HEALTH CONCERNS OF REFUGEES AND ASYLUM SEEKERS IN MALAYSIA 1

Sharuna Verghis2 and Xavier Vincent Pereira3 Health Equity Initiatives, Kuala Lumpur CONCEPTUAL FRAMEWORK OF THIS PAPER Refugee health needs are complex and require special considerations owing to their displacement and relocation experiences of loss of family, community and country, violence, torture and rape that are known to mark the pre-migration, transit and post arrival phases of their flight for safety and protection (1). International evidence suggests that refugees may experience enhanced vulnerability to adverse health outcomes, including adverse sexual and reproductive health (SRH) outcomes (25). Clinical and research literature in mental health also indicate that refugees and asylum seekers experience a significant degree of psychological distress and physical and psychological dysfunction arising due to uprooting and adjustment difficulties and symptoms of somatization, Depression and Post Traumatic Stress Disorder (PTSD) (6-8), which may be evidenced even five years after resettlement (6). Evidence related to refugee health concurs with the truism that health is multidimensional and inter-linked. It involves the physical, mental and social aspects of an individual. As such, the understanding of health and disease can be approached from different perspectives and adduced for different purposes. This paper seeks to maintain the integrated concept of health and the principle that health is not an end in itself, but a means to gain agency over ones life and engage in socio-economic and political life and processes (9). Further, given the objective of this consultation, which is to suggest a policy framework to the government, to address the issues of refugees and asylum seekers in Malaysia, this paper will specifically focus on the role of the State in guaranteeing the right to health of refugees and asylum seekers. This does not in any way preclude the significant role that needs to be played by other actors in the health sector, namely, health care professionals, international agencies, non governmental organizations and the community members themselves. Instead, in keeping with the right to health framework, it merely underscores the principle that States must generate conditions that promote positive health outcomes and reduce morbidity, which include the right to the underlying socio-economic determinants of health (including water, sanitation, food, housing, healthy occupational and environmental conditions, education, information etc) as well as to health care services (10, 11), and regulation of the roles of the different actors (12).

This paper was prepared for the Roundtable on Developing a Comprehensive Policy Framework for Refugees and Asylum Seekers, organized by the Bar Council, Malaysia, on 23 June 2009, Kuala Lumpur. Minor revisions have been made to the paper since. 2 Executive Director, Health Equity Initiatives (HEI) 3 Director, HEI & Associate Professor/Consultant Psychiatrist, Melaka Manipal Medical College The authors are grateful to Grant Mitchell, International Detention Coalition, for substantive comments related to immigration detention, and Peter Daniel, Malaysian CARE, for providing feedback to the sections on Infectious Diseases and Sexual and Gender Based Violence (SGBV)
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REFUGEE HEALTH CONCERNS IN MALAYSIA: POLICY, EVIDENCE AND CHALLENGES Though this paper attempts to cite evidence wherever possible, it is cognizant of gaps in the existing evidence base including limitations with regard to generalization of data, quality of available data and the need for further research. There are key issues like maternal health that have been left out of this paper because of the absence of data even though the issue has been continuously raised as a concern by the refugee community in meetings with NGOs. The paucity of data could be in part due to the pre-occupation of humanitarian actors with providing assistance on the ground, given the urgency and magnitude of the needs. Problems associated with generalizing existing data coincides with global trends in research with urban refugees arising from methodological difficulties that include definitional challenges regarding the boundaries of an urban area and for how long after arrival should one be classified as a refugee, absence of a sampling frame, heterogeneity of the refugee population including their adoption of other ethnic or national identities for survival, definitional challenges with regard to the size and composition of a household given multiple families cohabiting in common dwellings, and inadequate physical access to urban refugee lodgings which are often not well connected to transportation systems and infrastructural facilities (13). The cited evidence however, does give insights into the facets of reality experienced by refugees and asylum seekers in Malaysia with regard to health. 1. ACCESS TO GENERAL HEALTH CARE SERVICES Malaysia currently hosts an estimated 100,000 asylum seekers, refugees and stateless persons residing in Peninsular Malaysia (14). According to UNHCR, as of end June 2009, there were some 49,009 refugees and asylumseekers registered with UNHCR in Malaysia. Around 43,456 are from Myanmar, and 65.33% of these are men, while 34.66% are women. In addition, there are some 45,000 persons of concern as yet unregistered. Malaysia is not a signatory to the 1951 UN Convention Relating to the Status of Refugees or its 1967 Protocol, and refugees in Malaysia do not have access to complementary or temporary forms of system of protection in the country either in law or practice. Under the Immigration act 1959/63 (Act 155), any person who enters or remains in Malaysia illegally is liable to prosecution, which may result in detention, corporal punishment in the form of whipping, a fine and/or deportation. This illegal status often compromises the asylumseekers and refugees access to education, legal employment, health care and other social freedoms (15). Within the schema of a human rights approach to health, (General Comment 14, para 12 (a) to (d) of the International Covenant on Economic, Social and Cultural Rights), accessibility, namely that health facilities, goods and services have to be accessible to everyone without discrimination includes four interrelated dimensions, i.e,

Physical accessibility (safe physical reach) The underlying determinants of health and health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups Economic Accessibility (affordability) Payments for the underlying determinants of health and health facilities, goods and services are affordable and based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Information accessibility This includes the right to seek, receive and impart information and ideas concerning health issues Non-discrimination: Health facilities, goods and services must be accessible to all, especially the most vulnerable or marginalized sections of the population Policy In practice, state health care facilities are open to all refugees and asylum seekers, most often, regardless of their documentation status. In 2000, the Ministry of Health issued a circular to public health service providers to report undocumented non citizens. UNHCR reported recently that the Ministry of Health has confirmed that this circular has since been retracted.
Table1: WARD DEPOSIT4 HOSPITAL KUALA LUMPUR

In June 2005, the Ministry of Health agreed to provide UNHCR recognized refugees with a 50% discount on fees charged to foreigners for health care services at government hospitals. Reproductive health services, family planning and immunization are only accessible for those with a refugee card. Evidence

Ward Class

Medical Citizen Non Citizen RM 1400 RM 600 RM 400

Surgery Citizen RM 1100 RM 400 RM 30 Non Citizen RM 2200 RM 1000 RM 800

Maternity and O&G Citizen RM 800 Non Citizen RM 1400 RM 1000 RM 800

First class Second class Third class

RM 700

RM 200 RM 20

RM 350 RM 15

Source: Ward Deposit (cited 16 June 2009). Available from: http://www.hkl.gov.my/

A Rapid Appraisal of Needs of Afghan Refugees in the Klang Valley (16) conducted in May 2009, with 73 Afghan refugee heads of households, and a Participatory Action Research on Access of Refugees from Burma to Health Care Services in the Klang Valley (17) conducted in cooperation with 11 refugee organizations from Burma and 500 refugee respondents from January to April 2009, by Health Equity Initiatives (HEI), confirm earlier statements on access to health of refugees made by UNHCR and Mdecins Sans Frontires (MSF) respectively (1820). Results from the Rapid Appraisal of Needs of Afghan Refugees indicate that Afghan refugees struggle for access to health care services, including information accessibility, economic accessibility and physical accessibility (safe physical reach), because they are unable to communicate effectively with the health service providers, are barely able to manage their
1 USD = Malaysian Ringgit 3.5 approximately as on June 20, 2009. Available from: http://www.oanda.com/convert/classic
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health care costs and cited fear of enforcement authorities as their biggest fear when traveling to/from health care facilities. Information Accessibility
Table 2: I am normally able to communicate with someone at the health care facility in a language that I understand Valid Cumulative Frequency Percent Percent Percent Valid 1 All the time 4 5.5 5.5 5.5 2 Most of the 2 2.7 2.7 8.2 time 3 Sometimes 7 9.6 9.6 17.8 4 Rarely 13 17.8 17.8 35.6 5 Never 41 56.2 56.2 91.8 6 Not 6 8.2 8.2 100.0 applicable Total 73 100.0 100.0

The Rapid Appraisal indicated that only 6 of the 73 surveyed stated that they were almost regularly able to communicate with someone at the health care in a language they understood (1 person could speak Bahasa Malaysia well while 72 either do not understand or speak Bahasa Malaysia well; 8 persons had a good and satisfactory command over English while 65 do not understand and do not speak English very well). See Table 2. Economic Accessibility

An examination of the income and expenditure patterns of the 73 households indicates their inability to afford health care services. Only 16 of the 73 heads of households interviewed reported having full time work (see Table 3). The average monthly income Table 3: Are you currently working? of those who worked was RM Valid Cumulative Frequency Percent 595. Percent Percent
Valid Unemployed Part-time/casual Full-time Housewife/work at home Unable to work Total

The vast majority of respondents (93.2%) avoided going to the doctor because it cost too much. A large majority (67.1%) said that 6 8.2 8.2 94.5 they could rarely or only 4 5.5 5.5 100.0 sometimes afford medical care. 73 100.0 100.0 Of the 28 respondents (from a total of 73 households interviewed) who had chronic illness, only 8 said they were able to afford regular treatment. For those suffering from a chronic illness, the average cost per visit to a doctor was RM 25 (median and modal values). The average monthly expenditure on health care per household amounted to around 89 RM. The average charge paid at a private health care facility was about RM 40. Though the majority walked (33 out of 73) and took a bus (13 out of 73) to go to the clinic or hospital, on an average the cost of travel to a health care facility was about 12 RM per visit.
Table 4: Income and Expenditure Trends of Afghan Refugees Per Household Per Month Item Amount (RM) Average income per month if 595.00 they can find employment Average monthly rental for 464.72 housing Average monthly expenditure on 89.00 health care excluding average cost of travel to a health care facility per visit of RM 12 Average monthly expenditure on 86.00 education Average monthly expenditure on 479.00 food

36 11 16

49.3 15.1 21.9

49.3 15.1 21.9

49.3 64.4 86.3

For 52% for the Afghan refugees, the monthly rental for housing ranged between RM 400 to 600. About 30.6% of the Afghan refugees

spend up to RM 400 per month on rental. The average monthly rental for housing is about RM 464.72. Most (90%) are usually over-due on their rental payments. Amongst refugees who have been in Malaysia for less that 1 year, 52% had to change residence 2 or 3 times. And amongst those who have been in Malaysia for 1 to 2 years, 60.9% have shifted residence 2 to 3 times. It appears that, regardless of the period of stay, Afghan refugees in Malaysia shifted residence every 6 to 8 months. The majority cited high rental and over-crowding as reasons for shifting. Amongst those who had children, a majority (64.3%) of the households have at least 1 or 2 children of school going age. A significant proportion (28.6%) had 3 to 4 children of school going age. The average cost of education per household per month was RM86. Table 4 which shows the income and expenditure trends of Afghan refugees per household, clearly raises concerns about their ability to cope with their daily basic needs. The survey showed that indebtedness was high because most of them reported that they borrowed money as a way of coping with their needs of housing, education, health care and food. A future study on indebtedness of these refugees would be useful in understanding the impact of their most common coping strategy on their lives. It is no wonder then that 56 out of the 73 heads of households interviewed reported that they were unable to cope with their problems. 40 out of the 73 heads of households stated that their problems caused them to suffer from anxiety, stress, worry about the future. Table 5, on the other hand, shows how the inability to access health care services impacted the lives of the 73 Afghan refugee heads of households Table 5: How has your life been surveyed. affected by not being able to access
health services in Malaysia?

Physical Accessibility (Safe Physical Reach) Most respondents in the Rapid Appraisal done with the Afghan refugees cited fears of Police and RELA when traveling to health care facilities. In a separate Participatory Action Research (PAR) on Access to Health Care Services conducted by HEI with
Valid Worry, anxiety, stress Physical pain Depression, sadness Sleeplessness Problems with activities of daily life Loss of work Loss of income Increased dependence on family/friends Increased use of overthe-counter medication Personal relationship(s) suffered Other No change, life has not been affected Not applicable

Frequency 49 28 38 24 18 12 10 2

4 1 1 1

refugees from Burma, 458 out of 495 respondents stated that their Fig1: Participatory Action Research (PAR) on Access to Health Care Services with main fear when traveling to/from a Refugees from Burma Main Fear When Traveling to Clinic health care facility related to Police, Immigration and RELA and consequent detention and deportation. In the PAR with the
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refugees from Burma, 233 out of 495 had indeed been stopped by the enforcement authorities while on their way to/from a clinic. Fear of being robbed and physical violence also figures prominently in the list of fears cited by the Afghan and Burmese refugees when traveling to a health care facility. Challenges Evidence indicates that while health care services may be available, they are not necessarily accessible to refugees and asylum seekers. The main barriers to access to health services for refugees and asylum seekers are: 1. The cost of health care, which is unaffordable for refugees and even more prohibitive for asylum seekers who are required to pay the full foreigners rates at government hospitals. This is exacerbated by their inability to work. The absence of a livelihood also prevents them from accessing the underlying determinants of health like housing and education, as the evidence related to the Afghan refugees in the preceding section indicates. 2. The sustained fears of arrest, detention and deportation deter refugees and asylum seekers from seeking medical treatment. Perceived or real fears of physical violence and/or robbery are difficult to assuage in the absence of their ability to access protection and justice within the legal system. 3. Clearly linguistic barriers are a major obstacle in enabling refugees explain about their medical conditions and understand information vital for the protection of their health. 4. Even though this paper did not touch on the issue of discrimination experienced in the health system, there is evidence (17) to support such claims. The discrimination arises variously from cultural differences that influence the understanding of health and disease, and Othering processes that perpetuate social, political and legal norms that reinforce asymmetries of power between citizens and non citizens to the extent of creating social and political exclusions based on the manipulation of difference to which inferiority is ascribed (21). 5. Ares of concern where access to health services are wanting are: integrated primary care services for refugees outside KL and Selangor / availability of regular health screening, increase access to reproductive health services including ante natal services, and, dental services (22) 6. Other problems related to access to health care services and the underlying determinants of health for refugees are income restricted diet, lack of knowledge on health and knowledge of how to access services (22) 2. Mental Health of Refugees Policy In principle, the public health services provide emergency psychiatric services, including hospital admission, to all patients, even refugees and asylum seekers. Anecdotal evidence suggests that there are over 300 psychiatrists in the country. This number is less than the 719 psychiatrists that were needed in 2007 to meet the WHOs psychiatristpopulation ratio (23). This means that Malaysians themselves have to endure long waiting periods to see a psychiatrist in a public hospital. Psychiatrists in private practice are more
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easily accessible, but their fees would be higher than what one would pay in the public health services. This scenario applies equally to refugees and asylum seekers. Evidence Though the State run psychiatric services are available to refugees and asylum seekers with mental health problems, HEIs case management of psychiatric patients indicates that there are barriers to their access, especially economic accessibility. This is because asylum seekers who need to fork out the foreigners rates in deposits for in-patient care are unable to afford this, especially because those who are mentally ill are usually unable to work and sustain themselves in the first place. Mdecins Sans Frontires (MSF), an international NGO that provided medical services to UNHCRs persons of concern (PoCs) until February 2007 states that their mental health team provided a total of 725 counseling sessions from April to December 2006, the overwhelming majority of new patients were men (61%), mainly between the ages of 20-29 (45%). Of 725 mental health consultations, 119 patients were given clinical diagnosis and 60% were diagnosed with anxiety disorders, including post-traumatic stress disorder (PTSD). Some of the PTSD originated from psychological trauma in the country of origin, when people fled violence, persecution or wars. Patients have lost family members; seen friends or family killed and tortured in front of them; and/or been victims of sexual violence and torture. Of the 100 people MSF interviewed, 82 suffered sleepless nights, 69 had feelings of isolation, and 77 felt constant fear and worry. 56 people had experienced depression and 20% had suicidal thoughts. Frequent causes for depression included the difficulties associated with obtaining documents; the ongoing lack of security; very poor living conditions; the lack of work and the absence of opportunity to be resettled (19). Between May 2008 and April 2009, HEI saw a total of 88 refugee clients in 179 sessions. The majority of the clients were diagnosed as having Depressive Disorder, Anxiety Disorder, and Post Traumatic Stress Disorder. Precipitating factors for mental ill-health included continuous security threats (of arrest, detention and deportation), the experience of loss(home, family, friends, possessions, identity), inability to work and meet their basic living needs, problems with regard to registration, rape and sexual violence, exploitation by employers in terms of unpaid wages, and inability to access health care services. Past trauma including being subject to torture or witnessing torture and death of loved ones and were also found to be triggering factors for PTSD (24). In January 2009, HEI introduced mental health screening for Depression and Stress, as a means of reducing mental health morbidity and increasing mental well being. The mental health screening was integrated into the organizations mental health campaign. The objective was to allow for early detection of morbidity and facilitate early intervention. Diagnostic and Statistical Manual of Mental Fg:2 Percentage of Respondents Having Suicidal Thoughts Disorders, 4th Edition (DSM IV) No suicidal thoughts criteria was used to develop the Experience suicidal 7% Depression Self Quiz test. 3% thoughts "several days
6% 15% over the last 2 weeks Experience suicidal thoughts "more than half the day" over the last 2 weeks Experience suicidal thoughts "nearly every day" over the weeks last 2 weeks Missing Data

69%

Preliminary results from the mental health screening (Fig:2) indicate that 15% of the 469 refugees from Burma who opted to undergo the screening for Depression had suicidal thoughts for several days and 6% for
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more than half the day respectively, over the 2 weeks preceding the screening. 3% reported experiencing suicidal thoughts nearly every day over the preceding two weeks.
Fig 3 - Percentage of Respondents who Experienced Panic Attacks 8%

42%

50%

No Yes Missing Data

In a separate screening for Panic Disorder that was conducted with 100 refugees and asylum seekers by HEI in the Klang Valley, 50% demonstrated signs that indicated that they had experienced Panic Attacks. See Fig 3.

Precipitating events for clients who were diagnosed with more severe mental health problems detected through the mental health screening were linked to being detained in immigration detention centres, being trafficked on the Thai-Malaysia border and sold to fishing boats, and being whipped as part of the penalty for immigration related offences.
Box 1: CASE STUDIES: HEI MENTAL HEALTH SERVICES Case Study 1 Case Study 2 Trafficked on the Thai-Burma Torture, Fear of Deportation from Iran Border Nationality: Burmese Nationality: Afghan Sex: Male Sex: Female Marital Status: Single Marital Status: Married At age 12, the client witnessed three Taliban men who broke into the The client was suspected to be compound of the family home and killed her uncle and cousin while she involved with anti-government and the rest of the family watched. They were looking for her father, who movement in 2002 in Burma as had gone into hiding. The client was beaten with the butt of a rifle. his brothers were active in The family was saved by a neighbor. They hid in his house until the client politics though he claims he was and her sister were smuggled out of the country to neighboring Iran. She not. He was jailed for about a then lived with a friend of her fathers whose son she later married. Her year. He fled to Malaysia in 2004 and was arrested in 2005, husband was a documented refugee in Iran, but she was not. She lived with renewed fears of being deported for her lack of documents. jailed for 3 months. Thereafter She refrained from going out of her house for fear of being accosted he was deported to the Thaiby officials. On top of this, she had recurring thoughts of the event and Malaysia border and sold to flashbacks, as well as nightmares which disturb her sleep. Slowly, she work for fishermen at sea for started to isolate herself from others. Although her husband had UNHCR about one year. He suffered a documents, he found it difficult to earn a living in Iran due to the stroke while working at sea. At discrimination faced by Afghan nationals. that time, he attempted suicide The family moved to Malaysia in October 2008. Since then, her fears once. He returned to Malaysia about the Taliban have returned. in 2008. Symptoms: Suicidal thoughts, Depressed, no interest in doing anything, feel hopeless, insomnia. Diagnosis: Depression Intervention: Supportive counseling and psychiatric treatment Symptoms: Recurrent, intruding, distressing recollection of the traumatic event; flashbacks; intense psychological distress at reminders of traumatic event; persistent avoidance of stimuli associated with traumatic event; feeling detached or estranged from others; difficulty sleeping; irritability with outbursts of anger Diagnosis: Chronic Post Traumatic Stress Disorder and Major Depression Intervention: 1. Medication for Anxiety 2. Psychotherapy

Challenges Health vulnerabilities confronting the refugee population are largely systemic. Case study 1 shows the links between human rights violations arising from the refugee experience including human trafficking and health outcomes, both mental and physical health.
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See also case study 5 in Box 4. Case Study 2 is a case of prolonged suffering from a chronic mental health problem linked again to the refugee experience. What are our ethical and human rights obligations when confronted with people suffering such pain? 1. HEIs psychiatrist, clinical psychologists and counseling psychologist maintain that the two most significant and ongoing experiences of refugees and asylum seekers, namely of loss (of family, country, job, home, identity in the home country, and, all these and years lost in waiting for a durable solution in Malaysia) and ongoing security threats of arrest, detention and deportation prove to be a tremendous challenge in that they not only contribute to the underlying causes of mental health morbidity, but also hinder the efficacy of therapeutic interventions and thus the improvement in the health and well being of the community. 2. Outpatient care in public hospitals requires financial means even though consultation fees are cheaper. The cost of admission in the psychiatric ward is too expensive for asylum seekers and refugees (RM 700 in deposit at the time of admission). This is compounded by the fact that refugees with mental health problems and requiring admission would most often and typically be people who are unemployed because of their mental state. An issue related to the need for hospital admission is that though refugees continuously articulate the high stress they experience, they tend to seek psychological help only if the problem becomes serious, which is often when hospitalization becomes necessary. 3. Language barriers perhaps are most glaring in the context of mental health because personal communication that plays a key role in therapy is vital for their recovery. The absence of interpreters and translators in public hospitals compromises the quality of the communication between the health service provider and the patient. 4. HEIs experience has been that it is almost unfeasible to administer individual, intensive and long term psycho-therapy for those in need of such treatment, because most often they work in unprotected work sectors where it is impossible for them to get protected time needed for such healing and recovery. Other barriers include their inability to finance transport costs and security problems which hinder their mobility. 3. Sexual and Gender Based Violence (SGBV) Refugees may experience heightened vulnerability to sexual and gender based violence (25), especially those fleeing conflict (26). Women and girls are particularly vulnerable to sexual exploitation and abuse due to being trafficked or in order to access basic needs such as food, shelter, and security (25). SGBV has serious consequences for their reproductive and mental health. Mental health problems related to SGBV include PTSD and Depression (7, 8). International guidelines on the response to SGBV consistently incorporate HIV into harm reduction strategies that seek to diminish the harmful consequences of sexual violence as well as to prevent further injury and harm to the survivor. In addition, if the survivor presents within 72 hours, the medical protocol involves addressing the prevention of sexually transmitted infections, HIV, pregnancy, tetanus, Hepatitis and provide wound care and mental health care. A similar protocol exists for survivors who present more than 72 hours after the incident. The guidelines also spell out follow up actions in relation the medical treatment (27, 28).

Policy SGBV protection and care services, provided to the Malaysian public through the One Stop Centres, are available to women refugees and asylum seekers. However, they can only be accessed by refugee women if they file the required police report. Evidence The lack of documentation and consequent risks involved in lodging the required police report often prevents refugee survivors of SGBV from accessing medical services available through the One Stop Centres. According to a review initiated by UNHCR of its SGBV related files, a total of 156 incidents of SGBV were reported by 140 individuals in 2008, of whom 6 were men and 134 were women. The majority of the incidents which were reported by women from Burma and had occurred in the country of origin included rape and attempted rape. There were small numbers of reports from refugees from Somalia, Iran, Afghanistan, Sri Lanka and Indonesia. The review indicated that while counseling was consistently offered to the survivors, an extremely low number of medical check ups had been offered (29, 30). HEI has handled cases of SGBV with incidents occurring in origin country. However, given the national focus of this consultation, given below are two cases of SGBV handled by HEI (in the first six months of 2009) of incidents that occurred in Malaysia.
Box 2: CASE STUDY 3: HEI SGBV CASES FORCED LABOR, TRAFFIKCING, RAPE, TORTURE Nationality: Burmese; Sex: Female; Age: 37 years; Marital Status: Married The client was raped multiple times over an 8-month period by the agent who brought her to Malaysia. The perpetrator sent her to work in different restaurants to work as kitchen helper. He moved her from one restaurant to another restaurant within intervals of three to four days. He kept her isolated and in confinement. Sometimes he made her stay in houses where he had friends but warned her against speaking to anybody in the house. She did not have a permanent place to stay. She did not receive a single cent for the work she performed in different restaurants. The perpetrator forced her to have sexual intercourse with him several times against her will. She was very afraid and could not do anything to resist the perpetrators actions because of her captivity and his threats to harm her. The client found she was pregnant. After the perpetrator knew about her pregnancy, he forced her to drink alcohol on two occasions and stepped on her back with force for about 15 minutes, with the intention to abort the child. She attempted suicide twice. Some co-workers helped her to escape, and she was referred to HEI by a community health worker trained by HEI in mental health. Diagnosis-Mental Health: 1. Adjustment Disorder with symptoms of Anxiety and Depressed Mood 2. Post Traumatic Stress Disorder (PTSD) Interventions: 1. Crisis intervention supportive counseling, needs assessment, mental health status assessment 2. Referral to UNHCR for documentation and protection 3. Ensuring physical security including a safe place to stay 4. Psychiatric treatment and supportive counseling 5. Facilitation of termination of pregnancy preceded by abortion counseling at a private health facility

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Box 3: CASE STUDY 4: HEI SGBV CASES SEX TRAFFICKING, TORTURE, CHILD SEXUAL ABUSE Nationality: Burmese; Sex: Female; Age: 18 years (unable to verify); Marital Status: Single The client was sold to sex traffickers and forced into sex work as a child, initially in Burma, and later in Thailand and Malaysia. She was raped and tortured several times by groups of men in these countries. The client confirmed vaginal penetration and oral sex during rape. Torture included being burnt by cigarette butts in the area of the abdomen, knees, arms, forehead, penetration of a sharp object into the vagina, and, cigarette butts into the anus. She claimed that, one time, the perpetrators set a dog on her when she refused to have sex. The claims of torture coincide with visible scars on the body on the parts she claims were injured through torture. Diagnosis and Impression - Mental Health: 1. Acute and Transient Psychotic Disorder(in remission) 2. Regressed behavior and inappropriate show of affection (most probably due to CSA [child sexual abuse]) 3. Need for further assessment especially for Post Traumatic Stress Disorder (PTSD) Interventions: 1. Crisis intervention supportive counseling, needs assessment, mental health status assessment 2. Referral to UNHCR for documentation and protection 3. Ensuring physical security including a safe place to stay 4. Psychiatric treatment and supportive counseling 5. Only preliminary medical check up could be facilitated at a community clinic. Discussions are ongoing with doctors within the public health system to avail medical help for the client in the context of the existing legal dilemmas

The Committee on the Elimination of Discrimination against Women (CEDAW) in its Concluding Comments to Malaysia in May 2006 (31) made the following recommendations which if implemented by Malaysia would improve access of refugee women, especially SGBV survivors, to critical services. Adopt laws and regulations concerning the status of asylum seekers and refugees, in line with international standards to ensure their protection, in particular for women and their children Integrate a gender-sensitive approach while granting asylum/refugee status in close cooperation with international agencies such as UNHCR. Challenges SGBV in relation to refugees and asylum seekers present many complexities for healing as the two case studies demonstrate. 1. On the whole, access to medical treatment within the public health system is extremely problematic because of the requirement of a police report in order to access medical services. In the absence of legal guarantees that the survivor will not be arrested for lack of documentation, will not be refouled, and will have access to witness support, the requirement of a police report remains an impediment to healing and a mechanism that defeats its purpose of seeking to protect the survivor. 2. Access to medical treatment with the existing legal barriers is more complex when the survivors are children because of the tenuous position of care givers who are neither parent, foster parent nor one of the State bodies empowered by the Child Act to act on behalf of the child.

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3. In addition to the above, there could be lost opportunities to synergize cooperation between the local health system, NGOs, UNHCR and community organizations to develop more comprehensive systems of protection and healing for SGBV survivors because of the lack of knowledge of systems of support, cultural barriers and discrimination that survivors face in the community, the low level of awareness of the problem of SGBV experienced by refugees and asylum seekers in Malaysia, and the existing gaps in capacities to deal with SGBV. 4. The two serious HEI case studies of SBV incidents (cited above) which partly also took place in Malaysia seem to a certain extent to be linked to the problem of human trafficking. Preventive interventions, including health interventions, need to factor in this critical issue. 4. Infectious Diseases HIV and TB HIV is known to thrive under conditions of poverty, conflict and displacement (32). The very same factors that trigger the sexual and reproductive health problems arising from forced dislocation and relocation (7, 8) also produce pre-disposition to HIV infection. In addition, separation from families and familiar social support networks, lack of legal status, overcrowded and substandard living conditions, concentration in occupations that are poorly regulated or unsafe, limited access to educational opportunities, and barriers to accessing health care services, create conditions that exacerbate the vulnerability of refugees and asylum seekers to HIV. International guidelines on HIV recommend the inclusion of refugees and asylum seekers in all HIV related interventions. They also recommend the integration of HIV treatment and the promotion of access to voluntary HIV counseling and testing into HIV prevention as essential programmatic principles to stem the transmission of the HIV virus (33, 34). The logic of incorporating access to testing and treatment into prevention strategies could be extended to other infectious diseases like TB. H1N1 Pandemic Though this paper will focus on HIV and TB, a brief mention needs to be made about the H1N1 pandemic. Concerns have been expressed about possible outbreaks in camp settings with regard to refugees (35). According to the World Health Organization the impact of a novel pandemic influenza virus on refugee and displaced populations is expected to be severe. Some of the risk factors include overcrowding (especially in camp settings), poor access to basic health services and supportive care and treatment of complications, poor links to national disease surveillance systems, possible exclusion from national influenza preparedness and response activities, and lack of trained and equipped staff to investigate outbreaks and manage ill persons (36). Knowing the challenges involved in reaching urban refugees, and the fact that some of the risk factors identified above could equally be true for urban refugees, there is a need for consciously factoring in refugees and asylum seekers, in fact all non citizens, in national efforts to address the pandemic. UNHCR reports that it has had meetings with the Ministry of Health on this matter.

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Policy On the whole, certain practices of the Ministry of Health with regard to refugees with HIV and TB may be cited as good practice. These include the subsidy for treatment (details discussed below) and allowing community health workers cum translators to aid communication between the health service provider and refugees at some health facilities. HIV Refugees are recognized under Malaysias National Strategic Plan 2006-2010 as one of the marginalized and vulnerable populations (37). The Ministry of Health provides medical support to all persons of concern who hold UNHCR documents. They get a 50% discount off the foreigners rate and free admission at third class wards in government hospitals. Under this scheme, the Ministry of Health provides two of the three drugs with regard to HAART treatment free of charge. The third drug, Stocrin is subsidized by UNHCR. Refugees who are on the newly introduced three-in-one combination of SLN (Stavudine, Lamivudine and Nevirapine) receive this free of charge. The cost of viral load and CD4 count tests are subsidized by UNHCR. Hospital Sungai Buloh has allowed for 16 trained Adherence Support Community Counselors from Burma to be present at the hospital every Thursday to facilitate translation for refugees (from Burma) living with HIV. The Ministry of Health has also supported the proposal for testing and treatment costs that are currently borne by UNHCR to be included in Malaysias proposal to the Global Fund to Fight Tuberculosis, AIDS and Malaria, Round 9. Tuberculosis In principle TB testing and treatment at public health facilities, including at the Institut Perubatan Respiratori (IPR) is available equally to refugees and asylum seekers. Refugees who possess a UNHCR card are given treatment free of charge at IPR. Those refugees who do not have an UNHCR card need to pay RM 60 in registration, RM 25 in X-Ray test and RM 10 for the sputum test, at IPR. IPR has also allowed a Community Health Worker from the refugee community from Burma to be stationed at IPR once a week to facilitate translation and communication with refugee patients from Burma. Similarly, there are five Community Health Workers from Burma at the Pusat Kawalan Kusta Negara (PKKN)) in Sungai Buloh, every Friday, for the same purpose. Regular meetings between UNHCR and the IPR were initiated in late 2008 with the involvement of Selangor and Kuala Lumpur infectious disease control divisions. Evidence HIV According to UNHCR, the number of cases of HIV reported is increasing with approximately 224 active HIV cases amongst refugees in December 2008 and 90 persons on antiretroviral treatment. The increase in numbers is attributed to increased access to HIV counseling and testing rather than an increase in HIV prevalence. Most cases are reported in young persons
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between the ages of 25-35 and the majority of cases are reportedly sexually transmitted (38). Discrimination, social stigma, poor knowledge and lack of awareness among the refugee community are reported as barriers to the uptake of HIV counselling and testing (38). While this is true, it is equally true that there are extremely limited VCT services for refugees in the Klang Valley, where shortage of human resources and competencies related to pre and post test counseling, including linguistic barriers, impede the access of refugees to essential HIV prevention and diagnostic services. While the Malaysian governments support to Persons of Concern with regard to HIV treatment deserves appreciation, its role in including refugees and asylum seekers in HIV preventive programs could be strengthened more than the current level. Refugees living with HIV face numerous hurdles in accessing and maintaining adherence to HIV treatment. These challenges include language barriers, difficulties affording transport, lack of knowledge regarding transport, poor nutrition and lack of food, fear of arrest and harassment, and fear of accessing services due to stigma and discrimination (38). As part of the national HIV strategy of compulsory testing of pregnant mothers, pregnant refugee women also go through HIV testing during pregnancy. However, owing to human resource shortage of personnel and constraints of linguistic capacities of staff, group briefings replace individual HIV counseling and testing in many government health facilities. Tuberculosis Though a high number of Persons of Concern are referred to public hospital services for TB testing, there is an evidence gap in terms of their numbers and profiles. In three community clinics that HEI ran in 2008, 13 out of the 63 patients who accessed the services presented with symptoms of active TB requiring referrals for further investigations and second line treatment. Further, three TB education sessions that HEI conducted in 2008 for refugees with TB indicated low levels of knowledge of transmission of TB and understanding of the treatment regimen for TB. Feedback from the participants indicated the use of traditional medicine and cough mixtures brought from their country of origin by those who lacked economic accessibility to the local health care system (39). Many of the asylum seekers who presented with symptoms of active TB in the above HEI community clinics stated that they could not afford to pay for the TB tests at IPR or even the XRay test at a UNHCR partner clinic, and thus were not sure if they could pursue treatment. Challenges 1. The perspective that refugees and asylum seekers are outsiders and using national resources for their health somehow does a disservice to citizens is a long held notion of many policy makers. This is contrary to evidence and internationally accepted principles that recognize that infectious diseases and HIV do not respect borders and thus intercountry and multi-sectoral collaboration is imperative in combating these global health challenges (40, 41). Denying non citizens like refugees and asylum seekers access to free testing and treatment for infectious diseases poses a threat to the health of citizens as well in this rapidly globalizing world. It also runs contrary to norms in international law that
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affirm that refugees and asylum seekers should have equal access to the full range of preventive, curative and palliative health services (42) 2. Economic accessibility also seems to be a major barrier to accessing testing for TB. It is in the interest of the health of the local population that asylum seekers be provided access to free testing and treatment services for TB and other infectious diseases. 5. Detention Health There are several documents identifying international guidelines related to treatment of people in detention, including the protection of their health. Some documents that include provisions for health are the Standard Minimum Rules for the Treatment of Prisoners, The Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment, and the United Nations Rules for the Protection of Juveniles Deprived of their Liberty. Policy Until 2007, the Prisons Department had control of the management of Immigration Detention Centres (IDCs). Under their management, a private company was contracted to provide medical services to detainees in the IDCs. This changed in 2008, when the Immigration Department took over the overall management of the IDCs and the civil volunteer corps Ikatan Relawan Rakyat Malaysia (RELA) took responsibility for the management of security of the IDCs. This development also saw the cessation of medical services by the private company that had earlier been contracted by the Prisons Department of Malaysia. According to Commissioner of the National Human Rights Commission, SUHAKAM, Dato Siva Subramaniam as of May 28, 2009, the 22 IDCs in the country only have a visiting doctor and no permanent clinical dispensary manned by doctors or a medical assistant to help detainees (43). Evidence Poor detention conditions in Malaysian IDCs including overcrowding, poor sanitation, insufficient provision of food and water, and inadequate access to necessary medical and health services especially in relation to emergency care, treatment for infectious diseases and maternal health services, have been raised by Malaysian NGOs earlier (44). Other issues that have emerged are Depression, Severe and chronic Post-Traumatic Stress Disorder, Anxiety Disorder and suicidal ideation in relation to mental health, and, tuberculosis, beriberi, kidney problems and skin infections which were variously attributed to poor detention conditions and inadequate medical care (45). The recent outbreak of Leptospirosis in the Juru Detention Centre compounds the concern of deaths in detention which was also raised in Parliament when the then Home Minister Datuk Seri Syed Hamid Albar, in a written reply to a parliament question stated that 2,571 deaths of detainees had taken place in prisons, rehabilitation centres and immigration detention centres between 1999 and 2008, with causes of death attributed to fights, suicides and illnesses such as HIV/AIDS, septicemia, tuberculosis, cancer, heart and blood diseases, and asthma (46). HIV positive detainees have been denied access to medication in IDCs (14).

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A refugee with TB who accessed one of the community clinics run by HEI in 2008 reported that he did not have access to his TB medication while in detention and had to default treatment. This has also been reported by other refugees with TB who had been held in Malaysian IDCs. Pregnant women, children and babies are not provided special care, facilities, or supplies while in IDCs. Children are detained with adults, including unaccompanied minors (14). The continued arrest and detention of refugee children has grave implications for their mental health. A 17 year old girl who was held in detention for 15 days with her 14 year old sister in 2008, and was badly traumatized by the experience and brought to HEIs mental health services, presented with prominent symptoms of PTSD including reliving the detention experience. She also had poor appetite, intermittent insomnia, frequent headaches, fatigue, negative thoughts about herself, and an intense fear of uniformed personnel. Related to the issue of detention are the issues of whipping and trafficking of those who are deported to the Malaysia-Thai border. In a written reply to a parliament question on the numbers of those who were whipped, the Minister of Interior replied that from 2002 to 2008, out of the 47,914 who were convicted under the Immigration Act, 34,923 were whipped. The breakdown is as follows: 60.2% Indonesians, 14.1% Filipinos, 13.9% Myanmarese, 3.6% Bangladeshis, 2.8% Thais and 5.4% were other nationalities (47). The health risks involved in the process impact several aspects of the detainees health.
Box 4: CASE STUDY 5: HEI MENTAL HEALTH SERVICES - ARREST, DETENTION, DEPORTATION & TRAFFICKING Nationality: Burmese; Sex: Male; Age: 25 years; Marital Status: Single The client was arrested in July 2008 in Kota Raya, Kuala Lumpur and was in the lock up for 2 weeks before being sent to Sg. Buloh prison for 4 months. He was not whipped. From there, he was sent to Semenyih Detention Centre for 2 weeks from where he was deported to the Thai-Malaysia border. Since he was not able to recall his friends phone numbers, he did not have anyone to help him pay the money that the traffickers demanded. He stayed there for 2 weeks and during this time he stated that he was threatened and tortured by the traffickers. He was beaten everyday by the traffickers because he could not get anyone from Malaysia to help him with money. His family in Burma was also unable to help him. At the end, he managed to get the help of one refugee community organization and he was sent back to Malaysia. Symptoms: Nightmares, flashbacks, highly anxious, skin irritation, insomnia, Depressed. Provisional Diagnosis: Anxiety Disorder Intervention: Supportive counseling and referral for psychiatric assessment and medication if necessary

Challenges 1. The continued arrest and detention of refugees and asylum seekers contrary to international law is a contributing factor to various health problems experienced by refugees and asylum seekers. The health risks involved are easily preventable by applying the general principles involved (based on accepted international guidelines and standards) in the detention of refugees and asylum seekers that have been discussed before Recommendation 11 at the end of this paper. 2. The normative framework of the State in considering the issue of detention and IDCs is problematic. Policy makers in this country have long framed the discussions/interventions
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on/for non citizens in this country, migrant workers and refugees alike within a narrow traditionalist approach to security that reinforces threats to the stability and legitimacy of the State. This limited perspective ignores non traditional and human security risks including communicable diseases that have the potential to destabilize national development and world trade (48). It also does not clarify how the State reconciles the ethically indefensible treatment and outcomes of the treatment of non citizens in IDCs in the face of a growing body of evidence put forward by civil society groups and communities for almost fourteen years now, with the heightened duty and capacity of the State with regard to the right to life in a custodial setting. This gap in perspective with regard to health and the ethical foundation of State policy and actions with regard to refugees and detention needs to be resolved first. 3. The Jakarta Process multi-country review on the role of national human rights institutions in the protection and promotion of rights of migrants with irregular status raised the issue of problems related to compartmentalization and weak cooperation, or overlapping of jurisdictions and unclear division of responsibilities among government agencies in Malaysia concerned with migrant labor matters (49). This was perhaps most evident in recent times when it took an outbreak of Leptospirosis and deaths of two refugees for cooperation to take place between the Ministries of Health and Home Affairs/Immigration Department. 4. Unfortunately, in spite of and/or because of the absence of structural autonomy (50), the one body that has access to detention centres, SUHAKAM, the national human rights commission, has yet to conduct a public inquiry on deaths in detention centres even though individual commissioners have made strong statements on the poor conditions in IDCs and deaths of detainees, and, its reports have yet to be considered seriously by the government for action. 6. Childrens Health The vulnerability of children is among other things a function of their environment which can enhance or compromise their ability to reach their full potential as persons. Policy In principle, refugees with UNHCR cards have access to Maternal and Child Health (MCH) clinics and vaccination services. However, children cannot enter the public education system. The policy related to cost of services at public health care facilities for refugees and asylum seekers respectively apply equally to refugee and asylum seeking children. Evidence Refugee children are confronted with grave risks that run foul of the countrys international legal obligations with regard to the Convention on the Rights of the Child (CRC). In its Concluding Observations to Malaysia in 2007(51), the Committee on the Rights of the Child after evaluating evidence of Malaysias progress with regard to CRC raised the following concerns, all of which have implications for their health, development and wellbeing. Allocating resources for the protection of asylum-seeking and refugee children as a vulnerable group, evaluating, preventing and combating discriminatory disparities in their enjoyment of rights as children in Malaysia, particularly in terms of access to social and health services and education, and the registration of their births
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Abolishing caning and other forms of corporal punishment for those under 18 years of age, as these constitute cruel, inhuman and degrading punishment Taking urgent measures not to detain children for immigration proceedings, unless necessary for their best interests, and then for the shortest time possible Establishing a screening process to identify asylum-seeking and refugee children Developing legislation for the protection of asylum-seeking and refugee children, particularly of unaccompanied children, in line with international standards Using Section 55 of the Immigration Act 1959/63 (Act 155) to exempt asylum seekers and refugees from punishment under this Act, and to amend this Act in order to legalize their status Providing asylum-seeking and refugee children with access to free and formal primary, secondary and other forms of education, and access to official exams for those in informal education Strengthening collaboration with the UNHCR and other agencies to address humanitarian concerns to asylum-seeking and refugee children, including providing access to persons of concern in detention Groups working with refugee children state that the coverage of refugee children with regard to vaccination services is low. Refugee adolescents that HEI has interacted with have shared their worries and anxieties about time lost and life lost in waiting in a limbo like situation in Malaysia. They experience great concern about missing out on education and their ability to build a life for themselves. This has been a contributing factor to their mental anxiety and stress. Just like adults, refugee children have poor access to health education. Preliminary results from a joint study conducted by HEI and the School of Public Health and Tropical Medicine, Tulane University, USA (52), with 114 adolescent refugees attending one Chin (Alliance of Chin Refugees (ACR)) and two Kachin (Kachin Refugee Committee) community schools, showed the following results about aspects of their knowledge on the topics of Sex and Sexual Health.
Table 6: Knowledge of Chin and Kachin Adolescent Refugees on Sex and Sexual Health FREQUENCY QUESTIONS YES NO MISSING Has anyone ever taught you or discussed with you the way 35 76 3 that your private parts function? Do you know how the female fertility cycle works? 14 96 4 Do you know of any ways to prevent an unwanted 40 70 4 pregnancy? Do you know where to go for help if someone forces you to 27 72 15 have sex or physical intimacy with them? Do you think a sex education class giving you the correct information about sex would be useful for you and your 82 24 8 friends? TOTAL 114 114 114 114 114

Challenges 1. It is said that a civilization or a nation is judged on how it treats its weakest and most vulnerable members. Refugee children could be said to belong to this category in Malaysia. The lack of access of refugee children to education, health services, adequate nutrition, recreation and play, and most of all to a normal childhood is yet another morally indefensible situation. It also contravenes Malaysias international obligations via the CRC. The CRC is explicit in the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health
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(Art 24.1). This is yet another area where the State needs to clarify the ethical premises of its actions and their outcomes. 2. Documentation, financial costs and non citizen status are barriers to refugee children having access to much needed vaccination services, health education, primary health care and medical and health services. RECOMMENDATIONS ACCESS TO HEALTH 1. Apply rates paid by Malaysians for public health services to refugees and asylum seekers 2. Allow refugees and asylum seekers the right to work in order that they can finance their health needs and enjoy access to the determinants of health including food, housing, sanitation, and education for their children. 3. Extend the current good practice of having community health worker translators at Hospital Sg Buloh, IPR and PKKN to other hospitals and clinics run by the government in the country to increase information access and facilitate improved communication between the Person of Concern and the health care provider. 4. Simplify procedures and increase access of refugees and asylum seekers to maternal and child health services MENTAL HEALTH In addition to recommendation (3) and general principles on the undesirability of detention of those with mental health needs (55), 5. Waive the deposit of RM 700 required for patients requiring acute in-patient psychiatric care because they are a danger to themselves and to others and need this care 6. Apply the rates for outpatient care paid by Malaysians to refugees and asylum seekers because they require the treatment and do not have the resources 7. Review the policy of arrest, detention and deportation of refugees and asylum seekers for administrative infractions related to immigration offences in line with international guidelines and standards. This is because it has been evidenced that the arrest and detention of refugees and asylum seekers, is not only a barrier to access to health care, but also contributing to mental health morbidity and compromising the effectiveness of therapeutic interventions. Further, international guidelines advice against detention of people with mental health problems. SEXUAL AND GENDER BASED VIOLENCE 8. Waive all deposits and fees so that refugee and asylum seekers who are survivors of SGBV have access to the One Stop Crisis Centres in the country. In addition, refugee survivors of SGBV should be granted legal guarantees that they will not be charged for their undocumented status, will not be refouled and will be granted witness support where necessary. Implementation of such steps would be in harmony with the recommendations of Committee on the Elimination of Discrimination against Women (CEDAW) in its Concluding Comments to Malaysia in May 2006 (31) to adopt gender sensitive programming and laws and regulations that bring about the protection of women refugees and asylum seekers. INFECTIOUS DISEASES 9. Make the testing and treatment for infectious diseases free for refugees and asylum seekers because this is in the interest of the health of Malaysians and is part of the responsibility that countries share with regard to global health challenges
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10. Increase the access of refugees and asylum seekers to culturally and linguistically appropriate prevention programs related to infectious diseases DETENTION HEALTH General principles related to the detention of refugees and asylum seekers: In accordance with accepted international guidelines and standards (53-58) (and good practice): Detention should only be used as a measure of last resort. Where a person is subject to detention, alternatives must first be pursued. No one should be subject to indefinite detention. No one should be subject to arbitrary detention. Conditions of detention must comply with basic minimum human rights standards. Vulnerable individuals - including children, pregnant women, nursing mothers, survivors of torture and trauma, trafficking victims, elderly persons, the disabled or those with physical or mental health needs should not be placed in detention. In ensuring that conditions of detention are protective of the health of detainees, the government must, 11. Improve living conditions of detention centres and set up permanent clinics at immigration detention centres, under the purview of the Ministry of Health. The clinics should be equipped with a full time medical doctor and male and female medical assistants and with adequate facilities to be able to address first line treatment needs of detainees and make referrals for medical emergencies and second line treatment. 12. Include access to NGOs and welfare providers to assist with the broader psychosocial needs of detainees. In this regard, the government is also encouraged to work with international agencies like the International Committee of the Red Cross (ICRC) that have a commitment and capacity to support national efforts to increase the delivery of health services in detention centres. CHILDRENS HEALTH 13. Increase the access of refugee and asylum seeking children to vaccination services, health and other medical services, and, education. 14. Expedite and improve access for registration of births of refugee and asylum seeking children. Implementation of these recommendations would also reflect seriousness of the government of Malaysia in responding to the recommendations of the Committee on the Rights of the Child, 2007, (51) to allocate resources for refugee and asylum seeking children especially for social and health services and education, provide access to free and formal primary, secondary and other forms of education, and access to official exams.
REFERENCES
1. 2. 3. 4. 5. Kennedy P and Murphy-Lawless J. The Maternity Care Needs of Refugee and Asylum Seeking Women in Ireland. Feminist Review. 2003. No. 73. Exile and Asylum: Women Seeking Refuge in 'Fortress Europe'. 3953 Leiter, e. a. Human Rights Abuses and Vulnerability to HIV/AIDS: The Experiences of Burmese Women in Thailand . Health and Human Rights. 2006. Vol. 9, No. 2 , 89-110. Physicians for Human Rights. No Status: Migration, Trafficking, and Exploitation of Women in Thailand. Boston. Physicians for Human Rights. 2004 Purdin S, Khan T, Saucier R. Reducing maternal mortality among Afghan refugees in Pakistan. International Journal of Gynecology and Obstetrics 105 (2009) 8285 Esscher A O. Reproductive health in humanitarian assistance. A literature review. Uppsala. Centre for Public Health in Humanitarian Assistance. International Maternal and Child Health Department for Womens and

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6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

Childrens Health . Uppsala University. 2004. (cited 16 June 2009). Available from: http://www.kbh.uu.se/imch/phha/A%20literature%20review%20AOE.pdf Richard Ater. Mental health issues of resettled refugees. University of Washington. 1988 November 18. [cited 2009 January 31]. Available from: http://ethnomed.org/clin_topics/mental_health.html. Cardozo BL, Talley L, Burton A and Crawford Carol. Karenni refugees living in ThaiBurmese border camps: Traumatic experiences, mental health outcomes, and social functioning. Social Science & Medicine. 2004. 58. 26372644 US Department of Health and Human Services. National Institutes of Health News. PTSD, Depression Epidemic among Cambodian Immigrants. 2005 August 2. [cited 2009 June 02]. Available from: http://www.nih.gov/news/pr/aug2005/nimh-02b.htm. World Health Organization. Ottawa Charter for Health Promotion. First International Conference on Health Promotion Ottawa. 1986 21 November. WHO/HPR/HEP/95.1 General Comment 14 (2000) of the International Covenant on Economic, Social and Cultural Rights, para 11 World Health Organization [Internet]. The right to health. [cited 2009 April 21]. Available at: http://www.who.int/mediacentre/factsheets/fs323/en/index.html. Asher Judith. The Right to Health: A Resource Manual for NGOs. New York, USA. HURIDOCS, COMMAT, AAAS. 2003 Landau LB. FMO Research Guide: Urban Refugees. 2005? [cited 2009 April 18]. Available from: http://www.forcedmigration.org/guides/fmo024. Migration Working Group (MWG). A joint submission by members of the Migration Working Group (MWG) and the Northern Network for Migrants and Refugees (Jaringan Utara Migrasi dan Pelarian, JUMP) for the 4th Session of the Universal Periodic Review. 2009 Feb. US Government Bureau of Democracy, Human Rights, and Labor. Country Reports on Human Rights Practices -2006. 2007 March 6 [cited 2009 June 16]. Available from: http://www.state.gov/g/drl/rls/hrrpt/2006/78780.htm. Health Equity Initiatives (HEI), Rapid Appraisal of Needs of Afghan Refugees in the Klang Valley Malaysia. Forthcoming 2009 Health Equity Initiatives (HEI), Participatory Action Research on Access of Refugees from Burma to Health Care Services in the Klang Valley Malaysia. Forthcoming 2009 UNHCR. [Internet]. Refugees and health care. [cited 2009 April 21] Available from: http://www.unhcr.org.my/project/unhcr/theme/images/swf/refugeesinmsia.swf. Mdecins Sans Frontires (MSF). We are worth Nothing. Refugees and asylum seekers in Malaysia. 2007 [2007; cited 2009 April 21] Available from: http://www.msf.org/source/countries/asia/malaysia/2007/MSFbriefingpaper.pdf Czech mission funds mobile health care project for refugees in Malaysia. [cited 2009 April 21] Available from: http://reliefweb.int/rw/rwb.nsf/db900sid/EGUA-74JPVZ?OpenDocument. Johnson J L, Bottorff J L, Browne A J, Grewal S, Hilton B A, Clarke H. Othering and Being Othered in the Context of Health Care Services. Health Communication, 2004, Vol. 16, No. 2, Pages 255-27 Balasundaram S. UNHCR. Refugee health. 2009 Teresa Kok. Shrink numbers bad 4 health. 2007 [updated 2007April 23; cited 2009 June16]. Available from: http://teresakok.com/2007/04/23/shrink-numbers-bad-news-for-mental-health/ Health Equity Initiatives (HEI). Counseling and Case Files. 2008-2009 World Health Organization (WHO). Mental health of refugees, internally displaced persons and other populations affected by conflict. [cited 2009 January 31] Available from: http://www.who.int/hac/techguidance/pht/mental_health_refugees/en/. UNHCR. Refugees and HIV/AIDS. Executive Committee of the High Commissioner's Programme 20th Standing Committee Meeting. 2001. 15 February WHO. Reproductive health during conflict and displacement: A guide for programme managers. Geneva. 2000 WHO/UNHCR. Clinical Management of Rape Survivors: Developing Protocols for use with Refugees and Internally Displaced Persons. Geneva. 2004 Brigitta Vega Leyton. SGBV Review-2008. 2009 March. Brigitta Vega Leyton. SGBV incidents reported in 2008 to UNHCR Malaysia: Registered and Unregistered. 2009 March. Committee on the Elimination of Discrimination against Women. Thirty-fifth session Concluding comments of the Committee on the Elimination of Discrimination against Women: Malaysia. 2006 15 May-2 June Speigel, e. a. UNHCR, HIV/AIDS, and Refugees: Lessons Learned. Forced Migration Review. 2004; Vol 19. 21-23. International HIV/AIDS Alliance. Good practice update. Community based HIV testing and HIV treatment as prevention. 2009. June UNAIDS. Intensifying HIV/AIDS prevention. UNAIDS policy position paper. 2005 August.

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35. Schlein L. US Preparing for Possible H1N1 Swine Flu Pandemic. [2009 19 May; cited 2009 June 20]. Available from: http://www.voanews.com/english/2009-05-19-voa16.cfm 36. World Health Organization. Pandemic influenza preparedness and mitigation in refugee and displaced populations. WHO guidelines for humanitarian agencies. Second edition. Geneva, 2008. [cited 2008 20 June]. Available from: http://www.who.int/diseasecontrol_emergencies/HSE_EPR_DCE_2008_3rweb.pdf 37. National Strategic Plan on HIV/AIDS-Malaysia 2006-2010 38. Burton A. UNHCR. Brief Background: Refugee Inclusion in GFATM Submission for HIV. 2009 39. Health Equity Initiatives. Reports of TB clinics and education sessions 17-09-2008; 07-10-2008; 10-102008; 2008. 40. World Health Organization. HIV/AIDS challenge. 2000 [2000 March; cited 2009 June 18]. Available from: http://www.searo.who.int/EN/Section980/Section1162/Section1167/Section1171_4754.htm 41. Saberi Roxana. The Stanley Foundation. No Boundaries. Managing The HIV/AIDS Pandemic. [cited 2009 June 18]. Available from: http://vps.stanleyfoundation.org/initiatives/un21/resources/securitycheck/combating_hiv.php 42. General Comment 14 (2000) of the International Covenant on Economic, Social and Cultural Rights, para 34 43. Sabapathy K for Radio Australia. Malaysia detention centres 'violating rights' (updated 2009 May 28; cited 2009 June 20]. Available from: http://www.abc.net.au/news/stories/2009/05/28/2583663.htm 44. Migration Working Group. Joint Statement on RELA Taking Over Immigration Detention Centres. 2007, 7 December. 45. International Federation for Human Rights (FIDH) and Suara Rakyat Malaysia (SUARAM). Undocumented migrants and refugees in Malaysia: Raids, Detention and Discrimination. 2008 March 46. Migration Working Group. Deaths and Conditions of Detention of Migrants and Refugees. 2009 24 April. 47. SOALAN NO : 109. PEMBERITAHUAN PERTANYAAN BAGI JAWAB LISAN DEWAN RAKYAT. PERTANYAAN : LISAN. DARIPADA TUAN LIEW CHIN TONG (BUKIT BENDERA). TARIKH 16 JUN 2009. RUJUKAN 1768 48. Feldbaum H, Lee K, Patel P. The National Security Implications of HIV/AIDS, PLoS Medicine 3. 2006 no. 6. 774-78. 49. Verghis S and Conda E. Jakarta Process. Draft Report Traversing spaces of power. The role of national human rights institutions in the protection and promotion of human rights of migrants with irregular status and migrant domestic workers. Forthcoming 2009. 50. Asian NGOs Network on National Human Rights Institution (ANNI). Monitoring Report on the Performance of National Human Rights Institutions. 12th Annual Meeting of the Asia Pacific Forum of National Human Rights Institutions (APF). Sydney, Australia. 2007 24 27 September. 51. Committee on the Rights of the Child. Consideration of Reports Submitted by State Parties Under Article 44 of the Convention. Concluding observations: MALAYSIA. CRC/C/MYS/CO/1. 2007 25 June. 52. Aucoin V and Rudberg L. Knowledge of Adolescent Refugees on Sex and Sexual Health. Health Equity Initiatives (HEI) and Tulane University, School of Public Health and Tropical Medicine. Forthcoming 2009 53. UNHCR. Selected documents relating to detention. 2009 February. 54. UNHCR. Alternatives to Detention of Asylum Seekers and Refugees. Legal and protection policy research series. Division of international protection services. POLAS/2006/03. 2006 April 55. UNHCR. UNHCR Revised Guidelines on Applicable Criteria and Standards relating to the Detention of Asylum Seekers. 1999 February. 56. International Detention Coalition. Children in Immigration Detention. Position Paper. [cited 2009 June 22]. Available from: http://idc.rfbf.com.au/wp-content/uploads/2009/01/childrenpositionpape.pdf 57. International Detention Coalition What is immigration detention? [cited 2009 June 22]. Available from: http://idc.rfbf.com.au/aboutus/what-is-detention/ 58. E/CN.4/2003/85. 30 December 2002. SPECIFIC GROUPS AND INDIVIDUALS MIGRANT WORKERS Report of the Special Rapporteur, Ms. Gabriela Rodrguez Pizarro, submitted pursuant to Commission on Human Rights resolution 2002/62. [cited 2009 June26]. Available from: http://www.unhchr.ch/Huridocda/Huridoca.nsf/TestFrame/3ff50c339f54a354c1256cde004bfbd8?Opend ocument.

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