AMA calls for independent scrutiny of asylum seeker health

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Disturbing accounts of sexual assault, neglect and harm among asylum seekers being held at the Nauru detention centre reinforce the need for oversight by an independent statutory body of clinical experts, AMA President Dr Michael Gannon has said.

Leaked details of more than 2000 incident reports from staff at the Nauru Regional Processing Centre, published by Guardian Australia, reveal a litany of abuse, self-harm, sexual assault, inadequate health care and deplorable living conditions at the centre. The details come less than a week after a joint Amnesty International-Human Rights Watch investigation resulted in a scathing assessment of conditions at the centre.

Dr Gannon said the “disturbing” revelations, particularly regarding the treatment of children, leant fresh urgency to long-standing AMA calls for much greater scrutiny of detention centre operations and the provision of health services to asylum seekers.

“These disturbing reports echo long-held concerns by the AMA about the lack of proper physical and mental health care being provided to people in immigration detention,” Dr Gannon said. “The reports detail high levels of trauma and mental illness, especially in children being detained on Nauru.”

The AMA regularly received reports from asylum seekers and their advocates – from within and outside the medical profession – detailing failures to provide proper physical and mental health treatment and services for asylum seekers, he said, and called for children to be removed from detention and placed into care in the community.

Conditions at the Nauru detention centre have been condemned by Amnesty International and Human Rights Watch, who have accused the Federal Government of a deliberate policy of “appalling abuse and deliberate neglect” in its treatment of refugees and asylum seekers being held there.

In their report, based on interviews with 84 refugees and asylum seekers as well as an unspecified number of service providers, the non-government organisations described medical facilities on Nauru as rudimentary and said those with serious conditions frequently faced long delays before receiving specialist care.

In one account, a service provider said ambulances sometimes took up to three hours to respond to calls from the centre, and often people were discharged from the local hospital while they were still sick or half-conscious.

“We are not allowed to ask the hospital why they are being discharged, or what medication they’ve been prescribed, or for their medical records,” the service provider said.

Among the 2116 incident reports from detention centre guards, caseworkers and teachers leaked to Guardian Australia are numerous accounts of children threatening to kill themselves, engaging in highly sexualised behaviour, or suffering great emotional distress.

In one account, a group of security guards was heard to laugh moments after one of them was called to a young girl who had sewn her lips together. In another, a teacher reported that a student was “dreaming of blood and death and zombies” because his mother was on hunger strike and refused to hug him. Several reports detailed children sitting on the laps of security guards, including one girl who was “leaning her backside into the crotch of [name redacted]”, and a boy who was being bounced on the lap of a guard who was whispering in his ear.

Amnesty International and Human Rights Watch representatives who visited the island for 12 days last month said the circumstances in which people were being detained – a third of the 1200 refugees were living in cramped tents in hot and humid conditions, and all were limited to two-minute showers and forced to use filthy toilets – were physically draining and exacerbated mental health problems.

“Prolonged detention in appalling conditions exacerbated the trauma many had suffered from persecution in their home countries,” the report said.

Many of those interviewed reported having developed severe anxiety, insomnia, mood swings, prolonged depression and short-term memory loss while on the island, while children were suffering from nightmares and engaging in disruptive and troubling behaviour.

“Adults and children spoke openly of having wanted to end their lives. More than a dozen of the adults interviewed said they had tried to kill themselves…and many more said that they had seriously considered ending their lives,” the report said.

It included the account of a nine-year-old boy who told his mother that, “I want to burn myself. Why should I be alive? I want my daddy. I miss my daddy”, after his father was transferred to Australia, without his family, for medical treatment.

Amnesty International and Human Rights Watch said support and treatment for those suffering mental health problems was inadequate, and patients whose illness was severe enough to justify their transfer to Australia were returned several months later to the same conditions that had contributed to their trauma in the first place.

Dr Gannon said such treatment was unacceptable.

“The AMA’s position is clear – people who are seeking, or who have been granted, asylum within Australia have the right to receive appropriate medical care without discrimination, regardless of citizenship, visa status, or ability to pay,” Dr Gannon said. “Asylum seekers and refugees under the protection of the Australian Government should be treated with compassion, respect, and dignity.”

The AMA has reiterated its call for the creation of a national statutory body of clinical experts, independent of Government, with the power to investigate and report to the Parliament on the health and welfare of asylum seekers and refugees in Australia and in offshore detention.

“Australia’s atrocious treatment of the refugees on Nauru over the past three years has taken an enormous toll on their wellbeing,” Human Rights Watch Senior Counsel on Children’s Rights Michael Bochenek said. “Driving adult, and even child, refugees to the breaking point with sustained abuse appears to be one of Australia’s aims on Nauru.”

Amnesty International Senior Director of Research Anna Neistat, who was one of the researchers who visited Nauru, condemned the treatment of asylum seekers as “cruel in the extreme”.

The human rights organisations said the Australian Government’s failure to address what they described as serious abuses “appears to be a deliberate policy to deter further asylum seekers from arriving in the country by boat”.

But the Department of Immigration and Border Protection rejected the findings of the Amnesty report, which it said was conducted without consultation.

“We strongly refute many of the allegations in the report, and would encourage Amnesty International to contact the Department before airing allegations of this kind,” it said in a statement.

The Department said Australia did not “exert control” over the Nauruan Government, though it did fund accommodation and support services for “all transferees and refugees, including welfare and health services”.

“We welcome independent scrutiny of regional processing matters, noting that access to the [Regional Processing] Centre is a matter for the Government of Nauru.”

But the Government’s has been accused of trying to hide its treatment of asylum seekers behind a shroud of secrecy.

The Australian Border Force Act, passed last year, threatens up to two years imprisonment for detention centre staff and contractors who publicly disclose information about operations.

But Dr Gannon said doctors should be able to speak out without fear of retribution or prosecution, and the legality of the Act is being challenged in the High Court by the group Doctors for Refugees.

The AMA Federal Council is also looking into claims former medical director of mental health services for detention centre contractor International Health and Medical Services, Dr Peter Yong, was subject to surveillance by the Australian Federal Police.

Adrian Rollins

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Costs force ill to skip care

Almost half of patients with depression, anxiety or other mental health conditions and a third of those suffering asthma, emphysema and other chronic respiratory illnesses are skipping treatment because of out-of-pocket costs.

As the Medicare rebate freeze forces a growing number of general practices to cut back on bulk billing and increase patient charges, researchers have found that out-of-pocket costs for medical services and medications are deterring many with chronic illnesses from seeing their doctor or filling their prescription, potentially making their health problems more difficult and costly to treat.

They found that those with mental illnesses were the most price sensitive – 44 per cent reported deferring an appointment or leaving a script unfilled because of cost, as did 32 per cent with asthma or chronic obstructive pulmonary disorder and 27 per cent of those with diabetes. Even a fifth of cancer patients reported skipping treatment because of the expense.

Out-of-pocket charges were cited as a barrier to care even for some of those without a long-term health problem – 9 per cent said deferred care because of cost.

Lead researcher Dr Emily Callander from James Cook University said that although, as a whole, Australia enjoyed good health outcomes, her study showed that out-of-pocket costs were a substantial barrier to care, particularly for vulnerable and at-risk patients like the chronically ill.

She said the problem was particularly acute for patients with mental health problems.

“Those with mental health conditions were shown to have particularly large out-of-pocket expenditure and be more likely to forgo care, which indicates that the costs of mental health services may be prohibitively high,” Dr Callander and her colleagues wrote.

Out-of-pocket costs high

The research, which is part of an international Commonwealth Fund health policy study and draws on data from a NSW Bureau of Health Information survey of 2200 respondents, found that out-of-pocket expenses for Australia patients were high by world standards.

It showed that Australians paid an average of $1185 in out-of-pocket costs, compared with $987 for Germans, $947 for Canadians, $639 for New Zealanders, $488 for British patients and $421 for the French.

Dr Callander’s said research showed expenses for patients with chronic illnesses can be particularly high.

Stroke survivors, for example, spent an average of $1110 a year on health costs, including up to $32,411 in the first 12 months following their stroke. Those with arthritis, meanwhile, paid out an average of $1513 a year on treatment, with some spending as much as $20,527.

Those with asthma, emphysema and COPD reported spending an average of $1642 a year on out-of-pocket expenses, while those with a mental illness spent $1350 a year and those with high cholesterol spent $1423 annually.

By comparison, those without a chronic illness spent on average $660 a year on out-of-pocket health costs.

Dr Callander said the point of her research was not that out-of-pocket costs were inherently wrong, but could have a much more significant effect on vulnerable patients, like the chronically ill, than the broader community.

“I don’t think that out-of-pocket costs per se are a bad thing,” the researcher said. “I am not saying that we should not have them.

“But while maybe a $30 GP out-of-pocket charge might not seem much to most of us, for someone with a chronic disease who is unemployed it might seem a lot. For them it might mean a choice between seeing the doctor or having some extra food.

“It is the disadvantaged – the people with low incomes and ones with chronic health problems – who are the worst affected.”

Chronic catch-22

The chronically ill are caught in a double-bind. They often face much higher health expenses than most, while the effect of their illness is often to make it difficult for them to work.

Dr Callander said it was well documented that people with chronic illnesses were on lower incomes, had less wealth, and were more likely to be in income poverty, “which is likely because of the effect that chronic health conditions have on their ability to participate in the labour force”.

And, of course, the more they defer or forgo treatment, the worse their health becomes and the more expensive the treatment required.

Dr Callander’s research found that the combined effect of high out-of-pocket expenses and low incomes was to force 25 per cent of chronically ill Australians to skip care, exceeded only by the United States, where 42 per cent of patients with a chronic illness said they deferred treatment because of cost. By comparison, just 8 per cent of chronically ill Swedish patients and 5 per cent of British patients admitted to the same thing.

While in the past research had concentrated on a lack of available services as a common barrier to care, Dr Callander said the effect of cost had often been overlooked.

“The [study shows] that the cost of health care does act as a barrier to receiving treatment, particularly for those with mental health conditions,” the researcher said. “These findings come at a vital time when there has been much discussion abour the possibility of raising the cost of healthcare to individuals.”

She said it was of “vital importance” that there be policies aimed at promoting affordable health care for at-risk and vulnerable patients, “to ensure that out-of-pocket cost is not a barrier to treatment and do not widen the gap in health status between those of high and low socioeconomic status”.

The study has been published in the Australian Journal of Primary Health.

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