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doi:10.1111/jpc.12101

VIEWPOINT

Refugee children: Rights and wrongs

Karen Zwi1 and Gervase Chaney2
Community Child Health, Sydney Childrens Hospitals Network, Sydney, New South Wales, and 2Postgraduate Studies, Princess Margaret Hospital, Perth, Western Australia, Australia
1

How Does the Refugee Program Work?

Australia has had a highly controlled refugee intake of 13 750 people each year, around 40% of whom are under 20 years of age, with a recent increase in August 2012 to 20 000 per year.1 This intake has comprised approximately one third each from conict ridden countries in Africa (mainly Democratic Republic of Congo, Ethiopia, Sudan and Somalia), South/South-East Asia (mainly Burma, Bhutan and Sri Lanka), and the Middle East (mainly Afghanistan, Iraq and Iran).2 To qualify as a refugee, three conditions need to be met: (i) fullment of Refugee Convention conditions of persecution to the extent that return to ones country of origin would endanger life; (ii) character and security clearance; and (iii) visa medical conditions met, which largely requires treatment of public health conditions such as tuberculosis or exclusion for conditions overly burdensome on the Australian health care system.1 Once granted refugee status (or Permanent Protection) in Australia, support systems are considered generous by international standards and include housing support and case management for 6 months, 520 h of English lessons, and access to Medicare, public school enrolment and Centrelink benets consistent with other permanent residents.3 There are two components to the refugee program: Offshore and Onshore (Fig. 1). The former has been predominantly made up of the 6000 people own to Australia each year from refugee camps, where on average people wait 17 years for resettlement.4 This is part of Australias voluntary commitment to resolving the plight of 15 million refugees in protracted situations and is the third highest intake per capita in the world after Canada and USA.1 The Onshore component is made up of people arriving on our shores, either by boat or plane. Boat arrivals are subject to mandatory detention, even though around 90% will ultimately be granted refugee status. The majority of Onshore arrivals (62% between 2008 and 2011) come by plane and are usually processed in the community despite the lower likelihood of being granted refugee status (around 44%).5

Humanitarian/Refugee (N=60006500 per year)

Fig. 1

The refugee program in Australia.

Are Increasing Numbers of Refugees and Asylum Seekers Coming to Australia?

Australia is a signatory to the 1951 Convention relating to the Status of Refugees, of which a key tenet is that all people have a lawful right to enter a country to seek asylum regardless of their method of arrival or available documentation. The United Nations (UN) Convention on the Rights of the Child, signed by Australia in 1990, emphasises three Ps: Provision (of education, health and other services), Protection (from arbitrary detention, abuse and torture) and Participation (by children in decisions affecting their lives). The program in Australia is subject to a strictly enforced quota, with the Onshore and Offshore components being balanced to maintain a steady annual stream that, until this year, had not changed substantively for the last two decades (Fig. 2).2 Linking the Onshore and Offshore components is unusual in the international context, because the Refugee Convention applies mainly to our obligation to those arriving and seeking protection and does not need to be related to our voluntary contribution to the United Nations High Commissioner for Refugees (UNHCR) global resettlement program for those in refugee camps. In global terms, Australia processes only 2% of the global asylum applications (under 40 000 in the 5-year period 20072011), whilst USA, France and Germany had
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Correspondence: Associate Professor Karen Zwi, Community Child Health, Sydney Childrens Hospital, CNR Barker and Avoca Streets, Randwick, Sydney, NSW 2090, Australia. Fax: +612 9382 8188; email: Karen.Zwi@sesiahs.health.nsw.gov.au Declaration of conict of interest: None declared. Accepted for publication 30 December 2012.

Journal of Paediatrics and Child Health 49 (2013) 8793 2013 The Authors Journal of Paediatrics and Child Health 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

Refugee children: rights and wrongs

K Zwi and G Chaney

Fig. 2 Refugee program by category 19771998 to 20092010. (Source: DIAC. Australias Humanitarian Program. Information paper. April 2011. Available at http://www.immi.gov.au/media/publications/pdf/hp-client-info-paper.pdf). Note 1: Over the last 30 years, there have been waves of people who have arrived by boat in Australia in response to humanitarian crisis. These include the 19761981 arrivals mainly from Vietnam; the 19891998 arrivals mainly from Cambodia, Vietnam and Southern China; the 19992001 arrivals mainly from Afghanistan and Iraq. Note 2: Special Assistance Category refers to visa subclasses Emergency Rescue (where there are urgent and compelling reasons for resettlement) and Woman at Risk (for women living outside their home country where they are subject to persecution, without the protection of a male relative and in danger of gender-based victimisation, harassment or serious abuse). , Onshore; , Special Assistance Category; , Offshore special humanitarian; , Refugee.

around 280 000, 210 000 and 156 000 asylum claims respectively from 20072011.6 Australias global ranking in terms of hosting both asylum seekers and refugees is 46th with around 22 000 people, as compared with host countries such as Pakistan, Iran and Syria, with over a million such people each.7 There have been a number of highly publicised strategies to stop the boats in the last decade. These include the Pacic Solution introduced in 2001 (which moved processing outside Australia to Nauru and Manus Island, Papua New Guinea); Temporary Protection Visas and the 2012 Malaysian people swap deal (which proposed to take 1000 UN-certied refugees awaiting placement in Malaysia in exchange for sending 800 boat arrivals to Malaysia, but was declared invalid by the High Court of Australia).8 In response to the Report of the Expert Panel on Asylum Seekers,9 the Federal Government has recently passed legislation reinstating the Pacic Solution, as well as increasing the quota to 20 000 places. Children and unaccompanied minors are not excluded from offshore processing and have been transferred to these sites. The UNHCR have stated that they do not support the legislation and advocacy groups have concerns about the likely negative impact of this offshore processing, including the lack of a guardian for unaccompanied minors, extremely harsh conditions and potentially unlimited detention.10 These strategies have reduced the refugees right to appeal and to family re-unication and have made it easier for Aus88

tralia to return people to their country of origin or another country, which is against the fundamental principle of nonrefoulement (non-return) espoused by the Refugee Convention (Article 33). Although mandatory detention is cited as a deterrent to asylum seekers, its deterrent effectiveness has been questioned by government ofcials.11 Although difcult to prove, boat arrivals on our shores apparently correlate better with global migration than with any local policies. The increase in recent applications in Australia since 2009 correlates with the highest level of global asylum applications in industrialised countries since 2003.6

Who Is Subject to Mandatory Detention?

Mandatory detention is universally applied to all boat arrivals, including children. Onshore arrivals may be subject to mandatory detention in unusual circumstances, but are usually given Bridging Visas while being processed in the community. Detention has no dened upper time limit and individuals are not able to challenge their detention in a court of law. There are currently around 7633 people housed in Australias extensive detention network, which includes Detention Centres, slightly less restrictive Alternative Places of Detention (APODs) and Immigration Residential Housing (IRH), and Community Detention, where people have no work or study rights but can access health care and live unrestricted in the community.12

Journal of Paediatrics and Child Health 49 (2013) 8793 2013 The Authors Journal of Paediatrics and Child Health 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

K Zwi and G Chaney

Refugee children: rights and wrongs

facilities, described by Professor Patrick McGorry as factories for producing mental illness, have suicide and self harm rates 41 times the national average (with over 110 incidents and 6 completed suicides in 20102011).17,20,21 These rates are the subject of a current Ombudsman Inquiry.

Children in Detention
The 2004 Human Rights and Equal Opportunities Commission National Inquiry into Children in Immigration Detention identied synergistic risk factors for the high rates of psychiatric disorder and developmental delay seen in detained children. These factors included parental hopelessness, mental illness and reduced parental autonomy, lack of a safe predictable environment with child-friendly play and educational facilities, and exposure to repeated traumatic events, and have been seen in other national and international studies.1719 They were subsequently acknowledged by the Australian Government, with a policy shift in 2005 that children would no longer be housed in Immigration Detention Centres, but in Community Detention, APODs and IRH. The APODs and IRH facilities currently in use are highly restrictive lock-up facilities, though possibly with family rather than dormitory accommodation. No legislative change has been enacted and the Immigration Departments own value of children shall be detained only as a last resort has never been enforced, with mandatory detention remaining the default for children.20 There has been a recent increase in placement of families with children in Community Detention. The Minister for Immigration announced in 2011 that by the end of June that year, more than half of all children would be in Community Detention because protracted detention can have negative impact on their development and mental health.12 Families are generally processed within APODs by 3 months and then placed in residential housing, supported by the Red Cross, slightly reduced Centrelink payments and privately contracted health services. There have been minimal issues with non-compliance with these conditions. Unfortunately the proportion in Community Detention has decreased since June 2011. On 31 October 2012, 1555 children were in immigration detention, with under half (49%) in Community Detention and the remainder in other immigration facilities including 415 on the highly inaccessible Christmas Island.12 Children within the detention network have no clear child protection system governing their safety. Staff members working in the detention network have limited understanding of child protection issues and are not required to undertake Working with Children Checks, unless there is local state legislation.8

Fig. 3 One of several repeated images drawn by a 6-year-old detainee in which the detention centre fence dominates. The childs description: Theyre crying. Theyre all scared. Scared of the ofcers all of them (reproduced with permission from: Zwi K, Herzberg B, Dossetor D, Field J. A child in detention: dilemmas faced by health professionals. Med. J. Aust. 2003; 179: 31922).

Since 2009, the numbers in detention have increased dramatically as a result of arrivals, suspended processing of selected visa applicants (from Sri Lanka and Afghanistan), applicants awaiting judicial review and inability to meet the demand for processing.8 Processing time as of 31st October 2012 was over 3 months for 32% of applicants and over 2 years for 5%.12 During 2011, the average processing time for a child <18 years was 364 days.2 Length in detention correlates signicantly with new mental health diagnoses in adults.13 Detention centres are mostly in remote locations, with implications for access to specialist health care, education, lawyers, interpreters, and case managers, and contributes to long processing times.1417 Most detention centres are harsh lock-up facilities with institutional routines including regular head counts, removal of personal autonomy and little meaningful activity.14 The resulting inevitable despair and depression, well described in the mental health literature, is punctuated by a sense of injustice and frustration.15,16 This takes the form of riots, protests and hunger strikes, as well as highly symbolic acts of despair such as lip sewing and grave digging. Males in detention

Unaccompanied Minors and Youth

Around a third of children in detention are currently unaccompanied minors (children <18 years without an accompanying family member over 21). Like other children, they are housed either in APODs (60%) or Community Detention (40%). Some APODs are very remote facilities with inadequate access to appropriate schooling and recreation facilities.17
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Journal of Paediatrics and Child Health 49 (2013) 8793 2013 The Authors Journal of Paediatrics and Child Health 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

Refugee children: rights and wrongs

K Zwi and G Chaney

Fig. 4 Refugee children line up for a meagre handout of rice at their refugee camp in Monrovia. Photographer Carolyn Cole. Reprinted with permission of the Los Angeles Times.

Fig. 5 Cartoon by Bill Leak, published in The Australian, Jan 26, 2004, reproduced with permission Newspix / News Ltd.

The most signicant human rights issue specic to unaccompanied minors, highlighted in multiple inquiries and reviews, is that the legal guardian for unaccompanied children is the Minister for Immigration.8 An important question is: Can someone act as a guardian, in the childs best interests, and also be responsible for implementing the policy of mandatory detention, which effectively denies the childs rights to protection from arbitrary detention, provision of appropriate services and participation in decisions affecting him/her?
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Another concern regarding unaccompanied minors is placement. Currently, once in Community Detention, contracted providers place unaccompanied minors in residential housing with a full time carer in a group home arrangement. A report from the USA describes good functional outcomes in 304 Sudanese unaccompanied minors, the lost boys of Sudan, placed in foster care.21 They and their foster families were given extensive support, with group activities facilitating access to USA peers and connections with Sudanese peers with similar experiences.

Journal of Paediatrics and Child Health 49 (2013) 8793 2013 The Authors Journal of Paediatrics and Child Health 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

K Zwi and G Chaney

Refugee children: rights and wrongs

After 1218 months, 95% were attending school and felt supported, despite extreme exposure to war related violence and displacement.21 Several consultations conducted by the Refugee Council of Australia have highlighted that refugee youth are often highly motivated, driven to pursue higher education and perceive education as a source of hope for the future, but have become despondent at the practical difculties encountered in trying to cope with prior disrupted education, family stress, trauma effects on concentration and limited opportunities for skills training.22 To optimise the potential of the youth we resettle, we need youth-specic resilience building programs, access to learning vocational skills and support to integrate into the mainstream school system.

Age Determination Methods

The use of wrist X-rays to determine age in people claiming to be minors has received recent media publicity. Minors have greater entitlements in relation to family reunication and detention placement, and if they are crew of boats, to trial and incarceration as a minor rather than as an alleged adult people smuggler. Fortunately the Department of Immigration has accepted expert advice that age determination by X-ray is too inaccurate to determine precisely if a young person is under or over 18 years. It is recognised that there is no single reliable method of alternative age determination and holistic evaluation has been recommended including detailed narrative interviews in conjunction with current and historic clinical observations (onset of puberty, milestones, behaviour, demeanour) but is still imprecise and open to criticism.23,24 The Human Rights Commission recently published their report Age of Uncertainty Inquiry into the treatment of individuals suspected of people smuggling offences who say that they are children. This report is heavily critical of the use of wrist X-rays in age determination as well as the Commonwealth Department of Public Prosecution, the Australian Federal Police and the Attorney General Department for their reliance on and support for this method.25 The Attorney General has commenced a review of these cases, with a number already conrmed as minors released from prison and returned to Indonesia.

ous journeys or experienced disappearance of family members.30 Prevalence of mental health conditions varies so widely in the studies that have been done (396% for anxiety; 375% for Post-Traumatic Stress Disorder) that they provide more questions than answers in relation to measurement methodology and appropriate cross-cultural tools.30 Nonetheless, what we do know is that service utilisation is low and, although access issues may play a role, it appears that refugee children display high levels of resilience and low levels of dysfunction.27,28 Highquality evidence on mental health, development and long term health outcomes is critical to appropriate service development. An important issue that affects refugee child health is the requirement for national consensus on testing and treatment for latent tuberculosis, in order to provide optimal screening in children and management that will continue across State boundaries.29 Also Hepatitis B immunisation in refugee camps prior to departure could prevent the 510% of children who develop chronic infection, with concomitant risk of hepatocellular carcinoma, liver failure and cirrhosis, but this is unlikely to occur in the absence of cost effectiveness and feasibility studies.31 On the positive side, refugee children have very low rates of allergic disease and low rates of overweight/obesity on arrival (although this approximates Australian population levels with duration of stay).32,33 Studies in Australia and Canada suggest refugees display the healthy migrant effect, with some health parameters, such as preterm births, low birth weight, perinatal mortality, cancer mortality (excluding liver cancer) and rate of chronic conditions lower than host populations.34,35 Similarly some education and employment parameters are favourable amongst refugees. The refugee-like population has higher rates of current TAFE, technical or tertiary study (17.4% vs. 7.8%) than the Victorian population although a higher proportion have had no previous education (7.8% vs. 1.1%).30,36 Workforce participation is higher than Australian born citizens for rstgeneration humanitarian migrants educated in Australia and all second-generation humanitarian migrants.37

Successes in Advocacy
Professional bodies (including RACP) have had some advocacy successes, including coordinated advocacy against childrens detention in the 2000s that contributed to the shift away from housing children in detention centres.26 The Paediatrics and Child Health Division of RACP launched an ofcial policy document on the health of refugee children at the College Conference in 2007.24 Medications commonly used in refugee populations (such as vitamin D, some antimalarials, praziquantel for schistosomiasis, ivermectin for Strongyloides and terbinane for fungal scalp infection) were included on the Pharmaceutical Benets Scheme after concerted advocacy. In 2009, free health care access for asylum seekers was announced by NSW Health, bringing it in line with Victoria. In 2010 the RACP nominated one of the authors (KZ) to represent the College in the federal governments Detention Health Advisory Group (DeHAG), which seeks to provide independent expert advice on the health of people in detention. This has increased the child health expertise within DeHAG and has resulted in some key recommendations affecting the health of children in detention (although this was disbanded
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Health Care Priorities

The RACP has recommended that all refugee children be screened shortly after arrival for high rates of treatable, often asymptomatic disease but this has not been implemented systematically.26 States vary enormously in their approaches to population based screening and access to such services varies from around 20% in New South Wales to over 80% in Victoria and Western Australia.2729 Issues around language barriers and the need for interpreters can be a challenge for general practitioner and specialist services alike. Even more challenging is the provision of long term family-centred care after initial screening. There are also few services routinely evaluating child development and mental health in refugee children and young people, with the resultant knowledge gap and likely lack of suitable intervention. This is despite evidence that 2536% of refugee children have witnessed violence, undertaken danger-

Journal of Paediatrics and Child Health 49 (2013) 8793 2013 The Authors Journal of Paediatrics and Child Health 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

Refugee children: rights and wrongs

K Zwi and G Chaney

in August 2012 to be reconstituted with new terms of reference in 2013). In January 2012, the Department of Immigration and Citizenship (DIAC) accepted as ofcial government policy the Health screening policy for minors in immigration detention proposed by an expert group of Fellows via DeHAG. Yet to be implemented across the detention network, this seeks to ensure that the time children spend within the detention system is used to optimise their health, including access to growth monitoring, developmental surveillance, early intervention, pathology screening and treatment, and provision of child friendly health and education services.

bodies and practitioners need to engage in widespread public campaigns supported by the media.

What Would We Implement, If We Had the Floor?

The key issues for children and youth (and acknowledged by many commissions and inquiries) are as follows: detention as a last resort and the requirement to assess whether there is a good reason to detain a child, with the childs best interests as the primary consideration where it is required, the use of mainland metropolitan areas for detention periodic review and strict time limits to detention (possibly 3 days for children as recommended by the AMA28) legislative change abolishing mandatory detention a uniform code for child protection within the immigration system increase community processing with faster processing times amend laws regarding guardianship of unaccompanied minors with the appointment of an independent guardian (possibly the National Childrens Commissioner announced in 2012) universal post arrival screening and access to health care for refugees and asylum seekers access to education at early childhood, primary and secondary levels resilience building programs for youth and unaccompanied minors monitoring of long term health and educational outcomes of refugee children and youth to inform policy and practice a national approach to the collection and collation of data on access to care, epidemiology of health issues over the long term and policies and programs that best address refugee needs. From a purely utilitarian perspective, asylum seekers and refugees are generally resilient and resourceful populations who have ed in extreme circumstances. It is sensible to optimise their health and well-being rather than contribute to further harm. Most of the people we subject to mandatory detention have and will eventually become Australian citizens. We spent almost $800 million in 20102011 on the mandatory detention system, excluding the cost of subsequent mental health treatment.38 Could we not allocate resources better to assisting new arrivals to reset their lives and achieve what many seem highly motivated to do: access purposeful education and training, nd employment, optimise health and contribute to Australian society?

Some Evidence of Positive Progress

The recent increase in the refugee intake to 20 000 people per year brings us more in line with other developed countries. Increased use of Bridging Visas and Community Detention shortens duration of stay in detention facilities for those eligible. The average duration of stay in immigration detention has decreased from 277 days in November 2011 to 74 days in October 2012.12 The 20122013 Federal Budget has increased the funding to support unaccompanied minors. The NSW Refugee Health Plan will require Local Health Districts in NSW to report on key performance indicators in relation to refugee access to health services, staff cultural competency, data collection and research. Many local jurisdictions have highly effective programs targeting refugee engagement in art, sport, employment, education and health. The body of research evidence is growing and several studies looking at long term outcomes are in progress.

What Can Health Professionals Do to Make a Difference?

Health professionals can contribute to improving health outcomes through advocacy, policy development, research and service delivery at an individual, local and/or national level. Practitioners are highly effective advocates for their individual patients and many interventions can be transformational for refugee children and their families. Health professionals can, and do, advocate for and implement evidence based guidelines and accessible population-based service delivery (that targets all refugees and not only those who present for care) in their local jurisdictions. They can advocate for or design services that prioritise resources based on need and ensure delivery of equitable programs and services. This includes setting up systems to monitor, evaluate and drive improved outcomes for refugees. Important research includes documenting evidence of harm or effective practice, as well as lling the evidence gaps in relation to mental health and developmental outcomes. Health professionals can challenge policies and practices that impact negatively on the health of children and unaccompanied minors. Channels include non-government organisations (such as Get Up, ChilOut, Refugee Council of Australia), which often have more exibility than professional bodies, RACP and Medical Associations. Probably the most important mechanisms for effecting change in government policy is the challenging task of changing public opinion to the extent that humane, generous policies become vote-winners. To achieve this professional
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References
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