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Boycott or battle? Medicine’s refugee dilemma

Are medical professionals who work within the immigration detention network complicit in torture and child abuse, or do they have an ethical and moral obligation to help, despite the horrors of the system?

This was the central question at an Australian Medical Association forum in Sydney on Sunday, bringing together some 350 senior doctors, nurses, allied health professionals and medical students on the contested topic of health and asylum-seeker policy.

It was an inevitably political affair, with AMA President Brian Owler demanding a moratorium on returning children to immigration detention as the standoff over Baby Asha continues at Brisbane’s Lady Cilento Hospital.

Describing her removal as a line from which, if crossed, there could be no return, Owler also called for the immediate release of all children from facilities both in Australia and offshore, as well as the reinstatement of a national independent advisory body of clinicians on asylum-seeker health.

Critically, he said the Border Force Act must be amended to make clear that it did not silence doctors and nurses from speaking out about conditions for asylum-seekers.

Debate raged from the floor on whether an official boycott should be called on immigration facilities, with some doctors including former IHMS employees arguing that by working in the system they afforded it a “cloak of respectability and legitimacy.”

Another said the Rubicon had been crossed, accusing any doctor who accepted payment from IHMS of condoning torture and inhumane and cruel treatment and questioning whether Border Force chief medical officer John Brayley ought to be ejected from the AMA.

Psychiatrist Tanveer Ahmed stirred controversy by questioning how the panellists could be certain that the mental health problems they attributed to mandatory detention were not the result of other experiences by detainees, and criticising the speakers as “emotive”.

In a barnstorming and wide-ranging speech, Owler dismissed calls for a boycott and later told reporters that he believed it was not the majority position of AMA members to “lock ourselves out of the system”.

“I don’t agree that that’s the way forward, and not just because IHMS will just recruit (replacements) from overseas,” he said.

“The provision of medical treatment to asylum-seekers is not condoning the system or being complicit, far from it. It’s doing what doctors and nurses always do – they put their patients first.”

“It would not matter what the AMA said on this issue, doctors would go and care for these people. If we want to change the government’s approach it must be through the weight of public opinion.”

‘Take some courage’

Australian Human Rights Commission president Gillian Triggs and Greens leader, Richard Di Natale – a medical doctor – were in attendance, along with senior representatives from groups including the Australian Nursing and Midwifery Association and Medecins San Frontieres Australia.

Di Natale said he sensed a shift in the national debate, with state premiers banding together to open their borders to refugee children, ramping up the pressure on federal politicians.

“I think things are shifting, take some courage,” he told the forum. “Take something positive out of today, don’t go away feeling deflated, powerless.”

Refugee lawyer David Manne also urged doctors present to seek legal advice if they needed it, saying matters could always be taken before the courts in cases like Baby Asha’s and there was recourse.

Ultimately, the forum had a deeply personal dimension, with speakers sharing bleak stories of the stark realities of life – especially for children – in Australian detention facilities on Christmas Island and Nauru.

Professor Elizabeth Elliott, a consultant paediatrician at the Children’s Hospital at Westmead, was part of the Australian Human Rights Commission team that toured immigration detention facilities to prepare the Forgotten Children report.

She said the facilities were a “harsh and unsuitable environment” for children, whether unaccompanied or within a family group, “irreparably harming their health and mental health” for life.

“The financial cost is enormous but the personal cost is immeasurable,” said Professor Elliott, describing detention as “child abuse and tantamount to torture”.

Reflecting on the apathy, even antipathy, on the part of the Australian public, she said it was a classic case of the adage ‘out of sight out of mind’, with offshore detention designed to suppress the identities of those behind the razor wire.

“The lack of face, name or voice renders these vulnerable children invisible,” she said.

Recounting her time on Christmas Island, Professor Elliott said children lived in a physically and emotionally toxic environment, where they suffered flashbacks to their journey at sea or atrocities witnessed at home.

Wryly, she recalled one detainee noting that Australians seemed more concerned about Christmas Island’s crabs than they were about the welfare of detainees held there.

‘I feel like a killer, a criminal’

Professor Elliott said one of the most degrading and dehumanising aspects of their treatment was referring to detainees by their boat identifier rather than their name.

When she asked them to draw pictures 30% of detainee children signed with their boat number. One teenager told Professor Elliott: “I feel like a killer, a criminal, when they use my boat number.”

She said 10 mothers with infants were on suicide watch during her visit, having slashed their wrists, attempted to hang themselves or run headlong into walls of cement or glass.

Professor Elliott said she was “still haunted” by the words of one 12-year-old girl who bore the terrible scars of abuse in her homeland, had witnessed the attempted murder of her mother, and been in detention for 14 months.

Her brother had simply ceased to speak, and her baby sister was failing to thrive. The girl was refusing food and threatening to self-harm.

When they walked into her room, they found a small, still bundle under a blanket and Professor Elliott said they wondered for a moment whether the girl was alive.

She told them: “My life is really death. I want to die, because in death I can’t live here any more… How can I get free?”

Noting that “compassion appears to have gone missing on Christmas Island”, Professor Elliott said 38% of children reported that they were ‘always’ sad or crying and 128 children had self-harmed.

More recently, she interviewed 69 children at Darwin’s Wickham Point detention centre who had been held in Nauru, some for as long as 17 months, and said “these were amongst the most traumatised children we had ever seen”.

More than 95% of those aged 8 or older were at high risk of PTSD, and had received the highest score possible for hopelessness. They lived in constant terror of headcounts, were constantly stigmatised and had no chance to play.

When asked to express his hopes, one boy said “I just don’t want to see a fence anymore”.

Dark, chilling lawlessness

Nurse Alanna Maycock recounted meeting a six-year-old who had attempted to hang herself with tent ties, and a 15-year-old boy who had sewn his lips together, children “acutely aware of and surrounded by despair and abuse, day in, day out, every minute of every day.”

Women were forced to shower and bathe their children in open stalls with little more than a flimsy curtain for privacy, directly across from male guards.

At night, one woman was so terrified about having to walk 100m to the toilet she repeatedly wet the bed, something Maycock said she had never encountered in 20 years of nursing. Another had to use strips of her tent to stem her menstrual flow and wept as she walked past the male guards to the toilet, trailing blood.

When she referred a rape victim to the IHMS psychologist Maycock said their response was to ask ‘why didn’t she cry out?’ and to remark that she was wearing “provocative clothing” – shorts and a tank top, in the 40+ degree heat.

She also described witnessing guards brutalising detainees who were powerless to fight back because they knew it would jeopardise their asylum claim.

“There’s a dark, chilling feeling when you go to Nauru of lawlessness, guards can behave as inappropriately as they wish because there’s no repercussions,” said Maycock. “There’s a perception that the Australian government doesn’t want them here.”

Due to the restrictions of the Border Force Act Maycock said it was increasingly difficult for health workers to speak out “and when you work within a system where there are laws that prevent you carrying out your duty of care you need to question what kind of system that is.”

She had initially stopped speaking out, but haunted by nightmares of her own two sons being trapped in immigration detention and being unable to reach them, Maycock said she felt no choice.

“Every doctor and every nurse needs to ask are they comfortable with witnessing abuse, physical assaults and harm to children and not speaking out about it,” she said. “The Australian public needs to know what is happening in these centres.”

Paediatrician David Issacs accompanied Maycock to Nauru and said doctors confronted a “horrible conflict” – duty of care to patients versus obligation not to condone torture.

“I think we need to say that prolonged immigration detention is torture, that the AMA does not and will never condone torture under any circumstances,” he said. “Doctors must examine their conscience.”

“I don’t think a boycott works, but I do think we have to say to the government ‘you shouldn’t be putting us in this position’. And the only way they can do that is by closing detention centres both onshore and offshore.”