Australia has had a long history with refugees and asylum seekers, having successfully resettled over 750 000 individuals since the commencement of WWII . Our country has reaped enormous benefits as a result, including marked economic, social and cultural growth. Today however, Australia’s treatment of refugees and asylum seekers is highly contentious. There is no question that we are facing considerable challenges to ensure the just treatment of all those who arrive on our shores. But what are the obligations of doctors towards some of these challenges, and how can we become more informed and vocal about this topical issue?
As a medical student on my Psychiatry term at a western Sydney hospital, I had my first eye-opening encounter into the relationship between refugees and health professionals. A thin young man in his mid-20s had been brought in from the nearby Villawood Detention Centre, flanked heavily by security guards. He had recently survived his third attempted suicide and had been admitted for formal Psychiatric assessment. During the assessment, he looked at the team confidently and stated very clearly that he was not suicidal. He had swallowed a large quantity of unknown tablets to be brought out of the centre to speak with authorities and to beg for his release. Now that he had succeeded and he was here, he looked at us desperately and pleaded, “Please, please, don’t let them take me back there”.
This episode has haunted me in the years since. In retrospect, it’s clear to see how this young asylum seeker viewed our position: a team of Australian doctors – highly educated, skilled and well-respected in the community – a voice to appeal to the authorities to command his release from an unjust imprisonment.
The Psychiatry team later assessed him as having no imminent suicidal risk and watched helplessly as the two bulky guards led him away. We were shaken by the incident. We debriefed afterwards, telling each other how our duties as doctors in this instance were to perform an accurate Psychiatric assessment and ensure that he was medically stable. The legal issues were to be left in the hands of the professionals. There was essentially nothing else that we could have done. But was that entirely true? How far did our responsibilities as health professionals extend towards this young man and hundreds of voiceless others like him?
The roles and responsibilities of healthcare professionals
Many commentators argue that health professionals, by the very nature of their profession and standing in their community, have a moral and ethical obligation to advocate for the vulnerable members of our community. One such advocate is Professor Gillian Triggs, a prominent lawyer, activist and former President of the Australian Human Rights Commission. Professor Triggs was keynote speaker at the 2017 Annual Congress for the Royal Australasian College of Physicians (RACP), where she stated, “there is such a strong respect for the medical profession in the Australian community that it gives its members a special capacity and importantly, the credibility to speak up for vulnerable communities” .
Recent history demonstrates that doctors have an immense potential to garner support and media attention to ultimately generate positive change. Take the case of Baby Asha, an asylum seeker child who was the focus of a 10-day protest after she was transferred to Lady Cilento Children’s Hospital from Nauru for the treatment of burns. UN working groups had provided clear reports outlining that the conditions on Nauru were dangerous, especially for children. The doctors treating Asha refused to allow her discharge back to Nauru until a more suitable discharge destination could be identified . The protest garnered huge media interest and public support, resulting in the Government eventually agreeing to community detention within Australia for Asha and her family.
Professor Triggs further argues that the human rights movement relies upon the medical profession to underscore their position when legal and moral arguments are deemed insufficient. The unique position of the medical profession means doctors and nurses are often at the frontline of the mental and physical health of refugees and asylum seekers. In compiling the Forgotten Children report of 2014, Triggs reflected that without the medical evidence and opinions from the health professionals involved, the Human Rights Commission would not have made any substantial political point . Whether we like it or not, doctors have a distinctive influence amongst the public and within the political sphere. This influence comes with an enormous responsibility.
The basics – definitions
A refugee is defined as any person who, owing to a fear of being persecuted for reasons of race, religion, nationality, membership of a social group or political opinion, is outside the country of their nationality and is unable, or owing to such fear, unwilling to avail themselves of the protection of that country .
An asylum seeker is a term often used interchangeably with ‘refugee’, but means something different in the eyes of the law. An asylum seeker is a person who has sought protection as a refugee, but whose claim for refugee status has not yet been assessed. Not every asylum seeker will ultimately be recognised as a refugee, but every refugee is initially an asylum seeker. However, under international law, a person is a ‘refugee’ as soon as they meet the definition of refugee, whether their claim has been assessed or not. Regardless of the name applied, often these individuals have faced unimaginable suffering including poverty, marginalization, wars before they come to Australia .
It is a common misconception that it is a crime to arrive in Australia by boat without a visa and ask for protection. Article 14 of the Universal Declaration of Human Rights states that everyone has the right to seek asylum from persecution in other countries7. Human rights are universal basic freedoms and protections that apply to all peoples. It is not illegal for people to flee persecution in their homeland or to cross borders without documents or passports to seek asylum. It is not a crime under Australian law to arrive here by boat without a valid visa and to seek protection.
Despite this, a huge number of asylum seekers have been detained, often indefinitely, within Australia and on Christmas Island: As of 31st January, 2018  :
The physical and mental health risks of detention
Recent reports outlining the cramped and unsanitary conditions of several onshore and offshore detention facilities have questioned the medical care received by asylum seekers on Australian soil. A report released this month highlights the toxic, mould-prone tents on Nauru where at least 330 refugees and asylum seekers are currently living, including 36 children. Some tents and work buildings have been found to have levels of mould measured at up to 76 times the safe level. The negative health impacts of these overheated, contaminated and mouldy tents have been heavily documented in health reports for years on Nauru .
In addition to the poor conditions which contribute to serious health consequences, health services are grossly inadequate in detention facilities. This was tragically demonstrated in 2014 by the circumstances surrounding the death of Hamed Kehazaei, a 24-year-old asylum seeker who contracted cellulitis after cutting his foot on Manus Island. He developed septicaemia despite oral antibiotics . Health professionals on the island and onshore raised grave concerns about the delays in his transfer to a tertiary hospital. He was finally flown out of the island 36 hours after doctors on the island requested his urgent transfer and 68 hours after presenting unwell, yet Hamed died of overwhelming sepsis in Brisbane’s Mater Hospital. The gravity and frustrating injustice of this situation can be well recognised by health professionals .
The Nauru Files, a series of leaked reports published by the Guardian Australia, outline several additional troubling medical cases involving asylum seekers. These cases include a 70-year-old refugee with heart failure who waited almost a month for a doctor’s appointment, and a child held on Nauru suffering from suspected extra-pulmonary tuberculosis. It was recommended that the child be transferred to Australia for further specialist investigation, yet the child was refused a medical transfer and remained on the island .
There are approximately 50 asylum seekers and refugees currently awaiting surgeries, abortions and other treatment which cannot be performed at Nauru, including at least three women seeking to terminate a pregnancy for physical and psychological reasons . These patients not being considered for overseas medical treatment, in clear defiance of doctors’ recommendations [12, 13].
The severe mental health consequences of prolonged detention amongst refugees and asylum seekers cannot be ignored. Asylum seekers in detention suffer disproportionality high rates of depression, anxiety, sleep disorders and post-traumatic stress disorders. A recent UNHCR report on offshore detention observes that “the prolonged, arbitrary and indefinite nature of immigration detention in conjunction with a profound hopelessness in the context of no durable settlement options has corroded these individuals’ resilience and rendered them vulnerable to alarming levels of mental illness” . The national inquiry into the detention of children found that mental health disorders for children in detention are up to 34% compared to 2% for other children in Australia. In addition, 88% of children in detention suffered post-traumatic stress disorder and various levels of anxiety .
How to get involved
As outlined above, the medical care offered to this vulnerable group is vastly different to the health services available in the Australian community. The Australian Medical Association (AMA) has already made significant steps to bring doctors and other health professionals into the conversation. The AMA has revised its Position Statement on the Health Care of Asylum Seekers, urging the Government to establish a national statutory body of clinical experts, independent of the Government, to investigate and advise on the health and welfare of asylum seekers and refugees, and report their findings to the Parliament . Professor Brian Owler, President of the AMA, has encouraged doctors to become involved in refugee health, reiterating that doctors have an ‘ethical and moral obligation to act in the best interests of their patients and speak out about concerns in regards to the welfare of their patients, whether it be the treatment of an individual or whether it be at a system level .
As we have seen, advocacy is a powerful political tool. You can exercise that tool and help to make a difference in several effective ways:
Join your local refugee advocacy group:
Doctors for Refugees: https://www.doctors4refugees.org/
Refugee Action Coalition: http://www.refugeeaction.org.au/
Amnesty International Australia: https://www.amnesty.org.au/campaigns/refugees/
Attend the next public demonstration for refugee rights, or organise your own.
Details at: refugeeaction.org.au.
Write to professional bodies such as the AMA to place increasing pressure on the government. Encourage them to continue to support refugees and put an end to mandatory detention and off shore processing. Write directly to your local politician on behalf of the medical profession.
Tips for letter writing:
Volunteer for local programs such as the Waterwell project, a health promotion charity which hosts interactive health education sessions for newly arrived refugees and asylum seekers: https://www.thewaterwellproject.org/
Donate to causes such as Asylum Seeker Resource Centre, which provides free legal aid to expedite the release of asylum seekers from detention centres. https://www.asrc.org.au/