Refugee Children_Rights and Wrongs

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VIEWPOINT

Refugee children: Rights and wrongs

Karen Zwi1 and Gervase Chaney2

1Community Child Health, Sydney Childrens Hospitals Network, Sydney, New South Wales, and 2Postgraduate Studies, Princess Margaret Hospital, Perth,

Western Australia, Australia

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

conflict 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) fulfilment of Refugee Con-

vention 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 interna-

tional standards and include housing support and case manage-

ment for 6 months, 520 h of English lessons, and access to

Medicare, public school enrolment and Centrelink benefits con-

sistent 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 flown 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 com-

munity despite the lower likelihood of being granted refugeestatus (around 44%).5

Are Increasing Numbers of Refugees andAsylum 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 Con-

vention applies mainly to our obligation to those arriving and

seeking protection and does not need to be related to our vol-

untary 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

Correspondence: Associate Professor Karen Zwi, Community Child

Health, Sydney Childrens Hospital, CNR Barker and Avoca Streets, Rand-

wick, Sydney, NSW 2090, Australia. Fax: +612 9382 8188; email:

[email protected]

Declaration of conflict of interest: None declared.

Accepted for publication 30 December 2012.

Humanitarian/Refugee(N=60006500 per year)

Fig. 1 The refugee program in Australia.

doi:10.1111/jpc.12101

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around 280 000, 210 000 and 156 000 asylum claims respec-tively 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 Paki-

stan, 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 Pacific

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-certified 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 Pacific Solution, as

well as increasing the quota to 20 000 places. Children and

unaccompanied minors are not excluded from offshore process-

ing 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 unac-

companied minors, extremely harsh conditions and potentially

unlimited detention.10

These strategies have reduced the refugees right to appeal

and to family re-unification and have made it easier for Aus-

tralia to return people to their country of origin or anothercountry, which is against the fundamental principle of non-

refoulement (non-return) espoused by the Refugee Convention

(Article 33). Although mandatory detention is cited as a deter-

rent to asylum seekers, its deterrent effectiveness has been ques-

tioned by government officials.11 Although difficult 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 manda-

tory detention in unusual circumstances, but are usually given

Bridging Visas while being processed in the community. Deten-

tion has no defined upper time limit and individuals are not able

to challenge their detention in a court of law. There are cur-

rently 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

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.

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Since 2009, the numbers in detention have increased dra-

matically 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


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The most significant human rights issue specific to unaccom-

panied minors, highlighted in multiple inquiries and reviews, is

that the legal guardian for unaccompanied children is the Min-

ister 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 deten-

tion, which effectively denies the childs rights to protection

from arbitrary detention, provision of appropriate services and

participation in decisions affecting him/her?

Another concern regarding unaccompanied minors is place-

ment. 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 Suda-

nese 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.

Fig. 4 Refugee children line up for a meagre

handout of rice at their refugee camp in Monro-

via. 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 per-

mission Newspix / News Ltd.



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After 1218 months, 95% were attending school and felt sup-

ported, 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 edu-

cation as a source of hope for the future, but have becomedespondent at the practical difficulties 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-specific resilience building programs, access to

learning vocational skills and support to integrate into the main-

stream 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 reunification anddetention 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 Com-

mission 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 reportis heavily critical of the use of wrist X-rays in age determination

as well as the Commonwealth Department of Public Prosecu-

tion, 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 confirmed as minors released from

prison and returned to Indonesia.

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 sys-

tematically.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 practi-

tioner and specialist services alike. Even more challenging is the

provision of long term family-centred care after initial screen-

ing. There are also few services routinely evaluating child devel-

opment 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-

ous journeys or experienced disappearance of family mem-

bers.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 methodol-

ogy and appropriate cross-cultural tools.30 Nonetheless, what we

do know is that service utilisation is low and, although accessissues may play a role, it appears that refugee children display

high levels of resilience and low levels of dysfunction.27,28 High-

quality 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 hepatocel-

lular carcinoma, liver failure and cirrhosis, but this is unlikely

to occur in the absence of cost effectiveness and feasibilitystudies.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 Workforceparticipation is higher than Australian born citizens for first-

generation 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 official policy docu-

menton the health of refugee children at the CollegeConference

in 2007.24 Medications commonly used in refugee populations

(such as vitamin D, some antimalarials, praziquantel for schisto-

somiasis, ivermectin for Strongyloides and terbinafine for fungal

scalp infection) were included on the Pharmaceutical Benefits

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 theCollege in thefederal 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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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 official 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 usedto 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.

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 inOctober 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 collec-

tion and research. Many local jurisdictions have highly effective

programs targeting refugee engagement in art, sport, employ-

ment, 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 Makea Difference?

Health professionals can contribute to improving health out-

comes 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 pri-

oritise 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 filling 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 flexibility 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

bodies and practitioners need to engage in widespread public

campaigns supported by the media.

What Would We Implement, If We Hadthe 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 minorswith 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 refu-gees are generally resilient and resourceful populations who

have fledin extremecircumstances. 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 andachieve what many seem highly motivated to

do: access purposeful education and training, find employment,

optimise health and contribute to Australian society?

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