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WE are senior Australian clinicians who write in our individual capacity to express our concerns about the ongoing health and well-being of the former detainees still based on Manus Island and now in alternative accommodation. They, like all human beings, have a universal right – enshrined in the United Nations charter – to health and well-being. Their political and citizenship status should not affect this right. All politicians regardless of their political party should respect the human right to health and themselves be strong advocates of “health for all” without discrimination.
- We are deeply concerned about the ongoing refugees’ physical and mental health;
- There are reports of poor hygiene and sanitation, limited supply of electricity and inadequate living conditions. All of these exacerbate disease and ill-health;
- We are not aware of accurate information on the health status of the refugees since the “official” closure of the Manus Island Australian-governed facility;
- We are concerned about the harm and the adverse publicity to the international reputation of Australia, its government and its people.
Urgent action is required:
- We believe that there should be an immediate, independent review of the health status of those still on Manus;
- We are prepared both to participate in this and to nominate appropriate, independent and credible clinicians;
- We are of the opinion that such a review should ideally be made in conjunction with senior Papua New Guinean clinicians who would take the responsibility for informing their government.
We are willing to conduct this review pro-bono, arranging the appropriate mix of clinical specialties. We would require the Australian government to negotiate the diplomatic permissions and officially sanction travel to and within PNG, as well as agree to clinical assessment of willing individuals.
We believe that the humanitarian issues take precedence over politics. This is a matter beyond immigration and border control, but one that affects the health of people and others’ perceptions of our great nation.
Yours sincerely and with great concern at the current situation,
Professor David A Watters OBE ChM FRCSEd FRACS
Alfred Deakin Professor of Surgery, Deakin University
Past President Royal Australasian College of Surgeons
Laureate Professor Nicholas J. Talley MD, PhD, FRACP, FAFPHM, FAHMS
University of Newcastle, Newcastle, Australia
Past President Royal Australasian College of Physicians
Past Chair Council of Presidents of Medical Colleges
Mr Philip Truskett AM FRACS
Prince of Wales Hospital, Sydney
Past President Royal Australasian College of Surgeons
Dr Lindy Roberts FANZCA FFPMANZCA FAICD
Specialist Anaesthetist and Specialist Pain Medicine Physician
Sir Charles Gairdner Hospital, Perth WA
Past President of Australian and New Zealand College of Anaesthetists
Professor Patrick McGorry AO FRCP FRANZCP
Executive Director Orygen
Professor Youth Mental Health, University of Melbourne
President, International Association for Youth Mental Health
NHMRC Principal Research Fellow
President, Schizophrenia International Research Society
Professor David Fletcher FRACS
Director of Surgery, Fiona Stanley Hospital
Professor of Surgery, University of Western Australia
Professor Kingsley Faulkner AM Cit WA MB BS FRACS MDA (Hons)
School of Medicine, Fremantle,
University of Notre Dame Australia
Past President, Royal Australasian College of Surgeons
Dr Liz Marles FRACGP
Past President RACGP
Professor Bastian M. Seidel PhD, MACHI, MRCGP, FRACGP
Current President, The Royal Australian College of General Practitioners
Professor Bala Venkatesh, MBBS, MD (Int.Med), FRCA, FFARCSI, MD(UK), FCICM
Past President, College of Intensive Care Medicine (ANZ)
Adjunct Associate Professor Frank R Jones FRACGP
Immediate Past President of the Royal Australian College of General Practitioners
A/Prof Christopher Milross MD FRANZCR FRACMA FAICD
Past President Royal Australian and New Zealand College of Radiologists
Dr Mukesh Haikerwal AO RACGP
Professor School of Medicine Flinders University, Adelaide
Past President AMA
Past President AMA VIC
Professor Malcolm Hopwood MPM MD FRANZCP
Professor of Psychiatry, University of Melbourne
Past President Royal Australia and New Zealand College of Psychiatrists
A/Professor Michael Hollands FRACS
Westmead Hospital, Sydney
Past President Royal Australasian College Surgeons
Past Chair Council of Presidents of Medical Colleges
Dr Lee Gruner FRACMA FHKCCM GAICD
Immediate Past President Royal Australasian College of Medical Administrators
Dr Genevieve Goulding FRANZCA
Senior staff specialist anaesthetist, Royal Brisbane & Women’s Hospital
Immediate Past President, Australian & New Zealand College of Anaesthetists
Professor Lucie Walters
Professor Rural Postgraduate Medical Education, Flinders Rural Health South Australia
Immediate Past President Australian College of Rural and Remote Medicine
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Ismail, thank you for your comments. What I did learn in almost a decade of part time prison medical officer work is that in competent prison work one must separate one’s clinical care and concern for the patient from one’s knowledge of the reason for the prisoner’s incarceration. Apart from precautions taken to protect one’s self from violent and evil prisoners. It was never my role to advocate for a prisoner’s release.
I am intrigued at your qualification of ‘unauthorised maritime arrivals’. What do you mean using the phrase ‘so-called’? Certainly they had arrived, and had come by sea. So are you suggesting, in some way, that they were ‘authorised’? If so, by whom? They did not hold visa’s for entry, indeed most of them arrived without personal papers. Actually the phrase was in formal use by the Department of Immigration, as an objective, neutral, non-derogatory descriptor. ‘Boat people’ developed derogatory overtones, as did ‘asylum seekers’. They could not be described as ‘refugees’ until that status had been formally established. And, as I described, where hospital clinical care was necessary, these patients administratively – commonly ‘jumped the queue’ – and delayed the clinical care of Australian citizens. Is that equitable?
Your name is Muslim. Are you suggesting that ‘boat people’ – significantly a Muslim cohort – should have priority over ‘ordinary Australians’? Or that people who choose to come – uninvited – by boat, should immediately, on arrival, have all the rights and opportunities of Australian citizens?
As I started work, many of the arrivals were Hazaras from Afghanistan. Being quietly decimated in their home country by their ethnic rivals, the Pushtans, and Al Qaeda. For a decade they had (unwisely) supported the American and Australian military presence. I considered they should have been quietly encouraged and enabled to come. They were (at least would have been) our best protection against Islamic terrorism. As I left, we were being inundated by the scions of wealthy middle eastern families, who were coming as ‘refugees’ to stake a claim, so their families would be able to emigrate under ‘family reunion’ entitlements.
I am not against ‘immigration’. Nor providing a safe harbour for some ‘refugees’. It is a pity to have to make that implicit limitation. But, in practical terms, we cannot take them all. Appropriately integrating ‘boat people’ into our community costs much more, per person, than finding and qualifying refugees and refugee families, in refugee camps overseas, and bringing them in ourselves. And spending significant of our ‘aid money’ in the refugee camps, provides valuable assistance to an even larger cohort of needy people.
If you think we should choose to provide an effusive ‘warm welcome’ to all who choose to come this way, the numbers will rapidly multiply – indeed exponentially – and we will be bringing in some people who will turn around and injure and kill us. The flood may again, again with great difficulty, be arrested. But Australia will then (very probably) have a political backlash of a ‘hard right’ persuasion, that may make you feel unwelcome; as well as a long term economic crisis, as we seek to find resources for the new immigrants. That is what is happening overseas.
There is a much, much larger picture than a relatively few ‘unauthorised maritime arrivals’, now living in two Pacific paradises. And I trust that numbers of them have used their time productively, further educating themselves, while they looked for another place to live. It did not have to be Australia.
Come on you Anonymous writers, if Bree (#21) has the confidence to append her name to her strong conviction, so can you.
And why would the Editor give space to someone afraid to do so?
Charles McDonald , PO Box 1597 Byron Bay, phone 0415-411771
What an impressive c.v. From Bree. 30 years in 15 places and I presume 20 years in the other 13 places.I can imagine the empathetic,comprehensive holistic ongoing care your patients benefited by as well as the warm welcome the so-called unauthorised maritime arrivals received.
Thank you bree for your comments. More succinctly I would suggest what you have written for us is :
“Wake up and smell the roses!”
Bree, thank you for making the effort to lodge these salutary comments.
It is late in the cycle in these weekly commentaries, but yours is a vital contribution.
A DIFFERENT PERSPECTIVE
I would like to present a different perspective, from a different perspective. Indeed a past, a present and some future perspectives. I am a different doctor from the august signatories of the letter. I remain a GP simple, practicing GP, having held no august clinical, administrative or representative roles, But I have practiced on two continents: Australia and North America; and some islands: Malaita in the Solomon Islands, and Norfolk Island, north of New Zealand, south of New Caledonia. I have cared for indigenous people in a culture untouched by white domination and extortion, for Aboriginals in indigenous settlements in Mosman Gorge, and scattered in the vast spaces around Alice Springs. For rural Aboriginals around Mareeba, urban Aboriginals around Capalaba. And I can mention ordinary general practice in Port Macquarie, Los Angeles, Vancouver, Kelowna, two decades in Canberra, Beenleigh, Tweed Heads, Emerald, Stanthorpe and more than 10 clinics in 17 years on the Gold Coast. The work of prison Medical Officer in Canberra and in Alice Springs, and in Immigration Detention near Northam, WA and Weipa, Qld. This is a different CV, but I suggest it is as authentic as any of the letter’s signatories. Indeed, more so. I worked in Immigration Detention for more than 6 months [2012-2013]. Which of the signatories can claim that?
‘UNAUTHORISED MARITIME ARRIVALS’
As I started, at least one boatload of passengers arrived each week on Christmas Island. About 50 passengers. Each passenger had paid about $20,000. That was the current fare, according to my Immigration Department sources. The cost of the craft was piddling – a crapped out wooden fishing lugger. Commonly the boat never made it to Christmas Island. When the engine stopped, when the fuel ran out, the passengers phoned to the Australian Navy for rescue. (The Indonesian Navy never showed an interest.) The people smugglers learned their craft in Australian waters – they have since plied it with even greater skill in the Mediterranean. I do not know what profit they got overloading people into pneumatic rafts in Libyan ports. But the simple calculation was they were making at least a cool million dollars a week plying their trade out of Indonesia.
What was the inducement to their passengers? Simple: free board and lodging from the time the asylum seeker made it to Christmas Island, and free medical care. (There were those with orthopaedic war injuries, and one refugee arrived at Yongah Hill in hepatitis B cirrhosis – probably as a birth inoculation. He was hoping for a liver transplant.) The ultimate prize was Australian citizenship. But numbers of them had been told (so Immigration told me) that when they landed on Christmas Island they would be handed the title to the house that would be theirs when they landed in Australia. It was an out and out scam.
Their personal documents were taken from them when they boarded the fishing lugger – then tossed overboard. It would prove difficult to return asylum seekers back home on – or shortly after – arrival, if who they were and where they had come from was unclear. Certainly, in the camp, names, locations of origin and dates of birth changed quite frequently. So much so that we finally had to use the landing name and date of birth as permanent identifiers for the duration of their stay in detention. Otherwise the computerised medical files became intolerably corrupted.
PROCESSING
It became obvious to me that the ‘unauthorised maritime arrivals’ had been told to listen to their compatriots – and translators – at the camp. They would learn from them what reasonably could be regarded as a credible account of persecution. There would be an initial determination, then two levels of appeal, before a claim of refugee status could be rejected. This legal process all paid for by the Australian government. Just to reliably establish who they were, and what they claimed to have happened, immigration officials would commonly fly to their putative place of residence to make enquiries. At an average cost, quoted to me, of about $10,000 per refugee.
There were necessary health checks. Australia could not afford to release open cases of tuberculosis into the Australian community. I found the West Australian government was charging the highest private bed rate to the Commonwealth Government for hospital care, when it was needed. Asylum seekers had no Medicare entitlements. At least one hospital administration was eager for the work. But, at a lower admin level, admitting staff were unimpressed. Each admission from us meant an Australian citizen was displaced further back down the queue. Indeed, everyone on the queue effectively ratcheted back one place. And in West Australia at the time, even private health care was stratified and queued.
AN ANALYSIS
I left to care for indigenous Australians, as the Rudd/Gillard government began to close the door. I knew the new arrivals would no longer be happy little Vegemites. But the circumstance had changed. As I had started, it appeared to me that there had been a tacit truce between the people smugglers and the Australian government. The boat people had been arriving at a rate that we could handle. The cash flow to the people smugglers was constant, continuing and lucrative. When it became obvious that the Australian government was considering ‘pulling the plug’, the fare dropped to $5,000, but the asylum seekers began to arrive at more than four times the rate. While the lucrative cash flow remained the same, the facilities on Christmas Island were becoming overwhelmed. Inductions inevitably were to happen on the Australian mainland. We were to be asked to process raw intake at the camp at Scherger Air Force Base. Half an hour, no more, would be allotted for each arrival. Communication – as always – through an interpreter. It would be basic. The people smuggler’s policy, as I saw it, had changed. There no longer was a tacit understanding. Australia would not be able to stem the flow of asylum seekers. The people smugglers would continue to generate the same – or greater – cash flow.
This was the beginning of what is the ‘present circumstance’ – that continued as Australia was able to stem the flow. That is the circumstance we are in at present.
THE NEED FOR A PLAN
What my learned medical friends – with wide and deep experience in academia, clinical practice and administration – do not realise, is they must develop a total solution, and also consider their representative role. Or they could find themselves in what – in medical terms – would be an unmanageable epidemic. Social, societal – and medical. Inadvertently let loose open cases of antibiotic resistant tuberculosis into the Australian community, and where exactly will we be? Do these doctors only represent the interests of the asylum seekers on Manus Island, or do the also represent the interests of the fifty million displaced persons in camps around the world? Do they also represent the interests of Australian residents and citizens? What are the comparative rights of the detainees on Manus Island, and the much greater number of homeless, indigent Australians? How do these doctors resolve the intractable conflicts and contradictions between these groups? For example, are they prepared to write the same letter, in exactly the same terms, and represent the needs and status of half a million Rohingan refugees now displaced in Bangladesh? There are desperate medical needs, and enormous mental anguish. What is our responsibility to them? Do we bring them all to Australia? They would be enormously grateful for the lodgings, the food and water that have been so insultingly spurned by the Manus Island asylum seekers. If these have fled in fear of their lives, it is incongruous that they are now threatening self-harm and suicide. Australians in prisoner of war camps in two world wars patiently sat out the duration of their incarceration. They did not know when – even if – they would be rescued. The Manus Island internees should consider the many millions much less well off than they have been for the last 4 years. Certainly, their behaviour in the last two months may have rendered them utterly unattractive as prospective migrants in any third party country.
THE DILEMMA
If Australia has a moral obligation to re-settle them here, then it has a moral obligation to resettle in Australia ALL who set out by sea to come to Australia, and who we – because of our sense of duty and ethic – rescue at sea or on Christmas Island. And, I have – no doubt – the flood will start immediately. As in the Mediterranean, there is much, much money to make. This time the flood will be unstoppable.
I correct myself. There is a way to prevent people smugglers from making an obscene profit sending people partway to Christmas Island – people who can afford to pay them, who wish for comfortable board and lodgings, free medical care and ultimately, Australian citizenship.
That is to fly them – and those who deserve our care – fly them here ourselves.
Perhaps in a flotilla of 747’s.
All fifty million of them.
All paid for by us.
If that is not acceptable, please think of another solution, please detail and elaborate. With the full rigor of the ‘medical model’. From beginning to end. You are intelligent professionals. Please enunciate and enlarge on all the probable consequences, and how you would deal with each of them. This is an operation, like any surgical operation. It does not finish with the extraction of the tumour. You must obtain haemostasis, restore physiologic function, close up the wound, and manage the sequence and detail of post-operative care and rehabilitation. Indeed, this must all be planned, in rigorous detail, before you wheel the patient into the operating theatre. If there are threats to the community – infection for example – you must enunciate a plan to deal with that exigency.
Since Australia is a democracy, this must be a plan you can – and do – persuade the citizens of Australia to accept. Enunciated to them in explicit detail. Including all of its costs, objectively, credibly calculated.
And they must agree.
Sometimes, in medical practice, there are no simple, easy, fully satisfactory cures.
POSTSCRIPT
What about Australians who cannot afford today’s rentals and are now living on the street? One does not need the permission of the Australian government to seek them out. Are the signatories ‘deeply concerned about their physical and mental health’? Certainly they directly report poor hygiene and sanitation, inability to access electricity and adequate food, the most primitive living conditions.
Certainly, urgent action is required… Are the signatories prepared to spend a substantial amount of their time undertaking an immediate ‘independent’ view of the health status of all those citizens still on the Australian street? Themselves arranging ‘the appropriate mix of clinical specialties’ (It will probably take all of these organizing and selected clinicians at least 3 months of unpaid volunteer work. Indeed, the ‘mix of appropriate clinical specialties’ would expect to be paid. Would the signatories consider volunteering that payment out of their own pockets, or do the taxpayers fund it?)
Yes, Australian ‘humanitarian issues take precedence over politics’. But this is NOT ‘a matter beyond immigration and border control’. Instead it is much closer to home. It certainly affects the health of people – who already are Australian citizens, and have been all their lives.
Surely this is where Australian taxpayers’ money should first be spent.
Come on, colleagues, just where are your priorities and loyalties?
To Anonymous no 18 above. How can a my comments, or those of the author I quoted, be construed as personal attacks on people who cannot be identified? Baffling!
My family, living in a rural semi arid region of Australia, would be happy to exchange Manus Island conditions for our residence. I’d be happy to swap our water – currently a reddish shade of brown due to floods – for their plumbing. Did I mention our septic system broke down and we now must fork out tens of thousands to fix it? And imagine internet and cell phone coverage that actually works most of the time. I’m typing this in the morning as within a few hours internet will be slow to non-existent on this rural line. And generators that kick in when there is a power outage? How lovely. Here we just sit in the dark and eat by candlelight and try to sleep in the sweltering heat until the power comes back on – eventually. And for all this my husband and I both work full time to support our children, mortgage, car payments, and the astronomical electricity bill which covers among other things using an electric pump to obtain water from the difficult to access river. Solar pumps won’t cut it for this river, sorry. If someone offered to give us all this for free, but in a tropical paradise, we’d jump at the chance.
“We should be able to offer various views and be respectful of differing opinions without resorting to personal attacks”.
Well yes, except you’ve just now personally attacked all the Anonymous ones for being arrogant and self-absorbed (and scoundrels).
Q.E.D.
I am amazed at the clear lack of compassion in many of the anonymous responses. How could any humane person (let alone doctor) not be struck by the appalling circumstances in which these men now find themselves, and not want to see action to end their suffering.
In a 2012 paper on compassion in medicine*, Laura Ekstrom, professor of philosophy in Virginia, USA, I reckon succinctly sums up the apparent attitudes of many of our politicians and, it seems some of our fellow doctors:
“Arrogance and self-absorption…. hinder compassion. Those who are arrogant and self-absorbed become so full of a sense of their own ambitions, accomplishments, and prestige that they can fail to notice the needs of others, whom they may see as less worthy of respect and consideration than themselves and their “peers” (those who share their wealth, power, prestige and other accidental traits).
I agree with Andrew Watkins that, despite the editor’s comment, anonymity is “a refuge of scoundrels”! We should be able to offer various views and be respectful of differing opinions without resorting to personal attacks.
*Ekstrom LW. Liars, Medicine and compassion. 2012. Journal of Medicine and Philosophy; 37: 159-180.
I feel so strengthened by the spirit and act of this letter – so heartened that medical professionals continue to live with their ethical and noble responsibilities in this country, despite government efforts to dismantle their codes of conduct and humane sense. May you rise.
We are appalled at the disregard for the physical and mental well-being of the refugees shown by successive Australian governments, and wholeheartedly support this letter
The current load of “boat people” have surely had enough punishment for attempting to enter Australia by the back door. They should be expeditiously resettled into whatever country will take them and they are willing to go., including Australia. But let it be known that any further “back-door migrants” will be treated as harshly as those in detention now..
None of these people, upon arriving in Australian waters, were fleeing danger or persecution. They, mostly, arrived from Indonesia where they were not in danger of their lives. That being so, they got onto boats after paying people smugglers in order to capitalise on the social welfare system offered by Australia. Well, they never got here but they are still being supported by the Australian taxpayers. And, frankly, to say they are having a tough time when they are being fed, housed, educated and cared for medically while few of them appear willing to help themselves is a nonsense. If it’s such a hell hole, how come Manus Islanders appear to be doing fine? Get real… you invite them in and pretty soon another 50k will arrive. If you don’t control your borders, you control nothing.
(Perhaps, Andrew Watkins, if free speech was actually still valued in this country, and a view contrary to prevailing PC orthodoxy did not release a s..t-storm of social media abuse and a public crucifixion, then people would be more prepared to append their names to comments, that you interestingly have already adjudged as being the product of “trolls”).
Anonymous, MB,BS.
As doctors we have obligations to certain universal principles, that other groups (such as politicians) are apparently not always obliged to follow.
These principles sometimes override any other laws .Practising basic human rights principles is one such example.
This letter is timely ,however it is a shame that many more doctors have not signed it. I sign it too in the name of human dignity, that our government
is so resistant to uphold .
As doctors, it is axiomatic to advocate for the well-being of those who are unwell or ill-treated (although one wonders why that advocacy is so selective).
As politicians, it is crucial on this occasion to ignore that advocacy.
This letter again reveals the failure of well-meaning medical advocates to distinguish the personal from the policy: the state of these few unfortunates compared to the policy of border integrity. Acceding to the former will inevitably undermine the latter.
The letter deserves to be as widely promulgated as possible, as should be the governement’s hard-hearted rejection of its call, so the world and people smugglers can continue to see Australia’s firm intention to retain its right to determine who comes to this country and the circumstances in which they come.
EDITOR’S NOTE: To Andrew Watkins. MJA InSight, unlike the MJA, is a completely open access publication and is therefore available to the public, including people who choose to protect their identity, for whatever reason. All comments are moderated, and as long as they remain civil and non-defamatory, then they entitled to their opinion. Perhaps it does us all good to see the range of views out there in the community.
It is normal when publishing in MJA to use one’s name
Why are we allowing anonymous trolls to use this site? If they have something to say about asylum seekers they should at least have the guts to put their name to it
Fully support the letter, our treatment of asylum seekers is a bipartisan disgrace and a shame for the nation
Note also that the medical care of refugees, including authorisation / refusal of urgen medical transfers and other medical care decisions is now controlled by a non clinician, th eChief Medical Officer having resigned. Dangerous decisions were made under the previous regime, things must now be far worse. The AMA must take a position on this.
When are we going to have some politicians with spine, character and decency?
Virtue signalling is alive and well
Manus was the Legacy of Rudd
These antisocial economic migrants should be at home with their women and children working to improve their basket case economies.
Not defeating on the floor for someone else to clean
I fully support the letter but I dont think a medical review is adequate I think the refugees should be resettles as soon as possible We must find a better solution.
I dont think that the government will listen to reasonable arguement we need to back it up with evidence eg photos , video interviews to show the Australian people.
How about the health and well being of PNG nationals on Manus Island. Or does our compassion not extend that far?
It is unacceptable that refugees, having fled for their lives, now face further threats after years in limbo. They should not pay the price for our concerns with “people smugglers’.
To avoid charges of cultural, medical or just white imperialism, one presumes these doctors will all jump through the necessary hoops for registration as medical practitioners in Papua New Guinea.
They could even attend to needy members of the PNG population while they are there.
They otherwise risk being perceived as medico-political show ponies.
The situation is intolerable as it currently stands in PNG. The locals are understandably unhappy since in their perception our refugees have given up and have been leaching goods and services that should more rightfully be given to them. Meanwhile others of the locals have been supporting the refugees with food and other gifts and they feel that they are due something more in return than they are getting. I hope that you’re initiative will result speedily in a change for the refugees.
Thank you for writing and signing this important plea. Many ordinary Australians are doing the same, but your combined voices mean much more to politicians. Thank you also for the offers to travel to Manus to treat these wretched men.