19 September 2018

The health impacts of living in asylum limbo

Government Mental Health

Doctors working with asylum seekers living in the community say uncertainty and poverty are stopping trauma victims from recovering and causing healthy people to sink into despair.

For the more than 12,000 asylum seekers living in Australia, the limbo state of waiting years for resolution of their status is acknowledged as a cause of depression and anxiety, seen in this group more frequently than among other refugees.

Dr Mark Harris, a professor of general practice at the University of NSW who volunteers as a GP at the Sydney Asylum Seekers Centre in Sydney, says he has known asylum-seeker patients to wait as long as a decade for a decision.

“If you’re in that situation, and next week you might be forced to go back to your country, where you’ll be in fear for your life, that’s a pretty terrible way to live. You can’t get on with doing things that normal people get on with,” Dr Harris said.

“It has a particular impact on people who don’t have work rights and are dependent on any kind of government handouts – and recently there has been a real reduction in the number of people who get any kind of benefits from the government, which has meant the number of people who are just surviving are really struggling.”

The inability to make plans for themselves or their families left asylum seekers feeling helpless and magnified mental health problems, particularly people suffering from post traumatic stress disorder (PTSD).

“For people who already have PTSD, it is so very unhelpful. They’re unable to move on and also move past the traumatic experience that have happened to them,” Dr Harris said.

“The problem with PTSD is that people don’t just remember trauma but they re-experience it.”

Anxiety also impaired their performance at interviews, he said.

“Because they tend to be anxious at interviews, the remember things less well. One of the problems of anxiety and depression and PTSD is that it messes with your memory. So people will often give quite confused accounts of what has happened to them. If they are undergoing immigration interviews, that is interpreted as perhaps (a sign of) a false story, with immigration people not feeling their story is credible.”

Under plans foreshadowed last year by the Department of Home Affairs, the government is slashing assistance for asylum seekers under the Status Resolution Support Services (SRSS) program, which allowed them $247 a week – about $35 a day – and access to trauma counselling.

Staged reductions in the SRSS program are already under way, targeting single people first, with the aim of cutting the number of recipients by more half from last year’s roll of 13,000.  People in full-time study judged able to work have also been cut off.

Refugee advocates and social service groups have been petitioning Home Affairs Minister Peter Dutton to reconsider the consequences of stripping thousands more people of their meagre income support, especially families with children.

“A preventable humanitarian crisis looms in our communities across Australia: this government-created crisis will see people in our neighbourhoods, schools and communities thrown on to the streets,” Refugee Council of Australia CEO Paul Power said.

He said the decision affected people who might have years to wait for a visa outcome and was a “calculated cruelty” that denied their human rights and dignity.

Doctors agree that the policy is ramping up anxiety.

Dr Harris said some asylum seekers now living in the community on temporary bridging visas had been in detention and developed long-term health problems, reducing their ability to find and stay in work.

“Even though some people have work rights where they didn’t have, it’s not as though they can just walk into a job,” he said, adding many employers were not interested in hiring workers on temporary visas.

Dr Joanne Gardiner, a Melbourne GP with a special interest in refugee mental health, said patients were already struggling to survive by relying on NGOs and community charities while awaiting court and tribunal decisions.

“The trauma is bad enough – the nightmares, the flashbacks, the panic, the hypervigilance, the intrusive memories of the past – it is bad enough without living in dire poverty or worrying about being homeless,” Dr Gardiner told The Medical Republic.

Dr Gardiner said asylum seekers’ sense of safety also suffered because of guilt about family left behind.

“You have people who have come here to try to get a visa so they can bring their family. Then the whole thing is ripped apart because their visa is denied, the guilt and grief about people depending on them is enormous. The sense of failure,” she said.

“But the worst thing, really, for people is the uncertainty. They are waiting and waiting to be called to an interview and then they often wait quite a long time to get the outcome.”

One patient had waited five years and still had not had an interview to be determined as an asylum seeker.

“In the community, he is a particularly charming, delightful, well-resourced young man who is unfailingly courteous and polite. But because of the grind of living in limbo and not having seen his family for so long – he’d had had one parent die and the other is ill – I had to refer him to a psychiatrist,” Dr Gardiner said.

“He felt so low he said he wished the government would send him to Manus Island, where he would die.

“I often think what we do is helping people to endure the unendurable. And then we are part of the system that is promoting the unendurable, which is really awful,” she said.

In the United States, doctors and social workers have described government policy that induces uncertainty as a form of “structural violence” used to deter undocumented migrants and overstayers, such as denying family reunification and changing the rules around their status.

A recent article in the New England Journal of Medicine said officials of the US Immigration and Customs Enforcement service were commonly targeting free health clinics and schools in attempts to catch suspected illegal or undocumented migrants.

This not only led people to avoid healthcare, sometimes with dire consequences, but added to the mental health burden of the refugee and immigrant community, the authors said.

“Whereas uncertainty is deterring some immigrants and refugees from seeking health care, among those who already have established relationships with a clinician, we are seeing substantial increases in the numbers of patients seeking care for symptoms related to post-traumatic stress disorder — especially refugees who have survived torture,” they wrote.

While asylum seekers in Australia experience nothing like that level of persecution, access to Medicare is not available to many asylum seekers. Even when they do have Medicare, the system does not allow a doctor to bill for the use of an interpreter, which can make a consultation twice as long.

GPs working pro bono at NGOs, hospital clinics and an array of small community groups and charities carry the load.

Meryl Jones, the nursing unit manager at the Mater Refugee Complex Care Clinic in Brisbane, which cares for refugees and asylum seekers, said burnout could be a risk for health professionals in this line of work.

“It takes a toll on the patients, and there’s a toll on health professionals as well. That’s another unseen cost of all of this. People being traumatised vicariously by listening and knowing what they need to do for these patients but they can’t.  It’s a very difficult situation.”