EXPLAINER: NAURU'S HEALTH SYSTEM

A CYNICAL POLITICS OF MEDICAL NEGLECT 

By Nathan Brown & Sara Townend

(published in Avondale News Friday, August 3, 2018)

OBSTRUCTIONS TO PROVISION OF MEDICAL CARE ON NAURU

It is a serious allegation. Addressing the 38th Session of the United Nations Human Rights Council on July 2, Daniel Webb of the Human Rights Law Centre said this: “The denial of essential medical care has become the latest political tactic used against the refugees indefinitely imprisoned on Manus and Nauru.” He described the denial of care as a deliberate plan by cynical politicians to “harm refugees for their own political ends” as a form of “brutal and deeply cynical politics.”1 The Australian government version of care on Nauru directly contradicts this. Prime Minister Malcolm Turnbull says care is “compassionate, well managed and secure.”2

This article focuses on the second part of his assertion: that the care is “well managed.” Whether asylum seeker, refugee or Nauruan national, patients receiving health care on Nauru are subjected to a healthcare system beset by inbuilt inefficiencies, poor governance and quality processes and obstruction to care, which leads directly to delays, in some instances for years, in care. Webb’s assertion comes in part from the spate of cases heard in the Federal Court this year. These range in nature but have several factors in common. All involved refugees who had health service delivery of some type on Nauru and all were considered by doctors employed by IHMS—the contracted medical service provider to the Regional Processing Centre on Nauru—to require a level of care beyond that available on the island. Most of the refugees had been unwell for a significant time. Many of the health needs among refugees and asylum seekers involve severe mental health issues,3 but there have also been some cases with primary physical complaints.

The place
Nauru is an island in the Pacific Ocean, only 21-square kilometres in area situated 56 kilometres south of the equator. Of its population of 12,000, more than 1000 are refugees and asylum seekers sent to the island by the Australian Government. A wealthy nation during the boom in phosphate mining that peaked in the 1960s and 70s, the economy has largely relied on hosting the Regional Processing Centres for refugees since 2001. Australia is Nauru’s largest source of economic aid and activity. In 2017/18, Australia provided at least 25 per cent of Nauru’s gross domestic product in direct aid and in short-term employment contracts in northern Australia. Levels of skilled labour on the island remain low.4

Health is a major challenge for the Nauruan population. Life expectancy among the general population is 66.4 years. Obesity is seen in 90 per cent of the population and the prevalence of non-communicable diseases such as diabetes and renal and cardiac disease rank among the highest in the world. About 75 per cent of deaths, many premature and preventable, are from these diseases. There is also a “heavy burden of disability on individuals, families and workers.”5 Australia’s Department of Foreign Affairs and Trade reports poor health and education persist despite improvements in in the economy.6

The major healthcare facility is the Republic of Nauru Hospital. There is also a community health centre that offers diabetes and obesity-related services. There is limited reliable data available about these services but the statement from IHMS to last year’s Senate inquiry7 alludes to the poor facilities of an under-resourced hospital dependent on Australia for financial and pharmaceutical support.8 According to the Home Affairs website, the Australian government has given $26 million for an upgrade. This was completed between 2015 and 2017 and is ostensibly to cope with the increased demand placed on the system by the refugees. There are no significant details about how the money was spent in the upgrade.9 Other commentaries have reported that the hospital is limited in scope. Those who have worked at the centre speak about the new buildings but say it often lacks basic supplies.10

The process and provision of care: asylum seekers
This is the system and context in which asylum seekers and refugees access health care. About 230 asylum seekers living within the compound complex—including about 20 children—can seek the medical care provided by IHMS in a clinic on the compound. The 900 or so refugees—including about 100 children—have had their claims for refugee status processed, substantiated and accepted. They have been issued temporary protection visas and, as such, are expected to seek medical and health care from the Nauruan health system.

The Australian government has contracted IHMS to provide services in primary and mental health care. It provides services through two centres. For asylum seekers, there is a medical bay within the Regional Processing Centre, which was updated at a cost of $11 million. It provides services for asylum seekers and some refugees who still live there on the compound. There is a general practice-style medical clinic with adjunct mental health staff, six basic inpatient rooms and some emergency facilities. There is no external accreditation standard for this practice. At last year’s Senate inquiry, IHMS stated that contractually the services are “broadly comparable with health services available within the Australian community.”11

IHMS uses a computerised system for medical notes that is not connected to either the other IHMS clinic or the hospital notes system. IHMS also has access to some second opinions from visiting specialists, mostly psychiatrists and other mental health professionals. To date, it seems it has used the facilities of Telehealth on only one occasion. For any health care not available on the island, referral is made directly to Australian Border Force. The request is made internally to the IHMS senior staff in Australia, who submit an application—a Request for Medical Movement—to Australian Border Force.

The recently departed Commissioner of Australian Border Force, Roman Quaedvlieg, said on Twitter in April this year that medical information forms only part of the consideration.12 From 2015 to 2017, a chief medical officer was tasked with overseeing detention health care, but direct access to this person was limited during their tenure. A replacement CMO has recently been appointed, so it remains to be seen if there will be improvements in this process.

The process and provision of care: refugees
The process for accessing health care is different for those who have been processed as refugees and “released” into the Nauru community. IHMS staffs a basic primary health clinic attached to the hospital, intended as a transition for the refugees into the community. Contractually, this general practice clinic provides basic care, with some supplementary mental health care, and is required to meet the standard “broadly comparable with health services available within the Nauruan community.”13 The hospital provides more complex care, including all emergency care, paediatric care and surgical operations.14

As such, refugees requiring any sort of hospital care or specialist opinion are referred by the IHMS health clinic to the hospital. As stated previously, this hospital is part of a health system that requires constant support from the Australian Government. Data on the qualifications of the clinical staff does not exist but commentators have suggested there is variability in quality typical of many hospitals operating in similar environments within the Pacific, where Australian clinicians regularly go to provide up-skilling, education and clinical support.15

The general practitioner in the IHMS clinic who assesses that a patient requires more specialist intervention must refer to a specialist within the hospital system, as would be the case in the Australian healthcare system. But the difference begins at this point. While the doctors can refer, there is no guarantee the request will be acknowledged, understood or actioned in a way acceptable to medical standards in Australia. From his experience working with IHMS on Nauru, Dr Nick Martin—an experienced general practitioner and Senior Medical Officer on Nauru from November, 2016 to August 2017—estimates it takes four to six referrals before such requests are even acknowledged, then only one in four of those will be answered with a plan for medical follow up.16

Whatever the political justifications for the Australian Government’s border protection policies and regime, they will never warrant or justify the denial of essential medical care to those who have sought our protection.Nathan Brown and Dr Sara Townend

Once the Nauruan hospital doctor has seen the patient, refugees and Nauruan nationals alike have to wait for the ruling of a committee to process the request for treatment via the Overseas Medical Referral process. This is similarly slow and frustrating. In an affidavit presented in one of the recent court cases, Martin explained it like this:

“The OMR sat irregularly, was poorly minuted, often cancelled at short notice and often gave contradictory opinions, depending on which doctor was chairing it. If a doctor appointed by the Government of Nauru was dismissed, which was a frequent occurrence, then often the decisions made by that doctor were revoked. I regularly informed the Director of Medical Services, Dr Richard Leona, of the outstanding cases we had and copied in my IHMS superiors. These patients were routinely ignored by the OMR committee with no reasons given.”

If the hospital committee recommends further specialist medical care is needed, an application is then made to Australian Border Force. It is well known that such transfer requests are assessed at a high level within the department. Based on its public statement, those making these decisions have political views and aspirations based on the idea that they have “stopped the boats,” meaning these decisions are often made for non-medical reasons. As quoted above, members of this department have publicly stated that medical need is only one factor in considering such a transfer request. Even if we ignore the political consideration, this is an example of extremely poor governance, especially when the only recourse is legal challenge in the Federal Court.

An area medical director for IHMS recently conceded in correspondence that healthcare for refugees and asylum seekers was captive to these policies of the Australian Government, which resists all medical transfers:

“ABF has put extreme limitations on the types of patients that we can referral [sic] offshore—it does not stop us requesting these transfers but, as we are not in control of that aspect of things, the patients are entirely at the mercy of the decisions made by ABF as regards transfers.

“It is clear that refugees cannot access the same levels of care that are available to transferees residing at the RPC [Regional Processing Centre] and they cannot access an ‘Australian’ standard of care—certainly in relation to access to specialist care anyway. . . . All we can do is highlight the areas of inadequacy as regards medical resources and capability—which we have done on numerous occasions.”17

Martin, the former Senior Medical Officer, would concur with this view, commenting on Twitter in April this year that “EVERY TIME I tried to get a transfer, ABF obstructed it. Without fail.”18 Again, these are often political decisions made on political considerations, rather than the medical and healthcare needs that should be the primary considerations.

It is extremely concerning that so many obstacles are built into the healthcare of refugees and asylum seekers on Nauru. It is a system deliberately designed to confuse, delay and obstruct. Given the complexity of the task and the difficult history of their patients, even with the best systems, with robust governance, excellent resources in human and technical terms and good outpatient support, IHMS would be hard-pressed to adequately meet the complex health needs of the refugees. When you add the politicised obstructionism of Australian Border Force and the limitations of the medical care on Nauru, it is inevitable things will go wrong.

In the past month, there has been a litany of cases dealing with a range of extremely unwell patients of a range of ages challenging this denial of medical care. The cases range from denying a toddler with suspected viral encephalitis access to appropriate investigations and monitoring from a paediatric neurologist, denying transfer of a middle-aged woman with an occluded coronary artery, and the attempted self-immolation by a 14-year-old female. They represent an alarming cohort, unacceptable in any other setting in Australian healthcare. To date, the Federal Court has ordered that every patient should receive the medical care denied them, but this process represents unnecessary difficulty and delay.

In none of the recent cases has there been any challenge to or denial of the responsibility the Australian Government has for the health and wellbeing of the asylum seekers and refugees it is holding in the Regional Processing Centre on Nauru. This calls into question the adequacy of the infrastructure and practice of medical care provided to the people in these centres, as well as the larger brutal regime of the indefinite and mandatory detention of asylum seekers who have come to Australia by boat. If we cannot adequately care for refugees in such remote locations, this is another reason why this is bad public policy.

Whatever your political position on refugees and migration, the continuing failure to provide adequate healthcare to those in Australia’s care—and the deliberate and cynical perpetuation and exploitation of these failures for political purposes—means patients assessed as needing help are denied care. These patients are victimised not because of any uncertainty about their requirement for care on the part of medical staff who have assessed them but because of their political status.

This is not compassionate, well-managed or secure. This is unacceptable and untenable. Whatever the political justifications for the Australian Government’s border protection policies and regime, they will never warrant or justify the denial of essential medical care to those who have sought our protection.

REFERENCES

1. Daniel Webb, Statement at the 38th Session of the United Nations Human Rights Council, July 2, 2018.

2.  Dennis Shanahan, “Peter Dutton signals no softening of asylum policy,” The Australian, June 23, 2018, https://www.theaustralian.com.au/national-affairs/immigration/peter-dutton-signals-no-softening-of-asylumpolicy/news-story/67fd37c3c59bdda553a74734425742cf

3. K Zwi, S Mares, D Nathanson, A K Tay and D Silove (2018), “The impact of detention on the social–emotional wellbeing of children seeking asylum: A comparison with community-based children,” European Child and Adolescent Psychiatry, Vol 27, pages 411–22.

4. Department of Foreign Affairs and Trade, “Nauru: Aid Fact Sheet,” Australian Government, May 2018, http://dfat.gov.au/about-us/publications/Documents/aid-fact-sheet-nauru.pdf; Department of Foreign Affairs and Trade, “Development assistance in Nauru: Overview of Australia’s aid program to Nauru,” Australian Government, http://dfat.gov.au/geo/nauru/development-assistance/Pages/development-assistance-in-nauru.aspx; Jewel Topsfield, “Nauru fears gap when camps close,” The Age, December 11, 2017, https://www.theage.com.au/news/national/nauru-fears-gap-when-camps-close/2007/12/10/1197135374481.html

5. World Bank, Non-Communicable Disease (NCD) Roadmap Report (English), World Bank Group, July 10, 2014, page 6, http://documents.worldbank.org/curated/en/534551468332387599/Non-Communicable-Disease-NCD-Roadmap-Report

6. Department of Foreign Affairs and Trade, “Development assistance in Nauru: Overview of Australia’s aid program to Nauru,” Australian Government, http://dfat.gov.au/geo/nauru/development-assistance/Pages/development-assistance-in-nauru.aspx

7. Parliament of Australia, “Report: Serious allegations of abuse, self-harm and neglect of asylum seekers in relation to the Nauru Regional Processing Centre, and any like allegations in relation to the Manus Regional Processing Centre,” Commonwealth of Australia, April 21, 2017, https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Legal_and_Constitutional_Affairs/NauruandManusRPCs/Report

8. Department of Foreign Affairs and Trade, “Development assistance in Nauru: Supporting human development in Nauru,” Australian Government, http://dfat.gov.au/geo/nauru/development-assistance/Pages/objective-3-supporting-human-development.aspx

9. Department of Home Affairs, “Health services in Nauru,” Australian Government, https://www.homeaffairs.gov.au/about/corporate/information/fact-sheets/health-services-nauru; Department of Foreign Affairs and Trade, “Nauru: Nauru country brief,” Australian Government, http://dfat.gov.au/geo/nauru/Pages/nauru-country-brief.aspx

10. Nick Martin, “The Nauru Diaries,” Meanjin Quarterly, Autumn 2018, https://meanjin.com.au/essays/the-nauru-diaries

11. Senate Legal And Constitutional Affairs References Committee, “Opening Statement – International Health & Medical Services (IHMS),” March 15, 2017, http://www.ihms.com.au/docs/media/Select_Senate_Inquiry_Opening_Statement.pdf

12. ibid.

13. ibid.

14. Department of Foreign Affairs and Trade, “Development assistance in Nauru: Overview of Australia’s aid program to Nauru,” Australian Government, http://dfat.gov.au/geo/nauru/development-assistance/Pages/development-assistance-in-nauru.aspx

15. See Doctors Assisting in South-Pacific Islands, https://daisi.com.au/

16. Nick Martin, “The Nauru Diaries,” Meanjin Quarterly, Autumn, 2018, https://meanjin.com.au/essays/the-nauru-diaries/

17.  Ben Doherty, “Refugee girl at risk of suicide to be moved from Nauru to Australia after court action,” The Guardian (Australia), July 7, 2018, https://www.theguardian.com/world/2018/jul/07/refugee-girl-at-risk-of-suicide-to-be-moved-from-nauru-to-australia-after-court-action

18. Twitter reply to Roman Quaedvlieg, April 25, 2018.