No longer a place of refuge

In August 2010 the MV Sun Sea arrived off the coast of British Columbia carrying 492 Tamil men, women, and children. Less than a year earlier, in October 2009, 76 Tamil refugees arrived in British Columbia onboard the MV Ocean Lady. Passengers on both ships were fleeing war-torn Sri Lanka and claimed asylum upon arrival. At the same time, the number of Roma refugee claimants escaping persecution and discrimination in Eastern Europe increased to record levels.

In response to these mass arrivals, the government introduced a series of Bills that culminated in Bill C-31, the Protecting Canada’s Immigration System Act.¹ These reforms included many measures designed to deter asylum seekers, such as an expedited review process, denial of an appeal process, and increased wait times for citizenship and sponsorship of family members for some refugee claimants. These measures, combined with other government policies that substantially reduced health insurance for refugee claimants, have sparked a mass outcry from many professional organizations and civil society groups.

Also included in Bill C-31 is a controversial provision for mandatory detention of those refugee claimants designated by the Minister of Public Safety as “irregular.” This designation includes those for whom determining identities in a timely manner would be difficult, those suspected of criminality, or those suspected of having been smuggled into Canada.

Mandatory detention poses a serious threat to the health of refugee claimants, and such policies, which punish some of the world’s most vulnerable populations, are worrisome. Primary care physicians are frequently the first points of health care access for new immigrants and refugees. It is therefore important that we have a strong understanding of the negative effects of detainment, both to improve care for our patients, and to advocate for more responsible policies.

Refugee detention internationally

Detention of refugee claimants has been enacted in many developed regions, including Australia, the United States, and the European Union. Such policies have been roundly criticized.^2,3 In the United States, for example, civil society groups have denounced detainment conditions, while more than 100 detainees have died in custody since 2003, often due to neglect of their health needs.² For example, many such instances have been documented in which medical staff ignored women’s emergent health concerns and provided no access to routine medical care.⁴

In the Australian context, several medical organizations have voiced concerns since mandatory detention, including for children, was initiated in 1992.^5,6 In 2008, the Australian government acknowledged the damage that detainment inflicted on refugees. It called for detention only as a last resort, as well as an end to detention for children and improvement of conditions within detention facilities.

Detention and mental illness

Mental illness has emerged as the most striking health sequela of refugee detention. As a result of trauma in their country of origin, many asylum seekers experience considerable psychological distress,⁷ and there is accumulating evidence that detention is exacerbating the mental health difficulties of these already vulnerable and traumatized populations.⁸

Studies of asylum seekers in detention have shown markedly increased rates of major depressive disorder, posttraumatic stress disorder, suicidal thoughts, and self-harm, compared with asylum seekers not in detention.^9–11 Despite considerable pre-migration trauma, most detained asylum seekers identify detention itself as the source of their mental illness.¹¹ These mental illnesses are unsurprising given that asylum seekers have characterized detention as a dehumanizing environment of confinement, deprivation, isolation, fractured relationships, injustice, hopelessness, and a lack of agency.¹² This is compounded by a frequent lack of access to counseling and psychiatric services in many detention settings.⁴

The experiences of children in detention are of particular concern. While legislation officially precludes detention of minors younger than 16 years of age, recent reports indicate that the detention of children in Canada is commonplace.¹³ Parents placed in detention have the choice of placing their children with child protection agencies in a country that is foreign to them or having their children accompany them in detention. Detention is a traumatic environment for children; they regularly witness violent riots, violence against detainees, and suicide attempts, while also experiencing isolation and occasional separation from caregivers.^3,9,10 These experiences take a severe toll on pediatric mental health.⁹ Despite low levels of mental illness before detention, rates of mental illness among children in detention are exceedingly high.⁹ Language delays, behavioural problems, emotional numbing, depression, sleep problems, and weight loss are all common among children in detention.^9,14 One parent reported that her child “didn’t know how to play” as a result of being in detention.¹⁰

Infants are not immune to the psychological effects of detention; indeed they have shown signs of detachment disorder, in particular in the presence of parental mental illness.¹⁰ This lack of high-quality parenting is an important concern, with many parents believing that they can no longer support or care for their children owing to their own mental instability.⁹

Considerations for health care providers

Family physicians are usually the first point of health care contact for refugees entering Canada. Many refugee claimants will be provided permanent protection and will eventually become Canadian citizens. It becomes imperative for family physicians to be aware of the potential health effects of previous detention when treating such individuals in order to provide sensitive, effective, and comprehensive care.

Furthermore, physicians working in the detention system might need to critically analyze their role in providing care for detainees. Some commentators have pointed out the inherent conflict between the responsibility of the physician to provide care to those in detention, and the fact that treating patients within a system that harms patients’ mental health might make physicians complicit in such a system.¹⁵

Finally, as primary care providers we should continue to emphasize our roles as health advocates by using our experience and influence to comment on the health consequences of public policies. Several medical organizations in other jurisdictions have expressed their concerns regarding the damaging effects of detention. The Australian Medical Association recognized in a position statement that prolonged detention violated basic human rights and contributed adversely to health.⁵ The Australian Psychological Society has also recognized the detrimental effect of detention on mental health and has committed to advocating for the removal of such “unjust policies.”⁶ In Canada, the Canadian Bar Association has made a strong statement denouncing Bill C-31, calling certain provisions “unconstitutional and in violation of Canada’s International obligations,” while also stating that “detention is punitive and criminalizes certain refugee claimants … without regard to the genuineness of their need for protection.”¹⁶ As Canada proceeds with the use of detention for refugee claimants, Canadian associations of health care providers, such as the Canadian Medical Association and the College of Family Physicians of Canada, might want to follow suit. These organizations have already come out strongly against cuts to refugee health coverage and are ideally placed to make similar statements against mandatory detention that would lend considerable support to the growing opposition to these measures.

Healthier alternatives to detention

Unconditional release should always be the starting point against which the safety, humanity, necessity, and legality of all forms of refugee detention and monitoring should be evaluated. Nevertheless, there are many alternatives to detention for the purpose of establishing identity or assessing security concerns with the potential for far fewer negative health effects. These include supervised release into the community, reporting requirements, provision of transitional housing, and bail conditions.¹⁷ While the mental health outcomes associated with these alternatives have yet to be thoroughly studied, the opportunities for increased family unity, sense of autonomy, increased access to health care, and integration into the community would presumably lead to great improvement. Many case studies of these alternatives have also demonstrated substantial cost savings compared with conventional detention, and high rates of compliance with asylum procedures.^2,17

Conclusion

Mandatory detention has been repeatedly demonstrated to negatively affect the mental health of refugees. From infants to adults, time spent in detention has been associated with posttraumatic stress disorder, depression, suicide, self-harm, and impaired child and infant development, among other detrimental consequences. Given this evidence, it seems ill-advised to implement mandatory refugee detention in Canada, especially when similar policies have been abandoned in international contexts in favour of healthier, more humane, and more economical alternatives.

Primary care physicians have a responsibility to develop an awareness of these health sequelae in order to provide effective and sensitive care as patients navigate their transitions into the community. There is also a strong precedent for public position statements by medical bodies expressing concerns regarding refugee detention, and Canadian medical organizations should consider developing their own statements. As health advocates we must continue to be vigilant and critical of policies such as Bill C-31 that have clear links to poor health outcomes for some of the world’s most vulnerable populations.