Perspectives

Book Seeking asylum, losing hope

In 2001, harrowing footage of a 6-yearold child in an Australian immigration detention centre alerted the clinical and mental health community to a crisis. The boy and his family had already spent 18 months in detention, and in the notorious, and now decommissioned, Woomera Immigration Detention Centre, he witnessed riots, behavioural breakdown, and acts of self-harm as mass protests erupted. At the height of the riots, water cannons were turned on the detainees and guards in full combat gear attempted to restore order. He saw a family member attempt suicide by hanging and was terrorised by another persons attempt at self-immolation. This young boy became progressively more withdrawn and distressed, he began to refuse food and drink, and eventually became mute. He required admission to hospital and was diagnosed with an acute stress disorder. Rehydrated, he was returned to detention and relapsed. His parents, who both had major depression, were unable to support or reassure him. This scenario, although extreme, highlights many of the issues that face child asylum seekers in the highly politicised context of immigration. The plight of such children is the focus of Asylum-Seeking Child in Europe. The books contributors, who come from medicine, psychiatry, and a range of other disciplines, address what happens to refugee children during and after their application for asylum in different European countries. The mental health of these children is a key issue. Refugee children are often victims of war and displacement and have been exposed to traumatic events; they also face great uncertainty about their future. Children are usually dependent on parents and adults around them to support them in coming to terms with trauma and to shield them from the direct impact of traumatic experiences. Many child asylum seekers, however, do not
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benet from such parental protection. Such children are at increased risk of witnessing their parents trauma and depression, or of being separated from their carers. In the detention context, family breakdown and increasing feelings of hopelessness and helplessness are common. Observations and clinical work with detained parents has found that many experience guilt and pro-

Work with asylum seekers has taken many of us into a political arena that has stretched the boundaries of our traditional clinical role.
found depression about their situation and their failure to care for, and protect, their children. As a result of these issues, children often become withdrawn and prematurely self-sufcient. There have been reports of younger children wandering around detention camps engaging indiscriminately with adults. During riots and protests, children remain in the midst of disorder and adolescents can become active participants. It is not surprising then that the mental health effects of detention have become so important in terms of research and as an argument for reform. Some of the contributors to this book raise concerns about the high rates of post-traumatic symptoms in refugee children and the need to look at comprehensive intervention and social reintegration. Education services are crucial and can ideally provide children with an understanding of their own history of displacement and national identity, and help them develop the capacity to adapt to a new environment. Some traumatised children will require specialist mental health interventions. Survivors of war and those who have witnessed atrocities, for example, are more likely to have

persistent post-traumatic symptoms and developmental compromise. This does not imply, however, that an individualistic treatment approach is ideal. Any psychological interventions should be embedded within a model of family and social support and adaptation. What is important is that we recognise the seriousness of individual distress and engage with those traumatic symptoms that disrupt ongoing functioning. Psychiatrists in Australia and Sweden have reported asylum seeking children with a severe traumatic response that resembles pervasive refusal syndrome. The boy described above who became profoundly apathetic and withdrawn is an example of this state. These children may be in a life-threatening state of physical collapse and in need of hospital treatment, but the context in which these families nd themselves is crucial to any intervention. Provision of permanent protection and stability, and support in efforts to recreate a sense of purpose and meaning are central to the recovery process. The moribund child in a sense symbolises the despair and collapse of his or her family, and so interventions should not focus exclusively on the individual child. In less dramatic examples, traumatised children may require support to reintegrate their experiences and allow them to be put in the past so that they do not remain actively distressing in the present. Like the traumatised refugee children described in AsylumSeeking Child in Europe, many children from Australian detention facilities remain preoccupied by their experiences years after their release. They repeatedly draw pictures of riots and violence, play games of guard and prisoner, and have recurrent nightmares. Their experiences and history mark them as different from other children. Adaptation to community life has been a major issue for adolescent detainees; some remain angry and exhibit

Asylum-Seeking Child in Europe Hans E Andersson, Henry Ascher, Ullla Bjornberg, Marita Eastmond, Lotta Mellander, eds. Centre for European Research Gteborg University, 2005. Pp 204. 1400. ISBN 91-89608-15-1.

1997

Perspectives

Picture by a child held in an Australian immigration detention centre

maladaptive coping mechanisms, such as self-harm and aggression. Another vulnerable group of children highlighted in the book are those who have been born in detention environments.

Many of these infants have experienced emotional deprivation and neglect at the hands of overwhelmed parents in an environment that is completely unsuitable for the very young. Unsurprisingly, developmental compromise is common in these children. Although, as this book makes clear, the evidence of risk and damage to asylum seeking children is strong, the pathway to a humane response is less clear. In most countries, there is an inherent tension between refugee childrens rights to care and protection and policies to deter immigrants. Children have become pawns in a broader debate about what many people in the west perceive to be the threat of mass immigration. At least in Europe there seem to be some signs of progress. Emerging European Union policy seems to be moving towards

a much clearer focus on protection for children, including provision for displaced children. Perhaps the Australian experience can serve as a moral lesson to others and give us pause to consider the damaging implications of deterrent immigration policies that detain children with inadequate provision for health and welfare. The ethical dilemmas for clinicians are complex in providing quality care and advocacy when clinical decisions may be countermanded by the detention system. Work with asylum seekers has taken many of us into a political arena that has stretched the boundaries of our traditional clinical role. For most of us, the intersection of clinical, political, and ethical issues is now unavoidable.

Louise Newman
louise.newman@nswiop.nsw.edu.au

In brief
Exhibition Snapshots of HIV
While politicians, donors, and pharmaceutical companies wrangle over how to get antiretrovirals to those who need them, aid agencies are sometimes the only ones continuing to get drugs to patients. In an exhibition that documents Mdicins Sans Frontires HIV/AIDS programmes in Africa, photographer Pep Bonet does not pull his punches. His pictures are bold and uncluttered, and often brutal. Many are dening images of HIV diseasedisgurement, emaciation, and helplessness. But others offer snapshots of issues intertwined with HIV: the rape of young children because of the persistent myth in Africa that sex with a virgin will cure AIDS; the economic devastation wreaked by HIV as people become unable to work; and the link between migratory labourers and sex workers. Bonets talent lies in portraying his subjects as three-dimensional people rather than as passive victims. His images seek to provoke empathy rather than charity. Many health professionals are hardened to the effect of these sorts of images, but immunity can breed complacency. Bonet, like others, is insistent that the world can do more. The facts about AIDS can be found in medical journals, but its always worth looking at the bigger picture. Unsurprisingly, surgeons seem to be characterised by their can-do attitude and their privileging of life at all costs, whereas intensivists seem to weigh quality of life against likelihood of survival and use of scarce resources. Perhaps most interesting is the contrast between the US setting, where decisions rest on the principle of patient autonomy, and that in New Zealand, where withdrawal of care is solely in the purview of the intensivists. Although her methods are observational, Cassell is hardly a y on the wall. She comes out against the principle of patient autonomy, believing it passes the moral buck to avoid making difcult decisions. She prefers the moral calculus of the New Zealand approach that frames end-of-life decisions as a medical, not a moral, judgment. In the end, Cassell illuminates some of medicines most difcult issues.

POSITHIV+ An exhibition by Pep Bonet with Panos Pictures and Mdecins Sans Frontires. Showing at Honduras Street Gallery, London, UK, until Dec 22, 2005.

Priya Shetty
priya4876@hotmail.com

Book Fighting for life

Life and Death in Intensive Care Joan Cassell. Temple University Press, 2005. Pp 233. US$2295. ISBN 1-59213-336-3.

Joan Cassell has built her career on applying the ethnographic methods of anthropology to her savage tribe: surgeons. In Life and Death in Intensive Care, her scope widens to the interplay between intensivists, surgeons, nurses, and administrators in three surgical intensive-care unitstwo in the USA and one in New Zealand. The end result is a unique view of end-of-life Noah Raizman care in modern hospitals. nmr2002@columbia.edu

1998

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