Concerns raised in editorial in Medicine, Science and the Law journal and in BMA public letter
The Medicine, Science and the Law journal last week published an editorial article by seven medical experts on the challenges posed to mental health, ethics and the law by the Government's Rwanda policy and the new Nationality and Borders Act.
Image credit: UK GovernmentYou can read the editorial article online here.
In particular, the article highlights the significant negative mental health impacts that will be caused by the policy of transferring asylum seekers to Rwanda. As the article notes, the Memorandum of Understanding between the UK and Rwandan governments makes no reference at all to mental health.
The authors explain: "The policy has important implications for mental health. Refugees and asylum seekers have increased rates of some mental health conditions, particularly post-traumatic stress disorder (PTSD) and depression. The adverse impact of the new policy on such a population is likely to be substantial. In the face of extreme uncertainty and lack of hope, it risks provoking self-harm and suicide among some of those affected. It is therefore necessary to ensure that healthcare services in Rwanda have sufficient capacity to identify and manage people with mental health difficulties. However, the current provision of mental health resources in Rwanda is extremely limited, with only 12 psychiatrists working in the country (0.10 per 100,000 people), no child psychiatrists, and only two psychiatric hospitals. Additionally, the people of Rwanda are themselves known to experience high levels of mental health morbidity, including PTSD and depression, reflecting the mass genocide that occurred there in 1994. Sending asylum seekers from the United Kingdom to Rwanda may further reduce the availability of already scarce specialist services to the people of Rwanda."
Such concerns make it all the more important for doctors and lawyers to work together to ensure that all the necessary medical evidence is obtained for those facing removal, the article adds.
The authors said: "One way that doctors and lawyers can work together is through medicolegal reports. In its guidance document on handling third country inadmissibility processes, the Home Office states that non-protection human rights-based claims must be fully considered, including medical claims under Articles 3 and 8 of the ECHR. Therefore, for vulnerable asylum seekers due to be sent to Rwanda, it is important their legal representatives instruct expert clinicians to identify and report clinical issues which affect the individual's human rights. Key areas for judges to make decisions in such cases include information about physical injuries, mental health vulnerabilities and other factors such as sexual orientation which would affect their mental health if sent to Rwanda. The specific requirements for reports may include an assessment of fitness (or otherwise) to fly. This could include an assessment of whether the flight environment would exacerbate their mental health condition and whether any behaviour arising from underlying mental health conditions could interfere with the safe conduct of the flight. We encourage lawyers to consider whether obtaining evidence in the form of a medicolegal report on such areas of relevance may help to reach a fair decision, and doctors to develop the skills and experience required to conduct such assessments."
Additionally, the authors warn that the policy is likely to inflict moral injury on health professionals who consider the legislation to be fundamentally wrong and who will be required to participate in any part of the process. If health professionals are required to make decisions about asylum seekers' vulnerability and/or their fitness to fly to Rwanda, the moral injury will be worsened.
In a public letter published by the British Medical Association (BMA) last week, ten medical experts from the BMA and other organisations warned that the Rwanda policy will have a severe and irreparable impact on people's health, wellbeing and dignity.
The letter states: "Whilst Priti Patel's plans – modelled closely on the failed Australian system - have generated widespread condemnation on legal and practical grounds, there has been little focus on the catastrophic and irreversible harm they will have on the physical and mental health of individuals forcibly expelled. We have seen the disastrous medical consequences of Australia's offshore detention policy on people who needed protection. We can attest that it is unconscionable for the UK government to knowingly replicate this cruel system of forced removals and offshoring to Rwanda - or any other country - as it results in harm and abuse."
Traumatised asylum seekers should receive specialised care and support in the UK, the letter adds, and should not be expelled to another country, where they are likely to experience further traumatisation and their physical and mental health needs will not be met.
With regard to Australia's offshoring policy, the letter notes: "The policy catalysed a mental health epidemic amongst those seeking safety, with UNHCR finding cumulative rates of depression, anxiety and PTSD among refugees forcibly transferred to Manus and Nauru to be the highest recorded in the medical literature to date, at over 80 percent in both locations. Médecins Sans Frontières / Doctors Without Borders (MSF) provided mental health care to 208 refugees and asylum-seekers detained on Nauru Island. Of those, 60 percent had suicidal thoughts and 30 percent had attempted suicide."
The experts writing for the BMA say they are fundamentally opposed to the Rwanda policy on ethical and medical grounds, and they urge the British Government to abandon its plan before any further harm is done.
Natalie Hodgson, Assistant Professor in Law at the University of Nottingham's Human Rights Law Centre, also drew comparisons in a blog post last week between the Rwanda policy and Australia's policy of offshoring asylum seekers.
The blog post states: "In 2012, Australia started sending asylum seekers to offshore detention centres on Manus Island and Nauru. This policy was 'cruel, costly and ineffective'. People in offshore detention reported extreme levels of mental illness including depression, anxiety and post-traumatic stress disorder. 12 people died offshore. […] In 2016, medical experts found that 88% of the asylum seekers and refugees on Manus Island and 83% of the asylum seekers and refugees on Nauru were suffering from a psychological disorder. These levels of mental illness were significantly higher than among asylum seekers living in Australia, suggesting that the offshore detention environment was a factor in their mental health issues. There are already reports of significant distress among asylum seekers targeted for removal to Rwanda. The degree of psychological support available to asylum seekers in Rwanda is unclear. A policy that inflicts psychological harm on an already traumatised population is inhumane and should be reconsidered."
Hodgson says there is no evidence that the UK will be any better at preventing or addressing such issues than Australia.
Last month, the Refugee Council and the British Red Cross warned that recent Government policy was increasing distress and anxiety among asylum seekers in the UK.
Enver Solomon, CEO at the Refugee Council, said: "We have been receiving a number of worrying reports from our services working directly with people in the asylum system about the devastating impact the threat being expelled to Rwanda is having on them. We are hearing tragic stories about the severe impact on mental health, including young, vulnerable children who are terrified what will happen to them with reports of self-harm. We are concerned the government is not seeing the face behind the case and should be doing far more to exercise its duty of care towards vulnerable people."