A chilly protest in Melbourne is the latest in a series of actions by the medical profession against attempts by the Government to prevent doctors working in detention centres from talking publicly about their experiences.
This follows a national ‘call-out’ organised by the Australian Medical Students Association which involved medical students around the country calling all Federal Parliamentarians to lodge their objections to the Australian Border Force Act.
This legislation came into effect on July 1st 2015 and will make doctors criminally liable for disclosing any aspects relating to their work with asylum seekers.
The following piece by Dr Peter Young, Dr Ai-Lene Chan and Professor David Isaacs reviews the adverse psychological and physical health effects of mandatory detention doctors encounter, in order to highlight the need for ongoing discussion and transparency.
The authors are all experienced medical practitioners who have provided health care to people in a range of different detention centres, as follows:
Dr Peter Young is a Psychiatrist and former Director for Mental Health Services for IHMS – responsible for all the detention centres.
Dr Ai-Lene Chan is an Adelaide General Practitioner with Masters of Public Health and Tropical Medicine. She worked at Christmas Island detention centre in 2013 and 2014 and in Nauru in 2014
Professor David Isaacs is a Paediatrician who worked in Nauru
Doctors who work with asylum seekers within Immigration Detention Centres regularly confront their ethical responsibility to report substandard care, or concerns of mistreatment. Understanding of the health consequences of detention has relied on doctors, nurses, other health professionals maintaining their professional standards including health advocacy and speaking out. The emotional and physical situation of those in detention is grave and healthcare substandard. How can doctors work to professional standards in this setting and under the threat of prosecution? What is the ethical obligation of doctors to advocate for their patients? In alliance with professional groups including the Australian Medical Association, the Royal Australian College of General Practitioners, The Royal Australasian College of Physicians and The Royal Australian and New Zealand College of Psychiatrists the integrity of clinical independence needs to be protected from attempts to undermine it.
What does the Australian Border Force Act mean for doctors?
The independence of the medical profession has long been considered as a public good and a cornerstone of its integrity (2).Healthcare professionals who provide healthcare to asylum seekers in detention are employed through the service contractor International Health and Medical Services (IHMS). The restrictions placed on doctors working in Immigration detention results in healthcare that cannot be consistent with Australian codes of conduct and standards. However, doctors must sign restrictive contracts forbidding discussion of their work with anyone outside the system and any critical comment of IHMS or of the Department of Immigration and Border Protection (DIBP) in mainstream or social media (3,4).
Despite this, some have spoken out on the harm that mandatory detention causes to the health of detainees (5). From July 1st, however, the Australian Border Force Act puts in place further restrictions and significantly increases the potential penalties for speaking out, so that doctors and other healthcare professionals who relate their experience of working in detention can be prosecuted and face up to two years in prison (6).
Restrictions include clinical information sharing, research and professional discussion, even if these attempt to improve clinical practice and mitigate the negative health effects of detention. The Australian Border Force Act directly challenges professional codes of ethical conduct, including the safeguard of clinical independence and professional integrity from demands of third parties and governments (7).
With many detainees in community detention and former detainees now resettled in Australian communities it is important to remain informed of the health system they experienced in detention. However, the legislation aims to silence health professionals and others who advocate for their patients.
What has been learned so far about the adverse health effects of detention?
People living in detention have increased risk of mental health disorders including depression, anxiety and post-traumatic stress disorder (PTSD). PTSD associated with detention is multifactorial and in part an anticipatory response to fears of repatriation (8). Detainees commonly report suicidal ideation and self-harm (9). Psychiatric morbidity is independently caused and exacerbated by detention itself, and the degree of this is increased by length of time spent in detention (8, 9).
Refugees experience trauma-related mental illness from home and in transit that in most cases improves over time, but some will continue to experience long-term psychiatric morbidity (10). Recovery from trauma requires privacy that communal detention centres do not accommodate. Personal space is frequently intruded upon by staff and security (11).
Further undermining trauma recovery is the inability to feel safe due to uncertainties for the future. Therapeutic exploration of pre-existing trauma is limited while individuals remain under uncertainty and threat, consequently recovery is generally not possible until the person leaves detention and is in a safe and stable environment.
Children in detention are particularly vulnerable as they often do not understand the reason for it and worry they may be sent back (12). Children regularly experience flashbacks, or distressing memories of detention and feelings of hopelessness (11-13). Longitudinal monitoring shows the negative psychiatric impact of detention is sustained (10).
Children who have had their development interrupted by detention are not adequately assessed for their educational, welfare and service related needs (14). Parents (who may be traumatised themselves) are frequently unable to adequately provide care (13). The Forgotten Children enquiry, published by the Australian Human Rights Commission in 2014, found that children in detention on Nauru expressed extreme levels of physical, emotional, psychological and developmental distress (14).
Conditions related to environmental exposure are frequently observed in detention centres and include the effects of exposure to heat, humidity and toxins (14). Environmental related illness included chronic suppurative otitis externa, dermatitis, dehydration and chronic recurrent cystitis.
Prolonged detention exacerbates disease chronicity through inadequate treatment and infection control procedures. Conditions related to environment and overcrowding include bacterial, coliform and mite infestation, rapid transmission of upper respiratory infection and diarrhoeal disease. Acute illness demonstrates increased morbidity in the harsh environment and there has been one death in detention from bacterial cellulitis (15).
How are standards of care limited by detention?
Standards of care are challenged with frequent loss of pathology in transit, regular disruption of IT communications and underdeveloped pharmaceutical supply chains (14). Recall systems are non-functioning because of delayed test-to-result times, disorganised administrative procedures and frequent changeover of staff (5, 14).
Healthcare is further restricted by offshore isolation from specialised, or multidisciplinary services. Establishing a therapeutic relationship is impeded by frequent staff turnover and fundamental conflicts of interest. The overriding purpose of all contractors including health providers is to “stop the boats” and The Department of Immigration and Border Protection oversees clinical decision-making (14). Consequently, people in detention frequently have significant morbidity including chronic pain and functional impairment because they cannot access the diagnostic and treatment services they need.
How has the medical profession responded to the Australian Border Force Act?
In a unified response to the Act, professional bodies including Australian Medical Association, The Royal Australian College of General Practitioners, The Royal Australasian College of Physicians and The Royal Australian and New Zealand College of Psychiatrists have demanded amendment of the Act to protect health professionals and enable them to advocate and act in the best interests of their patients (16).
Peak medical bodies have also recommended that responsibility for the administration of healthcare in Immigration detention be transferred to the Department of Health rather than the DIBP and the establishment of a truly independent panel of health professionals to oversee and publically report on healthcare delivery in Immigration detention.
The independence and integrity of the medical profession is compromised by the current healthcare system within Immigration detention and is further eroded by the Border Force Act. Doctors who work with asylum seekers both in detention and the community should review the contractual restrictions placed on their practice and in the context of this new legislation assess its ramifications for their professional practice and ethical obligations.
Doctors are obliged to uphold the independence and integrity of the profession and the negative physical and psychiatric effects of indefinite mandatory detention should be scrutinised and documented. We need to remain educated in the consequences of these policies and to carry out our duty as health professionals to minimise these harms health.
Parliament of Australia. Australian Border Force Bill 2015. Available at: http://www.aph.gov.au/Parliamentary_Business/Bills_Legislation/Bills_Search_Results/Result?bId=r5408 (Accessed 29.6.15).
World Medical Association Declaration of Seoul on Professional Autonomy and Clinical Independence. World Medical Association 2008
Good Medical Practice: A Code of Conduct for Doctors in Australia. Medical Board of Australia March 2014
Jennett G. Leaked report reveals ethical fears of doctors conducting health checks on asylum seekers at Christmas Island. ABC online, 2013; 20 December. http://www.australiandoctor.com.au/news/latest-news/detention-centre-doctors-fear-for-regos (accessed June 2015)
Marr D. Doctors reveal ‘harmful’ standards of medical are for asylum seekers. The Guardian, 2013; 20 December. http://www.theguardian.com/world/2013/dec/19/revealed-doctors-outrage-over-unsafe-refugee-patients (accessed June 2015)
Burnside J. Why gag doctors in detention centres? What are we hiding? Julian Burnside, 2015; 23 June. http://www.julianburnside.com.au/why-gag-doctors-in-detention-centress-what-are-we-hiding/ (accessed June 2015)
Australian Medical Association. AMA Code of Ethics – 2004. AMA, 2006; 20 November. https://ama.com.au/position-statement/ama-code-ethics-2004-editorially-revised-2006) (accessed June 2015)
Robjant K, Hassan R, Katona C. Mental health implications of detaining asylum seekers: systematic review. Br J Psychiatry. 2009 Apr; 194(4): 306-12.
Keller AS, Rosenfeld B, Trinh-Shevrin C, Meserve C, Sachs E, Leviss JA, et al. Mental health of detained asylum seekers. Lancet. 2003;362(9397):1721–1723.
Steel Z, Silove D, Phan T, Bauman A. Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population based study. Lancet. 2002;360(9339):1056–1062.
Association of Services to Torture and Trauma Survivors. Submission to the National Inquiry into Children in Detention May 2014. Submission 165. Sydney: AHRC 2014. https://www.humanrights.gov.au/sites/default/files/Submission%20No%20165%20-%20Association%20for%20Services%20to%20Torture%20and%20Trauma%20Survivors.pdf
Zwi, K. Detained children risk life-long physical and mental harm. The Conversation. 2015; 19 February. https://theconversation.com/detained-children-risk-life-long-physical-and-mental-harm-37510
Steel Z, Momartin S, Hafshejani A et al. Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Aust NZJ Public Health. 2004 Dec;28(6):527-36
Australian Human Rights Commission. The Forgotten Children: national inquiry into children in immigration detention 2014. Sydney: AHRC, 2014.https://www.humanrights.gov.au/sites/default/files/document/publication/forgotten_children_2014.pdf
Om J. Hamid Khazaei: Rare bacterial infection killed Iranian asylum seeker detained on Manus Island. ABC Lateline 2014; 4 October. http://www.abc.net.au/news/2014-10-04/iranian-asylum-seeker-died-of-rare-infection/5790364 (accessed June 2015)
Royal Australian College of General Practitioners. Media release. RACGP calls for gag to be lifted on World Refugee Day. 2015; 20 June. http://www.racgp.org.au/yourracgp/news/media-releases/world-refugee-day/ (accessed June 2015)