HEALTH KNOWLEDGE SOCIETY (HKS)

THEME II:POPULATION, SOCIETY HEALTH AND ILLNESS Med1100/1200

Semester 1

TOPIC PAGE

Who is a refugee & asylum seeker 2

Global statistics 3

Camp based & urban refugees 4-5

Phases of refugee journey & health risks

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Refugee protection in Malaysia 7-8

Concepts related to migrant healthcare & the professional practice of medical ethics

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Communicating with refugee patients

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Test your understanding 13

This E-Book needs to be read in tandem with the lecture videos and the required reading.

Dr. Sharuna Verghis

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A REFUGEE IS A PERSON

• Who has a well-founded fear of persecution on grounds of race, religion, nationality, membership of a particular social group or political opinion.

• Whose own State or government is unable or unwilling to protect them.

• Who has crossed an international boundary.

• Who is unable to return durably to their country of origin.

Art 1(A)(2) of the UN Convention Relating to the Status of Refugees 1951 and Protocol Relating to the Status of Refugees 1967

One who is seeking international protection but whose status has not yet been determined

UNHCR, 2008

Watch this to know more about refugeeshttps://www.youtube.com/watch?v=GvzZGplGbL8

3 UNHCR, 2020

UNHCR, 2020

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CHARACTERISTICS OF A REFUGEE CAMP

• Segregation from the host population

• The need to share facilities

• A lack of privacy

• Plus overcrowding and

• A limited, restricted area within which the whole compass of daily life is to be conducted

HEALTH OUTCOMES IN REFUGEE CAMPS DEPEND ON

• Accessibility to health services, skilled health professionals & medication

• Distance, transportation and referral linkages to secondary/tertiary care

• Hours of operation of services

• Functional laboratory facilities

• Attitudes and behaviors of health workers

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• Do not live in camps

• Are dispersed among the urban poor in cities; but unlike, the urban poor, they cannot return to their country of origin durably

• Do not get systematic assistance of camp based refugees from UNHCR or the international community

• Face several protection challenges

URBAN

REFUGEES

Table-1: TOP COUNTRIES HOSTING REFUGEES AND ASYLUM SEEKERS IN URBAN AREAS @ Dec 2016

Refugees Asylum Seekers TotalEstimated Percentage

Outside CampsLebanon 1,012,969 13,745 1,026,714 100

Germany 669,482 587,346 1,256,828 100

Malaysia 92,054 56,311 148,365 100

Egypt 213,530 49,877 263,407 100

India 197,851 9,219 207,070 100Iran 979,435 91 979,526 97

Turkey 2,869,421 245,955 3,115,376 90

Jordan 685,197 35,615 720,812 79

Pakistan 1,352,560 4,856 1,357,416 67

Iraq 261,888 11,458 273,346 61***

Kenya 451,099 43,764 494,863 12.5

Thailand 106,447 5,010 111,457 7.5

Uganda 940,835 41,880 982,715 2.2

Verghis & Balasundaram, 2019

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COUNTRY OF ORIGIN

FLIGHT

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ARRIVAL / ASYLUM•

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VOLUNTARY REPATRIATION &

REINTEGRATION

RESETTLEMENT

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As of end March 2021, there are some 178,920 refugees and asylum-seekers registered with UNHCR in Malaysia.

Some 154,350 are from Myanmar, comprising some 102,560 Rohingyas, 22,430 Chins, and 29,350 other ethnic groups from conflict-affected areas or fleeing persecution in Myanmar.

The remaining individuals are some 24,570 refugees and asylum-

seekers from 50 countries fleeing war and persecution, including some 6,620 Pakistanis, 3,670 Yemenis, 3,270 Syrians 3,230 Somalis, 2,640 Afghans, 1,710 Sri Lankans, 1,210 Iraqis, 750 Palestinians, and others.

Some 68% of refugees and asylum-seekers are men, while 32% are women. There are some 45,720 children below the age of 18.

• Immigration law (Act 1959/1063) does not distinguish between refugees and undocumented persons. As such, under the law, they are considered “undocumented’.

• No legislative or administrative framework for protection of refugees.

• Children cannot attend mainstream school.

• No formal right to work.7

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The healthcare policies related to refugees and asylum seekers in Malaysia include healthcare policies related to non-citizens in general and healthcare policies related to refugees and asylum seekers specifically.

COST

With regard to healthcare policies related to non-citizens, all non-citizens pay an unsubsidized higher fee in public healthcare facilities compared to citizens.

Check out this link for information on the difference in fees for citizens and foreigners in public healthcare facilities:

http://www.hkl.gov.my/index.php/advanced-stuff/hospital-charges.

However, refugees and asylum seekers get a 50 percent discount off foreigners’ rates. But, this is also unaffordable because of the precarity of livelihood arising from the absence of the formal authorization to work.

MEDICATION

With regard to non-citizens, prescriptions are restricted to a five day supply from government hospital pharmacies in public hospitals, This policy especially limits access to care for those with chronic diseases.

In principle, while refugees are exempted from this policy, asylum seekers are bound by the terms of this policy. However, in practice, enforcement of this directive is mixed. As a result, sometimes, some refugees are not given medication for more than five days, while

at times, some facilities dispense medication for more than five days for asylum seekers.

UNDOCUMENTED STATUS

Additionally, there is a directive, 2001 Bil(1)dlm.KKM/62/BPKK(AM)/Pel-22-Garispanduan melaporkan pendatangtanpa izin yang mengdapatkanperkhidmatan kesihatan di hospital dan klinik kesihatan, which requires hospital personnel to report undocumented persons obtaining health services at public hospitals.

The implementation of this directive has been mixed.

Nevertheless, rights groups cite it as a source of fear impeding healthcare accessibility for refugees, while members of the medical and health community opine that it could constitute the phenomenon of’ ‘Dual Loyalty’.

Additionally, citing the compromise of good public health practice which requires a whole of society approach in controlling disease transmission, a ‘Don’t ask Don’t Tell Approach’ and ‘Firewalls’ are suggested as good public health policy.

https://www.unhcr.org/en-my/public-health-in-malaysia.html?query=refugee%20healthcare%20Malaysia

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Dual loyalty is the potential conflict between clinicians’ duties of ‘first consideration of the health of the patient’… and …’full technical and moral independence’ (World Medical Association, International Code of Medical Ethics) and their obligations to their employers, particularly governments.

You may read more about Dual Loyalty and Human Rights in Health Professional Practice here: https://phr.org/our-work/resources/dual-loyalty-and-human-rights-in-health-professional-practice/

Under a Don’t Ask Don’t Tell policy, healthcare personnel would not be required to ask or report an undocumented person to immigration authorities.

The rationale for this policy:✓ Importance of building trust in the

health system✓Good public health practice which

requires all sections of society to be engaged in preventing disease transmission

✓Maintaining safety for patients in healthcare facilities without discrimination

The practice of sanctuary cities or safe cities in North America covers counties, states, universities, hospitals, and school districts who assert that it is not their responsibility to enforce immigration law.

The rationale is to keep all residents safe and provide access to services on a fair and equal basis.

More on safe cities here: https://www.youtube.com/watch?v=7Na5trKVQ3s

Firewalls are about creating safe spaces to reduce inequalities in access to healthcare. They delink health services from immigration enforcement to ensure that everyone is treated on the basis of need, and not their documentation status. They seek to preserve the integrity of the health system.

The concept of firewall in practice in some countries in Europe can be accessed here: https://picum.org/firewall-tool-safeguarding-fundamental-rights-undocumented-migrants

To know how a firewall works in a healthcare setting, check out this infographic by PICUM: https://picum.org/wp-content/uploads/2020/02/Firewall_Health_ENG_WEB.pdf

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What is wrong with the term “illegal” or ’illegals”?

✓ It is linguistically not correct because ‘illegal’ is not a noun.

✓ Linguistic experts such as Prof. Otto Santa Ana from UCLA argue that it is neither “accurate nor neutral”, because other law-breakers such as those who might be caught jay-walking are not referred to as “illegal pedestrians”. According to him and other experts, it makes immigrants an ‘outlier in the naming system’.

✓ It defines a person by their behavior by labelling them instead of focusing on their behavior.

✓ It is legally not correct because in most countries living in another country without authorization is an administrative infraction, not a criminal offence.

✓ The act of crossing a border without authorization is illegal; not the person.

✓ The United Nations and major international press agencies have dropped the use of the word ‘illegal’ for ‘undocumented person’ or ‘person residing without authorization’. The Associated Press states that calling a person illegal because they lack documents is like calling a person diagnosed with Schizophrenia, a schizophrenic; the latter being pejorative.

Read more here: https://www.unhcr.org/cy/wp-content/uploads/sites/41/2018/09/Terminology

Leaflet_EN_PICUM.pdf.

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✓ Importance of reminders for appointments and follow up, especially if there is a history of psychological trauma.

✓ Allow time to build rapport and trust.

✓ Explain and emphasize doctor-patient confidentiality, patient consent, choice and control.

✓ Show your awareness of their problems but do not press for details to avoid retraumatization.

✓ Provide opportunities for patients to ask questions.

✓ Explain why you are asking questions.

✓ Avoid dismissing somatic complaints.

✓ Comprehensive history taking is important – biopsychosocial framework.

✓ Explain procedures and repeat information if necessary.

✓ Issues to remember in working with interpreter

o Importance of trained interpreters.

o Confidentiality on the part of the interpreter.

o Gender, ethnicity, religion of interpreter is important.

o Risks related to family. members interpreting.

o Maintain eye contact with the patient, not the interpreter.

✓ Make appropriate referrals for social service.

✓ Never refer a refugee or an asylum seeker to the embassy of their country of origin. Contact UNHCR or an NGO that supports refugees.

✓ Practice cultural competency & cultural safety. Be aware and respectful of their cultural beliefs.

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http://www.kaladanpress.org/images/document/2017/Witness%20to%20horro_English%20Final.pdf

This report includes the testimonyof twenty-one Rohingya womenwho fled to Bangladesh to escapethe Myanmar Army’s “clearanceoperations” in Maungdaw afterOctober 9, 2016.

https://reliefweb.int/sites/reliefweb.int/files/resources/Fortify%20Rights-SUHAKAM%20-%20Sold%20Like%20Fish.pdf

A joint report by the Human Rights Commission of Malaysia (SUHAKAM) and Fortify Rights finds reasonable grounds to believe that a human-trafficking syndicate committed crimes against humanity in Malaysia and Thailand against Rohingya men, women, and children from 2012 to 2015.

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1. Identify the characteristics of a refugee according to the 1951 Refugee Convention?

2. Who is an asylum seeker?

3. Identify the type of refugees that Malaysia hosts.

4. Identify the health risks in the refugee journey and some of the health problems they experience.

5. Identify the characteristics of the refugee protection environment in Malaysia.

6. What are the key features of the government healthcare policy related to refugees and asylum seekers in Malaysia.

7. What are some of the important considerations in communicating with refugee patients.

Dr. Sharuna Verghis

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