THE HEALTH OF TEMPORARY PROTECTION VISA HOLDERS

by Dr Mitchell Smith

Director of the NSW Refugee Health Service,DR MITCHELL SMITH, reports on the health issues facing refugees on Temporary Protection Visas.

‘Khaled’ sits disconsolately in front of me, describing how he was the first asylum seeker arriving in NSW to be given a Temporary Protection Visa (TPV). A wry smile crosses his face when he refers to his “luck”: but for the stroke of a pen changing policy, or arrival a few days earlier, he would now be a permanent resident here, like those refugees coming before him. Instead, doubts linger about being returned to Iraq and to the threat of lifetime imprisonment, beatings, and perhaps worse.
‘Khaled’ is lucky in one way in that he is in reasonably good health. Some of his colleagues are not so lucky. TPV holders have the same cross-section of health problems as others of refugee-like background. Psychological distress is common, sometimes with significant impacts on daily functioning. A mix of poor nutrition, lack of dental hygiene, limited oral health care and physical trauma frequently contribute to severe dental disease. The management of chronic conditions such as diabetes has often been interrupted. Those who have endured overcrowded and unhygienic conditions whilst fleeing may have been exposed to tuberculosis (TB) and other infectious diseases. TB in particular can lie dormant and undetected for many years, only to cause illness and a risk of infection for others much later.

One additional factor for TPV holders is that by definition they have been through the processes of mandatory detention and assessment of their claim for refugee status. A number of key agencies and researchers have expressed the view that detention is likely to be detrimental to the health of already traumatised people, particularly if prolonged(see reference notes 1 to 3). Additionally, fear of being returned to the country they’ve fled whilst awaiting the refugee determination process may also be psychologically damaging to asylum seekers.

So what do we know after the first 12 months of working with “TPVs” (or “785’s”, the DIMA visa category) as they’re now known? Some of the following has been gleaned from service providers in NSW (where there are now around 1,000 TPV holders residing). In addition the Refugee Council of Australia has recently documented health and other issues for TPVs from workers around the country.
Firstly, there are some positives, although qualified. Under revised regulations, full Medicare eligibility is now automatic for holders of a 785 visa. However, delays of six weeks or more have been experienced because applications had to go through State Head Offices of Medicare rather than being processed at the local branch. This situation appears to be improving at the time of writing this article.

Other problems have arisen from the practice of Medicare cards being issued for a three month period only; each re-issue of a card has meant an unnecessary period without access to health services. The cards are also blue in colour and are stamped “interim”. Both features are likely to cause confusion to administrative staff on the ground in health services with subsequent delays in, or denial of, access to care.

The second positive feature in terms of health care is ability to access the Early Intervention Programs which exists in almost all states and territories, funded by DIMA and run by the local torture & trauma services. This at least provides an opportunity for an overview of major psychological and other health problems, for which assistance can be sought. Unfortunately though, where there are more fundamental issues affecting well being such as inadequate housing, limited income support and poor English language skills, the referral options to assist with these are very few. This is due to government restrictions on the level of services that can be provided to these temporary residents.

And the negatives? Apart from the issues alluded to above, certain pervasive features of the temporary protection regulations are likely to be detrimental to the psychological well being of those affected. In particular, the uncertainty of outcome at the end of three years, and the inability to have any family join them in Australia, are mentioned again and again by those working with TPV holders. Those I have seen sit in their chairs weep at the thought of their wives (most TPV holders are men) and children that they have left behind. They are without any real prospect of seeing them for three years or more. They feel sorrow, loss, guilt, fear. Difficulties that TPV holders may have with anxiety, sleep disturbance and the like resulting from refugee trauma, may well be exacerbated by their worries about their family and their own future. Even if not made worse, these and other psychological symptoms are unlikely to resolve under such ongoing tension.
Some workers have described evidence of inadequate levels of health care provided in the detention centres, and problems caused by the lack of medical records relating to care given there (see reference 4). Concerns about the level of medical and dental care in our detention centres have certainly been raised before (see reference 2) . One problem appears to be inadequate communication between administration in the centres and health staff on site: in some centres the latter are not informed when detainees are to be released, and have no way of arranging medical follow-up.

The high level of dental and gum disease seen by myself and others reflects the poor oral health of refugees in general. Private dental care is out of the question for most due to the cost. Access to public dental services in most states is problematic in terms of waiting times, although in some states and territories there are systems to facilitate early dental health assessment and treatment for refugees. Those without access to appropriate care are at risk of ongoing discomfort, difficulties with eating and speech, and other complications.

Another phenomenon, reported anecdotally thus far, is that some men arriving by boat having transited in Indonesia or elsewhere have put themselves at risk of sexually transmitted diseases in those countries. Whilst some of these conditions are easily treated, others may lie dormant - including HIV infection. And although testing is compulsory as part of the immigration process, there is a window period after exposure whereby those infected may not test positive for three months, or (rarely) even longer. In a sub-group of the population that may normally be regarded as low risk (given their countries of origin and usual mores) and who are known to have had an HIV test on entry, this diagnosis could be easily overlooked in the future.

To finish, another case, ‘Mudaliyar’ from Sri Lanka. He was referred to me by STARTTS for help with a number of physical health problems. All of these related to his mistreatment over many long years by those accusing him of political activities. He’d suffered multiple arrests and beatings; torture - (physical, psychological, and sexual); injuries to his limbs, teeth, skin, joints, and other body parts. Never have I listened to a more horrendous depiction of what one human being can do to another. He endured that and survived. He endured clandestine travel to get here, then months in detention, and the fear of being sent back. Then, finally, release to freedom but not really: his wife and young child still in Sri Lanka, still at risk. And his own future still uncertain. The tears filling his eyes said it all.

References
1. Amnesty International. Australia - A Continuing Shame: the Mandatory Detention of Asylum Seekers. June 1998.
2. Human Rights & Equal Opportunity Commission. Those who’ve come across the seas - report on Mandatory Detention of Asylum Seekers. 1999.
3. Silove, D.& Steel, Z. The Mental Health and Wellbeing of On-shore Asylum Seekers in Australia. Psychiatry Research and Teaching Unit, UNSW 1998.
4. Refugee Council of Australia. Temporary Protection Visa Holders: Current Issues and Future Concerns. August 2000.

This article has been adapted from one written for the newsletter of the Ecumenical Migration Centre, Victoria.