CC BY-NC-ND
0doi: 10.1111/1753-6405.12663
Australia's refugee policies and their health impact: a review of the evidence and recommendations for the Australian Government
Anagha Killedar,1 Patrick Harris2
1. School of Public Health, University of Sydney, New South Wales
2. Menzies Centre for Health Policy, University of Sydney, New South Wales
Every year, Australia receives about 70,000 applications for humanitarian visas.1 Those who apply have often experienced persecution in their home countries. The government's policies to address these applications have been controversial for decades due to claims that they violate Australia's human rights' obligations. They frequently undergo revision, each time sparking fierce public debate. The policy landscape has not been systematically interrogated, limiting the depth of the debate. To initiate the interrogation, this commentary is based on a literature review of the health impacts of these policies on their target communities. We focus on the literature on mandatory detention, children in detention and temporary protection visas. We then discuss the limitations in the literature before arriving at some recommendations for improving Australia's policies.
Methods
We reviewed two types of literature: grey and peer reviewed.
To summarise Australian refugee policies, an internet search engine was used with the keywords: 'Australian; 'asylum', 'refugee; 'policy' and 'timeline' to identify histories published by refugee advocacy organisations. These timelines led us to key policy documents. The database Scopus was used to analyse the relationship between Australia's policies and health. The search terms used were "asylum seeker" or "refugee" or "humanitarian entrant" or "humanitarian visa" and "health* or illness or disorder", and "polic* or law or legislation" restricting scans to the title, abstract and keywords. The search was additionally restricted to a publication date after 2004
and Australian affiliation. These criteria generated 51 documents. An additional search term "systematic review" identified 15 such reviews. Their abstracts revealed that most authors focussed on specific policies or health effects, with only one Australian article, published in 2009, taking a broader outlook.2 To take into consideration recent changes to Australian policies, the original search was then restricted to articles from 2009 to present. This produced 39 documents that were scanned for relevance to the research question. An additional two articles were identified by searching the reference lists of scanned articles.
Australia's policies
Australia's Humanitarian Program was formally established in 1977 by the Fraser Government.3 The program consists of an offshore and onshore component. The offshore component is for those who apply for a humanitarian visa while not in Australian territory and are eligible for permanent residency and resettlement assistance. The onshore component is for those who apply for asylum after entering Australia with a temporary visa or without documentation.3 The onshore process has changed frequently in the past 35 years. In 1992, mandatory detention was introduced for individuals who entered the country without a visa; so-called "unauthorised arrivals".4,5 A detainment limit was set at 273 days but this was removed in 1994. In 2005, the 1958 Migration Act was amended to state that children must only be detained as a last resort. Currently, asylum seekers can be detained in onshore and offshore centres.
In 1999, Temporary Protection Visas (TPVs) were established for those who originally
entered Australia "unauthorised" but whose refugee status had been recognised. TPVs lasted three years, after which their holders had to reapply for refugee status. TPV holders also had limited access to resettlement services. TPVs were abolished in 2007 but reintroduced in 2014 in addition to the Safe Haven Enterprise Visa.6,7 Both visas now allow employment and access to government services, but are temporary and do not allow family sponsorship.8
Other changes to government policies include, in 2013, the establishment of "Operation Sovereign Borders', a military-led operation under which boats carrying asylum seekers have been diverted from Australia, and, in 2014, an agreement to resettle detained refugees in Cambodia.7 In May 2015, the Abbott government passed a law that forbids Australian Border Force employees to disclose "protected information" to the public.9
Mandatory detention
Mandatory detention of "unauthorised" arrivals claiming asylum in Australia is arguably the most controversial of these refugee policies. Since 2009, six articles have been published describing the detrimental effect that detention has on the mental health of detainees.10-15 Green and Eager's examination of asylum seeker health records found that those in detention for longer than 24 months, were 3.6 times as likely to develop new psychiatric illness than those detained for less than 3 months (95% CI, 1.1-11.0).15 Coffey et al's qualitative analysis of the experiences of 17 adult refugees who had been detained for, on average, three years demonstrated that three years post-detention participants had poor psychological well-being and suffered with a sense of insecurity, injustice, struggles with relationships and overall deficient mental health.10 Furthermore, there have been 28 known deaths in Australian immigration detention centres from 2010 to October 2016, 10 of which were known or suspected suicides.16 The reviewed research, primary and secondary, emphasised that persistent uncertainty and traumatic experiences in detention (e.g. self-harm and riots)11,12 are key factors influencing poor mental health. Overwhelmingly, published research demonstrated that mandatory detention exacerbates poor mental health outcomes.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Children in detention
Despite the last resort directives of the 2005 Migration Act amendment, as of June 2016, there were 49 children in detention centres and a further 296 in community detention.17 In 2014, the Human Rights Commission,18 published an extensive report in which they surveyed 11 of the 15 facilities on mainland Australia and Christmas Island, and 1,129 children and parents of the 3,101 total detainees at the time.19 They presented strong evidence of the poor health of children in detention and calculated that the average time children spent in detention was eight months. Thirty-four per cent of children in detention suffered from mental health disorders; more than twice the population rate in 4-17 year olds (13.9%).20 An overall 85% of the children surveyed said their emotional and mental health had been affected. Furthermore, children in detention were exposed to dangerous conditions with hundreds of cases of assault and self-harm reported in the 15 months of research. These reports are consistent with a review published in 2012 which described the prevalence of psychiatric disorders, self-harm and a widespread sense of futility among children.21 The majority of the literature is qualitative descriptive data, which reveal that the conditions in detention centres do not support the health and well-being of children. The most recent example of the effects of detention on children is the leak of more than 2,000 incident reports from the Nauru detention centre, submitted between May 2013 and October 2015.22 Of these reports, 51.3% relate to minors, with 30 reports of self-harm and 159 of threatened self-harm in children residing in this centre. They also further highlight conditions which may have led to these events including 66 reports of assault on children and comments about the poor conditions in the centre. While this review did not identify any studies which assessed the long-term impacts of immigration detention on children, a number of researchers have identified evidence of developmental delay in children in detention and highlight the potential of the environment for lasting effects on their mental health.21,23-25
Temporary visas
The provision of TPVs to "unauthorised arrivals" has also been widely demonstrated to have adverse health impacts. In 2009, Johnston et al compared physical and mental
health outcomes in Iraqi refugees with TPVs with those with permanent visas.26 While no evidence of differences in self-rated physical health was found (p=0.41 for general health and p=0.77 for physical functioning), there was strong evidence that TPV status was associated with self-rated psychological distress, after controlling for age, sex, marital status and pre-migration history of persecution, five years post-arrival (p<0.001). Those with TPV status had, on average, a 0.50 higher HSCL-25 score for psychological distress than those on a permanent visa (95% CI 0.30-0.71). Furthermore, 46% of those who had a TPV had symptoms consistent with clinical depression compared to 25% of those who had a permanent visa (p=0.003). While impossible to entirely separate the effect of detention from the effect of a temporary visa (all TPV holders would have spent time in detention), none of the individuals sampled had spent longer than 12 months in detention. Furthermore, interview data demonstrated that TPV restrictions cultivated anger and frustration in participants. Similar comparative studies in Afghani and Mandean refugees had consistent findings.27,28 As similar, if not worse, restrictions are placed on those in community detention and on bridging visas it would not be a stretch to apply the TPV findings to the asylum seekers under those circumstances as well. From 2010 to October 2016, there have been nine known deaths by suicide of asylum seekers on temporary or bridging visas.16
Limitations of evidence
While the evidence of the harmful effects of Australia's refugee and asylum seeker policies is extensive, the nature of the research poses some epidemiological weaknesses. Most studies were descriptive, used small sample sizes and non-random sampling due to limited populations and ethical issues in accessing vulnerable communities. However, the proportion and extent of the health issues reported were sufficiently striking, and supported by qualitative evidence, to accept the claims. Although bias may have resulted from participants exaggerating claims -due to a perception that it may assist their protection status - consistent results over different studies and ethnic groups suggest bias was not substantial.
Limitations of review
There are some limitations to this review that may affect the findings and response.
Firstly, only recent research articles were examined, which may have excluded relevant information. Secondly, academia has not kept pace with rapidly changing policies and the health effects of the most recent policies, such as Operation Sovereign Borders, are unknown. The lack of transparency of these policies also hinders research into their impact. Finally, most studies appeared to focus on the mental health impacts of Australia's policies. While physical health was measured in some studies, most did not which may limit the overall interpretation of the review to a mental health focus.
Recommendations
The reviewed evidence is highly indicative of the adverse health outcomes that result from Australia's refugee policies. Policies that foster uncertainty, hopelessness and exposure to dangerous conditions appear to be the most destructive. Here we present three recommendations to alleviate this impact.
Recommendation 1: Mandatory detention We propose that the most effective way to reduce the mental health impact on asylum seekers would be to remove the policy of mandatory detention to offshore facilities of "unauthorised arrivals". If any standard health and security checks are required for immigration they could be performed onshore. The duration required for these checks should be limited to two weeks maximum; this period was sufficient when the practice was first introduced.5 Once these assessments are completed, asylum seekers should be given bridging visas while their refugee status can be determined. These visas must allow access to healthcare, education, housing assistance and employment options. A strict time limit must be placed on refugee status determination. The current system of treating asylum seekers as guilty until proven innocent is not consistent with other refugee-accepting countries that do not use detention as a primary option.12 Furthermore, minors should not be placed in detention under any circumstances as the mental health risks are more acute.24
Recommendation 2: Visas The permanent refugee visa allocation must increase. Since the nation's humanitarian program began, the number of visas available has changed only minutely.3 It is argued here that since the allocation is only a small proportion of Australia's migration
program, and a negligible proportion of the total population, a greater number of asylum seekers could be resettled. In fact, the resources saved by abolishing some of the deterrent policies, such as offshore detention, could be utilised in resettling more refugees. As part of this increase, TPVs should be converted to permanent visas. The sense of certainty and ability to plan around permanent visas are likely to improve the mental health outcomes of current TPV holders.
Recommendation 3: Offshore application process
Our final recommendation is that a more efficient offshore application process must be established. As has been long argued by refugee advocates, dangerous journeys by sea will only be taken if there is no safer option. An increase in permanent visas should ease pressure on the offshore application process but would not assist those who have no access to UNHCR processes. A significant increase in the In-Country Special Humanitarian Visa (subclass 201)29 intake would allow asylum seekers to bypass the UNHCR and apply directly to Australia for a visa without leaving the country they are being prosecuted in by boat.
Conclusion
As they stand, Australia's immigration policies unfairly harm the mental health and survival of refugees and asylum seekers. Children and those with little access to offshore refugee application processes are some of the worst affected. Although these recommendations are unlikely to solve the health inequities experienced, they would help improve the mental health impact on these vulnerable populations while fulfilling the country's international obligations under the UN Refugee Convention.
References
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Correspondence to: Ms Anagha Killedar, School of Public Health, Edward Ford Building (A27), University of Sydney, Camperdown, NSW 2006; e-mail: anagha.killedar@sydney.edu.au
