WRITTEN EVIDENCE FROM MÉDECINS SANS FRONTIÈRES (RWA0015)

Médecins Sans Frontières / Doctors Without Borders (MSF) is an international, independent medical humanitarian organisation. We provide medical and humanitarian assistance to people affected by conflict, epidemics, disasters, or excluded from healthcare. At times, MSF may speak out publicly to bring a forgotten crisis into view, or to denounce abuses, or challenge the diversion of assistance, or to call out policies that cause harm, restrict access to medical care or essential medicines.  Our teams are made up of tens of thousands of health professionals, logistic and administrative staff - bound together by our Charter.  Our actions are guided by medical ethics and the principles of impartiality, independence and neutrality. We are a non-profit, self-governed, member-based organisation.

Médecins du Monde / Doctors of the World (DOTW) is an international and independent humanitarian organisation that aims to empower access to medical care to vulnerable and excluded populations. The organisation was established in 1979 and today operates or supports over 400 projects in over 70 counties. Since 1998 DOTW has been a registered charity in the UK. DOTW runs volunteer-led clinics with GPs, nurses, midwives and caseworkers that assists the most vulnerable members of the community –usually those with insecure immigration status - access to the healthcare they need. DOTW also run national advocacy programmes aimed at overcoming barriers to GP registration and access to secondary NHS care in hospitals.

Introduction

MSF’s teams have been responding to humanitarian needs and severe physical and mental damage inflicted on people seeking safety caused by harsh migration policies focused on deterrence, externalisation and containment.  We have extensive experience of providing medical care to asylum seekers, refugees and other migrants in Greece, Italy, France, Belgium, the Balkans, Nauru Island, Libya and on our Search and Rescue (SAR) missions in the Central Mediterranean.

DOTW UK have vast experience of providing medical care to asylum seekers and refugees in the UK. We have run medical outreach programmes and consultations in asylum accommodation centres, hotels and hostels used as contingency accommodation and large containment sites, such as Napier. This has provided us with a good understanding of the complex medical needs of asylum seekers and the conditions and medical care they need to heal and rebuild their lives.

MSF and DOTW have recently started a project providing medical care to men seeking asylum held at RAF Wethersfield, Essex, UK.  The vast majority of these men arrived in UK after the Illegal Migration Bill gained royal assent.  It is likely their asylum applications will be deemed inadmissible and they are at high risk of being sent to Rwanda. 

MSF and DOTW oppose the Safety in Rwanda (Asylum and Immigration) Bill (‘the Bill’) in its entirety. The evidence in this submission focuses on the medical and humanitarian consequences of the Bill.

Based on MSF and DOTW’s experience, the organisations are inclined to address one of the questions raised by the Joint Committee on Human Rights:

     Does the Bill give rise to any other significant human rights concerns?

1. Medical consequences: evidence of harms caused by outsourcing the asylum process and forced expulsions to third countries

MSF and DOTW are profoundly concerned about the UK government’s plans to fully externalise its asylum system and forcibly and permanently expel people seeking safety in the UK to Rwanda.

• The UK’s Rwanda policy to fully outsource its asylum system and remove people to Rwanda is directly drawn from Australia’s ‘offshoring’ model, where people who attempt to reach Australia via small boats are forcibly relocated and indefinitely detained on the islands of Nauru and Papua New Guinea.[1]  This approach inflicts severe and irreparable harm to the physical and mental health and dignity of the men, women and children subjected to it whilst violating fundamental human rights. 
• In 2017-18, MSF worked on Nauru island and there witnessed an alarming –sometimes fatal - mental health epidemic among adult and child refugees and asylum seekers on Nauru Island, closely linked to Australia’s offshoring policy. Data from the project demonstrated the high prevalence of severe mental health morbidities amongst MSF’s 208 asylum seeker and refugee patients: 60% had suicidal ideation and 30% had attempted suicide, including children as young as 9 years old[2]. 
• The high prevalence and severe mental health morbidities among our refugee and asylum seeker patients was evident. As observed by MSF staff, the high rate of depression among our patients was likely due to the traumatising conditions experienced on Nauru.[3]
• MSF witnessed a disturbing collapse of children’s mental health and the teams diagnosed 10 children and 2 adults with ‘Resignation Syndrome’[4], a life-threatening psychiatric condition where patients enter a comatose state in response to an ‘intolerable reality’ and where medical care is required to keep them alive4. 
• Fifty-five (26%) of MSF’s asylum seeker and refugee patients were medically evacuated from Nauru, the majority for psychiatric reasons after years of distress on the island and unable to access the medical care required.[5]
• The refugee and asylum seekers MSF treated were very vulnerable and the scale of traumatic events they had encountered prior to their indefinite detention on Nauru was extremely high. Seventy-five percent of MSF’s asylum seeker and refugee patients (including children) reported experiencing traumatic events in their country of origin and/or during their migration journey, including combat situations, threats of harm or death, sexual violence, torture and detention.[6]
• In total, 92% reported facing difficulties in Nauru, which likely exacerbated their feelings of vulnerability and mental health problems.  Among stressors experienced, 64% felt they could not control events in their lives and 64% said they had fears about the future. A recurrent theme that emerged was the sense of hopelessness that people felt at having no control over events in their own lives.  A former MSF patient held on Nauru Island told us: “If I was in my home country, the government wants to kill me straight away. I tried to come to Australia and the government kills me a little by little, step by step. They tormented me a lot over five years on Nauru because I have no future in my life.”[7]
• There is a clear link between family separation and developing mental health problems, especially for those who are subjected to arbitrary detention. 76 (37%) of MSF’s asylum seekers and refugee patients were separated from a partner, child or close family member. This separation contributed to the deterioration of their mental health.[8] 
• MSF cited the forced relocation, lack of pathways to protection, family separation and the indefinite nature of offshore processing policy to be the most significant contributory factors in the mental health suffering, which was some of the worst MSF has encountered in its 50-year history[9].
• In addition, beyond being harmful, incredibly expensive and an ineffective deterrent, UN experts found Australia’s offshore processing regime to be in breach of international human rights standards[10].

2. Access to medical care in Rwanda

• The British Medical Association has expressed concern that, once in Rwanda, the complex physical and mental health needs of asylum seekers will not be met due to critical shortage of skilled health workers, as evidenced by Rwanda’s inclusion in the WHO health workforce support and safeguards list 2023.[11]
• As referenced above, MSF and DOTW are concerned that people seeking asylum forcibly removed to Rwanda (or elsewhere) will struggle to access appropriate and timely healthcare. Many of those expelled will likely have survived torture, sexual violence and trafficking; most will have had traumatising migration journeys. They should receive specialised care and support, yet expelling them to another country is dangerous, exposing them to further traumatisation and harm.  

3. Risks of being forced to return to dangerous migration routes between Rwanda and the UK

• UNHCR and other experts lay out the risks that people deported from the UK to Rwanda may end up re-entering migration routes through smuggling and trafficking[12]. One of the key migration routes from East Africa to the UK (and other parts of Europe) passes through the Sahara Desert, Libya, the Central Mediterranean Sea then on to northern European countries. Along this route, migrants face numerous and significant health, humanitarian and protection risks. MSF is present in several countries along the route including Libya, the Central Mediterranean, Belgium and France and its medical teams have witnessed and documented some of these risks. These include:

• Migrants regularly being victims, and at immediate risk of trafficking, enslavement, torture, sexual abuse, extortion, arbitrary and indefinite detention in horrific conditions, and other extreme forms of indiscriminate violence more generally, as well as disease (Libya)[13].
• The risk of death at sea due to people being crammed into overcrowded, unseaworthy vessels, and high levels of trauma and compounding vulnerabilities of those rescued as well as fuel burns, hypothermia, severe exhaustion and psychological distress are commonly seen and treated by our medical teams on our Search and Rescue ship. Furthermore, MSF has witnessed the Libyan Coast Guard intercepting boats forcibly returning people to detention centres in Libya, where extreme violence is commonplace (Central Mediterranean)[14].
• Limited access to medical care, a lack of access to basic needs, including safe shelter, food and drinking water and relentless police harassment and brutality. Psychological harm and compounding of pre-existing trauma due to an increasingly hostile environment (Belgium and France)[15].

4. Harm in the UK

• There is evidence that the UK’s Rwanda policy is already causing profound harm to vulnerable individuals.  In 2022, medical assessments of 36 men, women and age-disputed children targeted for removal to Rwanda carried out by Medical Justice documented medical indicators of torture in 26 cases, with 15 having symptoms or a diagnosis of PTSD and 11 having experienced suicidal thoughts while in detention[16].  Clinical assessments, which were conducted with people from Iran, Iraq, Sudan, Syria, Eritrea, Vietnam, Egypt and Albanian, found that the threat of being deported to Rwanda was further exacerbating people’s mental health conditions, causing them to experience fear, confusion, and uncertainty about their safety and a loss of hope. For some clients there was an increased risk of suicide and self-harm. Charities that support asylum seekers say they are documenting a number of suicide attempts among those threatened with being sent to Rwanda.[17]

• The UK medical community in united in its opposition to the Rwanda policy, raising concerns about the physical and mental health, wellbeing and protection consequences. The British Medical Association (BMA), Royal Medical Colleges, Faculty of Public Health, MSF UK, Doctors of the Work UK and other medical organisations have repeatedly called on the government to abandon the policy, describing it as indefensible on ‘medical, ethical and humanitarian grounds’.[18]

(12 January 2024)