| National and International | ||||||||||||||||||||||||||||
| Wounded asylum seekers The situation and problems with respect to medical services at the East Japan Immigration Center |
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YAMAMURA Jumpei M.D. Minatomachi Medical Center, 7-6 Kinko-Cho, Kanagawa-Ku, Yokohama-Shi, Kanagawa-Ken, 221-0056 Japan. |
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Foreword |
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| There has been a rise in the number of cases of asylum seekers being detained for extended periods of time at immigration centers despite having applied for refugee status to the Japanese government. Many develop physical and mental symptoms in detention, but it is unlikely that they receive adequate medical care at immigration centers even when their conditions deteriorate. The author has experienced several cases where the serious condition of an asylum seeker only became apparent through consultation at a medical facility upon his/her release (1). |
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| In the aftermath of the 11 September 2001 terrorist attacks on New York, more than ten Afghan asylum seekers were arrested by immigration authorities in Japan for ‘illegal’ entry without valid visas. Lawyers representing them brought proceedings before the Tokyo District Court. As a result of subsequent judicial trials, five individuals were released and one was put on provisional release in October 2001. The author conducted medical consultations of the released asylum seekers at the request of a refugee support group. At the same time, the author sought detailed information from these individuals on the medical services available at the East Japan Immigration Center (EJIC) at Ushiku city, and in addition conducted interviews with those still detained at EJIC. This report outlines the health condition of detained asylum seekers and the current situation and problems with respect to the medical services available at EJIC, from the point of view of the asylum seekers (patients) themselves. |
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Objective and Methods |
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| Those included in the study were thirty-seven asylum seekers detained by
immigration authorities, of whom twenty two were Afghan, twelve Burmese
and three Kurdistan. Thirty-five were male, two female and were between
18 and 53 years of age, the average age being 31.9 years. The shortest
and longest periods of detention experienced within the group were 1 month
and 18 months respectively, with the average across the group being 7.4
months (Table 1). |
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Table 1: Sex/Age/period in detention by country origin
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Interviews were conducted face-to-face in Japanese, English, Dali, Persian and Burmese. Those that had been released from detention underwent medical consultation and screening tests such as chest x-rays, blood tests and urine tests, as well as consultation by expert doctors and psychiatrists, before a final diagnosis was reached. However, for those who were still detained at EJIC, only an interview across a glass division was permitted, and the diagnoses remain suspect. |
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Results |
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| Most asylum seekers developed physical and mental symptoms within two weeks
of arrival at the immigration center. Symptoms were diverse, ranging from
sleeplessness to weight loss, loss of appetite, headache, body pains, and
a sense of exhaustion etc (Figure 1). Over the average 7.4 months in detention, an average reduction of 8.4kg in body weight was observed. This corresponds to a weight loss rate of 1.0kg per month. However five detainees reported that at the time of being weighed an immigration staff member put his foot on the scale to increase the reading, and therefore the rate of weight loss may in fact be higher. Very high blood pressure was observed in five detainees, while slightly high blood pressure was observed in two detainees. All had normal blood pressure before being detained, and the blood pressure of four of them returned to normal after their release. Of the twenty-one detainees who had experienced persecution under the Taliban/military regime in Afghanistan/Burma/Turk, fourteen felt that the experience of detention in Japan brought back memories of their previous persecution in their home countries (Figure 2a,b). When the detainees had sought medical treatment at EJIC, the doctors they saw did not carry out any direct physical checks such as palpation or auscultation, and did not give any explanation for their diagnosis or treatment. Medicines had been prescribed for various symptoms, but in some instances the choice of medicine was left up to detainees themselves. No explanation of the medicines was given, nor were these medicines effective. In many instances, no interpreter was provided for communication with the doctor, and the detainees did not understand most of what was communicated. Overall, the aspects of treatment discussed above caused the detainees to mistrust the doctors provided at EJIC (Figure 3). Detainees repeatedly requested medical consultation at an outside hospital. Permission was not granted immediately, however, and they were forced to wait between 2 weeks to 6 months (2.0 months on average) before receiving medical consultation at an outside hospital. As for response in emergency situations, five detainees who attempted suicide and one detainee who suffered from fainting spells were taken to an outside hospital the following day, one detainee who suffered from fainting spells was taken after three days, one detainee who performed a hunger strike was taken after one week, and one detainee who refused food was taken after two weeks. However, one detainee who experienced chest pains and one who had hematomesis were given only symptomatic treatment (Table 2). |
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Table 2: Response in emergency situation |
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| n=12 | ||||||||||||||||||||||||||||
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| Most of detainees released from detention were diagnosed by doctor at outside
hospital with depression, eight with Post Traumatic Stress disorder (PTSD),
five with Acute Traumatic Stress Disorder (ATSD) and one with serious hypertension.
Five with positive protein in the urine and one with previous tuberculosis
was detected, but screening tests showed no other abnormalities. Medical
questions were posed within a limited time period to the five detainees
still in detention; phonacoscopic testing and physical checks such as palpation
and auscultation were not carried out on these detainees. One each of them
was diagnosed with suspected ischemic heart disease (IHD), suspected peptic
ulcer and suspected asthma (Figure 4). |
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Comments |
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| 1. Mental and physical symptoms of the asylum seekers in detention In many situations, asylum seekers have fled persecution in their countries of origin and already show signs of psychiatric disorder due to experiences of severe hardship. Western countries conduct screening tests, including mental health examinations, to determine the health condition of immigrants and refugees (2). However, it has been pointed out that some asylum seekers are detained by immigration authorities or the police for periods of up to several years, which may cause their mental condition to deteriorate (3) (4) (5) (6) (7). In Japan, many asylum seekers are also forcibly detained by immigration authorities, and this experience itself greatly impacts on their health condition. Moreover, asylum seekers are often treated in an inhumane way within the environment peculiar to the immigration center, and often develop a sense of fear from their subjection to verbal abuse. As a result, most detained asylum seekers express the following: "Why do I have to be treated like a criminal, when all I have done is apply for refugee status?" Asylum seekers experience apprehension about their future, as well as feelings of disconcertion, anger, and distrust towards their unjust detention term. Their mental condition becomes extremely unstable and as a result they start suffering from symptoms such as headache, sleeplessness, body pain and loss of appetite. The fear of being forcibly repatriated adds to their fear, leading to further deterioration of their mental condition, and ultimately to conditions such as PTSD or depression, which result in suicidal behavior or the initiation of hunger strikes. Such tendencies have been observed in the cases of the asylum seekers detained at the immigration centers in Western countries (3) (4) (5) (6) (7). Weight loss and increases of blood pressure have also been observed, which constitute objective measures of the health condition of detainees. These signs are due to the peculiar "culture" at immigration centers, which are likely to result in the accumulation of stress. In addition, there is a fear that qualitative physical conditions such as IHD, peptic ulcer and asthma may develop if asylum seekers are detained for a long period of time. The physical effect of hunger strikes may also result in irreversible nervous disorder and renal damage(6). Such physical and mental conditions continued after their release from the immigration center, and in many situations a sense of guilt at having been detained hinders their recovery. 2. Medical services available at the immigration center It is doubtful whether the immigration authorities respond to symptoms of medical conditions in detainees appropriately, given their failure to respond appropriately in most of the situations revealed above, despite the signs of deterioration such as attempted suicide, frequent fainting, abdominal pain and chest pain. Firstly, there is a significant problem as to the quality of the doctors provided at EJIC. Incredibly, most detainees claimed that doctors did not touch them, examine them, or offer any explanations on their physical and mental condition. Such detainees did not know what sort of disease was diagnosed or what sort of medication was being administered; thus they felt grave concern, however they had no choice but to take the medication provided despite their fears. Naturally, the patients developed a sense of mistrust towards the doctors. It is also problematic that no provision was made for medical consultation in the various languages spoken amongst the detainees, and that communication with them was not achieved. Moreover it is important that medical personnel understand the cultural background of the patients. For example, the author conducted the medical examinations of the released Afghan asylum seekers together with a Japanese doctor who spoke Persian, and it was obvious that the mere presence of a doctor who could understand their mother tongue had a strong psychological effect on the patients (8). Perhaps due to the lack of medication, it was common practice to display the available medicines and have the detainee himself choose one that he deemed appropriate. The prescription of medication by non-medical personnel should be viewed as problematic. Medication was also administered unnecessarily for symptoms such as headache, sleeplessness and fever, and in some cases the side effects of the medicine lead to deterioration in the detainees' health conditions (3). Because initial screening tests are not carried out, the immigration authorities do not have an accurate picture of the health condition of detainees. In western countries, initial screening tests are carried out on refugees and immigrants as a preventative measure against tuberculosis and other communicable diseases (2). The author's own research found high rates of tuberculosis amongst foreigners originating from developing countries (9) (10), and it has been reported that tuberculosis has been found amongst detained asylum seekers, and that it has spread to other detainees (3)(5). Detainees who attempted to commit suicide or who suffered from frequent fainting spells were left until the next day (in some cases three days) before being examined by a doctor at outside hospital, demonstrating the immigration center's complete lack of preparation for medical emergencies. A detainee can be released provisionally if he or she suffers irreparable harm, however that determination is entrusted to the immigration centre, and provisional release is rare. There is absolutely no appreciation that by the time irreparable harm is sustained, it is too late, and given the abovementioned situation with respect to medical treatment, there is a high risk that symptoms will be aggravated. In a previous case, "permanent damage" was sustained by a detainee who did not receive expert medical treatment for several months and then lost his hearing due to otitis media (1). If this was a general Japanese facility, it would probably be sued for negligence. This background of inadequate attention to medical treatment shows that medical matters are not independent of the immigration authority, and detention takes priority over medical care. In addition, the immigration centres do not house just refugee applicants, but “illegal migrants” are also detained there. The detainees are sometimes physically abused by immigration staff (11)(12). There are even examples of excessive violence leading to death (13). Violence at the hands of immigration staff (including verbal abuse) makes the detainees fearful, and can be a trigger for mental health problems such as PTSD. These cases are only sometimes publicised through supporter groups and lawyers, but there are likely many more cases of foreigners who have been subjected to inhumane treatment in the immigration centres, causing both physical and mental harm for which they do not receive treatment, and who are deported to their home countries with absolutely no public attention. |
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Proposal |
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| Medical treatment requires a relationship of trust between the patient and the doctor, but because the medical environment at immigration centers is inadequate, patients experience a high degree of mistrust towards their doctors provided at immigration centers. This poses a limit to the effectiveness of treatment through the prescription of medication. Such limitations need to be recognized, and if detention is absolutely necessary, immigration authorities need to take asylum seekers' experiences of persecution in their home country into careful consideration, and pay due attention to their health needs. In the event that detention leads to the deterioration of a detainee's health condition, immigration authorities under the Ministry of Justice should assume responsibility by providing medical services, including preventative care, taking the following points into account: ●Improve the quality of medical care. Provide clinically experienced doctors and counselors who have an understanding of different cultures at immigration centers; ● Make interpreters who are trained in medical knowledge and are able to administer health care in various languages available; ● Conduct initial screening tests as part of a policy of preventative care against communicable diseases; ● Train immigration staff in basic first aid/emergency medical care; ●Improve cooperation with outside hospitals; meet patients’ requests without delay, and contact and make arrangements with an outside hospital immediately upon deterioration of a patient's physical or mental condition; ●Institute periodic independent inspections of the medical services available at immigration centers; ●Permit medical consultation by doctors appointed by a refugee's legal counsel, to enable independent medical opinions to be obtained should this be requested. |
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In conclusion |
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| On a personal note, I have participated in refugee relief activities overseas on a number of occasions. Sometimes the government and people of the host country (which is almost always a developing country) threaten to deport the refugees, and sometimes refugees are repeatedly subjected to violence, including sexual violence, and theft. The refugees, who are in a weak position, have no choice but to endure it, because if they resist, they may risk deportation. The majority of refugees are treated as unwelcome guests. From this I learned that one of the functions of international relief activities, perhaps even more important than activities undertaken until now, is to protect the human rights of refugees against the host governments. International relief agencies by their very existence can prevent human rights abuses. Subsequently, I began work in a medical clinic in Japan. It never occurred to me that I would be treating refugees there. Then, I learned that refugees in Japan are also treated as unwelcome guests by the host government. Refugees who have fled from persecution should not be subjected to further hardships. In the same way as international relief agencies, we must constantly monitor the immigration centres, and seek to remedy the unjust human rights abuses against refugees of the Japanese government, change the excesses of the immigration law and system, and improve the medical treatment at the immigration centres. If this is not possible, Japan will be branded as a country that is backwards in terms of human rights protection, along with developing countries. |
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Reference |
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