent refugee children and families from accessing health care. Be informed about the specific physical and mental health problems faced by refugees, the appropriate screening assessments and management issues pertaining to these health problems, as well as the local health and welfare services available to assist refugee families. Adopt a compassionate and respectful approach to refugee children, young people and their families. Advocate strongly as individuals and within organisations to promote high quality care for refugee families. Monitor change (through special interest groups) in refugee health policy and practice. Most asylum seekers and refugees adapt successfully to life in Australia and New Zealand. However, many face extraordinary challenges as a result of government policies and practices. In contrast to a welcoming, supportive environment aimed at building resilience, access to health care is erratic, entitlements are variable, and some are denied rights to both employment and welfare benefits. The RACP supports the provision of multi-agency support both early after resettlement and over the longer term to ensure that refugee families can optimise their potential in Australian and New Zealand society. Existing strategies and services, which aim to protect and promote the health of refugees, have been poorly evaluated to date. The RACP supports dedicated government funding to research best practice, models of care and cost effectiveness so that future service provision can be developed informatively. The development of a culture in Australia and New Zealand where refugees are valued for their skills and diversity, and where politicians and the community at large demonstrate compassion and goodwill would contribute to the health and well-being of the refugee population. The College can take a lead role in implementing the recommendations presented in this policy statement in order to address the health of refugee children and young people. One of the major responsibilities for the College is to ensure that all Fellows in Australia and New Zealand have access to appropriate training and professional development programmes. Other key areas are (i) advocating for the relevant government policy changes required; (ii) supporting special interest groups to monitor change and update recommendations based on emerging evidence; and (iii) facilitating widespread dissemination of the recommendations among relevant parties, from decision-makers down to local level. This policy statement will be updated on a biannual basis to keep abreast of changes in government policy and to present new evidence as it becomes available. This document will be widely disseminated to all those working with refugee children and families, and to key organisations and policy-makers. It is intended for use as an advocacy tool to motivate for changes in policy and practice that will improve the health of refugee children and their families. Fellows are encouraged to advocate for the implementation of the recommendations presented and to advocate for best practice for refugee children. Specific guidelines addressing medical investigations and treatments recommended for infectious diseases in refugee children and adults can be accessed via http://health.gov.au/internet/wcms/publishing.nsf/Content/cda-cdi2904l.htm These definitions apply to the Australian and New Zealand contexts. As suggested by the United Nations High Commissioner for Refugees (UNHCR), this document uses the term ‘refugee’ in relation to asylum seekers, refugees and all those with refugee-like status.28 The United Nation Convention defines refugees as people who are outside their country of nationality or their usual country of residence and who are unable or unwilling to return or to seek the protection of that country because of a well-founded fear of being persecuted for reasons of race, religion, nationality, political opinion, membership of a particular social group, and among other things, are not war criminals or people who have committed serious non-political crimes.29 An asylum seeker is 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.30 The UNHCR acknowledges the right of every individual to seek asylum. UNHCR and UNICEF define unaccompanied minors as those children and young people under the age of 18 years who have been separated from both parents and who are not being cared for by an adult who, by law or by custom, is responsible for doing so.28 AUSTRALIA Edmund Rice Centre for Justice and Community Education http://www.erc.org.au The Forum of Australian Services for Survivors of Torture and Trauma (FASSTT) http://www.fasstt.org.au/ Refugee Council of Australia http://www.refugeecouncil.org.au/ Federation of Ethnic Communities Councils of Australia Inc (FECCA) http://www.fecca.org.au/ Human Rights and Equal Opportunity Commission http://www.hreoc.gov.au/ Refugee Review Tribunal (RRT) http://www.rrt.gov.au/ AUSTCARE http://www.austcare.org.au/ The Australian Trauma Web http://www.swin.edu.au/bioscieleceng/neuropsych/ptsd/ Australian Transcultural Mental Health Network http://www.austehc.unimelb.edu.au/asaw/biogs/A002027b.htm Royal Australasian College of General Practitioners (RACGP) http://www.racgp.org.au/Content/NavigationMenu/Advocacy/RefugeeAsylumSeekerHealthResourceCentre/default.htm Royal Australasian and New Zealand College of Psychiatrists (RANZCP) http://www.ranzcp.org/ University of New South Wales Centre for Refugee Research http://www.crr.unsw.edu.au/ La Trobe University Refugee Health Research Centre http://www.latrobe.edu.au/rhrc/documents/rhrc_brochure.pdf NEW ZEALAND Refugee Health Care. A handbook for health professionals. http://www.moh.govt.nz/moh.nsf/49ba80c00757b8804c256673001d47d0/d85ce7cd090faaa4cc256b050007d7cb?OpenDocument Refugee Council of New Zealand http://www.supportfind.com/rcnz/ New Zealand Refugee Law http://www.refugee.org.nz Refugee Status Appeals Authority http://www.nzrefugeeappeals.govt.nz RMS Refugee Resettlement http://www.rms.org.nz Refugees as Survivors New Zealand http://www.aucklandras.org.nz