Refugee Health in Australia: Comparing Public Health and Community Development

SWSP7133: Community Development in International Contexts
Refugee Health in Australia
A Comparison of Public Health and Community
Development Practice
Jacquelin L. Wright
4/26/2012

SWSP 7133Assessment 3 s4141186 Page 1
Introduction
Public health professionals have been uniquely placed to build the bridge between
health, human rights and cultural freedom for migrants in Australia. But as the scale and
austerity of the migration phenomena magnifies to remote and urban centres, and
instances of mental and physical ailments increase, workers committed to healthcare
are confronted by procedural complexities which impede on methods of treatment and
ultimately life-saving abilities (IOM 2003; WHO 2010; UNDP 2009; UNFPA-IOM, 2006;
UNHCR 2009; Zwi and Costillo 2002). Critical assessments of Australia’s public health
system have identified that most health interventions are founded upon assumptions of
diaspora communities1and in particular, refugees2 as “empty vessels” that lack the
appropriate knowledge to improve facets of their lives (Baum 1998; Baum et al. 2000;
Esman 1996; Harindranath 2006; Hounton et al. 2009; Safran 1991). This perspective is
simultaneous with a long history of political agendas which capitalise on health
frameworks to institute the barest minimum required and subject humanitarian
obligations to restrictive interpretation (Allotey 2003: 11; Hahn and Inhorn 2009: 10).
Alternatively, participatory approaches in community development practice have
attended to the historical context of health programs, as well as the political
environment in which they are embedded.
This essay concentrates on the social and cultural boundaries between the western
medical practitioner and the non-western client within the context of public health
practice, and argues for an improved approach to healthcare that accommodates
cultural epistemologies of well-being, community interests, and social kinship. Firstly,
the essay highlights the underlying challenges of achieving culturally competent
healthcare by examining a lineage of historically reductionist ideologies within the
western public health system. The following section explains the biomedical approach
of public healthcare, its implications on Australia’s refugees and diaspora cultures, and
will open up discussion for alternative community orientated approaches to healthcare.
A final case study of the “House Party Strategy” will bring to light the value of
participatory approaches for humanizing refugee healthcare. Ultimately, this
comparison will capture epistemologies of health and healing as they entrench diaspora
cultures, and inform stakeholders and sector participants about current issues for
refugees accessing and experiencing health care in Australia.

Challenges of Achieving Culturally Competent Healthcare
The history of social medicine has been one of progressive extension of the right of all
people to good health (Farmer 1999: 1487; WHO 2003: 7-10). Waves of health-care
reform have brought “magic bullet” solutions to worldwide outbreaks of emergent and
resurgent health problems including maternal and child health facilities, immunisation
programs, medicinal solutions to disease, adequate sanitation, contraception and risk
reduction strategies for sexual health (Apostolopoulos and Sonmez 2007; CMM 2013;
Rifkin and Walker 1986: 560; WHO 2003; CMM 2013). However since the launch of the
“health for all” revolution at Alma Ata in 1978, a dichotomous approach to primary
healthcare based on community participation, development and biomedical empiricism
has encumbered a series of inherent ethical and moral dilemmas (Prya 2012: 213-4;
Rifkin and Walt 1986: 560-62). The conversion of the former declaration for universal
social justice and health as a human right to more “primitive” foundations of healthcare
eclipsed by economic rationality and biomedical authority has left sizeable sectors of
the population deprived of equitable access to comprehensive healthcare (Farmer 2003:
1489; Janes 2009: 652-5). This is consequential to a number of technical and allocative
inefficiencies such as inadequate funding, mismanagement, and under staffing (Janes
2009: 655), as well as structural adjustments made by international institutions like the
World Bank who implement market-oriented reforms to social service systems which
under appreciate the strengths of the community-based approach to primary healthcare
(Butler and Cass 1993: 15; Janes et al. 2005: 7).
_________________
1 For the purpose of this essay, “diaspora communities” refers to ethnic-minority cultures which
collectively embrace, embodyand exhibit their cultural origins in trans-local contexts over time. It is
a fundamentally cultural phenomenon conditioned by existing political, social, economic and
physical forces, and premised on the preservation of collective histories and experiences for those
sharing sentimental links with their land of origin (Esman 1996: 316).
2Refugees are hereby defined as people who “owing to a well-founded fear of being
persecuted for reasons of race, religion, nationality, membership of a particular social group or
political opinion, is outside the country of his/her nationality and is unable, or owing to such fear, is
unwillingto avail himself/herselfof the protection of that country” (1951 Convention Relating to the
Status of Refugees).

The argument for further contextualisation and veracity in refugee health interventions,
procedures, and treatment rests upon a consortium of neoliberal ideologies concurring
that privatisation of biomedical and public health services constitute a reductionist
approach to cross-cultural healthcare (Lipsky and Lounds 1976: 89; Hahn and Inhorn
2009: 7) that western rationales for immigration health focus on interim treatment
rather than prevention (Gushulak and MacPherson, 2006; Rifkin and Walt 1989: 242);
that organisational models in healthcare are prepared by highly trained technicians
who are far removed from people’s needs (Allotey 2003: 38; Butler and Cass 1993: 15;
Foster 2009: 686; Hahn and Inhorn 2009: 682;Mansuri and Rao 2012: 49-52; Rosenfeld
1997); and that narrowly constructed and xenophobic visions of national interest have
contributed heavily to the inefficient delivery of healthcare to vulnerable social groups
(Hage, 2000: 194;Harindranath 2006: 137; Macphee 2004: 377-9; Prya 2012: 213-5;
Silverstein 2005: 367-71; Schuster 2005: 3-6; Zwi and Costillo 2002: 15-8). These issues
have become the focus of critical review by several scholars, foundations, and
institutions concluding that “measurable technical interventions should not be at the
expense of an empowering, developmental approach to care at the primary level”
(Petersen and Swartz 2002: 1011) and that knowledge of the socio-cultural
characteristics and impacts of recipient groups, as well as the historical and political
context of health programs is vital to ensuring culturally competent planning and
execution of health programs (Allotey 2003; Baum 1998; Butler and Cass 1993;
Hadjiyanni 1999; Hahn and Inhorn 2009).
The research field of “migration medicine” (CMM 2013) which responds to capacity
building objectives and knowledge bases surrounding population mobility and health
(Gushulak and MacPherson 2006: 6) has been particularly valuable to refugee health as
it considers the performance of particular health agencies and their response to health
risks and outcomes of each trajectory phase of pre-migration, migration, and
resettlement (Almeida and Thomas 1996; Anderson et al 1996; Apostolopous and
Sonmez 2007; Gushulak and PacPherson 2006; Hage 2002; Palinkas et al 2002; Schuster
2005; Zwi and Costillo 2002: 18). As identified by Gushulak and MacPherson (2006), the
five P’s of the migration health paradigm – “population mobility, prevalence gaps,
processes and phases of population mobility, population health, and perception of risk”
(p. 7-12) are attributable considerations for health therapists, community development

workers, medical experts and health policy developers in their identification,
understanding and approach to the realities and disparities of migrant populations
(Allotey 2003; Lee 2001; Marks and Worboy 1997).
The framework of human agency developed by Giddens (1984) has also been cited as a
way of demonstrating migration along a continuum of relatively high degrees of agency
to extremely limited eminences of agency (Hahn and Inhorn 2009: 12). Forced or
‘reactive’ migration, which characterises the experience of refugees, correlates with the
latter end of the continuum; where choices are made to escape from intolerable threats
(Richmond 1994). The epidemiological disparities associated with migration are hereby
derived from historical procedures of quarantine which excludes the settling migrant in
an attempt to safeguard the recipient population (Gushulak and MacPherson 2006:
1743). A counter-productive effect of this was evident during the attempt of Australia’s
Pacific Solution (2001-2007), whereby detained refugees and asylum seekers were at
higher risk of preventable diseases like malaria, pollegra, scurvy, and acute respiratory
infections than they had ever been before during their course of migration (Allottey
2003: 25, 42). These “policies of exclusion” which focus on national security and
principles of “protection” rather than real health issues related to resettlement are
therefore historically contingent agents of repression which exacerbate misconceptions
around appropriate applications of medical knowledge to foreign recipients of
healthcare (Moodie and Taylor 2000: 4-8; Silverstein 2005: 368).
The following section demonstrates how the existing construct of public health services
captures only a limited degree of experiential impact on refugees and other diaspora
cultures as recipients of healthcare by overlooking issues of injustice, and cultural
values, meanings, identity and belonging (Alexander et al. 2004; Allotey 2003;
Bariagaber 2006;). Particular focus will draw on the interplay of immigration and the
structure of the absorbing community within the Australian context to reveal much
about the cultural fissures that must be overcome to build integrated and participatory
approaches to health care.

Western Medicine and Top-down Behaviour: Critiquing the Public Health
Approach to Refugee Health
The moral assumption of public health to act, commit and respond with knowledge and
resources to perceived suffering has been further complicated by the concept of
“political will” and its administrative agendas (Farmer 2003, p. 1487; Janes et al. 2005,
p. 7). A long lineage of political stigmas based on dichotomous ascriptions of minority
status and identity, including “minority-majority, black-white, ethnic-mainstream and
immigrant-resident” have led to the detrimental failure of addressing perspectives and
concerns of populations in need (Zwi and Costello 2002, p. 15; Farmer 2003, p. 1489).
These created and sustained hierarchies have clearly influenced the quarantine-
associated historical basis of migration health practices which focus on medical
screenings for communicable diseases rather than the evolution of health
characteristics, such as trauma-associated health issues motivated by the migration
odyssey (Schuster 2002, p. 3-4; Silverstein 2005, p. 365).
The minority status of refugees, based on superficial parallels of marginality, otherness,
subordination, and affiliations with certain illnesses (Allotey 2003: 10) are more or less
representative of restrictive policies, cultural stigma, and discriminative attitudes
towards refugees as “carriers of disease” (Refugee Council of Australia 2000) and
immigration more generally as a “confrontation, violation of boundaries and contender
of semiotic systems” (Marks and Worboys1997: 34; Lipsky and Lounds 1976: 87;
Schister 2005: 3; Silverstein 2005: 364). Critical assessments of Australia’s public health
system have identified that these innate binary differences homogenise variations
within social groups (Baum 1998: 326), reduce the scope and intent of the traditional
development paradigm of Western medicine (Hage 2002: 197), and contribute to
assumptions of forced migrants as “passive participants in events unfolding around
them” (Allotey 2003: 17). Further, in relation to the International Covenant on
Economic, Social and Cultural Rights (ICESCR 2000) Australia’s public health services
are failing to:
“respect the right to health by, inter alia, refraining from denying or
limiting equal access for all persons, including prisoners or detainees,
minorities, asylum seekers and illegal immigrants, to preventative,

curative and palliative health services; abstaining from enforcing
discriminatory practices as a State policy…” (ICECSR 2000, paragraph 34).
The human rights framework for promoting health for all and preventing disease
provides the tools to support advocates in ensuring governments meet their obligations
(Allotey 2003: 11). However the goals of Western biomedicine as a social institution
have shifted away from a caretaking model based on experiential concerns to a
constructed framework based on diagnosis and treatment of physical determinants of
health (Priya 2011, p. 211). Complex forms of collaboration among international
agencies, governments, ministries and various nongovernmental organisations are
increasingly involved in the delivery of public health services and operate primarily
between the knowledge base of the “donor” or health practitioner, and the “recipient” or
patient of healthcare (Allotey 2003; Apostolopoulos and Sonmez 2007;Gushulak and
MacPherson 2006). Inadequate translation of public health knowledge into effective
action has been concomitant to this binary relationship (Hahn and Inhorn 2009, p. 5) as
a “consultative” type of power relationship (Fliert 2009: 96). Whereby traditional
organised approaches to dealing with migrants as recipients of healthcare emphasise
the “recognition, identification and management of particular diseases, illnesses and
other health concerns” (Gushulak and MacPherson 2006: 3) rather than recognising and
understanding patient knowledge repertoire, their accumulated life history, as well as
current social, economic, and health circumstances (Hahn and Inhorn 2009: 108).
Studies which examine the divergent perspectives of patients and providers have
concluded that inadequate resources, stressful life events, and deleterious
environments contribute to a patients’ perceived illnesses (Blume 1996: 19; Hunt and
Arar 2001: 352); and that health managers applying strictly clinical parameters
disregard the “life worlds” of patients and interpret noncompliance as a sign of
unwillingness to change (Hunt and Arar 2000: 108). A prime example of “medicalising”
responses to an essentially social phenomenon is the prescription of contraceptives for
Muslim women whose culture and custom forbids the use and talk of fertility control
(Butler and Cass 1997: 41), or the instinctive diagnoses and treatment of mentally
unstable and stressed patients as sufferers of post-traumatic stress disorder (PTSD)

(Allotey 2003: 47; Kinzie et al. 2007). Fears of developing dependence on prescriptive
medication, and an unknowingness or uncertainty of how medication can heal acute
symptoms provides sincere reason for non-Western patients to reject the use of
pharmaceuticals and vaccines (Bentley and Owen, 2008). Henceforth what may be
perceived by biomedical practitioners as constructive to diagnosis and treatment may
conflict with a refugee patient’s socio-cultural activities and place them at greater risk of
encountering multiple forms of stress (Kleinman 1988: 29; Wise 2002: 3).
The ultimate responsibility of public health professionals to ensure that all policies exist
to maximise health, wellbeing and equity is evidently reduced by a scientific emphasis
on, and political advocacy of, a biomedical model of health based on individual cases of
disease. Limited research regarding the effect of pharmaceuticals and westernised
health practices on the mental, spiritual and cultural spheres of migrants has
foreshadowed the reductionist, top-down behaviour of many western practitioners,
limiting their understandings of the changing health status of minority groups and the
attitudes of minority patients to the dominant medical culture (Marks and Worboys
1997: 7). Engaging in approaches that do not align with this paradigm of biomedicine is
said to embellish risks for medical practitioners as they “lose control” over their ailing
subjects(Hahn and Inhorn 2009: 8).However the following section demonstrates how a
community development approach to healthcare for refugees and minority groups will
better translate meaningful perceptions of local-level realities, health, and healing
across cultural boundaries and initiate community change from within affected
communities.
A Community Development Approach to Refugee Health:Participation, Self-
Mobilisation and the House Party Strategy
Gathered from the literature, it is undeniable that socio-cultural influences are inherent
within the interpretation, perception and the presentation of traumatic experiences and
their consequences of ill health for refugees and other diaspora communities
(Denborough 2008: 7; Fenton and Sadig-Sangster 1996: 67; Hahn and Inhorn 2009: 24;
Jaeckle and Georgakopoulos 2010: 4).Detrimental concerns of traumatic events such as

torture, sexual violence, harsh detention, uprooting, material losses (UNDP, 2009) and
prolonged human destabilisation remain in the personal and collective memory of
refugees long after the phase of resettlement (Alexander et al. 2004: 155-8; Jaeckle and
Georgakopoulos 2010: 4).Concurrently, Michael White(2007) explains that, when an
individual has experiences that are traumatic, there is a ‘significant shrinking’,
‘diminishing’, ‘corrosion’, and ‘invalidation’ of the sense of self (p.27).The role of the
community development worker to recognise imbalances of power and identity in
inter-group relationships (Butler and Cass 1993: 13), mediate and facilitate between
clients and systems in both public and private spheres (Lee 2001, p. 20), and build on
skills and opportunities for expressing cultural values, ideas, and practices around
health (Allotey 2003: 31), is therefore fundamental towards creating scope for
grassroots level local change within affected migrant communities.
Where “pseudo” or “consultative” participation rests with planners, administrators and
community elites (White et al. 1994: 17) within the public health sector, interactive
“genuine” participation in community development practice utilises multiple strategies
to grapple the “very core of power relations in society” by sharing ownership over
decision making processes (Servaes 1999: 198). Within the context of refugee health,
collaborative power relations characterised by self-mobilisation and local decision
making, have been identified as the most empowering for affected community groups
(Baum et al. 2000: 415; Eversole 2011: 52; Lipsky and Lounds 1976: 88; Mansuri and
Rao 2012; Morgan 2001: 223; Zigarus 1992: 17).Participatory development approaches
which facilitate interaction between individuals and socio-cultural environments can
work in response to “culture-bound illness expression, culture-bound syndromes, and
cultural bereavement” (Allotey 2003: 214; Cargo and Mercer 2008: 328; Hahn and
Inhorn 2009: 14; Hage 2002: 195; Ife & Tesoriero 2006; Zimmerman 1999: 170) and
identify the inequities that exaggerate the gaps between minority and majority
populations.
Butler and Cass (1993) have presented numerous case studies of community
development work for health in Australia’s multicultural context. Of particular interest
is Khai Wong’s study of the “House Party Strategy” which recognises the physical,

spiritual, and personal dimensions of life and health for Malaysian refugees. In an
informal home environment, this approach emphasises social determinants of health by
bringing together people that share similar experiences such as social isolation, cultural
shock, loss of family and kinship structures, and acculturation as a single parent in a
foreign society (Wong 1993: 42). Facilitating participatory communication around
themes of health expectations, foreign misunderstandings and experiences, the
community health worker is well informed of the social organisation and values of
affected diaspora cultures through the process of “access and linking”; that is “linking
workers to the targeted community, the community to the worker, community
members to each other and the community to specific projects” (p. 43).As a social
arrangement devoid of chauvinistic or threatening overtones that may be associated
with formal biomedical contexts, the “ethnic access” focus of the House Party strategy
provides education opportunities, cultural exchange, space for mutual understanding,
friendships and networking under favourable conditions. The statement below
summarises the experience of this informal approach for Malaysian refugees:
“Since the origins of this woman’s illness lay in her break with the beliefs
and practices of her own culture, her healing could only be effected through
the restoration of links with her own community” (Khai Wong p. 39 in
Butler and Cass 1993).
As a form of empowerment practice, this strategy exemplifies the importance of
individual experience in the process of personal as well as community transformation.
The urgent need for unique community services that better recognise the physical,
personal, and spiritual dimensions of life and health and respect cultural differences
between minority groups like refugees can be attended to by transparent and
strategically designed health programs such as this. With pertinence to previous
discussion, implementing health programs is a morally hazardous task that concerns
socio-cultural differences in symptom expression and must be designed to address
factors of accessibility and acceptability (such as location, stigma, linguistic barriers,
documentation and legal status, cultural healing modalities and practitioners), and
cultural boundaries between host societies and adapting migrants, as a means of
revisiting, analysing and understanding the emotional, spiritual, behavioural, and
physical presentation of the refugee patient.

This essay has presented the challenges of achieving optimum healthcare for refugees
and other diaspora communities within the biomedical framework of public health and
attended to these challenges with an alternative participatory approach within the field
of community development practice. Most notably, the reductionist ideologies inherent
to public health rhetoric are not conducive with the many cultural epistemologies of
mental and physical health, diet, risk, and ethno medicines avowed by foreign recipients
of healthcare and so too often the reality of illnesses are falsely represented (Glover
2009: 229).The potential of failure for communicating cultural perspectives has
therefore been vexed by institutional boundaries and tainted by political values within
Australia’s healthcare policies. In order to overcome the social and cultural boundaries
between the western medical practitioner and the non-western client, health
professionals need additional training in cultural competency, whilst working alongside
community development practitioners to better understand participatory approaches
for translating socio-cultural perceptions of health and healing. This will not only
facilitate refugee health interventions, procedures, practices and treatment, but will
promote medical syncretism, maximise resiliency and recovery for cross-cultural
patients, facilitate social cohesiveness and enhance the capacity of refugees to withhold
their traditional lifestyle, practices and beliefs in their host environment.

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