Detainees in the United Kingdom: Environment and Healthcare Conditions for People Held in Immigration Removal Centres
By Luz Flores Michel, Ph.D.
Cancer InCytes Magazine - Volume 4, Issue 1, Summer 2015
Published June 30, 2015
Managing Editor: Arvin Gouw, Ph.D.
Cover Art: Ping Cao
Immigration detention refers to the government practice of detaining asylum seekers and other migrants for administrative purposes. This article is an exploration of the way immigration detention operates in the United Kingdom. The first part covers the living conditions within the holding facilities, whereas the second discusses the issue of access to health care and the treatment of people with on-going medical conditions, both physical and mental.
Immigration detention is a process by which foreign nationals are deprived of their liberty whilst the authorities determine their immigration status. In the United Kingdom these individuals, commonly addressed as immigration detainees, are held in immigration removal centres (IRCs). Many immigration detainees are asylum seekers who have asked the UK government for refugee status and are waiting to hear the outcome of their application. Others are awaiting deportation following a failed asylum claim. The latest available immigration statistics released by the Home Office show that 49% of the 3,462 people who were in detention at the end of December 2014 have at some point sought asylum in the UK . The remaining 51% corresponds to other non-citizens with an irregular migration status. Pathways to irregularity include overstaying of a time-limited visa and the violation of restrictions attached to a legal residence permit.
The same immigration statistics indicate that 43% of people who were in detention at the end of December 2014 have been detained for more than two months . As the UK is the only country in Europe that sets no limits on how long people can be detained under immigration powers, this percentage also includes 108 people who have been detained for more than a year. Sometimes people held in IRCs cannot return to their countries of origin, even if they want to. Thus, they find themselves detained indefinitely. This usually happens when people are unable to prove their original nationality and therefore do not have a place to which they can be removed. Countries such as Algeria and Iran usually do not allow people to return unless they have a passport but most asylum seekers deliberately travel without one, intentionally making it difficult for them to return. Individuals can also experience lengthy holding times when their country of origin is considered too unsafe for deportation to take place. This is often the case for citizens from Somalia, Zimbabwe and most parts of Iraq.
While the terms “detention” and “removal centres” might bring to mind a transitory condition less serious than imprisonment, it can be the case that, given the design and operation of the detention facilities, detainees experience their time in an IRC as imprisonment of a particularly cruel kind. Currently, there are thirteen IRCs in the UK. Three of them are purpose-built, designed as high security (category B) prisons. Another four IRCs are converted former prisons. Of the total number of people who were in detention at the end of 2014, 74% of them were held in these particular centres . AVID, the national network of volunteer visitors to immigration detainees, has expressed their concern with regard to the use of high security spaces for the purpose of detention as they found that “the current physical environment of detention is unsuitable for those held under administrative powers . . . The conditions in which detainees are held are prison-esque, and the culture and regime of detention are increasingly punitive” .
People in detention in the IRCs live within strict regimes. These include limited freedom of movement within the centres, fixed eating and recreational times and mandatory nightly curfews. Rooms are similar to cells, bare and usually shared. In one of the former prisons, Dover IRC, much of the accommodation comprises six-bed dormitories. In some IRCs, toilets in the cells do not have a door. They just have a curtain, often poorly fitted to the wall. According to Detention Centre Rules  a range of recreational activities must be provided, however people in detention have reported these activities to be very limited [4, 6]. Furthermore, IRCs are not always equipped to provide self-improvement programs, presumably because detention is supposed to be for a short term only. Evidence of the difficult nature of the IRCs can be found in the words of Oumar, a Somali national who, after serving a prison sentence of three years and a half, had been in detention for one and a half years at the time of his testimony: “When I was in prison, I had my structure, when to get up, when to do what. I knew exactly how long I would stay, how many months left. And you could do training courses and obtain qualifications. Here you have nothing, you don’t know when it will ever be over . . . it is really depressing, so you basically sleep all day” . Other conditions that can further contribute to the prison-like atmosphere as well as to the feelings of isolation are the extreme restrictions placed on Internet access (during an inspection of Haslar IRC in February 2014 it was not possible to access the website of the independent charity Bail for Immigration Detainees ), the poor phone signal reception within the centres and the excessive noise travelling from one cell to another. After an official inspection of Brook House IRC in 2013, it was recommended that soundproofing should be introduced on the residential units as sounds reverberate around the wings . Likewise, during a visit to Yarl’s Wood IRC, it was noted that, in an attempt to decrease noise levels inside their rooms, detainees had stuck sanitary towels to the air vents in the walls . Nevertheless, despite the striking similarities between a prison environment and detention, the main difference, according to some detainees, is that a prison sentence has a defined limit, whereas in detention you do not know how long you are going to be detained. Or as one former detainee who spent three and a half years held in IRCs puts it: “in prison, you count your days down, but in detention you count your days up” .
Another documented concern with regard to the IRCs is the substandard quality of health care available to detainees [11, 12]. Detention Centre Rules [5, 13] dictate that people held in IRCs “must have available to them the same range and quality of services as the general public receives from the National Health Service”. Unfortunately, a very different reality is shown by the extensive evidence gathered by independent NGOs, such as Medical Justice, Detention Action and Gatwick Detainees Welfare Group, as well as by reviews commissioned by the government (as an example see The Tavistock report ). This medical evidence base speaks of systemic failures in healthcare provisions and of the harm caused to detainees by these shortcomings. For the purpose of analysis, the shortfalls in health services will be divided into two areas. These are: firstly, the shortcomings of the initial health screening process together with the resulting failure to identify and acknowledge pre-existing medical conditions, both mental and physical; and secondly, the inadequate provision of ongoing healthcare while in detention.
According to Detention Centre Rules [5, 13] a nurse should see all detainees within two hours of admission to an IRC, for an initial health screening. Additionally, the rules require all detainees to be given a physical and mental examination by the medical practitioner within 24 hours of their admission. It is during these initial meetings that detainees must be informed of their right to request an appointment with a doctor at any time. Initial screenings are estimated to take approximately 30 minutes, but in practice they have been found to be much shorter, usually lasting around 10 minutes . In addition to the brevity of the assessments, a variety of reports [6, 12, 15] have indicated that there are three conditions that particularly impede the identification and acknowledgement of vulnerabilities and pre-existing medical conditions. The first problem arises with regard to when and where the screening takes place. Understandably after a long, exhausting and presumably emotionally charged journey from wherever they have been detained or wherever they are fleeing from, detainees might not be immediately ready to disclose intimate medical details to a complete stranger. In addition, the settings in which initial screenings take place are oftentimes not conducive to detainees feeling able to speak freely; examples of such conditions include crowded rooms with little or no privacy and screenings taking place in the middle of the night [11, 15]. The second issue is that of language barriers, as professional interpretation services are not always used consistently during these assessments [16, 17]. Finally, it has also been found that healthcare professionals conducting these examinations may not have received proper training in recognizing signs of trauma or torture, mental illness or communicable diseases such as tuberculosis [11, 18]. The oral evidence submitted by Dr. John Chisholm of the British Medical Association (BMA) to the All-Party Parliamentary Group on Migration enquiry into the use of immigration detention in the UK says “the evidence that has come to the BMA from reports we’ve received is that the initial assessment is frankly very often inadequate” .
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A case example that serves to illustrate the shortcomings detailed above is the story of Anna, a victim of torture, rape and trafficking, who spent 12 weeks held at an IRC while pregnant. Her story has been documented in an investigation into the ineffective and damaging medical care of detained pregnant women . Anna claimed asylum on arrival to the UK. She was then transported to an IRC. Her initial health screening happened the next morning at 05:20, at which stage she was 4-5 weeks pregnant. Anna spoke almost no English at the time, yet during the assessment her English language ability was recorded as “fair”. Given the absence of adequate interpreting services serious communication problems continued. On one occasion Anna was found vomiting and crying so her roommate, who spoke a different language, was asked to interpret for the healthcare staff. Furthermore, there was a failure to identify Anna as a vulnerable detainee. A month after Anna’s arrival to the IRC, an independent Medical Justice doctor visited her. The resulting medico-legal report recounts Anna’s long history of physical, emotional and sexual abuse. It was reported how her pregnancy duration was consistent with her account of rape and how she presented scars from cigarette burns and from a burning knife, and patchy hyperpigmentation caused by pouring hot water on her. Despite this evidence she was not released. Finally 12 weeks after her arrival, Anna was liberated from the IRC, though her immigration case remained pending. Anna’s case speaks to the potential risks that can occur when initial health screening assessments are poorly conducted.
With regards to the provision of healthcare while in detention, it has been documented [11, 12, 20] that IRCs are generally only able to deliver basic medical care to detainees. Access to necessary treatments is not always available and there have also been reports of delayed access to medication [6, 19]. This can be particularly serious for those with serious complex health issues. For example, an investigation into the clinical care of detainees living with HIV concluded that interruptions and disruptions in antiretroviral therapy occur repeatedly in detention . The consistency, quality and suitability of the health care services are hindered by several factors including the pervasive culture of disbelief. In this way, the first obstacle in accessing healthcare is a dismissive attitude encountered by detainees when reporting symptoms [15, 18]. According to Dr. Naomi Hartree, clinical advisor of Medical Justice, staff in IRCs routinely ascribe behavior indicative of mental disorders to intentionally disruptive or manipulative behavior by detainees . Physical symptoms, unless observable, are sometimes equally met with skepticism and unresponsiveness. Gatwick Detainees Welfare Group has reported the case of a man who was convinced that he had broken his leg during an accident while in detention. The healthcare staff at the IRC told him that this was not the case. Six weeks later he was finally taken for an X-ray at a local hospital and the diagnosis of broken leg was confirmed . It should also be pointed out that the lack of trust goes both ways. Anecdotal reports [4, 15], from both detainees and volunteer visitors, suggest that people in detention do not always see a distinction between custodial and healthcare staff, which can lead to poor doctor-patient relationships.
One of the difficulties that contributes to the low standard of ongoing health care for detainees is inefficiencies relating to IRC’s medical records system. This is particularly disruptive for people with on-going conditions, as transfers of detainees from one IRC to another are fairly regular . The catastrophic potential consequences of poor medical record keeping are exemplified by the death of Brian Dalrymple [22, 23], a US citizen who suffered from schizophrenia and hypertension. Brian came to the UK on holiday, but was refused entry because his behavior appeared unusual and uncooperative. As a result he spent six weeks in detention. While in detention, it was documented that Brian did not appear to be completely rational in his thinking, yet a psychiatric assessment was never carried out. As he was found to have dangerously high blood pressure, a hospital referral was made. It is understood that Brian discharged himself against medical advice. Three days before his death, Brian was transferred from one IRC to another. However, he arrived there without his medical records. Staff at the second IRC were not made aware of his current state of health. The inquest into Brian’s death concluded death by natural causes (ruptured aorta) compounded by neglect. The jury's narrative verdict stated: "Throughout Mr. Dalrymple's detention at Harmondsworth, medical record-keeping was shambolic" .
Regarding the treatment of detainees with mental health conditions experts have raised the question as to whether it is really possible to treat serious mental illness satisfactorily in a detention setting [15, 18, 25].
According to the Royal College of Psychiatrists , given the harsh living conditions and the lack of specialized mental health treatment resources, IRCs are not appropriate therapeutic environments to promote recovery from mental illness. C was trafficked to Europe as a teenager. After years of being beaten, raped and tortured he found his way to the UK but ended up held in an IRC. Over the three years that C has spent in detention, the UK Border Agency has made eight cursory attempts to deport him. These attempts have been unsuccessful because nobody is sure about his nationality. C was born in the Bakassi peninsula, which used to belong to Nigeria, but is now governed by Cameroon. Immigration officials from both countries refuse to admit him back, and thus C remains locked in limbo. C has been diagnosed with Post-Traumatic Stress Disorder and has tried to commit suicide on more than one occasion. Medication has been prescribed to relieve secondary symptoms of depression and anxiety, yet given the absence of specialized psychiatric services within the IRC, the trauma-focused cognitive-behavioral therapy recommended by two independent psychiatrists has not been delivered. C’s medical needs are not being met in detention. His case exposes some of the shortcomings with regard to the provision of healthcare for detainees with severe mental health needs.
This is a very complex area, but having examined the use of detention within the immigration system in the UK, it is possible to see how the current practice is far from ideal. People should be treated justly and humanly throughout the immigration process. However, after reviewing the conditions within IRCs, one can understand why detainees might not always feel that to be the case. It is also possible to grasp how certain detainees cannot tell the difference between serving a criminal sentence and merely being held for administrative convenience in an IRC, particularly given the use of high security environments. Government policy is that vulnerable people are unsuitable for detention, and yet some of those currently detained have serious healthcare needs or have experienced trauma, such as torture or rape. The gap between policy and practice in relation to the detention of vulnerable people puts their mental and physical health at serious risk. Fortunately, the belief that the current process of detention needs an urgent rethink is not only held by those directly affected by the experience of detention. There is also a wide range of organizations, including non-profits, think tanks and independent inspectorates, as well as members of the Parliament, working not only to improve the welfare and wellbeing of people held in detention but to also advocate for the fair and humane treatment of all immigration detainees. The way immigration detention operates in the United Kingdom is in urgent need of significant improvements. For those currently held in detention, reform cannot come soon enough.
About The Author
Luz Flores Michel, Ph.D., is a theoretical chemist. Her research focuses on the computational analysis of molecular recognition in protein-ligand systems. For two and a half years she was part of the Gatwick Detainees Welfare Group team providing emotional and practical support to asylum seekers and immigration detainees held in Tinsley House and Brook House immigration removal centres.
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