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Preference: World Health

1236

Missing malaria? Potential obstacles to diagnosis and hypnozoite eradication

Poor specimen collection and limited availability of primaquine may be putting patients at risk

Recently, one of us experienced an episode of probable malaria on returning from fieldwork in the Solomon Islands. Although a clinical diagnosis of malaria was made, and the illness responded to empirical therapy with artemether–lumefantrine (Riamet, Novartis), a laboratory diagnosis was not achieved.

Suspected malaria in travellers who have returned to Australia from overseas will present without notice and, owing to the often severe nature of this illness, will require immediate attention. This may occur in localities where personal consultation with an infectious diseases physician is not possible. Primaquine for the eradication of malarial hypnozoites from the liver may not be readily available. In this article, we aim to provide brief expert guidance on the diagnosis of malaria, the use of primaquine for eradication therapy and the implications of the limited availability of this treatment in Australia.

Patients presenting with fever should be questioned about their travel history. Clinicians should be mindful that malarial relapse (Plasmodium vivax and P. ovale) or recrudescence (P. malariae) may occur months, or even years, after primary infection. Further, relapse may be the first symptomatic presentation.1 Therefore, any patient with pyrexia and a history of travel to an endemic area in the past 3 years might be considered as potentially having malaria.2

Initial investigation

Clinical suspicion should be raised in patients who demonstrate specific symptoms associated with the disease, such as relapsing fever, rigors or chills. Note that immune-naive people may not always present with the typical cyclical fevers of malaria.2,3 Unless a separate, simultaneous, pathological process is present (such as concurrent dengue fever, other infections or a non-infectious cause), the presence of localised symptoms, a rash, or the onset of symptoms within the prepatent period (7 days) after initial travel to an endemic area may assist in excluding a diagnosis of malaria.3

Laboratory investigation of patients who potentially have malaria requires blood collected in EDTA anticoagulant tubes immediately on presentation. Both thick and thin film microscopy should be requested. As morphological changes in parasites will develop within hours, blood should be delivered to the laboratory within an hour of collection. Immunodiffusion-based rapid diagnostic antigen tests should also be performed if available, but these tests do not supplant microscopy.4 Currently, there is no consensus regarding the correct timing and number of specimens required to exclude a diagnosis of malaria. It appears that a single collection is often sufficient for diagnosis.3 However, further specimen collections taken shortly after the onset of febrile paroxysms may be necessary for the detection of P. falciparum malaria, as this species is sequestered in the deeper microvasculature at other times during its life cycle.2,3

Returned travellers who have used malaria prophylaxis may occasionally still acquire malaria, even when they strictly adhere to the dosage regimen.1 In such cases, the parasitaemia is often very low, requiring multiple blood collections for diagnosis, but individuals with little or no prior exposure will still be significantly unwell. Very rarely, malaria may be acquired during short stays in endemic areas; for example, during airport stopovers.5

The role of PCR

Polymerase chain reaction (PCR) testing represents a more recent and highly efficacious method for the detection and speciation of malaria in febrile patients. Nevertheless, specimen collection during an afebrile period may lead to a false-negative PCR test result. Due to its expense and limited availability, PCR testing is currently restricted to confirmation and speciation, or cases where a malaria diagnosis is strongly suspected but microscopy and antigen testing are negative.

Primaquine

Infection with relapsing species of malaria (P. vivax and P. ovale) requires eradication of hypnozoites from the patient’s liver using primaquine. P. ovale malaria requires half the dose of primaquine used in cases of P. vivax. Some strains of P. vivax acquired in the South Pacific and South-East Asia may need higher doses of primaquine for eradication.6 Tests for glucose-6-phosphate dehydrogenase deficiency should be performed on all patients before primaquine therapy, in order to avoid potentially life-threatening oxidative events in enzyme-deficient individuals. Currently, primaquine is erratically available in hospital pharmacies and may not be stocked at all in smaller, regional facilities. Also, it cannot be accessed under the Pharmaceutical Benefits Scheme, despite being indicated in Australian therapeutic guidelines.6 These factors limit its availability to hospitals and community pharmacies. For example, when malaria presents and is treated in general practice, the limited availability of primaquine could result in this important therapy not being administered, especially in regional, rural and isolated areas.

In summary, given increasing rates of travel to endemic areas by Australians, clinicians may be faced with a case of malaria at any time. Hence, it is important that they have the correct specimen-collection and treatment protocols at hand. Primaquine should be available through the Pharmaceutical Benefits Scheme to patients treated in a community setting.

The Australian medical response to Typhoon Haiyan

Our well equipped civilian professionals made a rapid and valuable contribution to internationally coordinated aid

On the morning of 8 November 2013, category 5 Typhoon Haiyan (known locally as Typhoon Yolanda) made first landfall over Eastern Samar province in the Philippines. Sustained, damaging winds of 235 km/h gusting to 275 km/h were accompanied by a tidal storm surge and subsequent inundation. The official number of fatalities stands at 6190, with 28 626 injuries attributed to the event, and over 16 million people affected.1

On 9 November, as reports indicated the scale of the disaster, the government of the Philippines officially requested international humanitarian assistance. Eastern Samar and Leyte provinces, including the major population centre of Tacloban (population 220 000) sustained catastrophic damage.

As part of a $40 million assistance package, the Australian Government deployed a field hospital and a fully self-sustaining civilian medical team with a mandate to assist the Philippines Department of Health in immediate postdisaster medical care. The first Australian medical assistance team (AUSMAT) of 37 medical, nursing, paramedical and logistics professionals deployed on 13 November with over 28 tonnes of equipment. They were relieved on 27 November by a second team of 37.

At the direction of the Philippines Department of Health, a field hospital with 35 inpatient beds, two operating tables, an outpatient clinic and a resuscitation room was deployed to Tacloban, the most critically affected population centre. Clinical activity commenced 7 days after Typhoon Haiyan made landfall — one of the fastest deployments of a foreign field hospital to a sudden-onset disaster.2 The field hospital was registered as a Type 2 facility under the new World Health Organization guidelines for foreign medical teams in sudden-onset disasters.3 This was the first occasion on which a host government was able to use the WHO guidelines to assess the contribution of foreign medical teams.

The AUSMAT field hospital rapidly became a critical adjunct to the overall medical response in Tacloban, providing surgical and trauma care while the major local referral centre gradually restored its own surgical services. The surgical casemix, reflecting the nature of the disaster, comprised a high proportion of traumatic injuries from high-velocity debris. As the deployment continued, individuals with minor to moderate injuries, but who had not yet sought medical care, presented with wound infections that were frequently exacerbated by intercurrent type 2 diabetes. Many of these patients had either been searching for lost family or attempting to rebuild their homes and livelihoods, but not attending to their own need for health care.

During a 23-day operational period, 238 surgical procedures were performed, of which 90 were considered major. A total of 2734 patients were seen. Based on average numbers of outpatients, this meant that, for the time it was operational, the AUSMAT field hospital was as busy as the Royal Darwin Hospital emergency department. In addition to surgical patients, our clinicians treated patients with a variety of acute and chronic medical conditions, ranging from respiratory tract infections and diarrhoeal illness through to uncontrolled hypertension.

Operation Philippines Assist marked two critical points in the evolution of Australia’s capacity to provide professional, emergent medical relief after sudden-onset disasters. It was the first occasion on which a clinical team comprising members from each state and territory was deployed (it also included an orthopaedic surgeon and logistician from the New Zealand Medical Assistance Team). This was also the AUSMAT field hospital’s first deployment overseas as part of an Australian response.

Historical perspective on AUSMAT

Previous responses funded by the Australian Government to regional natural disasters such as those in Aceh, Yogyakarta, Samoa and Christchurch were managed through the state-based disaster medical assistance teams model, with involvement of some multijurisdictional teams. Since 2010, the AUSMAT concept, derived from the global movement towards professional, trained medical disaster-relief teams, has become the national model for medical disaster response. AUSMAT training and deployment is primarily coordinated via the Darwin-based National Critical Care and Trauma Response Centre under the auspices of the Australian Government Department of Health. Each state and territory has a coordination focal point linking local health departments to the national team.

Since 2010, over 400 health professionals and medical logisticians have undergone specific and tailored training to deliver care in typical austere, resource-poor environments. The team member training course focuses on safety and security, cultural awareness, team dynamics in the field and familiarisation with equipment. Its centrepiece is a high-fidelity 36-hour simulated deployment to a fictitious nation where each key competency is tested in field conditions. Specific courses for surgeons and anaesthetists, team leaders and medical logisticians have also been developed.

AUSMAT also has a nationally agreed set of standards governing all aspects of deployment including vaccination and predeparture health checks, in-country codes of conduct and postdeployment psychological debriefing. These standards, documented in the national AUSMAT manual,4 have been endorsed by the Australian Health Protection Principal Committee and ensure that the Australian Government maintains a consistent and predictable medical response to regional disasters.

The need for standards in disaster response

Sudden-onset disasters attract a wide variety of responders, from clinicians trained specifically in humanitarian and disaster response to well meaning but untrained individuals or teams. As seen over a number of natural disasters in the 20th and 21st centuries, significant harm to a disaster-affected population can be caused by foreign medical teams who are either untrained in disaster medicine or poorly resourced and not self-sufficient.5

Analysis of responses to the 2010 Haiti earthquake provided clear evidence of the effects of underprepared and underresourced teams. A review of the surgical response in Haiti found that amputation rates varied considerably between foreign surgical teams, from 1% of surgical procedures to over 45%. The lowest rates occurred among specialised orthoplastic teams experienced in limb salvage.6

One account of a trauma team’s experience in Haiti documents the rapid overwhelming of the team by the scale of the disaster, forcing them to self-evacuate. The authors suggest that individual and institutional medical responders partner with experienced disaster-relief organisations to “facilitate the personnel from the more developed countries to learn how to live and work under unfamiliar austere circumstances”.7

Typhoon Haiyan was a typical natural disaster in that it attracted responders with varied training and differing levels of self-sufficiency, ranging from skilled government teams from Australia, Japan, Korea and Belgium, and well known non-government organisations (NGOs) such as the International Committee of the Red Cross and Médecins Sans Frontières, through to individuals who were essentially “disaster tourists”. In between were many small NGOs and philanthropic organisations. Frequently, the AUSMAT team was asked to supply medications or other supplies to teams that had arrived in the country inadequately equipped to provide effective care. Typically, these teams were not participants in the WHO and Philippines Department of Health global health cluster coordination process.

An extensive body of literature points to the key competencies required by medical disaster responders. Clinical medicine, public health and disaster incident management are the core disciplines practised by disaster health professionals.8

Similarly, the AUSMAT concept is firmly rooted in the philosophy that disaster health professionals must have key clinical and humanitarian competencies. First, they must be registered to practise in their stated profession. Too often, clinicians, under the pretext of saving lives at all costs, extend themselves far beyond their scope of practice without following the fundamental principle of medical practice — first do no harm.

Second, health professionals must be able to perform their clinical specialty in a disaster context. It is outdated practice to pluck individuals from their clinical practice in developed-world tertiary hospitals and deposit them in a disaster zone, expecting them to be able to function in austere circumstances with limited resources. Not only does poor patient care result, but it may cause psychological and professional distress for the clinician. Fortunately, in Australia, the clinical experience of many doctors and nurses in rural and remote settings means they are ideally suited to the demands of practice in an austere environment.

Finally, to appreciate the context in which they work, health professionals must have a set of core humanitarian competencies. These range from an understanding of international humanitarian norms through to self-management skills in the field and an ability to operate safely and securely in difficult circumstances.

AUSMAT’s efficient and timely deployment to Tacloban demonstrated the importance of preparedness and consistency. A repository of well trained and prepared clinicians and support staff with a suite of appropriate skills meant an effective response could be mounted. While training is obviously required for preparedness, the importance of an agreed consistency in disaster training is less obvious. The AUSMAT response to Typhoon Haiyan showed well the advantages of both.

The need for qualified and capable medical professionals to be deployed to assist disaster-affected populations will continue into the future. It is the responsibility of organisations rendering assistance to ensure that personnel are trained in the nuances of humanitarian and disaster medicine and to adhere to the new international standards for deployment of foreign medical teams.

The devastation of Tacloban in the wake of Typhoon Haiyan was mirrored across the Philippine provinces of Leyte and Eastern Samar

Surgeons Vaughan Poutawera (New Zealand) and Cea-Cea Moller (South Australia) complete a skin graft for a diabetic patient with typhoon-related injuries

The Australian field hospital in Tacloban, with outpatient tents in the foreground and wards and operating theatre behind (blue-and-white tents)

Doctors for the Environment Australia: achievements and lessons learned

Political ideology has proved to be the greatest obstacle to DEA’s ability to reduce the health hazards of climate change

Doctors for the Environment Australia (DEA), created in 2002, aimed “to utilise the skills of members of the medical profession to address the ill health resulting from damage to the natural environment at local, national and global levels”.1 This agenda was overwhelming, and with humanity’s astonishing failure to stop the rise of greenhouse gas emissions and the gathering pace of climate change, DEA has focused on the medical threats of climate change. As a medical organisation, DEA was a frontrunner in its forthright recognition of this problem, which the World Health Organization now regards as the defining health issue of our time. DEA maintains that the established medical colleges and organisations need to speak out more strongly about the health hazards of climate change.

Since our inception we have had committed assistance from many distinguished medical and scientific colleagues. The late Tony McMichael was a founding member and tireless supporter of DEA with his advice and valuable long-term involvement with students and politicians. He helped us with policy and landmark publications. DEA and global public health owe him a huge debt.2

In 2009, the DEA made a policy decision to advocate and educate on the health effects of using fossil fuels as well as climate change. This led to our work on the health effects of coal combustion, which is actually an expensive form of power generation.3,4 The DEA promotes renewable energy as a replacement for coal, and educates about the potential harms of unconventional gas exploration and production.

In 2010, the DEA began to encourage its membership to divest from fossil fuel industries by pressuring the “big four” banks to withdraw from financing fossil fuel expansion, thus presaging the current and gathering momentum to encourage divestment from the fossil fuel industries.

In recent times DEA’s advocacy has included providing advice to governments and oppositions on the health impacts of coal seam gas, shale gas and coal, campaigning to save the Tarkine region in Tasmania from further mining developments, challenging the Victorian Environmental Protection Agency for approving a new coal-fired power plant and contributing to the development of the Climate Commission’s report, The critical decade: climate change and health.5

Of the problems faced when the DEA was formed, the most underestimated was political ideology as an impediment to progress.6,7 In Australia the health aspects of climate change are decided in an unequal contest between public health and an alliance of government, industry and much of the media. Health impact assessments are invisible in the crusade to push fossil fuel development and cut green tape. The scientific aspects of climate change are dismissed as “crap”. The conservative mind has become fixated on the perceived threats to economic growth imposed by the environmental movement. The intent of DEA has been to present global environmental change as a vital health concern and an increasing cost to our economic futures. In this regard, the Australian Government’s action on the carbon tax and the renewable energy target can be regarded as a threat to the vital public health need to reduce greenhouse gas emissions.

The DEA website (http://dea.org.au) provides details of our submissions, policies and activism. However, our greatest achievement has surely been involving medical students as full members who contribute to all levels of the decision making and to the activities of state committees, visits to ministers and members, letter writing and presentations to parliaments. More than 300 students attended this year’s DEA conference. This promises a wave of informed activism and medical knowledge that is essential for action on public health over the crucial next 20 years.

Although most DEA members are practising doctors, all sections of the medical community are represented as reflected in our promotional video.8 We believe our clinical appreciation of vital public health issues strengthens our advocacy.

When we ask doctors for help, the usual response is “I don’t have time but I agree with your cause”. To these colleagues we say, “Our work is funded almost totally on membership fees, so by joining you are helping”. You can join here: http://dea.org.au/join.

[Comment] The spirit of Mexico: a decade on

November, 2014, marks the 10th anniversary of the Mexico Ministerial Summit on Health Research, attended by 20 ministers of health and delegations from 51 countries. Convened by the Government of Mexico, the Global Forum for Health Research, and WHO, the Summit endorsed the role of knowledge for better health1 through the Mexico Statement2 and a resolution passed at the World Health Assembly in 2005.3 Initially driven by the strong personal commitment and vision of WHO’s then Director-General, the late Lee Jong-wook, much progress has been made in the past decade; however, substantial challenges remain.

Peers or pariahs? The quest for fairer conditions for international medical graduates in Australia

Implementing recommendations of the parliamentary inquiry and international codes of practice on employment of IMGs

It has been more than 2 years since the final report of the inquiry into the registration processes and support for overseas-trained doctors1 was tabled in Parliament. The scope of the inquiry was extensive, involving over 200 submissions and 22 public hearings held in 12 different locations across Australia. In the foreword of the report, entitled Lost in the labyrinth, Steve Georganas, Chair of the Committee, acknowledged that “whilst IMGs [international medical graduates] generally have very strong community support, [they] do not always receive the same level of support from institutions and agencies that accredit and register them”.1 The report outlined 45 recommendations which, if implemented, would create a fairer registration and accreditation system without compromising patient safety.

In spite of the significant cost of the inquiry, borne by taxpayers, its recommendations have yet to be formally endorsed by the federal government. This is not a new situation. Over the past 25 years, a number of major inquiries have investigated the fairness and/or effectiveness of the registration and accreditation system, but have largely failed to produce meaningful improvements.2 For instance, in 2005 the Australian Competition and Consumer Commission and Australian Health Workforce Officials’ Committee recommended fairer methods of assessing and recognising the credentials of overseas-trained specialists, but those recommendations were not fully implemented either.

The failure to implement meaningful reforms in line with the recommendations has meant that the current two-tier system for IMGs and Australian-trained doctors persists. These differences arise from a complex array of registration, accreditation, immigration and workforce policies, which perpetuates a multifaceted process of discrimination and exploitation of qualified medical practitioners.3

A case in point is section 19AB of the Health Insurance Act 1973 (Cwlth), more widely known as the 10-year moratorium. The moratorium stipulates that IMGs must work in underserviced areas for up to 10 years. This restriction is unparalleled in the developed world. Not only does it cause significant personal hardship, family stress and cultural isolation, it also places limits on professional development and career opportunities.

In addition, the 10-year moratorium may be ineffective as a strategy to sustainably increase the number of doctors in rural Australia. Results of a study examining career progressions of doctors 5 years after they completed their training in rural practices showed that 73% of Australian-born doctors remained working in rural practice, whereas only 23% of IMGs followed a similar career path.4 Australian-born doctors choose to remain in rural practice because of their familiarity with a country lifestyle and the presence of a support network for spouses and children. However, “lack of familiarity with rural living and isolation from family and friends”4 were reasons mentioned to account for the relocation of most of IMGs to urban settings after they had satisfied the regulatory mechanisms that compelled them to remain in rural areas.

The author of a Prairie Centre of Excellence for Research on Immigration and Integration working paper stated that, in Canada, placement schemes under which IMGs from overseas are recruited to work under limited registration in remote regions “have not provided a long-term solution for provinces seeking to address the needs of under served areas”.5 He concluded that placing IMGs in underserved areas has produced a “medical carousel” of IMGs leaving rural areas once they obtain their unrestricted licenses.5 Given the failure of such a policy to produce its intended results in a country with an arguably comparable health care system, the 10-year moratorium should be progressively phased out in Australia. In the Lost in the labyrinth report, the Chair concluded that “a review of the 10 year moratorium would be appropriate and timely”.1

Many of the doctors recruited to redress health care workforce shortages were never informed about the restrictions they would be subject to on their arrival in Australia. Yet, pursuant to section 72 of the Health Practitioner Regulation National Law (enacted in all states and territories), any IMG on a Temporary Work (Skilled) (subclass 457) visa who, for any reason, ceases to be registered with the Medical Board of Australia, will be left with only 28 days to find an immediate alternative or leave the country. Also, there is no fair appeal and grievance process for IMGs with 457 visas, many of whom work in designated Area of Need (AoN) positions. The impact of restrictive policies on the personal and professional lives of IMGs in Australia has been ruinous. For example, doctors with 457 visas and their families do not qualify for health care services under Medicare. In a recent case in rural Queensland, a United States-born doctor had to pay a thousand dollars for treating his own daughter’s broken arm while he was on duty at the local hospital.6 Overseas-trained doctors and nurses are intrinsically involved with providing health services under Medicare, a characteristic not shared with any other group of temporary worker in Australia.

An independent integrity review commissioned by the Ministry for Immigration and Citizenship7 confirmed that 457 visa holders are potentially vulnerable to exploitation. For example, IMGs have reportedly been forced to work up to 80 hours per week, as documented in one of the submissions to the parliamentary inquiry1 (submission 101, page 75). The current system contravenes recommendations of major government policy reviews. The first recommendation of the final report of the Visa Subclass 457 Integrity Review advises that subclass 457 visa holders should “have the same terms and conditions of employment as all other employees in the workplace”.7

In addition, the Commonwealth code of practice for the international recruitment of health workers, adopted by Commonwealth Health Ministers in 2003, determined that IMGs should be “protected by the same employment regulations and have the same rights” as their local counterparts.8 Similarly, The World Health Organization Global code of practice on the international recruitment of health personnel, adopted by the 63rd World Health Assembly in 2010, of which Australia was a signatory member, established that migrant health personnel should “enjoy the same legal rights and responsibilities as the domestically trained health workforce in all terms of employment and conditions of work”.9

In Australia, IMGs who attained medical qualifications in the United Kingdom, United States, Canada, New Zealand and Ireland are entitled to an accelerated registration process (competent authority pathway), whereas IMGs who qualified elsewhere must undergo a multiple choice examination and a structured clinical assessment (standard pathway). Local graduates are not required to undergo a similar formal assessment. The waiting period to sit for the clinical component can be long, which may curtail employment opportunities for many IMGs. The procedures involved in the registration and integration of IMGs have been described as not ideal.10

Workplace based assessment (WBA) is an alternative route based on a 6-month assessment process, which can also be delivered in regional Australia. Entry into the WBA program has the same eligibility criteria as the standard pathway, which includes an English language proficiency test. It has been shown that the WBA is a cost-effective form of assessment that facilitates a straightforward integration of doctors into the local health care system.10 The committee that conducted the parliamentary inquiry recommended that colleges of specialists also adopt the WBA model to assess the clinical competence of specialist IMGs (recommendation 8, chapter 4, page 96), given that this assessment methodology is “a much more reliable and accurate evaluation of clinical skills of the IMG” (chapter 4, page 84).1

Notwithstanding the recommendations of the parliamentary enquiry,1 the WBA remains available only in a limited number of training sites for non-specialists, and only a limited number of colleges of specialists have incorporated the WBA into their evaluation processes. Many overseas-trained specialists remain working in AoN positions for years when this period could have counted towards their registrations through WBA. There remain colleges who still insist on using simulated assessment conditions to determine whether a colleague and specialist in his or her own right is sufficiently qualified to practise in a jurisdiction where he or she has in fact been practising competently for several years.

There is no argument that patient safety must be the number one consideration in recommending reforms to the system. A central conclusion of the Lost in the labyrinth report was that “improvements in registration processes for IMGs must be achieved without compromising the high standards that Australians expect from medical practitioners”. Yet, there remain the flagrant breaches of the codes of practice mentioned above, which buttress a de-facto two-tier system in Australia whereby disempowered IMGs have to bear the burden of hindrances that do not apply to local graduates. These discriminatory policies are ethically indefensible, given the overt violations of principles of non-maleficence, beneficence and justice that result.

The unfair hindrances faced by IMGs are irreconcilable with principles of equity and mateship that are at the core of Australian society. There is still an opportunity for political leaders and medical authorities to rectify these inequities by implementing the recommendations from the parliamentary inquiry and the principles sanctioned in international codes of practice.

Will current health reforms in south and east Asia improve equity?

To the Editor: Hipgrave and Hort review health reform initiatives in south and east Asia and draw attention to the increasing privatisation of services and the inequity created as the poor have less access.1 More importantly, countries in south and east Asia are enjoying a period of economic development that has resulted in urbanisation and lifestyle change, specifically dietary change, in both urban and rural populations. This has resulted in a nutrition transition, which is associated with the chronic non-communicable disease (NCD) “epidemic”.2 The trends are that the poor in these countries will have higher levels of risk factors for chronic NCD.3

Health systems in most low and middle income countries have been designed for episodic care for acute conditions, and not for primary health care involving the continuity of care required for managing chronic disease. Second, most of these countries have made negligible investments for prevention of risk factors through population-based programs. Third, intersectoral policies to deal with “upstream” issues, such as marketing of unhealthy food, are not yet in their reform agenda.

Australia’s success in tobacco control and reduction of HIV/AIDs are lessons that we can share. However, the same cannot be said of food policy, and many countries have failed to resist the pressures of the multinational food industry.4 Countries in south and east Asia require intersectoral policies on healthy food to achieve a long-term, sustainable solution to health inequity.5

Australia’s treatment of refugee and asylum seeker children: the views of Australian paediatricians

Many Australian paediatricians have been, and will be, providing care to refugee or asylum seeker children. They come from countries evenly spread among Africa, Asia and the Middle East, and demonstrate a different disease spectrum to Australian children.1 Australia hosts about one refugee per 1000 inhabitants.2 Children are proportionally overrepresented, with around 40% of Australia’s refugee intake being less than 20 years old, similar to the global refugee population.3 These children bring unique medical, cultural, social and linguistic characteristics, and paediatricians need to know how to manage them (Box 1).15

There are scant data on how well paediatricians understand the health and health-related rights of refugees and people seeking asylum. Concerns have been raised that the medical profession’s knowledge is suboptimal.9,16 General practitioners and medical directors have limited knowledge of support services available to them.17 Only one-third of the GPs studied had used a professional interpreter service while managing refugees, while 60% knew that the Translating and Interpreting Service (TIS) is available free of charge.18 However, there are no data for paediatricians.

Refugees and people seeking asylum suffer from physical and mental health problems attributed to experiences in their country of origin, transit countries and Australian detention centres.15,19–21 Refugees and people seeking asylum attempting to access health care services in Australia face geographical, cultural and linguistic barriers.22,23 To best serve children and adolescents, paediatricians need to know about relevant screening practices and Medicare arrangements.24

We sought to determine the knowledge and attitudes of Australian paediatricians in relation to the health of refugee and asylum seeker children both onshore and offshore.

Methods

Questionnaire

To establish the sample for our survey, we began with the Royal Australasian College of Physicians (Paediatrics and Child Health Division) register of paediatricians in Australia and New Zealand. We used the filters “general paediatrician” and “community paediatrician” to select those practitioners most likely to be managing refugee and asylum seeker children. We removed those who were retired or were working overseas (eg, New Zealand). In November 2013, we sent an email to paediatricians on this list with a link to a SurveyMonkey online questionnaire (Appendix 1). We followed up with one reminder email in December 2013 and a final email in January 2014.

Our survey had six sections:

  • terminology (clinical vignettes about a child’s visa status and legal guardianship);
  • health care delivery issues (Medicare eligibility, fee waiver programs and interpreters);
  • visa and screening process (communicable disease screening and transmission risks);
  • support for Australia’s asylum seeker and refugee policies;
  • support for Australian Medical Association [AMA] and Royal Australasian College of Physicians [RACP] statements; and
  • respondent demographics.

We conducted a pilot questionnaire with medical students, who took 5 to 8 minutes to complete the survey, after which the survey was shortened.

Ethics

Ethics approval was granted by the Sydney Children’s Hospitals Network and the University of Sydney (HREC LNR/13/SCHN/266). No incentives were provided to participants.

Data analysis

Data were expressed as the percentage of valid responses for each question. We used IBM SPSS version 21 to compare responses (α = 0.05) by demographic characteristics (all determined a priori) with χ2 analysis, or a two-tailed Fisher exact test whenever there were less than five valid responses.

Results

Target population

There were 599 paediatricians in the RACP register working in “general paediatrics” or “community paediatrics”. After excluding duplicates and those listed as retired or semiretired, overseas or without an email address, 419 paediatricians remained. A further 76 were excluded due to the email bouncing or because they were no longer in practice in Australia, leaving 343 eligible paediatricians (Appendix 2).

Characteristics of respondents

There were 139 respondents (response rate, 40.5%). Respondents’ characteristics were broadly representative of all Australian general paediatricians (Appendix 3). Most of the paediatricians completed all of the questions (90.6%–100% for non-demographic questions).

Questionnaire results

There was no difference in the proportion of respondents who saw refugee and asylum seeker children more than once per month (versus less frequently) in relation to paediatricians’ sex (P = 0.45), training in Australia versus overseas (P = 0.36) or having less than 10 years’ clinical experience versus more (P = 1.00).

Asylum seeker terminology and legal guardian

Ali is a 12-year-old boy from Afghanistan who travelled to Indonesia by plane with his 15-year-old brother, then by boat to Christmas Island. Ali’s brother asked the Department of Immigration and Citizenship (DIAC) for protection from the danger they faced in Afghanistan due to their Hazara ethnicity.

Li is a 10-year-old girl from China who arrived in Australia by plane with her father on a tourist visa. The day after they arrived, Li’s father asked DIAC for protection from the danger they faced in China due to their membership of Falun Gong.

Most respondents correctly classified Ali and Li as “asylum seekers” (Ali, 113/139, 81.3%; Li, 114/139, 82.0%). A small majority correctly identified the Minister for Immigration and Citizenship as Ali’s legal guardian, given that Ali was an unaccompanied minor (83/139, 59.7%).

Medicare eligibility

Fatima is a 17-year-old who has recently fled persecution in Iraq. She comes to see you about a productive cough that has developed over the past few days. She is otherwise well. She informs you that she is not an Australian citizen but she cannot remember what visa she currently holds.

Sixty-five of 134 respondents (48.5%) correctly identified that all refugees hold Medicare cards, but only some categories of asylum seekers are eligible for Medicare. Practitioners who saw refugee or asylum seeker patients “more than once per month” were more likely to select the correct answer than others (15/21, 71.4% v 48/107, 44.9%, P = 0.03). Practitioners with less than 10 years’ experience were just as likely to select the correct answer as those with more experience (8/22, 36.4% v 55/106, 51.9%, P = 0.19).

Fee waiver programs

An intern at a tertiary hospital emergency department calls you about one of your patients, Maya, who has just presented in the final stages of labour. Maya is 17 years old and fled persecution in Fiji. She does not have a Medicare card. The intern asks you whether Maya will be required to pay for all medical costs associated with the admission.

Only 12 of 133 respondents (9.0%) correctly identified that fee waiver programs are available for non-elective services in most Australian states for asylum seeker patients who request treatment at public hospitals but who do not possess a Medicare card.11–13 Practitioners who saw asylum seekers more than once per month had no greater knowledge of these services compared with other respondents (1/21, 4.8% v 10/106, 9.4%, P = 0.69). Over a quarter of respondents (36/133, 27.1%) thought that the hospital administration decided whether to bear an asylum seeker child’s hospital costs.

Interpreters and Medicare

Dhati is a 12-year-old refugee from Nepal who comes to see you with a urinary tract infection. She is accompanied by a friend as she has very limited English.

Similar proportions of respondents would arrange a face-to-face interpreter (59/132, 44.7%) as a telephone interpreter (63/132, 47.7%), with no differences by demographic characteristics (Box 2). Almost half of the respondents who would use a telephone interpreter were not aware of the TIS Doctors Priority Line (29/63, 46.0%).

The vast majority of respondents (118/133, 88.7%) reported no prior knowledge of the Medicare eligibility hotline, but 99 of this group (83.9%) planned to use it in the future. There was no difference between the proportion of respondents who gained their degree in Australia versus overseas who knew of the TIS Doctors Priority Line (54/104, 51.9% v 13/23, 56.5%, P = 0.69) or the Medicare hotline (12/104, 11.5% v 2/23, 8.7%, P = 1.00).

Pre-departure screening

Mr and Mrs Nazif and their four children (Mohammad, 16 years, Sheeva, 14 years, Wasim, 12 years and Fahran, 8 years) fled Afghanistan for Indonesia, where they were granted refugee status by United Nations High Commissioner for Refugees (UNHCR). They are all well and none has any significant past medical history.

Very few respondents were aware which refugee and asylum seeker children would undergo chest x-rays for tuberculosis (TB) screening (11/130, 8.5%) and be tested for HIV (18/129, 14.0%) as part of their initial health screening (Box 3). The most common response was “I don’t know” (chest x-ray, 59/130, 45.4%; HIV, 73/129, 56.6%).

Most respondents (103/128, 80.5%) reported that they thought there was “no” or “low” risk of refugee children transmitting HIV or TB.

Offshore processing and mandatory detention

Only 17/127 (13.4%) of respondents correctly identified that most applicants wait in UNHCR camps for an average of more than 10 years before resettlement to Australia. Most (98/127, 77.2%) responded “1 to 10 years” to this question.

One hundred and one of 126 respondents (80.2%) disapproved or strongly disapproved of offshore processing in Papua New Guinea (PNG) and 103/127 (81.1%) agreed or strongly agreed with the AMA statement that detention of asylum seeker children was a form of child abuse (Box 4).25 Male respondents were more likely to approve of offshore processing than female respondents (13/66 v 0/58, P < 0.001. Ninety of 127 respondents (70.9%) disapproved or strongly disapproved of detention of asylum seeker children (Box 5). There were 25 respondents who “strongly approved” of detention of children. Of these, 23 “strongly agreed” or “agreed” with the proposition in the next question that “detention of asylum seeker children and their families is a form of child abuse”.

One in five respondents left comments, including:

  • reluctance to use government services for asylum seeker children for fear of adverse consequences on the child’s visa application;
  • concern about the “long-term damage” and the “high social, medical, psychological and hence economic costs” associated with current policies, in respect of which they were “appalled” and “ashamed”;
  • “dismay” over the constantly changing nature of refugee and asylum seeker policies (“walking in a mine field when faced with this subject”); and
  • “ ‘strongly disagree’ was often ‘not strong enough’ ”.

Responses by frequency of contact

Box 6 shows that paediatricians seeing refugee and asylum seeker children more than once per month were more likely than others to know: who had access to Medicare cards (P = 0.03); the Medicare hotline (P = 0.005); and that refugees accepted into Australia had stayed an average of more than 10 years in UNHCR refugee camps (P < 0.001). However, there were no differences in any of the other responses between these groups of paediatricians.

Discussion

This is the first study to investigate the knowledge and attitudes of Australian paediatricians about refugees and asylum seekers. This study also describes how paediatricians across Australia conduct consultations with refugee and asylum seeker children. Most paediatricians surveyed used the correct terminology of “asylum seeker” rather than “boat person” or “illegal immigrant”. However, we found serious gaps in knowledge in relation to Medicare eligibility, whether asylum seekers would be charged for essential health care, and the Medicare priority and TIS hotlines. There was also confusion about children’s screening tests during the visa application process. We found very strong support for the AMA contention that mandatory detention of children was a form of child abuse and overwhelming disagreement with the current policy of immediate removal of asylum seekers to PNG with no prospect of future immigration to Australia.

Two vignettes described the journey taken by Ali (by boat) and Li (by plane) to seek protection in Australia. Following recent policy and legislative changes, pursuant to sections 46A and 46B of the Migration Act 1958 (Cwlth), Ali would currently be classified as an “unauthorised maritime arrival” and would be barred from applying for a protection visa unless the Minister for Immigration and Citizenship (now Minister for Immigration and Border Protection) exercised his non-compellable discretion to lift this restriction.5 The terms “illegal immigrant” and “boat person” are not appropriate as applying for protection in Australia is a legal process provided for by the Migration Act 1958 (Cwlth) and consistent with Australia’s international obligations under the United Nations (UN) 1951 Convention Relating to the Status of Refugees and 1967 Protocol Relating to the Status of Refugees. The children in our vignettes could not properly be classified as “refugees” until their claims for protection were assessed on their merits.5

We found that most paediatricians understood that the Minister is the guardian of an unaccompanied minor.7 The Minister thus detains children while also being their legal guardian (with a duty to act in their best interests). To resolve this conflict of interest, the RACP in a position statement in 2013 called for an independent legal guardian for these children. As most paediatricians considered mandatory detention a form of child abuse, it cannot be in the children’s best interests.

We found gaps in paediatricians’ knowledge about Medicare eligibility. Medicare rights are held by all refugees and by asylum seekers who hold bridging visas to which such rights are attached.4,9 Although respondents who didn’t know the answer could ask colleagues and other contacts, the high percentage of “I don’t know” responses highlights the need for better training and education in this area. This is further complicated by some asylum seekers being supported by International Health and Medical Services (IHMS) and the Red Cross. However, these complexities were beyond the scope of this study.

Poor knowledge of hospital fee-waiver programs could limit access to hospital care and could be obstructed by this perceived cost burden, and health professionals might not be referring asylum seekers as they otherwise would.

Better knowledge of the pre-visa screening process may help to avoid duplications or omissions and thereby minimise financial and time burdens for patients and their paediatricians. This information is available — a copy of pre-departure screening results is given to Settlement Services International by the Department of Immigration and Border Protection on arrival. We are concerned that some health care workers may not know how to access this information and families are not being provided with it to bring to appointments.

Data derived by use of questionnaires are limited by potential responder bias; however, our sample was representative of Australia’s general paediatricians and responses did not differ greatly by demographic characteristics. Question wording and ordering may have resulted in our study underestimating disagreement with current policies. In questions 12 (approval of PNG proposal) and 15 (agreement with AMA statement that mandatory detention is child abuse), we outlined a policy or statement and then asked for approval or disapproval, whereas in question 14 (approval of detention of children), we outlined the RACP position calling for the end of detention for child asylum seekers, and then asked for approval or disapproval of detention of children (rather than of the RACP position). This may explain why almost all those who strongly agreed with detention of children also agreed with the proposition that mandatory detention was a form of child abuse.

Refugee and asylum seeker health care is complex with frequent government policy changes. Nonetheless, our findings show that there is considerable confusion about their legal and health access-related rights and the services currently available to assist in delivering care. As a group, paediatricians strongly oppose the detention of children and forced offshore processing of protection visa claims. Australian health care professionals need better training and education to be able to provide best practice health care to these most vulnerable children.

First, medical practitioners can ensure they have up-to-date knowledge of the health problems common among refugee and asylum seeker patients and develop an awareness of information sources and local services available to support the assessment and care of refugee and asylum seeker patients.

Second, medical practitioners can be important advocates for the rights of the specific children they see. This may include writing to the Minister to request that a child be removed from detention and that families be reunified. If such approaches are unsuccessful, the matter may be referred to the Commonwealth Ombudsman. Doctors may choose to contact their parliamentary representatives expressing support for the AMA, RACP and Australian Human Rights Commission positions on people who are seeking asylum and are in detention.

On 19 August 2014, the Minister for Immigration and Border Protection announced measures to enable children to be released from detention onto bridging visas, but only if they arrived before the arbitrary date of 19 July 2013. At the time of his announcement there were 876 children held in detention, including some in Nauru. All of these children should be released from detention immediately, irrespective of their date of arrival.

1 Practical information for managing asylum seekers and refugees

Terminology

  • An asylum seeker is a person who is living outside their country of origin and has applied for recognition as a refugee.4
  • A refugee is a person who is living outside their country of origin and has a well founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion.5
  • An unaccompanied minor is a person aged < 18 years who has arrived in Australia without a natural parent or a relative ≥ 21 years old.6 The Minister for Immigration and Border Protection is likely to be the designated legal guardian of unaccompanied minors.1,7

United Nations High Commissioner for Refugees (UNHCR) camps

  • Refugees processed offshore have waited, on average, > 10 years in refugee camps run by the UNHCR before resettlement to Australia.1

Medicare eligibility and charging patients

  • All refugees have Medicare cards and are entitled to health care cards under the same conditions as Australian citizens (some waiting periods are waived).8
  • Some asylum seekers have Medicare rights attached to their temporary visas.4,9–10
  • To check a patient’s Medicare eligibility, contact the Medicare enquiry number (132 150, press “1”) or access Health Professional Online Services (http://ww.medicareaustralia.gov.au/hpos).
  • To check eligibility for the Asylum Seeker Assistance Scheme, contact the Australian Red Cross (02 9229 4111).
  • A public hospital fee waiver program for asylum seekers without a Medicare card is available in most Australian states and territories (no formal policy found for Northern Territory and Western Australia). In New South Wales, a fee waiver is available for certain public health services including emergency care for acute conditions, some elective surgery, and ambulatory and outpatient care to maintain the health of patients with acute and chronic conditions, and to provide patients with maternity services and mental health services.11–13

Translating services

Screening

  • Applicants for a permanent visa in Australia are required to undergo a chest x-ray for tuberculosis screening (those aged ≥ 11 years) and HIV screening (those aged ≥ 15 years or if there is a history of blood transfusions or clinical indications suggesting HIV infection, or that the child’s mother was or is HIV positive).14
  • For more information on past screening and immunisations for patients in detention, please contact International Health and Medical Services Community Detention Assistance Desk on 1800 689 295 or email cdad@ihms.com.au.

2 Paediatricians’ responses to questionnaire items, by paediatrician demographic characteristics

 

Sex

Where degree obtained

Clinical experience

Responses

Female (n/N)

Male (n/N)

P*

Australia (n/N)

Overseas (n/N)

P*

< 10 years (n/N)

≥ 10 years (n/N)

P*

Sees refugee children at least every month

11/59

9/66

0.45

19/105

2/23

0.36†

3/22

18/106

1.00†

Described Ali as an asylum seeker (Ali is a 12-year-old boy from Afghanistan arriving by boat with no visa)

53/59

50/66

0.04

88/105

17/23

0.26

19/22

86/106

0.76†

Described Li as an asylum seeker (Li is a 10-year-old girl seeking protection arriving by plane on a tourist visa)

51/59

54/66

0.48

90/105

16/23

0.06

15/22

91/106

0.046

Knew that the Minister for Immigration and Citizenship was Ali’s legal guardian as Ali was only accompanied by his 15-year-old brother

39/59

37/66

0.25

62/105

14/23

0.87

13/22

63/106

0.98

Knew there was a fee waiver for essential hospital-based care

7/59

4/65

0.35†

7/105

4/22

0.10†

2/22

9/105

1.00†

Knew some asylum seekers and all refugees had Medicare cards

32/59

31/66

0.42

48/105

15/23

0.09

8/22

55/106

0.19

Used phone or in-person interpreter when patient did not speak English

57/58

58/65

0.07†

96/103

21/23

0.67†

22/22

95/104

0.36†

Knew about Medicare hotline

8/59

6/65

0.45

12/104

2/23

1.00†

3/22

11/105

0.71†

Knew about Translating and Interpreting Service Doctors Priority Line

36/59

29/65

0.07

54/104

13/23

0.69

12/22

55/105

0.86

Knew who received chest x-rays before arrival

6/59

4/66

0.52†

7/105

3/23

0.38†

2/22

8/106

0.68†

Knew who received HIV screening before arrival

12/59

5/65

0.04

13/105

4/22

0.49†

3/22

14/105

1.00†

Considered that refugee and asylum seeker children posed a low or no risk of disease transmission

50/59

50/65

0.27

85/104

18/23

0.70

20/22

83/105

0.25†

Approved or strongly approved of immediately sending asylum seekers to Papua New Guinea

0/58

13/66

< 0.001†

11/103

3/23

0.72†

4/22

10/104

0.27†

Knew that refugees stayed an average of > 10 years in UNHCR refugee camps before settling in Australia

9/59

8/66

0.61

17/105

0/22

0.04†

4/21

13/106

0.48†

Approved or strongly approved of mandatory detention of children

11/59

24/66

0.03

27/104

8/23

0.39

6/22

29/105

0.97

Agreed or strongly agreed with AMA statement that detention of asylum seeker children was a form of child abuse

50/59

52/66

0.39

85/104

18/23

0.70

15/22

88/105

0.09

AMA = Australian Medical Association. n = no. of paediatricians giving each response. N = no. of paediatricians who answered question. UNHCR = United Nations High Commissioner for Refugees. * 5% significance was determined with χ2 analysis whenever there were more than 5 valid responses, and with a two-tailed Fisher exact test whenever there were less than 5 valid responses. † Less than 5 valid responses.

3 Paediatricians’ knowledge about tuberculosis and HIV screening of refugee and asylum seeker children*†

* Participants were asked to respond with reference to a clinical vignette that described a family of two parents and four children. The family was granted refugee status by the United Nations High Commissioner for Refugees. They are all well and none has any significant past medical history. † Applicants for a permanent visa in Australia are required to undergo a chest x-ray (those aged ≥ 11 years) and HIV screening (those aged ≥ 15 years, or if there is a history of blood transfusions or clinical indications suggesting HIV infection, or the child’s mother was or is HIV positive).14

4 Paediatricians’ responses to Australian Medical Association’s statement that “detention of asylum seeker children and their families is a form of child abuse”25

5 Paediatricians’ approval or disapproval of offshore processing and detention of asylum seeker children

* In July 2013, the Australian Government announced a proposal to send all asylum seekers arriving by boat to Papua New Guinea for processing and that “As of today asylum seekers who come here by boat without a visa will never be settled in Australia”.26 † As at June 2012, over 1000 children were recorded as being held in detention in Australia. The Royal Australasian College of Physicians released a statement in May 2013 entitled “Leading paediatricians call for the immediate end to children in detention”.27

6 Paediatricians’ responses to questionnaire items by how often paediatricians saw refugee and asylum seeker children

 

Frequency of seeing refugee and asylum seeker children

  

Responses

At least once per month (n/N)

Less often than once per month (n/N)

P*

Described Ali as an asylum seeker (Ali is a 12-year-old boy from Afghanistan arriving by boat with no visa)

17/21

88/107

1.00†

Described Li as an asylum seeker (Li is a 10-year-old girl seeking protection arriving by plane on a tourist visa)

19/21

87/107

0.53†

Knew that the Minister for Immigration and Citizenship was Ali’s legal guardian as Ali was only accompanied by his 15-year-old brother

12/21

64/107

0.81

Knew there was a fee waiver for essential hospital-based care

1/21

11/118

0.69†

Knew some asylum seekers and all refugees had Medicare cards

15/21

48/107

0.03

Used phone or in-person interpreter when patient did not speak English

20/21

97/105

1.00†

Knew about Medicare hotline

6/21

8/106

0.005

Knew about Translating and Interpreting Service Doctors Priority Line

12/21

55/106

0.66

Knew who received chest x-rays before arrival

4/21

6/107

0.06†

Knew who received HIV screening before arrival

5/21

12/106

0.13

Considered that refugee and asylum seeker children posed a low or no risk of disease transmission

17/21

86/106

1.00†

Approved or strongly approved of immediately sending asylum seekers to Papua New Guinea

1/21

13/105

0.46†

Knew that refugees stayed an average of > 10 years in UNHCR refugee camps before settling in Australia

8/21

9/106

< 0.001

Approved or strongly approved of mandatory detention of children

2/21

33/106

0.06†

Agreed or strongly agreed with AMA statement that detention of asylum seeker children was a form of child abuse

17/21

86/106

1.00†

AMA = Australian Medical Association. n = no. of paediatricians giving each response. N = no. of paediatricians who answered question. UNHCR = United Nations High Commissioner for Refugees. * 5% significance was determined with χ2 analysis whenever there were more than 5 valid responses, and with a two-tailed Fisher exact test whenever there were less than 5 valid responses. † Less than 5 valid responses.

The importance of effectively combating HIV/AIDS through tackling the social aspects of the pandemic post-2015.

An open letter to Ban Ki Moon

Mr Secretary General:

This letter starts with one patient.

I met her on my second day at Kenyatta National Hospital, on the paediatrics ward. I would like to tell you her name, but she had never been given one, so I called her “Beautiful”. She was 3 months old and had never left the hospital. Twenty-four hours after a traumatic birth to an HIV-positive mother who had not accessed the care freely available to all pregnant women for prevention of mother-to-child-transmission, she had been abandoned. Despite having no name, she already had a status: positive. When I met her she didn’t cry, because in her short life she had learnt that no one came when she did. She was developmentally delayed because, in such an underresourced department, caring for the well child was not the physician’s priority. “What makes a mother give up her child?” I asked one of the junior doctors. He responded: “It happens; there are usually more of them”. I explained that I didn’t understand, and the doctor’s response was as sharp as the answer was obvious — I was right. I didn’t understand. “Having HIV is more than just a disease here”, he said, “it is a lifetime of struggling against prejudice. It is a life sentence”.

I knew the proportion of AIDS-related fatalities had decreased dramatically with the upscaling of highly active antiretroviral therapy (HAART) availability.1 In Kenya, where 300 000 children are HIV positive,2 this little girl was my first insight into the social issues involved in the pandemic; unfortunately she wasn’t going to be my last. During my elective I was involved in the daily diagnosis and management of many HIV-positive children. I saw at first hand the reluctance of caregivers to permit HIV testing, diagnosis and treatment for their children, and there was a significant loss to follow-up. It is estimated that for each paediatric HIV/AIDS case reported in Kenya there are 3–4 other infected children undiagnosed.3 Beautiful’s situation forced me to confront the staggering social and cultural barriers to combating HIV/AIDS in some of the world’s worst-affected countries.

The fight to achieve Millenium Development Goal 6 with regard to HIV/AIDS (achieve universal access to treatment by 2010 and begin to reverse its spread by 2015) has champions from doctors to musicians and has achieved falling infection rates and increasing availability of HAART. However, given the plight of Beautiful, and countless children like her, I have come to believe that a paradigm shift in our approach to providing prophylaxis and treatment is desperately needed. In order to achieve the AIDS-free generation that UNICEF deems possible, the interplay of stigma, socioeconomic status and a distrust of health care professionals has to be better understood and addressed. As physicians and policymakers, to successfully tackle the epidemic affecting not only Kenya’s children, but the world’s, we need to see past the disease and consider the dramatic effect such a diagnosis can have on a patient and his or her family.

I spent 3 weeks in Kibera (Nairobi’s biggest slum), where it is estimated that between 10% and 25%4 of children are HIV positive. The poorest neighbourhoods lack the necessary infrastructure to combat the spread of HIV. I met young girls, orphans of the pandemic, who had dropped out of school and had no other means to survive but through transactional sex work, resulting in pregnancy, poor health and HIV infection.5 One 14-year-old girl said she didn’t see the point of condoms; she was going to die of AIDS anyway. The brutal truth is that statistics bear out this young girl’s dark prediction. In homeless youth, HIV infection progresses rapidly to disease, and mortality is greater than 50% by 15 years of age.6 I met this girl while I was working in a free clinic serving the slum. Clearly, access to health care wasn’t the issue.

During my time on the ward, Beautiful did not require anything more than her daily feed, something that the health care workers were only too ready to provide. But for the boy in the next cot it was different. He was also HIV positive and had been admitted for treatment of an AIDS-associated infection, which necessitated frequent blood tests. Not one of the ward staff were prepared to carry these out. So I did.

One study found 9% of doctors routinely refused treatment to HIV-positive patients or their children, considering it a waste of resources.7 When I read this statistic, I was ashamed to be part of the same profession that turned away people in so much need. I cannot imagine how devastating this must be for patients who simply have to live with the implications of their doctor’s prejudice.

I was shocked that prejudice against those with HIV was reflected in health policy. Comprehensive Care Clinics (CCC) seemed like an unnecessary segregation of HIV sufferers. In Kenya the CCC’s only function is to maintain the care of HIV-positive patients, and they are held in specific locations at specific times for only this purpose.8,9 Consequently, mothers do not bring their children, since their HIV status would be disclosed by simply attending.10 One mother told me “I am so afraid my neighbours will see me and they will know”, such is the stigma surrounding HIV. This fear translates to antenatal clinics, where up to 16% of women refuse HIV testing11 and 36% do not return for the results.12 Likewise, 30% of HIV-positive breastfeeding mothers go against medical breastfeeding advice so as not to disclose their HIV status.13,14

Yet, pioneering initiatives are breaking down these barriers. For instance, the results of a study being conducted at Kenyatta, centred around encouraging parents to disclose their own status and that of their child to trusted friends and family members, thus far indicate a positive correlation between disclosure and compliance with medical advice and treatment. In debunking this culture of secrecy, investigators are seeking to promote family-centred HIV care.15 The international community should look to these examples, building on their founding principles; to beat AIDS we must do more than diagnose and treat. This is what effective global health should look like post-2015.

I left Kenya and Beautiful in August, having contacted a charity-run orphanage and asked them to give her a home. When I had first arrived at the Kenyatta National Hospital I saw a straightforward choice for patients when given access to free medical treatment: say yes. What I learned was to see the devastation of the disease from the patients’ perspective. To me the devastation was in high viral load, but to them it meant ostracism, poverty and prejudice. Their diagnosis meant no quality of life. And there is no point in having a treatment if those who need it don’t access it. What I learnt is not only applicable in Kenya: the time I spent there opened my eyes to the challenging and unyielding nature of practising medicine in resource-poor settings.

Global health as a discipline has something to heed from this lesson as well. HIV treatment services fall short in the provision of care, not because of resources, but because they only focus on the biological aspects of HIV and not the impact such a diagnosis has upon the lives of the patients and their families. The post-2015 agenda should build on the valuable foundations of Millenium Development Goal 6 — the aspiration to reverse the spread of HIV/AIDS and provide universal treatment. However, in seeking to improve the lives of affected populations and countries we must be sure to consider HIV holistically rather than just biologically.

Mr Secretary General, I implore you, renew your commitment to the fight against HIV/AIDS, but this time deal with the social and cultural barriers to accessing treatment. In this way we must work together to ensure that no more children, like Beautiful, are left nameless.

Sincerely,

Heather Kitt

Ethical challenges for doctors working in immigration detention

The health of asylum seekers in Australia’s immigration detention centres has been the subject of a doctors’ letter of concern and two recent reports.1–3 Here, we present an analysis of the ethical dilemmas faced by health practitioners working in these centres1 and seek to promote a strong and considered policy discussion.

Australia’s Department of Immigration and Border Protection (DIBP) contracts a private health service provider, International Health and Medical Services (IHMS), to provide health care to immigration centre detainees at an Australian standard.4 However, media and other reports from Christmas Island,1 Manus Island2 and Nauru3 have raised serious concerns about the quality of care provided and whether health care professionals have been able to fulfil their professional and ethical obligations to patients in these facilities.1–3

Ethical conflicts and challenges

Doctors working within the immigration detention system may experience conflicting loyalties to their patients, their employer and the DIBP. The Australian Health Practitioner Regulation Agency (AHPRA) code of conduct for doctors recognises the significance of conflicts of interest:

Multiple interests are common. They require identification, careful consideration, appropriate disclosure and accountability. When these interests compromise, or might reasonably be perceived by an independent observer to compromise, the doctor’s primary duty to the patient, doctors must recognise and resolve this conflict in the best interests of the patient.5

The Australian Medical Association (AMA) code of ethics6 also advises how doctors should respond to conflicts of interest and to conditions that are judged to be unacceptable for adequate health care:

Refrain from entering into any contract with a colleague or organisation which may conflict with professional integrity, clinical independence or your primary obligation to the patient.

… ensure that you do not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman, or degrading procedures …6

The AMA statement on medical professionalism7 further describes how a doctor’s ability to deliver patient-centred care may be compromised by an employer or government and advises that:

When responding to these challenges, the medical profession and its individual members have a duty to advocate that the health care environment remains patient-centred at all times and a responsibility to ensure that the health needs of patients remains the doctor’s primary duty.7

Despite its obligations to both its patients and the DIBP, IHMS has publicly maintained that no conflict of interest exists.8 However, the inadequate health screenings of asylum seekers on Christmas Island in 2013 demonstrate this type of conflict. In response to DIBP targets, health assessments were rushed, fewer investigations were performed and asylum seekers were transferred to regional processing centres within 48 hours, before results of investigations were available.1 This resulted in failure to identify acute and chronic illnesses before patients were transferred to sites with limited medical facilities.1 This practice continued in the face of objections from the Royal Australasian College of Physicians.1

Some tasks requested of doctors in immigration detention centres are inappropriate in the context of health care, such as requests to refer patients for age assessment by the DIBP. This process is not a part of the patients’ health care and is not in their best interests.1,9 Doctors have been required to prescribe medication en masse to expedite transfer to regional processing centres, with no patient consultation and despite potential contraindications.1 For example, the combination drug for malaria prophylaxis, atovaquone–proguanil hydrochloride, was prescribed without any individual patient consultation, and it was not clear if asylum seekers were informed about the indications for and possible adverse reactions to this drug.

Degrading, harmful and inappropriate incidents have occurred, including requiring asylum seekers to undergo health assessments while exhausted, dehydrated and filthy, with clothing soiled by urine and faeces; addressing individuals by number instead of name;1,2 artificial delays in transfer of patients for tertiary care;1 confiscation and destruction of medications, medical records and medical devices;1 and detention of children despite clear evidence of significant harm.1,9–11

These rushed and inappropriate practices can have harmful consequences for patient wellbeing. These have included the loss of an unaccompanied child’s hearing aid, which was not replaced, and the child went on to develop self-harming behaviour; and the abrupt cessation of anticonvulsants in a child, resulting in worsening of seizures.10,11 Tragically, delays in transfer are likely to have contributed to the recent death of an asylum seeker from sepsis, resulting from a cut to his foot.12

Responding to conditions of practice in immigration detention centres

Doctors who work in detention centres may feel an ethical responsibility to voice their concerns, but this may conflict with their obligations to their employer. The question should be asked: is working within immigration detention an ethically tenable prospect for Australian doctors and other health professionals? Several answers present themselves.

First, a doctor may advance the “no worse off” argument — that any individuals refusing to work within the system will be replaced by others willing to do so.

Second, it might be argued that it is better to have a compassionate person delivering the best care possible within the constraints of the detention system than to have that person leave, not knowing who the replacement will be. However, remaining silent goes against the imperative to advocate for patients’ interests.7

Third, a doctor might work as contracted in the system, yet still advocate for asylum seekers by speaking out about deficiencies in their care. But it is unclear how much “advocacy from within” is enough. If that advocacy becomes ineffective, is there a point at which the doctor becomes effectively complicit with the system?

Finally, some doctors terminate their contracts when they see the realities of the detention health care environment. However, while this strategy preserves the individual’s professional integrity, it may jeopardise patient care by resulting in an immediate workforce shortage.

The work culture in immigration detention centres discourages open expression of personal concerns by staff, with documented cases ending in dismissal.13 Formal complaints can be made but have rarely effected change.1 The diffusion of personal responsibility associated with reporting complaints to senior staff is a powerful factor in the immigration detention system. Health practitioners who lodge complaints to formalise their objections may judge this to have met their responsibilities. However, in reality, this may not represent effective advocacy for patients when failure to act on complaints is a systemic problem. Other doctors, increasingly frustrated with the lack of progress, may burn out and abandon their advocacy attempts. In our experience, many resolve to wait out their contracts and leave, never to return.

Appealing to bodies external to their employer becomes a last resort. However, individuals who do so face the possibility of legal action for breaching confidentiality agreements. Health care professionals can notify AHPRA, which provides protection from such agreements, but AHPRA’s scope is limited to the conduct of individual practitioners rather than dysfunctional health systems as a whole.14 There is little else individuals can do without significant personal risk.

Is it time for a boycott?

Given reports that the health care currently provided to asylum seekers in immigration detention may be both substandard and harmful, a coordinated response to the problem is now needed to ensure change occurs.

Should health care professionals consider boycotting the provision of services in immigration detention until conditions are made satisfactory? The potential role of a professional boycott to motivate change should be openly discussed. Any decision made requires leadership from the professional bodies responsible for ensuring standards of care and ethical conduct. Any resulting policy and advice in relation to health care within immigration detention needs to be clear.

We call on the colleges and the AMA to lobby for effective change, so that asylum seekers receive appropriate care and those delivering it are not professionally compromised. We also call for robust, independent and transparent monitoring of standards within immigration detention, and a system to register and independently deal with complaints.

An open letter to the Prime Minister, the Honourable Tony Abbott, MP

A call for active leadership on climate change

This week the Journal publishes an open letter from 12 medical and health scientists to the Prime Minister urging that climate change be included on the agenda for the upcoming G20 meeting that he is hosting in Brisbane in November. The letter argues that climate change and health are interlocked with the global economy, and that vigorous and enlightened debate about the consequences of climate change on human health is justified at a meeting focused on international economics.

An interview with Professor Jeffrey D Sachs, a prominent American economist and Director of The Earth Institute at Columbia University and past Chair of the World Health Organization’s Commission on Macroeconomics and Health, calls on Australia to show leadership. Sachs has served as special adviser to two Secretaries-General of the United Nations, first guiding the development and then the implementation of the Millennium Development Goals, which seek to reduce global poverty, particularly through health gain for mothers and children and through reduced HIV and AIDS, by 50% by 2015. His primary concern today is with achieving sustainable development before a malignant tipping point occurs in global temperature.

The interview and the open letter both call for action from the Australian Government. We look forward to a positive response.