Dr Janani Devaraja and Ashvinderjit Kaur, members of the Malaysian Doctors for Women & Children shared an opinion piece on refugee health as part of the International Day for the elimination of Racial Discrimination on 21st March 2023. First published online in CodeBlue by The Galen Centre on 22nd March 2023.
Refugees have genuine health needs, but face barriers in accessing treatment, which can lead to worsening health outcomes.
Refugees are people who flee their homes due to risk to their lives and/or personhood if they remain or return to their homes. The concept of seeking refuge have existed since the time of yore.
The Gospel of Matthew recounts the flight of Joseph, Mary and infant Jesus Christ from Bethlehem to Egypt to escape King Herod’s massacre of male infants. In 662 AD, Prophet Muhammad left for Medina from Mecca due to threats to his life and the then-fledgling Islamic community.
The Parsi community fled to Gujarat, India between the 8th to 10th centuries to escape religious persecution. The First World War created millions of refugees in Europe and Russia, whose descendants today are indistinguishable from the pre-war population of the country their ancestors fled to.
The 1951 Refugee Convention defines a refugee as “someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group.”
Adopted in 1951, this convention formally set the moral and legal obligations for states/countries to protect people who were fleeing persecution and conflict. The convention initially only applied to refugees displaced within Europe before 1951, but subsequently the 1967 Protocol removed the geographical restrictions.
Countries that ratify the 1967 Protocol also follow the 1951 Refugee Convention as per Article 1 of the 1967 Protocol. To this date, 149 countries have ratified the 1951 Refugee Convention and/or 1967 Protocol. My home country, Malaysia, is sadly not one of them.
And while we grumble over what we are owed and how much we get to keep, the displaced wait at the door. They are painters and surgeons and craftsmen and students. Children. Mothers. The neighbour who made a good sauce. The funny girl from science class. The boy who can really dance. The great-uncle who always turns down the wrong street. They endure painful transformation, rising from death, discarding their faces and bodies, their identities, without guarantee of new ones.Dina Nayeri, The Ungrateful Refuge
This is not to say that Malaysia does not have any refugees. Malaysia has approximately 180,000 refugees, of whom a quarter are under 18 years of age. The majority of refugees are from Myanmar, with the rest from Pakistan, Palestine, Afghanistan, Iraq, Yemen, Somalia, Sri Lanka, and Syria.
There is no national legal framework to govern refugees and asylum seekers, thus in the eyes of the law, they are indistinguishable from stateless people and undocumented migrants.
Malaysia’s position is that being a non-signatory to the international conventions, the stay of refugees in the country is deemed only temporary; until a permanent resettlement is found.
However, achieving permanent resettlement for refugees is becoming more difficult, as more countries are restricting the number of refugees they accept. Hence, a ‘temporary’ stay may continue for several generations.
The Malaysian government manages refugees in the country via the United Nations High Commissioner for Refugees (UNHCR). UNHCR begun its operations in Malaysia in 1975 with the arrival of Vietnamese refugees fleeing the Vietnam war.
UNHCR cooperates with the government, private sector, and charitable organisations to safeguard and provide assistance for refugees in health care, education, financial support, and counseling. They also help reintegrate refugees into mainstream society, and for some to resettle them permanently in another country.
Those that UNHCR deem are genuine refugees will receive a card that confirms they are under the protection of UNHCR; to provide immunity from being prosecuted based on immigration status8. However, the card has no legal value.
The government and society at large still see them as “illegals”, putting them at risk of exploitation, xenophobia, arbitrary arrests, and for some, deportation to the countries that persecuted them in the first place. Raids against refugees and asylum seekers are common, including on children, and 151 people have died at immigration detention centres between 2016 to 2019 with no public investigation.
In Malaysia, refugees live at the margins of society. Many refugees live in overcrowded and unsanitary conditions, which increases their risk of contracting infectious diseases. Refugees are often not covered by employment laws, putting them at risk of mistreatment, being paid lower wages, unjust dismissal, and not being compensated for work related injuries.
Refugee children cannot enter the public school system, thus receive informal education through UHNCR or charitable organisations which can be patchy and their qualifications can be unrecognised. Some cannot even go to school at all and become child labourers.
Raids on refugees and asylum seekers lead them (including children) to be placed in overcrowded, unsanitary detention centres with no UNHCR oversight.
I want to have the chance to send my son to school,” she said. “I dream about having a normal life like everybody else … that one day I will be a citizen in a country where I will feel at home.Raghda, a refugee in Malaysia
Poor living conditions, separation from family members and support networks, and uncertainties regarding legal status have all proven to increase prevalence of psychiatric disorders amongst the refugee and asylum seeker population. A significant number of Rohingya refugees had major depressive disorders, generalised anxiety disorders, and post-traumatic stress disorders (Kaur K, Sulaiman AH, Yoon CK, et al. Elucidating Mental Health Disorders among Rohingya Refugees: A Malaysian Perspective. International Journal of Environmental Research and Public Health 2020, Vol 17, Page 6730. 2020;17(18):6730. doi:10.3390/IJERPH17186730).
Racial discrimination against refugees also exists among Malaysians. Refugees are often viewed as troublesome, criminals and reservoirs of infectious diseases. An Ipsos study found that only 24 per cent of Malaysians believe that those claiming to be refugees in Malaysia are genuine.
The Covid-19 pandemic further exacerbated xenophobia against refugees (especially Rohingya refugees) due to sensationalist reporting by journalists and viral social media posts.
People are saying we should go home. They don’t understand that the thing with Rohingya is that we cannot return home. If we do, we will be killed. We are facing genocide in Myanmar.Shakirah, a refugee in Malaysia
This discrimination harms resettlement and integration for refugees and asylum seekers, who are already facing trauma and persecution in their home countries. Refugees who face discrimination have a lower sense of belonging, less hope for the future, a lower sense of control, and poorer mental health outcomes.
Discrimination can also lead to negative cardiovascular, respiratory, and gastrointestinal health outcomes among refugees and asylum seekers.
Malaysia’s health care system offers primary and secondary care to all UNHCR refugee card holders or asylum seekers with appropriate documentation. They can receive this care with a 50 per cent discount off the foreigners’ rate at any government health care facility.
But pregnancy is an exception, with the women required to pay the full foreigner costs of antenatal care and childbirth. Those without any official documentation have to pay the full foreigner costs for all treatments.
Even with the discount, these costs can be prohibitive, especially when considering that most can only work in low-wage jobs. There are refugee clinics, but these only offer basic health services.
There is also a risk of detainment and deportment if those without official documentation seek services in a government-run facility, leading to many not accessing services when they need it.
Hence, you have a group of people with genuine health needs. but face barriers in accessing treatment. This leads to worsening health outcomes.
Health and social problems are worse when society is unequal. Achieving a more equal society reduces crime and improves physical and mental health in both the rich and poorer segments of the population.
Thus, improving the lives of refugees and asylum seekers while they are in Malaysia will have the benefit of improving the lives of Malaysians as well. Ratification of the 1951 convention and the 1967 protocol by Malaysia would ensure the rights of refugees and asylum seekers are safeguarded.
With the ratification, refugees and asylum seekers will have the legal recognition and resources to improve their wellbeing and integrate into the community. They can then be part of the country’s workforce and contribute to the economy.
Access to health care and quality education will be positive steps forward to improve physical and mental health among this community, and will have positive spillover effects onto Malaysians as well.
Integration into Malaysia society will benefit both refugees and Malaysians, fostering a more cohesive and equal society.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.