Blog post written by Lucia Chaplin. Lucia is a medical doctor working in psychiatry at East London NHS Foundation Trust, shortly to start her Core Psychiatry training at South London and Maudsley NHS Foundation Trust. She has recently completed the RLI’s MA in Refugee Protection and Forced Migration Studies.

My experiences working on an acute psychiatric ward in London, UK, leave me with little doubt as to the importance of housing for asylum seekers and refugees.

It is well-accepted amongst mental health professionals that safe and secure accommodation is of central importance to both physical and mental health. This is uncontroversial and has a significant ‘evidence-base’ (see here and here), and yet amongst those with mental health problems, housing continues to be a significant barrier towards recovery.

From a public health perspective, damp and overcrowded spaces provide an ideal environment for the spread of infectious diseases, and poor housing conditions can lead to falls, fire-related injuries, and respiratory conditions, among others. More familiar to me in a mental health context, however, is the anxiety, low mood and re-traumatisation that can be a consequence of the uncertain and fragile housing conditions faced by many of our patients.

The poor conditions in which asylum seekers in the UK are housed has been well-documented by various charities and campaign groups (see here and here), to the extent that in a 2014 Commons Select Committee Report, the provision of asylum accommodation was summarised as being ‘often unacceptably poor’. While I can only speak from a UK context, similar conditions or even worse can, of course, be found around the world.

When we would see our patients in their ward rounds, many of our conversations would primarily be focussed on housing. The most obviously shocking were the stories of mouldy walls, infestations of rodents and insects, and of holes in external walls. These stories were surprisingly common across both British nationals and asylum seekers and refugees. Many have told their housing associations and local councils about these problems many months, even years ago, but little has been done. This is not always due to refusal or long waiting lists as, often, poor mental health makes the administrative and emotional burden of raising concerns, and following through with them, extremely difficult, and with insufficient support, communication between parties can break down easily.

More common still, however, are conditions that are less dramatic but which can, nevertheless, be harmful to someone’s mental health such as living next to a busy road or a train track. Perhaps there are gangs operating in nearby flats and buildings or simply groups using drugs or alcohol in communal areas. For an asylum seeker or refugee, many of whom suffer from what we might call mental health ‘symptoms’ from a Western medical perspective, regardless of whether or not these meet the specific criteria for post-traumatic stress disorder, depression or generalised anxiety disorder, for example, home is vital for healing from mental illness, through its role in safety, security, belonging, and predictability. It is important not to underestimate the impact of the regular stress caused by constant traffic noise, sirens, neighbours shouting, or even roadworks. One patient described the impact that ongoing building work was having on his mental health, as builders were walking past his window on the third floor regularly across scaffolding that had been erected across the building. Experiences of trauma can cause what we could describe as ‘hypervigilance’, meaning an intense and exaggerated sense of danger, and a heightened response to external stimuli such as noise and movements. For this patient, regularly having people walking past his window had triggered panic attacks in a space that should have been safe.

It is arguably far too great a burden on the state to arrange for every resident to be given a spacious, well-lit, quiet home, set back from the main road and in an entirely safe neighbourhood. Of course, houses must be built along train tracks and busy roads, and many urban areas are noisy and have antisocial behaviour. The question remains, therefore, of where the bar should be set in terms of minimum standards.

I have been struck by the several different meanings of ‘protection’ since starting the RLI MA in Refugee Protection and Forced Migration Studies. Protection has a particular meaning in a legal context, as well as in a humanitarian context. Protection, however, does not have a specialised medical meaning.  For an intervention to ‘protect’ against an outcome is for it to actively make an outcome less likely, to guard or shield against, as in the vernacular. What meaning, therefore, can be taken from Article 17(2) of the recast European Reception Conditions Direction, stating that “[EU] Member States shall ensure that material reception conditions provide an adequate standard of living for applicants, which guarantees their subsistence and (my emphasis) protects their physical and mental health”?

The natural reading of this promise is the idealised situation I outlined above, where no possible uncertainty, discomfort or stress could be caused by housing – certainly unrealistic. But there don’t appear to be any other standards by which this ‘protection’ of mental health can be measured, leaving the interpretation of Article 17(2) open and consequently rather meaningless from a medical point of view. I am left curious as to whether the standards of ‘protecting physical and mental health’ are higher than simply not subjecting people to torture, inhuman or degrading treatment, a low bar indeed.  

The announcement in January 2019 of the awarding of a 10-year asylum accommodation contract to Mears, Serco, and Clearsprings to start in September 2019 has led to a mixture of hope and concern amongst campaigners. Migrant Help have been awarded a contract to provide advice and guidance to asylum seekers as a single point of access for support, called the Advice, Issue Reporting and Eligibility (AIRE) Services. This, along with the departure of the notorious G4S from these contracts, may represent the opportunity for an improved accommodation system for asylum seekers, although concerns have been raised regarding the lack of consultation with key stakeholders, including local authorities, however, and minimal opportunity for public scrutiny of these contracts.

There remain, therefore, important questions regarding what changes have been made that will lead to any concrete improvements, or whether any improvement in standards is likely in the near future until the legal requirements for reception conditions are further interrogated by practitioners and decision-makers.

Photograph: ©Geograph

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