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Submission to the National Inquiry into Children in Immigration Detention from

the Melbourne International Health and Justice Group

About the Melbourne International Health and Justice Group

(The MIHJG is a coalition of people from various institutions not the institutions themselves)

Department of Justice and Youth Studies at the Royal Melbourne Institute of Technology
The Department of Justice and Youth Studies (JYS) is part of the Faculty of Education, Language and Community Services (FELCS) at RMIT University. JYS offers undergraduate courses in Criminal Justice Administration and Youth Affairs, as well as Masters by Research and PhD programs. The two undergraduate courses offered are designed to educate professionals and others whose work is directed to enabling groups and individuals to improve their ability to control their own lives within the framework of community aims and goals. JYS and FELCS staff are actively involved in research and teaching that addresses issues of globalisation and localisation, cultural diversity and the development of strategies for inclusive community services and social development.

Associate Professor Scott Phillips has extensive experience in social policy development. His research interests cover multiculturalism, policies and strategies for responding to the needs of people from diverse linguistic and cultural backgrounds, multicultural drugs education and the role of organised sport in promoting social development among culturally diverse youth. He teaches in the fields of ethnography and public policy.

The Centre for International Health, Macfarlane Burnet Institute for Medical Research and Public Health
The Centre for International Health (CIH) at the Macfarlane Burnet Institute for Medical Research and Public Health (Burnet Institute) leads the Institute's collaboration with other Australian, overseas government, and international agencies to promote the health of populations in less developed countries. The CIH provides technical support, program management, assistance with public health policy development, and training related to communicable disease prevention and control in the broader context of community-based primary health care and refugee health care.

CIH staff have been actively involved in emergency preparedness and response programs and work closely with the Office of the United Nations High Commissioner for Refugees, the World Health Organization, the International Committee of the Red Cross and many non-governmental organisations to develop technical guidelines and conduct training courses. Members of staff are involved in training Australian and International personnel for work in refugee and emergency settings.

The Centre for Culture Ethnicity and Health
 Established in 1993 by the Victorian government when an agreement was established between the then Department of Health and Community Services (DHS) and the North Richmond Community Health Centre (NRCHC) to establish a Centre for Ethnic Health, the Centre for Culture Ethnicity and Health (CEH) was to play a major strategic role as a provider of information, research, and education and training with an emphasis upon the promotion of organisational cultural change in mainstream health and welfare agencies.CEH is seen as a principal resource and clearing house in the area of health and cultural and linguistic diversity, to the primary health care sector in Victoria.

Department of Public Health Nutrition, School of Health Sciences, Faculty of Health and Behavioural Sciences, Deakin University
 The School of Health Sciences is committed to excellence in teaching, research and service. Its major focus is on enhancing understanding of the behavioural, biological and social determinants of health and human performance. This fundamental knowledge underpins the development, implementation and evaluation of innovative strategies designed to enhance health and human performance, and informs our teaching programs.
Strategic focus of major research programs includes nutrition and physical activity in population health and social and cultural determinants of population health. The School and the University support staff including Dr Cate Burns using research and expertise to inform discussion in the National Inquiry into Children in Immigration Detention. Dr Cate Burns has particular expertise in social nutrition and nutrition of vulnerable groups.

Introduction
 The concerns of the Melbourne International Health and Justice Group

The members of the Group are concerned with the health of all asylum seekers in detention but of special concern for this submission is the health of children in detention.

Children are fragile, dependent and developing; if the support system is weak, they are among the very first to suffer. Children must always be seen in the context of their families and community. Although age-specific requirements for the nutrition and health for example, of refugee children should be addressed as part of food and medical programs for the general refugee population, specific activities have to be undertaken for children. Above all it must be remembered that children are not small adults. Their needs are quite specific and immediate.

The submission appeals to all stakeholders concerned, notably the Australian government and service providers to provide a forum to address the issue of asylum seekers. Alternative methods that accord with the Convention on the Rights of the Child and other International and Australian standards and based on sound ethical and moral principles could be debated.

The circumstances with respect to children in detention centres, the diversity of their backgrounds and the number and status of children may vary from one centre to another. We will not focus on particular details, however. Rather, we are addressing our concerns in terms of an evidence-based picture of the detention experience of asylum seekers in Australia. While there may be no single common feature of experience across all the detention centres, there are, in our view, resemblances between the centres as to the sorts of experiences and issues that asylum seekers face as a consequence of being detainees in those centres. Our submission is based on addressing the impact of these characteristic features of the migration detention experience.

Our concerns extend to the several hundred asylum seekers detained on Manus Island of Papua New Guinea and in Nauru. It is reported that around one third of the people on Manus Island are children under 17 years of age and around 50 small children are included. [1]

The Melbourne Group for International Health and Justice is particularly concerned by the Government's policy whereby asylum seekers are 'farmed out' to other countries as part of the so-called 'Pacific solution' rather than providing refuge according to international obligations for people seeking refuge in Australia. Although these people are not criminals they are detained in secure inaccessible camps. It is not possible to monitor the conditions of their incarceration. However there are clearly human rights violations involved:

A policy designed to place people in precisely this situation of being stateless flies in the face of giving people (especially desperate asylum seekers) a genuine fair go.

Equally, the 'Pacific solution' is no solution at the policy level. In fact, it has the potential to do Australia actual harm. We have been perceived by our Pacific neighbours to be bullying small island states into accepting refugees on our behalf. As reported on Foreign Correspondent (ABC, 17 April 2002) there are suggestions by some of our Pacific neighbours that Australia's foreign policy in this area is being prosecuted in terms of payments and development assistance inducements. These are being perceived and portrayed by some Pacific countries (as the ABC program revealed) as bribes.

There is also the realisation in Australia that the amount of taxpayers' money spent by the Government to deliver refugee determination services at great expense in offshore locations, far exceeds the amount required for providing services to people onshore in Australia.

The secrecy surrounding these centres means that information concerning provision of services and conditions is not available. However, there are several principles involved. Standards of care for refugees are set by UNHCR and other international bodies Equal Australian standards could be expected. Both Papua New Guinea and Nauru are developing countries that struggle to provide services to their own people. We believe it is immoral to expect these countries to extend their scarce resources, or even use resources supplied by outsiders, to care for people who are Australia's responsibility. Alternatively, standards of care may not be met. We are aware that malaria is endemic in the Manus Island area. The question arises as to whether, in line with refugee health protocols, pregnant women and children under five years are provided with appropriate malaria chemoprophylaxis. [2] [3]

Without transparency and accountability, these issues cannot be monitored.

The Group's principles

The Group endorses the underlying principles of the UNHCR's Guidelines that children who are seeking asylum should not be detained and the Preamble of the UN Convention on the Rights of the Child that covers the need for a healthy, supportive family environment as a prerequisite for a healthy child. Implicit in the principles is that release of children from detention or non-detention of children must not result in their separation from their families or guardians.

The Group expects that, as a signatory to the UN Convention on the Rights of the Child, the Australian government will use this document as a major reference point in the care of all children who are asylum seekers and will move swiftly towards the release of children and their families into the community. Article 37 of the Convention requires that the detention of minors shall be used only as a measure of last resort and for the shortest appropriate period of time and Article 22 requires that States take appropriate measures to ensure that minors who are seeking refugee status or who are recognised refugees, whether accompanied or not, receive appropriate protection and assistance.

Call for leadership

The group calls upon the Australian government (and all political parties) to show bipartisan leadership in basing our treatment of refugees on sound ethical principles associated with the Universal Declaration of Human Rights as well as the fundamental values associated with neighbouring, peace and justice. It is time for leadership to be shown in establishing that the inhumane treatment of refugee children (and their parents/guardians) is unacceptable to the community standards of the Australian people.

Executive summary

As an introduction, we provide a brief overview of the global situation and population movement, international standards concerning the rights of refugees and asylum seekers including standards for the care of refugee children in detention and Australian standards for health care of children in detention.
Then the submission addresses the issues of refugee children in detention in Australia in four sections:

1. Mandatory detention of asylum seekers in Australia: its impact on children and the need for alternative approaches
2. The impact of detention on the health of refugee children
3. Exploration of cross-cultural issues and barriers to delivering culturally competent services in detention centres
4. Nutritional issues associated with mandatory detention of refugee children.

The evidence-based picture of the detention experience for asylum seekers in Australia presented in this submission suggests there is an urgent need for Australia to re-consider its approach to receiving asylum seekers and processing their claims to refugee status.

Keeping people in de-humanising lock-ups, where adults, young people and children experience violence, vilification and abuse, can only worsen their mental health outcomes as well as those of our society in general when traumatised asylum seekers are eventually released into the community.

The Melbourne Group for International Health and Justice is also concerned by the Government's policy whereby asylum seekers are 'farmed out' to other countries as part of the so-called 'Pacific solution' rather than providing refuge according to international obligations for people in distress who have sought refuge in Australia.

As a society, we threaten to do ourselves collective psychological harm if we continue turning a blind eye to the incarceration and mistreatment of desperate people who, by whatever means available to them, have sought refuge in our midst.

The Australian Government should consider how an alternative to mandatory detention could be designed and implemented so that we can balance legitimate concerns about national security with humanitarian obligations to assist desperate people seeking refuge from persecution for themselves and their families.

This submission recommends that the Australian government give immediate priority to examining the cost effectiveness of a community-based approach to the reception, detention, determination, integration and resettlement of refugees as described in Section 1. More broadly, the submission calls upon all political parties to commit to leading the community in a bipartisan process of rethinking and redesigning our policy approach to asylum seekers and refugees.
Specifically, the following recommendations are made:

Health Issues

Accommodation in the community is recommended. However, until a policy of release of detainees is in place there must be compliance with basic standards of health care for families and children in detention.

It has been shown that community involvement does not seem to be a priority in detention centres. However, refugee community participation could enhance the delivery of the following programs that should be present as a minimum:

Cultural Issues

The social and mental well-being of all refugees, but particularly of refugee children, can be most effectively assured by the quick re-establishment of normal community life. [4]

Issues associated with nutrition

Children and their families should be accommodated in the community where they can make their own decisions about food purchases and preparation.
While children remain in custody:

Appointed staff need expertise in nutrition including the cultural aspects of food and nutrition monitoring.

Methodology used in this submission

In preparation for this submission we interviewed staff, service providers, observers and ex-detainees. In addition we consulted

In certain cases individuals are not identified in the text due to the need to protect their identity.

Abbreviations

ABC Australian Broadcasting Corporation
ACM Australasian Correctional Management
AMA Australian Medical Association
CIH Centre for International Health (Burnet Institute)
CRC Convention on the Rights of the Child
DIMIA Department of Immigration, Multicultural and Indigenous Affairs
HIV Human immunodeficiency virus
ICCPR International Covenant on Civil and Political Rights
MCH Mother and Child Health
MJA Medical Journal of Australia
NEDA National Ethnic Disability Alliance
STI Sexually transmitted infection
UNHCR United Nations High Commission for Refugees
UNICEF United Nations Childrens Fund

The Global situation and population movement

Large-scale movements of refugees and other forced migrants have become a defining characteristic of the contemporary world. The global refugee problem has confronted the world with a range of practical and ethical dilemmas. Countries close to areas of conflict are faced with caring for millions of refugees while countries further afield, such as Australia, are not beyond the reach of a small number of people each year, desperate for refuge. Refugees and other displaced persons will continue to seek refuge, even in places such as Australia, which are very remote from their own countries.

Refugees are defined as people who have crossed international borders fleeing war or persecution for reason of race, religion, nationality, or membership in particular social and political groups. They are protected by several international conventions. In the International conventions, the term 'refugee' includes a person in need of international protection, regardless of the legality or illegality of her or his status in the country of refuge and whether or not refugee status has been recognized formally. This term includes asylum-seekers whose claims to refugee status have not been definitively evaluated and other persons of concern to the High Commissioner's office. [5]

The vulnerability of asylum seekers

Displaced people are often suffering the devastating effects of exhaustion, bereavement, separation from loved ones, family and community, ill-health or injury, poor shelter and water supplies and inadequate food availability. Whenever people are uprooted, for whatever reason, they are placed at an increased risk of physical and emotional ill health. The public health consequences of population displacement have been extensively documented (Toole and Waldman . [6] Trauma prior to and during their exodus is an important determinant of the health status of refugees on arrival in a country of asylum. Harassment, physical violence and grief will in many cases have added to the trauma of flight.

All of the above elements combine to reduce the physical and emotional reserves of the affected population. Inappropriate care on arrival at their destination can only exacerbate the problems. With the removal of control of all aspects of their daily life, increased manifestations of depression and even of destructive behaviour including sexual violence are not uncommon.

All issues that impact on the health of families in detention will clearly impact on the health of the children. Children are at grave risk of suffering permanent psychological injury.

We know so much more about the brain, and how it influences future mental health problems and now we couldn't do any worse if we want to guarantee poor mental health outcomes.

Dr Shanti Raman, Paediatrician, 2002 [7]

Dr Michael Dudley, chairman of Suicide Prevention Australia and head of the faculty of Child and Adolescent Psychiatry at the Royal Australian College of Psychiatry, the profession's peak professional organisation visited Woomera in January 2002 and said that conditions at Woomera for the children were akin to those in a concentration camp and he described long term impact on children's health such as withdrawal and bedwetting that could be expected. [8]

International standards concerning the rights of refugees and asylum seekers

UNHCR's Guidelines on applicable Criteria and Standards relating to the Detention of Asylum-Seekers state in the Introduction that

The detention of asylum-seekers is in the view of UNHCR inherently undesirable. This is even more so in the case of vulnerable groups such as single women, children, unaccompanied minors and those with special medical or psychological needs. Freedom from arbitrary detention is a fundamental human right, and the use of detention is, in many instances, contrary to the norms and principles of international law. Article 37 of the Convention on Human Rights explains that detention must be 'used only as a measure of last resort and for the shortest appropriate period of time'.

UNHCR, 1999; This document relates also to the UN 1951 Convention and the 1967 Protocol relating to the Status of Refugees. Geneva, Switzerland.

UNHCR's Guidelines on applicable Criteria and Standards relating to the Detention of Asylum-Seekers, February 1999 in Section 3 of the introduction explain that provision for protection of refugees applies not only to recognised refugees but also to asylum-seekers pending determination of their status, as recognition of refugee status does not make an individual a refugee but declares him to be one.
UNHCR's Guideline 3 explains that, in conformity with Executive Committee Conclusion No. 44 (XXXVII) 1986, the detention of asylum-seekers may only be resorted to, if necessary:

(i) to verify identity. This relates to cases where identity may be undetermined or in dispute.
(ii) to determine the elements on which the claim for refugee status or asylum is based.

This statement means that the asylum-seeker may be detained exclusively for the purposes of a preliminary interview to identify the basis of the asylum claim. This would involve obtaining essential facts from the asylum-seeker as to why asylum is being sought and would not extend to a determination of the merits or otherwise of the claim. This exception to the general principle cannot be used to justify detention for the entire status determination procedure, or for an unlimited period of time.

The guidelines relating to the detention of asylum-seekers further state that

Detention of asylum-seekers which is applied for purposes other than those listed above, for example, as part of a policy to deter future asylum-seekers, or to dissuade those who have commenced their claims from pursuing them, is contrary to the norms of refugee law.

The Executive Committee Conclusion No. 44 (1986) discusses the limited circumstances when asylum seekers can be detained, and sets out basic standards for their care.

Standards for the Care of Refugee Children in Detention

International standards that are particularly relevant to the protection of children are 'Refugee Children: Guidelines for protection and care' ( UNHCR 1994) and the Convention on the Rights of the Child.

These documents cover issues of

Refugee children: Guidelines on protection and care UNHCR 1994 provides a sound basis from which to examine the care of refugee children in detention in Australia. These guidelines are based on the relevant Articles of the UN Convention on the Rights of the Child and do not conflict with the standards expected in mainstream Australia nor with the relevant aspects of standards for health care of children in the juvenile justice systems in Australia. Of particular interest also, are the United Nations Rules for the Protection of Juveniles Deprived of their Liberty, 1990.

Australian Standards
 Australian standards for health care of children in detention

In Australia, there are standards for management of health care of children in custody. The application of these standards is limited in that they are intended for juveniles who are being punished for breaking Australian laws.

Children seeking asylum are not in the category of 'being punished' and have rights beyond those of children in juvenile justice custody. However the standards for Juvenile Custodial Facilities determine that health care must at least equal the health care provided for children in mainstream Australian communities.

The New South Wales document, Standards for Juvenile Custodial Facilities [9] states that the underlying principle for care of children in custody is adherence to the United Nations Rules for Protection of Juveniles Deprived of their Liberty, 1990.

The State Government of Victoria, Department of Human Services' 'Framework for the Delivery of Juvenile Justice Health Services, September 2001', also states as a principle for the delivery of health services that quality of health care must be at least equivalent to mainstream services and also at a minimum meet national and relevant international standards of service provision to juvenile justice clients.

ABC radio reported [10] that the South Australian government was not satisfied that standards applied at Woomera met the South Australian standards. The South Australian authorities were informed that these standards did not apply as Woomera was a Commonwealth Government installation.

The provision of services to asylum seekers in detention in Australia is contracted to specialist companies but the Terms of Reference provided by DIMIA indicate that there must be compliance with certain standards which are set out in the Schedule: Immigration Detention Standards. This document covers all aspects of detention functions and includes reference to factors that impact on health and care of children in particular.

A stated underlying principle is that Immigration detention is required by the Migration Act and is administrative detention, not a prison or correctional sentence. Nevertheless the detention centres in Australia all exhibit characteristics of secure prisons including surrounds of high wire fences topped with razor wire.

Section 1.
Mandatory detention of asylum seekers in Australia: its impact on children and the need for alternative approaches
 Associate Professor Scott Phillips
RMIT University, Melbourne, Australia

Introduction

There is a growing body of evidence of psychological disturbances among refugees held in long term detention in Australia. And the mental health implications affect children as well as adults.

This section of the submission does three things. First, it provides an evidence-based picture of the experience of being in mandatory detention as an asylum seeker in Australia. There are by now considerable and alarming eye-witness accounts and first-hand reports that show how the current Australian mandatory detention regime for asylum seekers systematically diminishes and abrogates the human rights of asylum-seeking children and adults (particularly parents) held in detention. The detention system does this by subjecting adults and children to physical and psychological abuse. In doing so, the detention system for asylum seekers contributes to worsening the mental health of Australian society as a whole when traumatised detainees are eventually released into the general community.

Second, the evidence base will be used to argue the urgent need for the Australian Government to reconsider and alter its current arrangements for receiving asylum seekers and assessing their claims to refugee status. In this context, the submission will outline alternative approaches that would better meet our legitimate national security and public health concerns as well as our long-established humanitarian undertakings and obligations to assist asylum seekers in a compassionate, considerate and caring way.

Third and finally, the submission calls upon the Australian Government (and all the political parties) to show bipartisan leadership in basing our treatment of asylum seekers on sound ethical principles associated with the Universal Declaration of Human Rights as well as the fundamental values associated with neighbouring, peace and justice. It is time for leadership to be shown in establishing that the inhumane treatment of asylum-seeking children (and their parents/guardians) is unacceptable to the community standards of Australian people.

1. The detention experience of asylum seekers
 In preparing this submission, I have worked with colleagues in the community health sector, universities and public health research institutes. On the basis of our interviews with detainees, detention centre workers and former detainees now living in the community, cross-checked with written reports by health workers, detainees and detention centre visitors, we have been able to assemble a very clear picture of the asylum seeker's experience of detention here in Australia.

Although there is some variability of conditions across the different detention centres run by Australasian Correctional Management (ACM), there are nevertheless several recurring characteristic features of the detention experience in these centres. The experience of mandatory detention is proving to be particularly damaging not only for adults but also for the children and adolescents whose lives are bound up with the mandatory detention system. The characteristic features of the detention experience of asylum seekers may be highlighted as follows:

A. Intimidating physical environment:
Detainees find themselves faced with an essentially intimidating prison-like environment.

B. Intimidating human environment:
Detainees are subject to a range of intimidatory behaviours and procedures.

Some detainees have suffered intimidation and reprisals after acts of advocacy, protest or revolt. Authorities have instituted room searches, confinement in solitary cells, restrictions in receiving visitors, and obstacles to accessing legal representation or medical care. During a hunger strike in July 2000, all electrical power and water supplies to the cell block where the hunger strikers were residing were cut off, affecting uninvolved women and children. [15]

C. Sense of boredom and aimlessness:
Due to a general insufficiency of activities, recreational resources and educational activities, detainees are subjected to long periods of unstructured time. The dearth of adequate childcare facilities, coupled with the cramped conditions families usually live in, means that children have insufficient opportunities for play as well as education. These conditions give rise to feelings of boredom, aimlessness and apathy especially when people have been detained for extended periods of time. [16]

D. Nutritional inadequacy:
There are common reports of detainees being served standardised institutional food that is culturally inappropriate. This is no small matter, as some people are unable to eat culturally inappropriate food, which means that their nutritional needs are not being met properly. Details concerning issues associated with nutrition are provided in Section 4.

E. Cultural identity diminished:
Detainees regularly experience a sense of their cultural identity being diminished. They are subjected to culturally inappropriate service delivery, staff behaviour and communication. Experiences of discrimination and lack of respect shown to them by detention officers and other officials give rise to feelings of stigmatised identity. Issues associated with culture are dealt with in detail in Section 3.

F. Exposure to violent incidents:
The Human Rights and Equal Opportunity Commission, in its 1998 report on the conditions of detained unauthorised arrivals, noted evidence of violence between detainees - especially within families - as well as between detainees and custodial officers. [17]

G. Mental health deterioration:
Medical health professionals have noted a pattern of mental health deterioration, with each successive depressive stage closely associated with each stage in the refugee determination process. Four stages are identifiable: (1) a non symptomatic stage; (2) a primary depressive stage; (3) a secondary depressive stage; and (4) a tertiary depressive stage. These have been well characterised elsewhere, so I will only summarise the observations of others here. [18]

The non-symptomatic stage is associated with the early months of detention - prior to the primary refugee determination decision. While the detainee is shocked and disoriented they are sustained by a sense of hope that their detention will be short-lived once their claim of refugee status is upheld.

The primary depressive stage occurs after a detainee receives a negative decision and realises that they face the prospect of forced repatriation or continued detention in Australia for an indefinite period while they apply for a review of the negative decision. Depressed detainees commonly enter a primary revolt stage which manifests itself variously: some become protestors (engaging in hunger strikes); others become advocates (seeking to raise public awareness of the realities experienced by detainees); and some become aggressors (becoming involved in confrontations, riots and violent incidents with guards and other detainees).

The secondary depressive stage is consequent upon the rejection of the asylum seeker's application by the Refugee Review Tribunal. The depressive reaction at this stage becomes more severe and debilitating. These detainees now virtually cease communicating their concerns to others and become largely withdrawn. Some may become passive resisters and attempt escape.

The tertiary depressive stage is predominantly characterised by hopelessness, passive acceptance of their fate and a pervasive fear of being targeted or punished by the managing authorities. Paranoid tendencies lead detainees to become untrusting of people. Detainees in this stage of depression spend long periods of time alone, and develop psychotic symptoms such as delusions and auditory hallucinations. In the most extreme cases people engage in repeated acts of self harm resulting in a need to be hospitalised.

H. Disrupted sense of security and psychological stability among children:
There is evidence in our media on an almost daily basis of young children and adolescents held in refugee detention centres being exposed to highly stressful instances of violence and abuse. The long-term effects of this can only be imagined at this stage. What is clear is that they have experienced disruptions in their developmental pathway due to breaks in their schooling, possible loss of a parent or both parents (through death or separation) and the trauma associated with their initial decision to flee their country of origin. [19]

The primary effect on children of the detention environment, exposure to hunger strikes, demonstrations, episodes of self-harm and attempted suicide, and forcible removal procedures, is that a child's sense of security and stability is disrupted. [20] A secondary impact is mediated via the child's parents, whose ability to be nurturing and protective parents is diminished as they progress through the successive stages of depression associated with the asylum seeker's detention experience. Depressed parents are at risk of becoming neglectful or abusive of their dependent children as the course of their own detention progresses.

Psychological disturbances experienced by children are wide and varied. These include separation anxiety, sleep disturbances, nightmares, bed wetting and impaired cognitive development. Sultan and O'Sullivan report that 'at the most severe end of the spectrum, a number of children have displayed profound symptoms of psychological distress, including mutism, stereotypic behaviours, and refusal to eat or drink'. Children of parents who reach the tertiary depressive stage appear to be particularly vulnerable of developing a range of psychological disorders. [21]

Visit any migration detention centre in Australia and a similar texture of experiences will emerge. The detainees I have visited and spoken with, for instance, have made the following points:

2. Alternative approaches

The above picture of the detention experience for asylum seekers in Australia suggests there is an urgent need for Australia to re-consider its approach to receiving asylum seekers into our midst and processing their claims to refugee status. The current environment is evidently humiliating, terrifying and abusive, and this is having a profoundly negative impact on the development of children and adolescents caught up in this system through no fault of their own.

The psychological impact of detention
 The nature of the impact can best be gleaned from the accounts of parents or children themselves. The following statements come from affidavits by detainees.
The mother of a boy who was held in a solitary confinement cell without access to a toilet recounts how her son described the experience to her. (Names have been anglicised to protect the family.)

My son, Andrew, later described to me his experience in detention. He said in words to the effect of: 'I needed to go to the toilet and called the guards. After a few minutes four guards came rushing down the corridor. They broke into my cell wearing CERT [Centre Emergency Response Team} gear and armed with blocking cushions. They pushed me back and held me against the wall. One guard held my legs, the other held my hands behind my back. A third guard used his arm to encircle my neck and hold me tightly. I thought I would choke. The fourth guard swore at me. When I answered back, the officer punched me in the face.' [22]

It is understandable that parents held in detention are concerned about the effect the experience has on their children. One detainee, released after 17 months into the Perth community on a Temporary Protection Visa and separated from his family who remain in the Port Hedland detention centre, speaks for all asylum-seeking parents when he says:

Since being in detention Charlotte, now 16 years old, and Jessie, now 12, have changed completely. While I was in Port Hedland with them they became more and more anxious and distressed. They began to lose interest in eating food and had difficulty sleeping. The whole family is living in a room that is 2.8 by 2.5 metres. [23]

I do not propose to list case after case here. These are well documented by now, and can be readily reviewed by inspecting published cases posted on the Children Out of Detention (Chilout) website.

My point is simply this: that many of the children and young people in detention (as at December 2001, some 582 - 53 being unaccompanied minors) are being exposed to violence, degradation and abuse. They are seeing instances of self harm and attempted suicide. And they are being confined in ways that abrogate their human rights. They are living in conditions at the detention centres that violate the United Nations Convention on the Rights of the Child (CRC).

Jaqueline Everitt, an advocate for asylum seekers who is reading for a Masters in international law, has put the matter cogently, when she states:

Is there any other country prepared to lock up endlessly, children who have not been charged with any crime? These children, who have already suffered in their own country, who have made a frightening and perilous journey to get to Australia and are possibly already among the most traumatised of the world's children, have their trauma compounded by being taken to a forbidding place and locked behind the razor wire, their rights neatly incised.

They are out of sight of the Australian people. If we don't see them, we don't know they're human. They can't be real.

It's an irony that Australian law provides for mandatory reporting of suspected child abuse by professionals - and mandatory locking up of child asylum seekers. We call both these practices government policy. One protects, the other destroys. [24]

Statements such as those by Everitt, and more recently a wave of statements of concern by a broad range of citizens, suggest the need to rethink the current approach to receiving and processing asylum seekers who come to our shores seeking protection from persecution and abuse.

The call for alternatives

Professor Alice Tay, President of the Human Rights and Equal Opportunity Commission, as early as December 2000, called upon the Australian Government to develop a fresh approach to the issue of asylum seekers, including considering a community release program. In a press article at the end of 2000, Professor Tay noted:

There are alternatives. They have been used elsewhere and Australia should explore the options and implement alternatives as a matter of priority. [25]

Most recently the Head of Amnesty International, when visiting this country in early March, called upon the Australian Government to consider alternatives to its approach. Calls such as these reinforce the view that the time for exploring and implementing more humane alternatives is now.
But just what are these alternatives?

This submission will outline some of the main alternatives proposed by the UNHCR and then point to two particularly noteworthy alternatives: one developed by the Swedish government after addressing similar issues to those which we are currently facing, the other proposed by our own Human Rights and Equal Opportunity Commission (HREOC).

The UNHCR Revised Guideline on Applicable Criteria and Standards relating to the Detention of Asylum Seekers (February 1999) address the issue of alternatives to detention. The fourth guideline specifies that alternatives to the detention of an asylum seeker pending a determination of their status should be considered. Choices about appropriate alternatives would need to be based on assessment of each individual's particular circumstances and the prevailing local conditions. The fourth guideline spells out the main alternatives to detention that could be considered by governments. These are reproduced here (in italics):

(i) Monitoring Requirements.
 Reporting Requirements:
Whether an asylum-seeker stays out of detention may be conditional on compliance with periodic reporting requirements during the status determination procedures. Release could be on the asylum-seeker's own recognisance, and/or that of a family member, NGO or community group who would be expected to ensure the asylum-seeker reports to the authorities periodically, complies with status determination procedures, and appears at hearings and official appointments.
Residency Requirements:
Asylum-seekers would not be detained on condition they reside at a specific address or within a particular administrative region until their status has been determined. Asylum-seekers would have to obtain prior approval to change their address or move out of the administrative region. However this would not be unreasonably withheld where the main purpose of the relocation was to facilitate family reunification or closeness to relatives.
(ii) Provision of a Guarantor/ Surety
Asylum seekers would be required to provide a guarantor who would be responsible for ensuring their attendance at official appointments and hearings, failure of which a penalty most likely the forfeiture of a sum of money, levied against the guarantor.
(iii) Release on Bail
 This alternative allows for asylum-seekers already in detention to apply for release on bail, subject to the provision of recognisance and surety. For this to be genuinely available to asylum-seekers they must be informed of its availability and the amount set must not be so high as to be prohibitive.
(iv) Open Centres
Asylum-seekers may be released on condition that they reside at specific collective accommodation centres where they would be allowed permission to leave and return during stipulated times.
These alternatives are not exhaustive. They identify options which provide State authorities with a degree of control over the whereabouts of asylum-seekers while allowing asylum-seekers basic freedom of movement. [26]

Discussion of the alternatives
 Elements of these UNHCR guideline approaches have been developed elsewhere. The Australian Government should consider how an alternative to mandatory detention could be designed and implemented so that we can balance legitimate concerns about national security with humanitarian obligations to assist desperate people seeking refuge from persecution for themselves and their families.

The Swedish Government's experience in this regard is instructive. A paper by Grant Mitchell, the Coordinator of the Asylum Seeker Project, Hotham Mission, Melbourne, has drawn attention to the lessons that Australia could learn from Sweden in this area of public policy. [27] As Mitchell notes:

Sweden has been successful in building a functioning reception process that allows for a just and humane treatment of asylum seekers while they await a decision, addresses national security concerns and effectively removes failed refugee-claimants. Sweden has also been successful in quickly integrating resettled refugees into society.

Mitchell explains how most asylum seekers in Sweden live freely in the wider community.

Once a person has been cleared by immigration and has indicated that they wish to seek asylum, she or he is taken initially to the Carlslund Refugee Reception Centre, close to the main international airport in Stockholm. At this central reception centre they are signed in and have a Caseworker allocated to them. [28]

The Caseworker's role is to explain the refugee determination process and the rights and entitlements that asylum seekers have while they await a decision on their refugee status. In addition, caseworkers ensure that each client's asylum application is processed correctly and that interpreters and legal representation are made available where necessary.

The Carlslund Refugee Reception Centre encompasses a refugee medical centre, accommodation, a group home for unaccompanied minors, the Carlslund Detention Centre, and for the Migration Board (which is the government body responsible for the reception and processing of asylum seekers in Sweden). After spending at least 2 weeks in the Carlslund Reception Centre, to complete the initial application and to undertake health or support need assessments, an asylum seeker is moved to one of Sweden's regional refugee centres while they await a decision. Where an applicant has family or close friends in Sweden they can choose to live with them. This occurs in more than half of all cases.

In the majority of cases, an asylum seeker's application will take more than four months to determine. In such cases, the applicant is entitled to work. Free housing is made available to asylum seekers, but they must provide for themselves if they have enough money. For a fee of around A$10, emergency medical and dental procedures and prescriptions are provided. Asylum seeker children receive the same medical coverage as Swedish children. [29]

Mitchell's paper reveals the Swedish system as providing a supportive and engaging physical and human environment. Regional refugee centres comprise groups of flats and apartments in small communities close to a central office reception, which includes childcare and recreation facilities. Asylum seekers are required to visit the reception office at least monthly for their allowance, news on their application and need and risk assessment.

Caseworkers assigned to each asylum seeker by the Migration Board make these assessments and, where appropriate, refer clients for medical care, counselling and other services. Caseworkers are also must provide 'motivational counselling', to prepare the asylum seeker for all possible immigration outcomes and to assess the risk of their absconding should they receive a negative decision. Asylum seekers in urban areas work in a similar way with a caseworker, whom they are required to visit at the local Migration Board office. All asylum seekers awaiting a decision are encouraged to participate in some form of organized activity such as English or Swedish lessons if they are not working.

The Swedish system has not always been like this. Mitchell notes that prior to comprehensive changes being introduced in 1997, the Swedish approach was similar to the detention regime which operates in Australia, and the Swedish Government faced many of the issues that currently face Australia. He writes:

Many of these problems, including riots, mass hunger strikes and worker safety have been addressed due to comprehensive changes by the Swedish government following an inquiry in 1997. The changes included:

  • The removal of private contractors and the police from the detention centres
  • Dividing detention into 3 categories: initial health, security and identity checks; investigation; realising return for individuals at high risk of absconding
  • Implementing a caseworker system aimed at need and risk assessment, the informing of rights and preparing detainees for all possible immigration outcomes
  • Increasing transparency in management and operation, with centres to be run more like closed institutions than prisons
  • Ensuring all staff are trained to work with asylum seekers and show appropriate cultural and gender sensitivity and respect to all detainees
  • Increasing access for NGOs, clergy, researchers, counsellors and the media
  • Allowing for freedom of information, such as access to internet, NGOs and the option to speak to the media
  • Allowing for regular meetings between staff and detainees on the running of the centres and ensuring detainees are aware of complaint mechanisms
  • Ensuring legal counsel and the right to appeal is available
  • Ensuring no children are held in detention for extended periods and removing families as soon as possible.

Mitchell concludes that Sweden's integrated approach to detention and reception has been helped by the caseworker system - especially by preparing clients for either return or settlement. Furthermore, the system of release into the community after initial checks has resulted in a significant reduction in public outcry, not only in relation to the use of tax payer's money but also as regards the previous system of detention. The reduced use of detention, when coupled with the caseworker system, has not led to large numbers of asylum seekers absconding.

Finally, detention is not completely excluded from the Swedish system. Asylum seekers living in the community who are assessed as likely to abscond prior to receiving a final decision are placed in detention for removal. But these instances are rare, because the caseworker system has encouraged failed refugee claimants to comply and return after a final decision has been made. Mitchell notes that this compliance has been achieved by:

Australia and asylum seekers alike could benefit from introducing a system along the lines adopted in Sweden. Indeed, a similar sort of approach has already been suggested by the Human Rights and Equal Opportunity Commission (HREOC) in its 1998 report Those who've come across the seas: Detention of unauthorised arrivals. The alternative option proposed by HREOC has been outlined by the President of HREOC, Professor Alice Tay, as follows:

This option proposes community release while claims are finalised. People who present a real threat to national security or public order would not be released. Individual assessments would be made on the risk of absconding. Most could and should be released on their own promise to report as needed to deal with their claims. [31]

In its bare outlines, this system would not be too dissimilar from the Swedish model, suitably adapted to Australian circumstances. It would allow us to move back towards a moderate, compassionate and humane approach to the issue of receiving, processing and settling asylum seekers. And it would help us to take a more humane and constructive approach to removing and re-settling unsuccessful applicants.

What is required now is to see the issue in terms other than nationalistic xenophobia. It is possible to preserve Australia's legitimate self interest while nonetheless upholding universal human rights consistent with our international obligations. And this will require clear and ethical leadership.

3. Time for a new sort of leadership on the refugee issue

Alice Tay has rightly called for a fresh approach to be taken to the way our national community deals with asylum seekers. As she observes:

Some time in the past decade we lost our compassion towards asylum-seekers and became insular and hard-hearted. Australia's refugee policy is moving from a humanitarian one to a punitive one: from a relatively liberal assessment of individual circumstances against our international obligations to preventing entry and punishing those who slip through the net. [32]

Regrettably, the two main political parties in Australia have adopted this more or less punitive approach. And this has been done largely because political leaders have been concerned to calibrate their policy stances in accord with what they perceive as community opinion on the issue of refugees. The xenophobia associated with Hansonism and the One Nation Party has had a lot to do with the way that the two major parties have effectively demonised refugees and portrayed them as a threat to Australia's national security.

But this is an issue that requires leadership on sound ethical principles appropriate to ensuring not only Australia's future but its role in developing a just and sustainable global society. Leadership of this kind is not possible if the focus is only upon alignment of policies with popular opinion so as to secure national electoral ascendancy.

As Alice Tay reminds us:

Sadly, the mandatory detention of asylum-seekers and others who arrive without visas is popular with a community more concerned about continuing to enjoy reasonable prosperity than sharing a little of it with the needy. It is also worth mentioning that the two main political parties are more or less in agreement on how to deal with the errant and desperate few who enter the country without authorisation. In balancing national security interests and individual human rights, the pendulum has swung too far in the direction of border protection and national security. There are times when one must turn away from the will of the people and swim against that tide; times when the humanitarian obligation should be paramount. Now is the time to rethink Australia's policy of mandatory detention. [33]

Alice Tay is not alone in calling for such a rethink and leadership against the grain of popular sentiment.

Malcolm Fraser (the former Liberal Prime Minister) recently has formed a broad alliance of citizens from across the political spectrum who are concerned to pressure the current Government to develop a more humane approach taken to the way Australia receives and processes asylum seekers.

Greg Barns, a former Howard Government adviser and now the endorsed Liberal Party candidate for the 2002 Tasmanian state election, also has called upon the Government to reconsider its approach to this issue. He observed in a recent press article that 'the problem with the current policy by the Howard Government towards asylum seekers is that it actually devalues the humanity of asylum seekers through its characterisation of them as offenders against humanity'. [34] He notes the British Conservative Party's Home Affairs spokesperson, Humfrey Malins, who recently observed that mandatory detention of asylum seekers is unjustifiable because these 'people have not committed any offence. They are not criminals'. [35]

Justice Marcus Einfeld has been vocal also in calling upon the Government and the community to take a fresh and humane approach to addressing the needs of asylum seekers. Faith community leaders are also joining the chorus. The list could be extended. The point to draw from these expressions of concern is surely this: A policy of mandatory detention of asylum seekers is inhumane and unjustifiable. It flies in the face of compassion and logic. It is out of keeping with the golden rule of treating others as we would want to be treated that underlies commonsense morality.

Any policy that involves locking up the children of asylum seekers is doubly indefensible. Not only does it defy logic, ie their parents have not committed an offence by seeking asylum from persecution, so neither they nor their children should be locked up in the first place. It also contravenes the UNHCR's Guidelines and the UN Convention on the Rights of the Child (CRC). For example, Articles 2, 3, 9 22 and 27 of the UN CRC make it clear that detention of children is not in the best interests of the child and is inherently discriminatory. Article 2 specifically requires States to protect children from discrimination or punishment on the basis of the status, activities, expressed opinions or beliefs of a child's parents, legal guardians or family members. As a signatory to these UN instruments, Australia urgently needs to rethink its approach.

The time has come for us to look at how we can best align our national security and economic concerns with our international commitments to promote human rights and build a just and sustainable world order. For, in the context of globalisation, it is simply not possible to secure the one without the other.

This submission recommends that the Australian government give immediate priority to examining the cost-effectiveness of a community-based approach to the reception, detention, determination, integration and resettlement of refugees. More broadly, the submission calls upon all political parties to commit to leading the community in a bipartisan process of rethinking and redesigning our policy approach to refugees.

We are in a particular moment of our history where there seems to be a growing sensibility among our people that the way we deal with refugees could be done not only differently but better. The former senior public servant, John Menadue, has reminded us of this:

In the end, the government must abandon its xenophobia and punishment of the vulnerable and traumatised. It must abandon mandatory imprisonment. It doesn't work. Australia has a self interest as well as a humanitarian responsibility in this. Refugees have made, and continue to make, an outstanding contribution to his country. They are risk takers, highly motivated and prepared to leave everything for the sake of a new start for themselves and their children in a new country. We need more of that spirit in Australia. [36]

We could, indeed, do with more of that spirit. But what is required to grow that spirit in Australia is a fresh commitment to principles of justice and fair treatment.

We need to commit openly, as a national community, to welcoming and assisting any adults and children who seek safe harbour and new beginnings on our shores.

We need to put in place policies and procedures that protect vulnerable global citizens, especially children, from abuse and trauma when they venture amongst us, against all odds, in search of freedom, hope and justice.

We need to show wisdom and leadership on this issue. And these have to be built on a clear recognition that securing our future development will not be based on exclusionary concerns with protecting national borders from desperate people doing desperate things in desperate circumstances.

We must recognise that our future development and stability can only be assured if it is grounded on an ethic of inter-existence and productive diversity. By welcoming risk takers, and offering them a chance to contribute to the development of Australia and the world, we are most likely to build a humane, tolerant, diverse and capable national community. And in doing that we will contribute to securing not only our own national stability but also to a truly just and peaceful world.

Conclusion

We have, by now, heard reports from former workers in detention centres of the brutal conditions inside them. We have, by now, read accounts and seen television footage of people driven to extremes of personal action to try to have their conditions improved or to escape them. As a result, Australians increasingly are forming a shared view that the operations of these detention centres are not transparent and are out of line with community standards.

There is enough evidence in the public domain to suggest that the Government should move beyond its detention regime for asylum seekers and towards a community-based reception regime.

Keeping people in de-humanising lock-ups, where adults, young people and children experience violence, vilification and abuse, can only worsen their mental health outcomes as well as those of our society in general when traumatised asylum seekers are eventually released into the community.

Ultimately this is a question of upholding people's human rights.

All people, especially those fleeing from persecution, should be treated with dignity and compassion. It is their right.

As a society, we threaten to do ourselves some collective psychological harm, if we continue turning a blind eye to the incarceration and mistreatment of desperate people who, by whatever means available to them, have sought refuge in our midst.

Australia's detention centres have become silent places where people from different backgrounds, but with the same sentiments, fears and hopes as all human beings, are being systematically denied some of their most basic freedoms.

These freedoms, these liberties, are part of the universal notion of what it is to be human. At the moment, we live in a state that is taking liberties - liberties that are intrinsic to all people, as human beings, as citizens of the world. We are all being diminished as a result.
It is, by now, incumbent on all of us to speak up and speak out about ensuring the rights of all people, whatever their background, whatever their circumstances, to a just and dignified life.

For it is through creating the conditions in which all people can exercise their fundamental human rights that we can best promote the mental, physical and social health of all people in Australia as well as the wider world, now and into the future.

Section 2.
The impact of detention on the health of refugee children
The Centre for International Health (CIH), Macfarlane Burnet Institute for Medical Research and Public Health Beverley Snell and Michael Toole

This section provides observations on the lives of children and their families in Australian detention centres and offers informed assessment of likely long term impacts on health. In addition, the authors suggest more appropriate responses.

Definition of health
 In line with the WHO definition of health, the group sees health as not merely the absence of disease but as a state of complete physical and emotional wellbeing.

Family and living environment

The child, for the full and harmonious development of his or her personality, should grow up in a family environment, in an atmosphere of happiness, love and understanding. [37]

The following questions arise:

Observations

There is evidence that in Australian detention centres families are housed in cramped conditions with very little privacy. In many cases families are housed in units of multiple groups separated only by a curtain. There are few facilities for family activities. Adults have no control over their daily lives or that of their children.

Families may be separated from each other because they did not all arrive together. It is reported that people are housed in different sections of detention centres according to the stage of the processing of their claims. Frustration is increased by the fact that detainees are unaware of the progress of their appeals for refugee status and they are rarely able to communicate with relatives and friends. In many cases, families remaining in the country from which they fled do not know whether the detainees are alive or dead or conversely, the detainees don't know whether their family members are alive or dead.

Impact
 In these conditions both parents and children suffer. Parents become frustrated, tired and impatient and have difficulty in being good parents. Children are exposed to the psychological distress and despair of parents living in confined conditions with little control over their lives, and unaware of their legal status as refugees. Children cry, fight, or become very withdrawn. Parental distress and anxiety can seriously disrupt the normal emotional development of their children and can contribute to both psychological and physical illness. Examples of the psychological impact of these conditions are also discussed in Section 1.

Recreation
 The relationship between nutrition and physical activity is integral to a child's development. Nutrition is dealt with in detail in Section 4.

Article 6(2), Convention on the Rights of the Child explains
States Parties shall enure to the maximum extent possible the survival and development of the child.
Article 31(1), Convention on the Rights of the Child declares
State Parties recognise the right of the child to rest and leisure, to engage in play and recreational activities appropriate to the age of the child and to participate freely in cultural life and the arts.

Observations
 Of concern are reports from detention centres that children have very restricted facilities for play, for example a small internal section in the men's area at Maribyrnong, external areas of bare earth in the blazing sun with no appropriate facilities at Woomera where more than 100 children are held.

The following reports from the sources cited in this submission [38] illustrate conditions in Australian detention centres

An ex-detainee explained that there was no organised child care in Woomera when she was there. She volunteered to run daily child care activities but there were no facilities provided.

Rest, leisure, play and recreation are vital for the healthy development of the child. In order to ensure the appropriate development of children in immigration detention and provide them with the highest attainable standard of health, they must be provided with opportunities, spaces, equipment and education that encourage and facilitate physical activity and sport. [39]

Interaction with the physical environment is stated to be an innate and necessary propensity in all people, including children. [40] The quality of play experience for children will be related to the environment in which it takes place.

Australia's obligations under the Convention extend beyond merely treating illness to ensuring the development of the child to the maximum possible extent, [41] and preventing, treating and rehabilitating disabilities. [42]

The UNHCR Guidelines for the care and protection of children state that
Refugee camps, settlements or reception centres should have play areas from the outset. The play areas must be free from hazards and must fit in with the rest of the community.

The United Nations rules for the Protection of Juveniles deprived of their Liberty require that
The design and physical environment should be in keeping ….. with the need for privacy, sensory stimuli, opportunities for association with peers and participation in sports, physical exercise and leisure time activities

Impact
 Normal development milestones like crawling, walking, talking may be delayed because of lack of space and the opportunity to move and the atmosphere of despair and frustration that inhibits normal interaction. According to Dr Shanti Raman, Paediatrician : [43]

Young babies and toddlers seem not to be reaching key milestones in their development.

Physical manifestations of frustration in children include bed-wetting and mutism. [44] The psychological impact of these conditions is discussed in detail in Section 1 of this submission.

Pliskin [45] describes social and cultural problems of Iranians brought on by revolution, war, immigration, and changes in family status as being expressed as narahati - depression, nervousness, sadness and anger that are usually masked or expressed nonverbally through sulking or not eating. Children exposed to this sort of family behaviour commonly respond with disturbed behaviour but also by exhibiting symptoms of somatised illness. The illness can be manifest physically as well as mentally with for example, headaches, tiredness, abdominal pain and gastric disturbances. It is important that clinicians trained to understand these problems are employed. But more important is the support of the family to remain a nurturing unit. Montgomery and Foldspang [46] are among authors who stress the prime importance of the family environment in maintaining the health of children.

Community support
 Isolation between families in different sections of detention centres can prevent access to the support mechanisms that may be available within communities and have a very negative effect on psychological and emotional wellbeing. The UNHCR guidelines stress the importance of involving members of the refugee community in community activities to support families. The question arises - are there persons among the refugee community who could provide regular activities for refugee children such as non-formal education, play and recreation? The communities reflect most facets of a common community, there are teachers, lawyers, health workers, etc. So skills within the community could be beneficially employed in many areas.

Health workers who know and can help their communities should be integrated into the health delivery system (recommended by UN guidelines). Community teachers, child care workers and other leaders are also important. It is doubtful whether these approaches are encouraged.

Environmental Safety
 Safety in both the living environment and the built environment are crucial to the maintenance of family wellbeing and security. There is little specific evidence about safety standards in detention centres. We recommend that HREOC examine facilities and ensure that there is compliance with national occupational health and safety standards.

The Australasian Standards for Juvenile Custodial Facilities specifies that centres as a whole must comply with occupational health and safety standards and provide a safe living environment. These Australasian standards use the United Nations rules for the Protection of Juveniles as their reference point.
The United Nations rules for the Protection of Juveniles deprived of their Liberty state

… [they] have the right to facilities and services that meet the requirements of health and dignity
…. the design and structure of detention facilities should be such as to minimise the risk of fire and ensure safe evacuation from the premises. There should be an effective alarm system in the case of fire, as well as formal and drilled procedures to ensure the safety of juveniles.
Concerning the built environment, the Australasian standards specify that standards are in line with the United Nations rules for the Protection of Juveniles deprived of their Liberty in that

Services meet the requirements for health and human dignity

Of further concern to us are reports of access to toilet facilities. In some cases the toilet block can be up to 500 m away. Because of the distance from the toilet block and the environment, children have been known to wait until they are incontinent. [47] Female ex-detainees have reported their unease about passing men 'who hang around' the toilet block and mothers will not allow their children to go to the toilet blocks alone. Visitors and ex-detainees have described the toilets in Woomera detention centre as being 'filthy and splattered with blood'. [48] [49] [50] This situation does not comply with the UN Rules specifying that

Sanitary installations should be so located and of a sufficient standard to enable every juvenile to comply with their physical needs in privacy and in a clean and decent manner

Health services
 The UN Committee on Economic, Social and Cultural Rights has identified six core obligations on the right to health under Article 12, which include:

Initial assessment
 In line with the recommendations of the Royal College of Paediatricians and Child Health [51] we believe it is important that children among families seeking asylum are initially assessed by a clinician with expertise about children. Any problems identified will need to be addressed according to best practice in Australia. Growth assessment is routine procedure for Australian children.

Observation
 It has been reported that initial assessments are carried out by a Registered Nurse not by paediatricians nor clinicians with specialised knowledge of children. They focus on conditions of 'public health importance only'. [52] There is no evidence that health professionals who conduct the initial assessments have any training in the conditions that may be unfamiliar in Australia but which may be present among newcomers nor is there any evidence that they have any cross-cultural training. The preparation of a health file for each child as a basis for ongoing health care, is not an outcome of the initial assessment. The UNHCR Guidelines specify the need for personal records, including health records, for each child.

Impact
 If a comprehensive health assessment is not undertaken, conditions affecting eyes, ears, skin, teeth, gums, etc as well as growth and development may not be detected. There may also be conditions uncommon in Australia and unfamiliar to Australian clinicians that should be noted. Examples might be nutritional deficiencies and conditions associated with parasites. We consider that there should be awareness of previous common problems of the populations represented by people detained in the centres. An initial assessment also provides a benchmark against which to measure any health developments and to guide subsequent health responses.

Without a personal health file, it would be difficult for health professionals to care adequately for each child and provide appropriate follow-up.

Appropriate curative services including dental services
 It is crucial that children have the benefit of an effective primary health care program including a health monitoring program. In order to deliver effective primary health care a comprehensive initial assessment, on which to base ongoing care, is needed for each individual. Personal records for each child will enable ongoing health assessments and monitoring of children's psychological and physical development. The file (record) should follow the child through the detention centre and into the community when the child is released. We are pleased to note that immunisation against vaccine-preventable diseases is undertaken in all detention centres and records are maintained appropriately and provided to the child or carers on release.

The UNHCR Guidelines state, not only that it is necessary to ensure that children have the benefit of an effective primary health care program, but that health services should be implemented with the full participation of the community.

According to our informants, services provided are solely curative and provided by staff without cross cultural training and without special training in the management of disorders that are common in the home countries of detainees. Monitoring of children's psychological or physical development is not an integral part of the health services.

Problems have arisen regarding durable solutions when refugees have been inappropriately diagnosed by mental health professionals without adequate experience regarding the situational stress reactions or sufficient cross-cultural skills and understanding.

Specialised services are needed. Special difficulties such as trauma from witnessing or being a victim of torture, sexual assault or other forms of violence, require the involvement of a qualified mental health professional trained to work with children. Such a professional should preferably be of the same ethnic background as the refugees or at least have good cross-cultural skills. Her/his role could be either to provide treatment directly or to guide and support members of the family or community to do so.

Removal from the family unit should be avoided. Unless it is necessary to prevent abuse or neglect, a child should not be separated from her/his family and community for treatment. Even if it is not possible to get the specialised help the child needs, all positive action to normalise the life of the child is good.

Commonly reported symptoms of displaced children have been somatic complaints, social withdrawal, attention problems, anxiety, and depression. Zivcic [53] assessed the health of Croatian adolescents who had been displaced by war and found displaced children manifested more negative emotions (especially sadness and fear) than did their local peers, based on self-report as well as parents' and teachers' reports. Sikic [54] showed that hyperactivity, anxiety and psychosomatic disturbances to be rare in non-displaced children; more frequent in refugee, and most expressed in displaced children.

Access to health services
 The processes involved in consulting health professionals have been described by ex-detainees, staff and observers. Detainees have to satisfy guards of their needs in order to consult health professionals. Informants have also referred to the processes should a detainee require treatment outside a centre or admission to hospital. Detainees may be handcuffed or otherwise restrained and accompanied by one or more guards. Small children may be accompanied by a parent but a guard is also present. This procedure raises questions of confidentiality as well as maintenance of dignity.

Access is multidimensional concept and includes consideration of the number and type of services, staffing, cultural appropriateness and communication skills of staff. Issues associated with culture and communication are addressed in Section 3.

The Australian Medical Association (AMA) has asserted that within and beyond detention centres, detainees are often deprived of basic medical care, particularly emergency care. The AMA has argued that the government should provide temporary access to Australia's universal subsidised system of health care. This provision would be in line with Australian standards for custodial care of children that recommend care at least equal to care in the mainstream community. [55] [56] [57]

This provision would also ensure access to essential drugs in line with the UN Committee on Economic, Social and Cultural Rights core obligations and also in line with the Rules for the Protection of Juveniles Deprived of their Liberty, United Nations 1990:

Every juvenile shall receive adequate medical care, both preventive and remedial, including dental, ophthalmological and mental health care, as well as pharmaceutical products and special diets as medically indicated

It has been reported that without access to Australia's universal subsidised system of health care, detainees have been denied access to the most appropriate medication because of cost. [58]

Other incidents have also been reported that highlight the need for access to appropriate care. At Villawood, for example, where despite formal recommendations by medical practitioners in February for a patient to receive specialist care, and repeated informal requests by independent doctors nothing occurred until finally this patient became moribund. She was a first time mother and her child was considered at risk from her condition. At that time a lawyer organised an emergency independent assessment and reported that it had been difficult to achieve given DIMIA and ACM bureaucracy. This action resulted in an emergency admission to hospital. A second similar case occurred a week later. Pressure had been exerted by ACM to resist specialist interventions on the basis of budgetary considerations. [59]

We would recommend that any health staff employed should be independent of ACM to avoid conflict of interest.

Dental care is not routinely available in detention centres and it has been reported that conservative procedures are not available and that dental pain is treated with paracetamol - a mild analgesic. However, extractions are performed.

Public health practitioners must be concerned to learn that the dentist's main activity is tooth extraction and that the main health 'treatment' was advice to 'drink more water' [60]

Women's' Health services
 The UNHCR guidelines stress the importance of the appointment of women health professionals. There is no evidence of attention to family health services, appointment of female health professionals or specialised women's services.

We asked informants whether refugee women have access to primary health care services which provide for the monitoring of the health of pregnant and lactating women. According to our informants regular antenatal care is provided by nurses in detention centres. However, while it is reported that the contractors prefer midwives, they do not ask for nor provide cross cultural training for their employees.

The procedures associated with delivery vary between detention centres. It has been reported that the practice of sending women alone for delivery to a hospital far from the detention centre has resulted in women waiting as long as possible and sometimes being involved in an obstetric emergency without appropriate medical support.

According to our informants there is no routine MCH support for women. Formulae for infant feeding are not available so by default, breast-feeding is 'promoted' without support. Use of milk products is not monitored and cow's milk is reported to be used inappropriately for infants less than 12 months old. There are reports of formulae being provided to mothers of infants by friends in the community.

According to our informants there is no nutritional status surveillance of infants and young children, see Section 4.

Adolescents:
 The UNHCR guidelines raise the questions:

Although adolescents may have adult bodies and perform many adult roles, generally speaking they have not fully developed the emotional maturity and judgment, nor achieved the social status, of adults that come with life experience. In refugee situations, adolescents do need the 'special care and assistance' given them by the CRC: they are still developing their identities and learning essential skills. When the refugee situation takes away the structure they need, it can be more difficult for them to adjust than for adults. Their physical maturity but lack of full adult capabilities and status also make them possible targets of exploitation, such as in sexual abuse.

Refugee Children: Guidelines on protection and care 1994

It has been reported that there are no special services available for adolescent boys or girls.

Culturally appropriate and sensitive services are needed to provide accessible services to both boys and girls and adolescent boys and girls have specific health and emotional needs that will need to be addressed. Special cultural issues associated with young females are discussed in Section 3.

Afghan women have come from a culture where they were denied access to health care if there was no female health professional available. It is important that female health professionals are available in Australian facilities because these young women may seek health care from a female professional before a male.

There are also structural conditions that have a negative impact on the reproductive health of adolescent girls in particular, eg lack of privacy about person health and no cross-cultural staff training. A young female ex-detainee described how women have to complete a form including the date and personal details when they need sanitary towels. They are supplied with ten pads and face possible questioning by a staff member, who is not always a woman, if more are needed. [61]

Suggested activities
 Group activities should emphasize peer leadership. Sports, group discussions and community projects are examples. They can support adolescents in making the transition to adulthood by discussions on issues such as sexuality and adjusting to the host country culture.

Health education for families, including the risks and means of preventing diseases with