National Inquiry into Children in Immigration Detention

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Background Paper 4: Health and Nutrition

1. States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.

Article 24, Convention on the Rights of the Child.

1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Article 12, International Covenant on Economic, Social and Cultural Rights. [1]

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

World Health Organisation definition of "health" in the Preamble to the Constitution of the World Health Organisation.

In this Background Paper

National Inquiry into Children in Immigration Detention
Child asylum seekers
The right to health: core obligations
Food and nutrition
Hygiene and sanitation
Clothing and bedding
Shelter and environment
Physical activity
Health services and assessment
Questions for submissions

1. National Inquiry into Children in Immigration Detention

In November 2001, the Human Rights Commissioner announced an Inquiry into the adequacy and appropriateness of Australia's treatment of child asylum seekers and other children who are, or have been, held in immigration detention. The terms of reference for the Inquiry include consideration of the health of child asylum seekers and the impact of immigration detention on the well being and healthy development of children. [2]

This background paper provides an overview of international human rights standards on health that are relevant to the Inquiry. It refers primarily to the Convention on the Rights of the Child (the Convention) but also to other international human rights standards (including the International Covenant on Economic, Social and Cultural Rights (ICESCR)) where relevant. [3]

This paper is intended as a reference and guide to individuals or organisations wishing to make a submission to the Inquiry. It should be consulted where relevant, but it is not necessary to refer to a background paper when making a submission. For further information about the Inquiry, general information on relevant international treaties and standards and the material used in the background papers, see Background Paper 1: Introduction. This and other background papers are available on the Human Rights and Equal Opportunity Commission web site at http://www.humanrights.gov.au/human_rights/children_detention/background.html.

The term "child asylum seeker" is used throughout the background papers. While the focus in these papers is on children who have been detained when seeking asylum in Australia, it is not intended to exclude other children who have been detained. The Inquiry relates to any child who is, or who has been, in immigration detention. "Child" refers to any person under the age of 18.

Treaties, Rules and Guidelines

Treaties that have been ratified by Australia, such as the Convention on the Rights of the Child, are binding on Australia in international law. The implementation of treaty rights of people in Australia are monitored by United Nations treaty bodies, such as the Committee on the Rights of the Child or the Human Rights Committee.

The fact that Australia has ratified a treaty does not automatically incorporate it into Australian domestic law. Only when treaty provisions are incorporated into Australian law do they create enforceable rights in Australia. However, courts should interpret a law to be consistent with the provisions of a treaty that Australia has ratified.

Other international documents and instruments such as United Nations Rules, General Comments by treaty bodies, United Nations High Commissioner for Refugees guidelines, United Nations General Assembly Declarations and publications by United Nations agencies are not binding on Australia as a matter of international law. They are, however, persuasive in interpreting treaties and contain goals and aspirations reflecting a consensus of world opinion.

2. Child asylum seekers

Child asylum seekers are likely to have experienced varying levels of violence and human rights abuses before or during their journey to Australia. The child's flight from her or his home country may include experiences of war, persecution, death, sexual assault, violence, fear, flight and displacement. These experiences make the child vulnerable to disease, trauma and other threats to their health, such as nutritional deficiencies.

Under the Convention, Australia must ensure that every child in Australia, regardless of nationality or immigration status and regardless of how the child arrived in Australia, enjoys the highest attainable standard of health and rehabilitation. [4] The UN Committee on the Rights of the Child [5] has on several occasions raised the issue of child asylum seekers and pointed out that the Convention accords them the same rights as other children in relation to health care. [6]

The health needs of child asylum seekers are, however, often far greater than those of children raised in Australia, due to the damaging physical conditions, emotional trauma and nutritional deficiencies that they have commonly experienced.

The Inquiry welcomes submissions on the appropriateness and relevance for child asylum seekers of the health care standards in Australian State and Territories. The Inquiry also welcomes submissions on the needs of unaccompanied children and the impact on their health of having no parent or adult caring for their physical health, nutritional and emotional well being.

3. The right to health: core obligations

The UN Committee on Economic, Social and Cultural Rights has identified six core obligations on the right to health under article 12, ICESCR, which include:

access to health facilities
nutritionally adequate and safe food
basic shelter, sanitation and safe drinking water
essential drugs
equitable distribution of all health facilities
a public health strategy and plan of action. [7]

In considering the right to health, the underlying principles of the Convention should be always considered. All actions concerning the child should be non-discriminatory (article 2), ensure the best interests of the child (article 3) and allow the child to participate in decision making concerning her or him (article 12). [8]

4. Food and nutrition

States Parties shall pursue full implementation of [the right of the child to the highest attainable standard of health] and, in particular, shall take measures … to combat disease and malnutrition… through the provision of adequate nutritious foods.

Article 24, Convention on the Rights of the Child.

Food has critical nutritional, cultural and social dimensions for the well being and development of all children. According to the World Declaration and Plan of Action for Nutrition, [9] children are the most nutritionally vulnerable group of people in the world. This is especially true for child asylum seekers whose access to nutritional food may have been seriously limited for prolonged periods in their countries of origin and during the course of their journey to Australia. [10]

Nutrition

In becoming a party to the Convention, Australia has committed to provide every child in Australia with the highest attainable standard of health, including providing adequate nutritious foods. What is "adequate" will depend on the particular nutritional needs of each child.

The maintenance of appropriate nutritional standards is vital to the normal healthy development of every child. [11] The nutritional needs of child asylum seekers are generally related to micro-nutrient deficiencies caused by conditions in the child's country of origin, the often long and arduous journey to Australia and the unfamiliar food and conditions upon arrival in Australia.

Assessment of a child's nutritional needs

There is general international consensus that the best way to measure a child's health and nutritional status is by assessing the individual child's growth against standard weight-for-height, height-for-age and weight-for-age charts such as those produced by the World Health Organisation, taking into account cultural and geographic differences in child development.[12] In order to evaluate a child's nutritional needs, there should be an initial assessment of the child's height and weight upon arrival, and careful ongoing monitoring of any micronutrient deficiencies that the child may have. [13]

Health screening and assessment should be made by medical practitioners who are familiar with the particular deficiencies suffered by children from developing countries and refugee backgrounds (which may not be prevalent among Australian children), taking into account the history and background of each child. Special care must be taken when establishing the background of an unaccompanied child whose knowledge of his or her personal history is likely to be incomplete (see Background Paper 7: Legal Status).

In assessing the nutritional adequacy of the food provided to child asylum seekers, an appropriate starting point is Article 24(2)(c) of the Convention. International studies have shown that nutritional deficiencies in refugee camps and countries of origin of asylum seekers are widespread [14] and must be taken into account when determining the nutritional adequacy of the food provided to each child.

The nutritional needs of pregnant women and mothers

The Plan of Action arising out of the 1990 World Summit for Children states that "[m]aternal health, nutrition and education are important for the survival and well-being of women in their own right and are key determinants of the health and well-being of the child in early infancy." [15] Australia is obliged under Article 24(2)(d) of the Convention to "ensure appropriate pre-natal and post-natal care for mothers". [16] This includes ensuring that the special nutritional needs of pregnant women and new mothers are met. Poor maternal nutrition is associated with various disorders in babies and with low birth weight.[17] Mothers also have increased nutritional needs whilst breastfeeding and may need education and encouragement to breastfeed their babies. The World Health Organisation recommends exclusive breastfeeding for six months, with introduction of complementary foods and continued breastfeeding thereafter as an important aspect of a baby's diet. [18]

Cultural considerations

In those States in which ethnic, religious or linguistic minorities or persons of indigenous origin exist, a child belonging to such a minority … shall not be denied the right, in community with other members of his or her group, to enjoy his or her own culture [or] to profess and practise his or her own religion.

Article 30, Convention on the Rights of the Child.

Serious micronutrient deficiencies in child asylum seekers may be the result of the child having experienced disruption to family and cultural associations with food during flight. This may be due to separation from family members usually responsible for food preparation, or not being able to fulfil cultural or religious practices surrounding food preparation and consumption. This is especially true for unaccompanied children. According to the United Nations High Commissioner for Refugees (UNHCR), when addressing malnutrition in refugee children it is vital to consider the cultural acceptability, palatability and digestibility of the food provided, in addition to its nutritional quality. [19] Cultural considerations must be taken into account with respect to food type, preparation and serving, particularly considering the traditional roles of family members in relation to the child's food. It is therefore vital that children in immigration detention are provided with food that is culturally and religiously appropriate [20] and that it is possible for the child's family members to prepare and serve the food in accordance with the family's cultural practices (including appropriate times of day). The Inquiry welcomes submissions on this point.

Water

States Parties shall pursue full implementation of [the right to health] and, in particular, shall take appropriate measures… to combat disease and malnutrition… through the provision of adequate … clean drinking-water, taking into consideration the dangers and risks of environmental pollution.

Article 24(2)(c), Convention on the Rights of the Child.

A major factor affecting the health of children as well as adults is the availability of clean water. [21] Australia is obliged under the Convention to provide every child in immigration detention with adequate clean drinking water. The drinking water provided to children in immigration detention should be readily available and easily accessible at all times. The UNHCR recommends that a minimum of twenty litres of drinkable water is required for each person every day for cooking and drinking. [22]

5. Hygiene and sanitation

The environment in detention facilities may give rise to conditions for the spread of infection and disease among children unless appropriate hygiene and sanitation measures are put in place. The risk of a child contracting an illness due to poor hygiene is heightened for a child asylum seeker whose immune system may be functioning at a sub-optimal level due to previous illness, poor nutritional status or absence of immunisations.

Hygiene and sanitation are therefore key issues in terms of both appropriate facilities and education for children and their families. In terms of facilities, the UNHCR recommends that there be at least one toilet for every twenty people, with family toilets serving six to eight people being preferable. [23] Toilets must be constructed, located and lit to ensure safety and ease of use for children.[24] Bathing and showering facilities should enable every child to maintain general hygiene by bathing or showering daily in privacy at a temperature suitable to the climate. [25]

In order to prevent illness and disease among children in an immigration detention setting, it is vital that high standards of personal hygiene be maintained. Australia is obliged under article 24(2)(e) of the Convention to ensure that parents and children "are informed, have access to education and are supported in the use of basic knowledge of… hygiene and environmental sanitation". All adolescents should receive appropriate information and counselling about their health. The realisation of their right to health is dependent on youth-friendly health care which respects confidentiality and privacy and includes appropriate sexual and reproductive health care advice.[26]

6. Clothing and bedding

Detention facilities should ensure that each juvenile has personal clothing suitable for the climate and adequate to ensure good health, and which should in no manner be degrading or humiliating.

Rule 36, United Nations Rules for the Protection of Juveniles Deprived of their Liberty.

In order to prevent illness and infection, it is important that children have sufficient changes of clean clothing, particularly underwear, and suitable footwear. Australia should ensure there are appropriate facilities for children and their families to clean and maintain clothing. [27] Children's underclothing should be changed and washed as often as necessary for the maintenance of hygiene. [28]

In keeping with the requirement that clothing not be degrading or humiliating,[29] clothing provided to children in immigration detention should be culturally acceptable and modest where necessary.

Children must also be provided with clothing that is appropriate to the climate and gives effective protection from rain and sun.[30] Whilst young children are usually more vulnerable to the cold than adults, child asylum seekers are especially susceptible to illness where they have had nutritional deficiencies and prior illnesses.

Each child in immigration detention should be provided with separate and sufficient bedding, which should be clean when issued, kept in good order and changed often enough to ensure cleanliness. [31] As with clothing, children's bedding should be appropriate to the climate, with sufficient blankets provided where necessary.

7. Shelter and environment

The availability, distribution and location of shelter, schools, playgrounds, waterpoints, health centres and recreational facilities all affect the safety and well-being of refugee children.

UNHCR Guidelines on Protection and Care, ch 5.

The design and layout of detention facilities raises issues of children's safety, security, privacy, play and physical activity needs.

It is important for the health, psychological and physical needs of children that there be sufficient space in detention facilities. Children and families must have sufficient space to allow them a minimum degree of privacy in order to maintain some semblance of family life. [32] The UNHCR recommends a minimum of 3.5 square metres living space per person within a shelter and thirty square metres per person gross area for the overall site, excluding playgrounds and sports fields. [33] The UNHCR recommends that the standards of space, privacy and freedom of movement must be adequate for parents to meet the developmental needs of their children and to raise them with dignity. [34]

Detention facilities should be designed with a view to ensuring families' and children's personal security. The layout should ensure that children are close to all basic facilities and are provided with protection from the elements. This may mean establishing several community entities for larger groups of asylum seekers, each with its own communal basic facilities.[35]

Children in detention facilities are extremely susceptible to accidents. [36] The environment in the centre should be designed to avoid accidents, and parents should be advised as to how to prevent their children suffering accidents in their new and foreign environment. [37] Effort should be taken to prevent children suffering accidental burns or poisoning, and to ensure that there are no dangerous areas or objects around the detention facility that may give rise to accidents. [38]

Accident prevention also includes ensuring that there are plenty of safe play spaces for children so that that they do not have to seek alternate play spaces that may be away from parental supervision or otherwise dangerous. [39] Shade is important for play spaces, both to protect from the sun and to make play spaces comfortable for children so that they will use them.

The Inquiry welcomes submissions on the adequacy and appropriateness of the design of detention facilities and whether the child's privacy, recreation and play areas are appropriate (see also Background Paper 3: Mental Health and Development).

8. Physical activity

States Parties shall ensure to the maximum extent possible the survival and development of the child.

Article 6(2), Convention on the Rights of the Child.

State Parties recognize the right of the child to rest and leisure, to engage in play and recreational activities appropriate to the age of the child and to participate freely in cultural life and the arts.

Article 31(1), Convention on the Rights of the Child.

Rest, leisure, play and recreation are vital for the healthy development of the child. In order to ensure the appropriate development of children in immigration detention and provide them with the highest attainable standard of health, they must be provided with opportunities, spaces, equipment and education that encourage and facilitate physical activity and sport. [40]
Interaction with the physical environment is stated to be an innate and necessary propensity in all people, including children.[41] The quality of play experience for children will be related to the environment in which it takes place.

9. Health services and assessment

2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures… (f) [t]o develop preventive health care, guidance for parents and family planning education and services.

Article 24, Convention on the Rights of the Child.

The right to health must be understood as a right to the enjoyment of a variety of facilities, goods, services and conditions necessary for the realization of the highest attainable standard of health.

Committee on Economic, Social and Cultural Rights, General Comment 14, 4 July 2000, para 9.

Australia has recognised the right of every child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. [42] As outlined in Background Paper 3: Mental Health and Development, States Parties to the Convention are required to "develop preventive health care" in addition to providing education and guidance to parents.

Each child asylum seeker should receive medical treatment and care in a manner which is culturally appropriate and which respects her or his inherent dignity. The relevant standard must be commensurate with that provided in the general community, taking into account the special needs of child asylum seekers outlined earlier. [43] The Inquiry welcomes submissions on the appropriate health care standards for children immigration detention.

Initial assessment of a child's health care needs

Every juvenile has a right to be examined by a physician immediately upon admission to a detention facility, for the purpose of recording any evidence of prior ill-treatment and identifying any physical or mental condition requiring medical attention;

The medical services provided to juveniles should seek to detect and should treat any physical or mental illness, substance abuse or other condition that may hinder the integration of the juvenile into society. Every detention facility for juveniles should have immediate access to adequate medical facilities and equipment appropriate to the number and requirements of its residents and staff trained in preventive health care and the handling of medical emergencies. Every juvenile who is ill, who complains of illness or who demonstrates symptoms of physical or mental difficulties, should be examined promptly by a medical officer.

Rules 50-51, United Nations Rules for the Protection of Juveniles Deprived of their Liberty

In order to be provided with preventive health care and with the highest attainable standard of health and access to appropriate facilities as outlined in the Convention, each child asylum seeker should undergo a medical examination and health care needs assessment by trained health professionals on arrival in Australia. [44] Examination of the child "by a physician immediately upon admission to a detention facility" should record and identify "any physical or mental condition requiring medical attention". [45] The medical assessment should seek to identify any physical or mental condition requiring medical attention, including the effects of any previous abuse or violence. [46] Medical care, where possible, should be provided to detained children "through the appropriate health facilities and services of the community in which the detention facility is located". [47]

As children may come from countries that do not have a policy for neo-natal or post-natal screening of some medical conditions, children should be examined for these upon arrival, with referral to a paediatrician if any of these conditions are suspected. [48] The Inquiry welcomes submissions from health care experts on the appropriate initial assessment procedures for children in immigration detention.

Australia's obligations under the Convention extend beyond merely treating illness to ensuring the development of the child to the maximum possible extent, [49] and preventing, treating and rehabilitating disabilities. [50] The Inquiry welcomes submissions on assessment and screening needs for developmental delay, delay in walking, poor visual fixation or uncertainty about response to sound. Assessment may be required for learning difficulties that may be due to hearing, vision or developmental problems. The rights of children with permanent disabilities are discussed in Background Paper 5: Prevention, Treatment and Accommodation of Disabilities.

Ongoing medical care

States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures: … (b) To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care.

Article 24(2), Convention on the Rights of the Child.

Every juvenile shall receive adequate medical care, both preventive and remedial, including dental, ophthalmological and mental health care, as well as pharmaceutical products and special diets as medically indicated. All such medical care should, where possible, be provided to detained juveniles through the appropriate health facilities and services of the community in which the detention facility is located, in order to prevent stigmatization of the juvenile and promote self-respect and integration into the community.

Rule 49, United Nations Rules for the Protection of Juveniles Deprived of their Liberty. [51]

After initial assessment and treatment when they first arrive in Australia, child asylum seekers have the right to "necessary medical assistance and health care … with emphasis on the development of primary health care" under article 24(2)(b) of the Convention. This requires the health care needs of children in immigration detention to be regularly monitored.[52] In order to ensure that every child receives 'preventive and remedial' health care, health care programs may need to be individualised and coordinated. Such programs should include a structured immunisation program for all child asylum seekers under Article 24(2)(a) of the Convention, in accordance with the relevant national standards. [53] All medical records of the child should be recorded on a confidential file (see Background Paper 7: Legal Status).

The Inquiry welcomes submissions on the form primary health care should take and whether this requires an individual health care plan to be implemented for each child in immigration detention. The Inquiry also welcomes submissions on the appropriate health care models for child asylum seekers and how health care in detention facilities compares with health care in Australia's States and Territories, including the necessary ratio of medical professionals to children in immigration detention.

Medical personnel should be trained in cross-cultural health care, including the special needs of child asylum seekers. [54] Care should be taken for children who may feel uncomfortable in discussing their health problems openly (especially if they relate to past sexual or violent incidents) or who are fearful about the proposed examination or treatment. Studies indicate that child asylum seekers may focus on non-specific pain as their main concern, avoiding mention of specific details or psychological symptoms. [55] Unaccompanied children may require special support in health care, as they may not have an adult carer to bring them to the attention of medical authorities. Medical communications with a child asylum seeker may need to utilise an interpreter unless the child is able and comfortable in discussing health matters in English. [56] The Inquiry welcomes submissions on these points.

Dental Care

Dental health care is important for child asylum seekers, particularly younger children. Australia should ensure that preventive and remedial dental health care is available to all child asylum seekers.[57] Preventing, identifying and treating decay in a timely manner reduces the need for extractions. The detention of child asylum seekers should not result in their dental health being adversely affected. The Inquiry welcomes submissions on this point, including reference to relevant Australian State and Territory standards on dental health for children.

Ante-natal care and birth

States parties … shall take appropriate measures…to ensure appropriate pre-natal and post-natal health care for mothers.

Article 24 (2)(d), Convention on the Rights of the Child.

2…States Parties shall ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation.

Article 12, Convention on the Elimination of All Forms of Discrimination against Women.

Paediatric specialists have suggested that appropriate pre-natal health care includes providing pregnant women with services (including counselling) for ante-natal screening for malformation, hepatitis B, HIV and haemoglobinopathies.[58] Given the impact that a pregnant woman's emotional wellbeing may have on the health of her child, [59] the health and mental health of pregnant women in immigration detention may need to be monitored and access to specialist mental health services made available.

The Inquiry will consider the extent to which women asylum seekers should be given access to similar childbirth facilities that are available to non-asylum seeking women giving birth in public hospital facilities. Arrangements should be made wherever practicable for children to be born in a hospital outside the detention centre, and special accommodation should be provided for all necessary pre-natal and post-natal care and treatment. [60]

After birth, infants and children under five years may require access to early childhood services. These services typically include help with feeding difficulties, [61] guidance on the child's feeding needs and day-to-day care, education on child development, counselling for post-natal depression, and advice concerning the child's immunisation program and parenting in general. Interpreters should be available where necessary. The Inquiry welcomes submissions on this point. The Inquiry also welcomes submissions on the screening and health needs of newborn babies.

As outlined earlier, the World Health Organisation, in addition to UNICEF, [62] has stressed the importance of breastfeeding to a baby's diet, including its extensive nutritional, immunological and psychological benefits. Where the mother is having difficulties breastfeeding, early assistance from a health professional experienced in breastfeeding management, a lactation consultant or a breastfeeding counsellor should be provided.

10. Questions for submissions

The following questions relate to the maintenance of a child asylum seeker's health while in immigration detention and may assist organisations and individuals in making submissions to the Inquiry.

How does Australia meet its commitments to the health of child asylum seekers under article 24, Convention and article 12, ICESCR, with regard to its legislation, policy and practice?
What are the relevant Australian State and Territory standards and practices on health care provision?
What coordination, if any, is there across government departments to ensure the health care needs of child asylum seekers are met? To what extent are relevant professional bodies involved in outlining these standards?
What are the initial assessment and screening procedures in place for child asylum seekers? Are there any gaps?
Are individual health care programs in "the best interests of the child"? How do they work?
How does health care work in practice in detention facilities?
Are there adequate and suitable staff?
How can a child asylum seeker access health care?
How are pregnant mothers and families supported in immigration detention?

ENDNOTES:

1 See General Comment 14 of the Committee on Economic, Social and Cultural Rights (CESCR): General Comment 14: The right to the highest attainable standard of health, UN Doc E/C.12/2000/4, 11 Aug 2000, which elaborates the provisions of article 12 of the IESCR. The Committee has referred to article 12 as being the most comprehensive provision on the right to health in international human rights law. It imposes on State Parties a binding duty to ensure that each person can control her or his own health and body, including sexual and reproductive freedom, and "the right to a system of health protection which provides equality of opportunity for people to enjoy the highest attainable level of health.": CESCR, General Comment 14: The right to the highest attainable standard of health, UN Doc E/C.12/2000/4, 4 July 2000, para 8.

2 The full terms of reference are available at http://www.humanrights.gov.au/human_rights/children_detention/terms.html.

3 International instruments and guidelines such as the United Nations Rules for the Protection of Juveniles Deprived of their Liberty (1990) and UNHCR (1994), Refugee Children: Guidelines on Protection and Care, Geneva (UNHCR Guidelines on Protection and Care). These standards are outlined in greater detail in Background Paper 1: Introduction.

4 Article 24, Convention, read in light of the principle of non-discrimination in Article 2. Background Paper 1: Introduction.

5 The Committee supervises the Convention of the same name; see Background Paper 1: Introduction.

6 See for example the Committee on the Rights of the Child, Concluding Observations of the Committee on the Rights of the Child: Denmark (Initial report), UN Doc CRC/15/Add.33.m, 15 Feb 1995, para 14.

7 In CESCR, General Comment 14, para 43, the Committee outlines the State's core obligations in relation to health as at least the following obligations:
"(a) To ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;
(b) To ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom from hunger to everyone;
(c) To ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable water;
(d) To provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs;
(e) To ensure equitable distribution of all health facilities, goods and services;
(f) To adopt and implement a national public health strategy and plan of action, on the basis of epidemiological evidence, addressing the health concerns of the whole population; the strategy and plan of action shall be devised, and periodically reviewed, on the basis of a participatory and transparent process; they shall include methods, such as right to health indicators and benchmarks, by which progress can be closely monitored; the process by which the strategy and plan of action are devised, as well as their content, shall give particular attention to all vulnerable or marginalized groups." See too paras 53-54.

8 See Background Paper 1: Introduction.

9 International Conference on Nutrition, Rome, December 1992. See http://www.fao.org/docrep/u5900t/u5900t01.htm.

10 Many asylum seekers arrive in countries of asylum in poor health as a consequence of past deprivation and prolonged periods with a sub-optimal diet. See LK Ackerman, 'Health problems of refugees', Journal of American Board of Family Practice, 10(5) p337 cited in C Burns, K Webster, P Crotty, M Balinger, R Vincenzo and M Rozman (2000) 'Easing the transition: food and nutrition issues of new arrivals', Health Promotion Journal of Australia, 10(3), p230 at p231.

11 UNHCR Guidelines on Protection and Care, ch4.

12 World Health Organisation, WHO Global Database on Child Growth and Malnutrition, http://www.who.int/nutgrowthdb/intro_text.htm, 8 August 2001. Weight and height measures are appropriate for children. The appropriate measure for babies is length.

13 See article 24(2), Convention. See also the Plan of Action for Implementing the World Declaration on the Survival, Protection and Development of Children in the 1990s, UNICEF, 1990: See http://www.unicef.org/wsc/plan.htm#Food.

14 M Toole (1992), 'Micronutrient deficiencies in refugees', The Lancet, 339: 121 pp1-15 (C Burns, K Webster, P Crotty, M Balinger, R Vincenzo and M Rozman (2000) 'Easing the transition: food and nutrition issues of new arrivals', 10(3), p231.

15 Plan of Action for Implementing the World Declaration on the Survival, Protection and Development of Children in the 1990s, UNICEF, 1990; http://www.unicef.org/wsc/plan.htm#Role.

16 See also article 12(2), Convention on the Elimination of All Forms of Discrimination of All Forms of Discrimination against Women (CEDAW), ratified by Australia in 1983, which obliges it to "ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation."

17 Poor nutrition in pregnant women may cause spina bifida (associated with inadequate folate intake) and iodine deficiency disorders (permanent mental retardation associated with inadequate iodine intake): The Royal College of Paediatrics and Child Health and the King's Fund (1999), The Health of Refugee Children: Guidelines for Paediatricians, London.

18 World Health Organisation (2001), 'Note for the Press No.7', 2 April 2001; http://www.who.int/inf-pr-2001/en/note2001-07.html.

19 UNHCR Guidelines on Protection and Care, ch5.

20 General Comment 22 of the Human Rights Committee (which supervises the International Covenant on Civil and Political Rights) states that "[t]he observance and practice of religion or belief may include not only ceremonial acts but also such customs as the observance of dietary regulations…"; General comment 22: The right to freedom of thought, conscience and religion ( Art. 18), 30 July 1993.

21 Plan of Action for Implementing the World Declaration on the Survival, Protection and Development of Children in the 1990s, UNICEF, 1990. See http://www.unicef.org/wsc/plan.htm#Child.

22 UNHCR Guidelines on Protection and Care, ch5.

23 UNHCR Guidelines on Protection and Care, ch5.

24 UNHCR Guidelines on Protection and Care, ch5.

25 Rules 13,15 and 16, United Nations Standard Minimum Rules for the Treatment of Prisoners (1955); Rule 34, United Nations Rules for the Protection of Juveniles Deprived of their Liberty; also Guideline 10(ix), UNHCR (1999), Guidelines on applicable Criteria and Standards relating to the Detention of Asylum-Seekers (UNHCR Guidelines on Detention) (1999).

26 CESCR, General Comment 14, para 23.

27 Rule 18, Standard Minimum Rules for the Treatment of Prisoners.

28 Rule 17(2), Standard Minimum Rules for the Treatment of Prisoners.

29 Rule 33, United Nations Rules for the Protection of Juveniles Deprived of their Liberty; Rule 19, Standard Minimum Rules for the Treatment of Prisoners.

30 Guideline 9.5, Immigration Detention Guidelines, issued by the Human Rights and Equal Opportunity Commission, March 2000.

31 Rule 33, United Nations Rules for the Protection of Juveniles Deprived of their Liberty.

32 UNHCR, Guidelines on Protection and Care, ch5.

33 UNHCR, Guidelines on Protection and Care, ch5.

34 UNHCR, Guidelines on Protection and Care, ch5.

35 UNHCR, Guidelines on Protection and Care, ch5.

36 The Royal College of Paediatrics and Child Health and the King's Fund (1999), The Health of Refugee Children: Guidelines for Paediatricians, p10.

37 Under Article 24(2)(e), Convention, Australia is obliged "to ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of…the prevention of accidents".

38 See discussion in Background Paper 3: Mental Health and Development.

39 UNHCR Guidelines on Protection and Care, ch5.

40 See Background Paper 3: Mental Health and Development.

41 See Background Paper 3: Mental Health and Development.

42 Article 24, Convention.

43 Article 12, IESCR; article 24, Convention; Principle 24, Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment.

44 Rule 50, United Nations Rules for the Protection of Juveniles Deprived of their Liberty. The purpose of the examination must be clearly explained to the child in terms they can understand, and the child's consent should be sought. Suitable interpreters should be used, where necessary, to ensure that a valid consent is obtained. The Royal College of Paediatrics and Child Health and the King's Fund (1999), The Health of Refugee Children: Guidelines for Paediatricians, p9.

45 Rule 50, United Nations Rules for the Protection of Juveniles Deprived of their Liberty. Each institution should have at least "one qualified medical officer who should have some knowledge of psychiatry. The medical services should be organized in close relationship to the general health administration of the community or nation. They shall include a psychiatric service for the diagnosis and, in proper cases, the treatment of states of mental abnormality." See also Rule 22(1), Standard Minimum Rules for the Treatment of Prisoners.

46 Principle 24, Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment (1988); Rule 50, UN Rules for the Protection of Juveniles Deprived of their Liberty, Guideline 10, UNHCR Guidelines on Detention.

47 Rule 49, United Nations Rules for the Protection of Juveniles Deprived of their Liberty. This is in order "to prevent stigmatization of the juvenile and promote self-respect and integration into the community".

48 See CESCR, General Comment 14, para 14. Conditions could phenylketonuria, hypothyroidism, cataracts, congenital cardiac disease or congenital hip dislocation. Children should also be screened on arrival for HIV, gastroenteritis, tuberculosis, hepatitis B, malaria, typhoid and schistosomiasis. See the Royal College of Paediatrics and Child Health and the King's Fund (1999), The Health of Refugee Children: Guidelines for Paediatricians, p10.

49 Article 6, Convention.

50 Article 23, Convention.

51 See also Principle 24, Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment: "A proper medical examination shall be offered to a detained or imprisoned person as promptly as possible after his admission to the place of detention or imprisonment, and thereafter medical care and treatment shall be provided whenever necessary. This care and treatment shall be provided free of charge."

52 Article 25, Convention, which details the child's right to periodic review of her or his treatment.

53 See The Australian Immunisation Handbook 8th Edition, Australian Government Department on Health and Ageing (2003).
In particular, all children should be immunised against diptheria, tetanus, whooping cough, poliomyelitis, measles, mumps and rubella at the appropriate stage within their first year or shortly thereafter. http://www1.health.gov.au/immhandbook/pdf/handbook.pdf

54 See UNHCR Guidelines on Protection and Care, ch4, also discussed in Background Paper 2: Culture and Identity and Background Paper 3: Mental Health and Development. Experience in treating refugee and asylum seeking children will guard against making erroneous diagnoses or missing important information (such as evidence of torture). A UK study conducted in 1996 found that the training of inner city primary health care professionals was generally inadequate to deal with the needs of refugees in their area. 'Warning sounded over refugee role', Doctor, 3 October 1996 cited in The British Medical Association (2001), The Medical Profession and Human Rights: Handbook for a Changing Agenda, Zed Books, London, p393.

55 The British Medical Association, The Medical Profession and Human Rights: Handbook for a Changing Agenda, p393.

56 Rule 6, United Nations Rules for the Protection of Juveniles Deprived of their Liberty.

57 See Rule 49, United Nations Rules for the Protection of Juveniles Deprived of their Liberty; Rule 22(3), Standard Minimum Rules for the Treatment of Prisoners.

58 Ante-natal screening for HIV is now universal; see The Royal College of Paediatrics and Child Health and the King's Fund (1999), The Health of Refugee Children: Guidelines for Paediatricians, London.

59 See UNHCR, Guidelines on Protection and Care, ch4. For an Australian reference see "The Health of Young Australians" report, endorsed by the Australian Health Ministers Conference in 1995.

60 Rule 23, Standard Minimum Rules for the Treatment of Prisoners.

61 Breastfeeding should be promoted as "this method of nutrition provides complete, hygienic food for the healthy growth and development of infants", and includes an obligation to "promote the stimulation of lactation of mothers not able to produce sufficient milk by teaching the mothers to frequently put the child to the breast." UNHCR Guidelines on Protection and Care, ch5.

62 WHO/UNICEF, The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (1990). Full text at http://www.unicef.org/nutrition/index_24807.html

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