Use of Royal Darwin Hospital emergency department by immigration detainees in 2011

Several thousand people arrive in Australia without a visa each year and seek asylum by applying for recognition as refugees. While awaiting processing, these asylum seekers are involuntarily detained by the Australian Government for periods ranging from 1–2 months to several years, and, in 2011, the majority of detainees had been in detention for at least 6 months.1 Previous studies have shown a high burden of physical and psychiatric morbidity — especially mental health problems, self-harm and suicide attempts — in asylum seekers, particularly those held in immigration detention.2-5

Darwin, in the Northern Territory, receives a substantial proportion of the asylum seekers who arrive in Australia and on Christmas Island by boat, and had two major immigration detention facilities in 2011. The first, the Northern Immigration Detention Centre, is a high-security detention centre that houses men, and has a capacity of 456 people. The second, Darwin Airport Lodge, houses families and unaccompanied minors, and has a capacity of 435 people. A third major facility opened in Darwin at Wickham Point in December 2011, and has a capacity of 1500 people. In a 2010 report, the Australian Human Rights Commission raised serious concerns about the provision of health services to immigration detainees in Darwin.6 In a 2013 Auditor-General report, it was shown that about 40% of surveyed immigration detainees in Australia said that their basic health care needs had not been met.7

Despite large numbers of immigration detainees in Darwin, only one public hospital serves their needs — the Royal Darwin Hospital (RDH), a 350-bed teaching hospital with an emergency department (ED) that sees about 65 000 patients per year. We noticed a large burden of morbidity, particularly self-harm, in asylum seekers attending the RDH ED in 2010 and 2011. Since no data quantifying this burden were publicly available, we undertook a retrospective audit of RDH ED attendances by immigration detainees during 2011.

Data were entered into a purpose-built Microsoft Access database and analysed using Stata version 10 (Statacorp). As we did not have access to accurate data on the number of people in immigration detention in Darwin during 2011, we estimated the denominators using data summaries on the number of people in immigration detention that are released every 1–2 months by the Department of Immigration and Citizenship.1 These reports provide detainee numbers for immigration detention centres (IDCs) (eg, the Northern Immigration Detention Centre), but only provide national-level summary data for facilities classified as alternative places of detention (APODs) (eg, Darwin Airport Lodge). We assumed that the proportion of total Australian mainland detainees resident in APODs in Darwin was the same as the proportion of total Australian mainland detainees resident in IDCs in Darwin. Hence we estimated the number of immigration detainees in Darwin in each month of 2011 for which data were available as: NIDC + (NIDC ÷ MIDC × MAPOD). In this calculation, NIDC is the number of detainees in the Northern Immigration Detention Centre, MIDC is the number of detainees in all mainland IDCs combined, and MAPOD is the number of detainees in all mainland APODs combined. The mean of these monthly numbers was calculated as an estimate of the average number of detainees resident in Darwin during 2011.

The study was approved by the Human Research Ethics Committee of the Menzies School of Health Research and Northern Territory Department of Health and Families.

In 2011, there were 770 ED attendances at RDH by 518 individual detainees; the mean (SD) age of these detainees was 27.6 (12.2) years, 112 (21.6%) of them were aged < 18 years, and 413 (79.7%) were male. Iran and Afghanistan were the two most common countries of birth (283 and 90 individuals, respectively), followed by Iraq (63), Indonesia (24), Sri Lanka (14), and other countries (44).

We estimated that there was a mean of 776 individuals living in immigration detention in Darwin during 2011 (monthly range, 561–920 individuals) (Box 1). If we assume there was no population turnover during this time, this would mean that 518 ÷ 776 = 66.8% (95% CI, 63.3%–70.1%) of these people attended the ED at least once in 2011. If we assume the entire population was replaced every month, then the proportion who attended the ED at least once would be 66.8% × 1/12 = 5.6%. Given that the median length of stay by asylum seekers in immigration detention in 2011 was about 9 months,1 we estimate that 66.8% × 9/12 = 50.1% (95% CI, 47.0%–53.2%) of immigration detainees in Darwin attended the RDH ED at least once in 2011. The mean monthly ED attendance rate for detainees was 1.06 attendances per person-year and, based on 9-month length of stay, we estimate that 1035 people passed through Darwin’s immigration detention facilities in 2011.

A high burden of morbidity has previously been described in asylum seekers and immigration detainees in Australia3,5 and overseas.2,4,8-10 The primary health care services at Australian immigration detention facilities were described as understaffed and inadequate in a 2010 Australian Human Rights Commission report.6 Our 2011 data support that assessment for three reasons: the number of ED presentations was much higher than one would expect for a population with access to primary care services; there was a high number of repeat ED attendances by some individuals; and, compared with all patients, detainees had a low rate of admission after attendance at the ED.

As we analysed attendance using broad diagnostic categories, it is likely that we underestimated the extent of psychological morbidity. The most common non-psychiatric complaints (myalgias, headaches, non-specific abdominal pain and non-cardiac chest pain) are symptoms that are commonly due to somatisation in people with psychological distress.

The large number of ED attendances by immigration detainees also puts a substantial burden on the RDH ED. The 770 attendances by detainees during 2011 represented over 1% of all ED attendances. Despite generally low acuity in terms of triage category, resource utilisation was high, with significant proportions of patients needing x-rays, blood tests and referrals to inpatient teams. We did not collect data for 2012 or 2013, but we note that the number of RDH ED attendances by immigration detainees appears to have declined since 2011, probably due to increases in primary health care resources in immigration detention facilities in Darwin and a decrease in average length of stay (277 days in November 2011 v 114 days in February 2013).1 We hypothesise that this was also influenced by the Australian Human Rights Commission and Auditor-General reports6,7 and by public advocacy.

Our study has several limitations. The main limitation relates to the difficulty in obtaining clear and accurate data on the number of people in detention in Darwin during 2011. As a result, we estimated denominators by extrapolation of available data; hence we may have underestimated the number of immigration detainees in Darwin and thus overestimated the proportion who attended the ED. However, as the total capacity of the immigration detention facilities in Darwin during most of 2011 was about 900, we believe our estimated average population of 776 reflects the true situation in Darwin in 2011.

We interpreted the lower admission rates for detainees in each triage category to mean that primary health care services at the immigration detention facilities were deficient, because generally people are discharged from hospital when they have a condition that is of low acuity and severity and could be managed adequately in primary care. Alternatively, for non-medical reasons, doctors might have had a higher threshold for admitting detainees to hospital (eg, detainees were being discharged to supervised accommodation). Irrespective of the explanation, the high numbers of ED attendances and repeat attendances support the assertion that primary care services for people living in immigration detention in Darwin in 2011 were deficient.

We collected our data retrospectively, mostly in categorical form, so our results lack detail about individual diagnoses and presentations. However, the data on diagnoses are likely to be accurate because they were coded and recorded prospectively by doctors as a routine part of ED practice. A prospective real-time study would provide more accurate data, and could include a qualitative component, but this would require time and funding that was beyond the scope of our study.

Our data show that there was a high prevalence of unmet health need, particularly relating to psychiatric morbidity, and limited access to primary health care services, for immigration detainees in Darwin in 2011.