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Matters Arising

Asylum seekers and healthcare

Philip Ruddock

MJA 2002; 176 (2): 85-87

To the Editor: The article by Sultan and O'Sullivan on detention of asylum seekers in Australia in the 3/17 December issue of the Journal1 contains several errors of fact and distortions that I believe you have an obligation to address. While I am not addressing medical issues, this nevertheless goes to the issue of credibility.

The article made several claims that are factually wrong and would not have withstood even cursory examination had you sought verification. I will not attempt to deal with all distortions and factual errors, but your readers should be made aware of at least some elements.

Detention is not arbitrary. It is humane and is not designed to be punitive. Staff are provided with cultural-awareness training and are expected to interact with detainees in an appropriate manner. Further, the level and range of medical services available to detainees exceed those available in many regional areas of Australia.

It is true some people have been detained for some years. However, Sultan and O'Sullivan neglected to mention that these cases are ones where people have been found to have no lawful right to remain in Australia, but have been pursuing all legal avenues or have been refusing to cooperate with departure arrangements.

Another distortion and half-truth relates to a hunger strike where "power and water supplies were cut to the cell block . . . affecting uninvolved women and children". Firstly, there are no cells at Villawood and the alleged cell block was actually a recreation room. The water supplies were cut when earth-moving equipment outside the centre accidentally cut the mains supply to the area, affecting surrounding homes and the centre. Water containers were provided for the detainees until the water supplies were restored.

What Sultan and O'Sullivan do not tell you about the power supply was that it was cut when detainees ripped wires out of electrical equipment and threatened to use them to electrocute staff. This action obviously also posed a risk to the children who were moving in and out of the room.

A small number of protesting detainees were denied access to the visitors' area because of the disruption their actions would cause to the majority of detainees who were not involved in the protest.

Head counts have taken place at 2 am, but what you were not told was that these followed escapes and are not routine.

The claim that there has been a dearth of educational and resource material is a factual error. It is disappointing that a publication of your standing did not make even cursory enquiries on simple factual issues.

  1. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long term detention: a participant–observer account. Med J Aust 2001; 175: 593-596. <eMJA full text>

(Received 10 Dec 2001, accepted 10 Dec 2001)

Parliament House, Canberra, ACT.

Philip Ruddock, MP, Minister for Immigration and Multicultural and Indigenous Affairs, Minister Assisting the Prime Minister for Reconciliation.

In reply: Asylum seekers and healthcare

Aamer Sultan, and Kevin O'Sullivan

MJA 2002; 176 (2): 85-86

In reply: The Minister for Immigration and Multicultural and Indigenous Affairs, Mr Philip Ruddock, claims that our article contains several errors of fact and distortions. He does not comment on the substantive concerns of the article, but implies that the errors undermine the credibility of our finding — that prolonged detention of asylum seekers appears to cause serious psychological harm. In response, we will address the alleged errors of fact and then the credibility of the observations made in our article.

The Minister states that we failed to identify the factors leading to long periods of detention for some asylum seekers. It is clearly stated in the article that "lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status". The Minister's response adds nothing of substance to this and fails to identify the other major factor accounting for prolonged detention, namely the difficulties in removing individuals who are stateless or from countries such as Iraq and Afghanistan.

The Minister states that nightly head counts at Villawood occur only after escapes. Unfortunately, the Minister has not been accurately briefed on this matter. Nightly head counts have been a regular practice at Villawood. One of us (A S) has documented proof from the minutes of both the Community Reference Committee and the Centre Manager's detainee meetings held at Villawood, which record the concerns of the detainees and the refusal of management to discontinue the practice. Moreover, this practice was openly acknowledged by the operators of Villawood to the Parliamentary Joint Standing Committee which visited the centre in February 2001.1 It is pleasing to note that, after the publication of our article, nightly head counts have been discontinued in the Stage Two section of Villawood.

There are conflicting accounts between detainees and management regarding the events surrounding the hunger strike referred to by the Minister. One of us (A S) sent a complaint about this incident to the Commonwealth Ombudsman. In his reply, the Ombudsman quoted a letter from the Department of Immigration and Multicultural Affairs dated 27 October 2000, which states: "I can confirm that power to the recreation room was cut-off for a short period of time to ensure the safety of the detainees participating in the protest action who had been threatening self harm". There is no mention of attempts by detainees to electrocute staff, as suggested by the Minister, and one of us (A S) has spoken to some of the detainees involved in the protest, who have categorically denied this. Many detainees remain highly sceptical of the official explanation offered regarding the lack of water to the block where the hunger strikers were being held. The very existence of the mass hunger strike and the conflicting accounts of the incident all attest to the emotionally charged environment that has at times existed at Villawood, which was the major point of discussing this incident in our article.

We made it quite clear that there have been recent improvements in recreational resources at Villawood. However, as stated in our article, there had been a long history of neglect of this issue. This was confirmed by the statement of the Human Rights and Equal Opportunity Commission in 1998 that "the recreation facilities at Villawood are inadequate for the number of detainees being held there".2 Moreover, despite recent improvements, our statement that detainees face long periods of unstructured time remains true.

Although we did not discuss the issue of whether mandatory detention was arbitrary, it is worth noting in response to the Minister's claim that the Human Rights and Equal Opportunity Commission concluded that "In some instances, individuals . . . have been held for more than five years. This is arbitrary detention and cannot be justified on any grounds".2

The failure of the Minister to consider the substantive issues we raised, namely the negative psychological effects that long-term detention appears to be having on asylum seekers, was disappointing. As we stated, we attempted to report our observations in what we consider to be an objective and truthful manner. Nothing in the Minister's response suggests that we have failed to do this. Even if the findings in our report were to be entirely dismissed, Steel and Silove (in the same issue of the Journal)1 document compelling evidence of the serious psychological symptoms observed among long-term detainees.

In conclusion, we can only offer a continued exhortation for the Minister to attend to the collective weight of evidence indicating a mental health crisis within Australian detention centres.

Villawood Detention Centre, Villawood, NSW 2163.

Aamer Sultan, MB ChB, Physician and Immigration Detainee, Villawood Detention Centre; Kevin O'Sullivan, BSc, PhL, DipClinPsychol, Former Visiting Clinical Psychologist, Villawood Detention Centre.
  1. Joint Standing Committee on Foreign Affairs, Defence and Trade, Human Rights Sub-Committee. A report on visits to immigration detention centres. Canberra: Parliament of the Commonwealth of Australia, 2001: 53.
  2. Human Rights and Equal Opportunity Commission. Those who've come across the seas: The report of the Commission's Inquiry into the detention of unauthorized arrivals. Canberra: HREOC, 1998: 182, 52.
  3. Steel Z, Silove DM. The mental health implications of detaining asylum seekers. Med J Aust 2001; 175: 596-599. <eMJA full text>

(Received 18 Dec 2001, accepted 18 Dec 2001)

In Reply: Asylum seekers and healthcare

Derrick M Silove, Zachary Steel

MJA 2002; 176 (2): 86

In reply: Several aspects of Mr Ruddock's letter concern us. The tendency to evade the substance of the message and instead to attack the messenger, in this case the MJA, is unwarranted. Fortunately, the Journal's reputation rests secure with its more usual, considered readership, but the accusation that the MJA has acted in a cursory manner is particularly jarring — the media response by the Minister to the publication of the relevant articles occurred within hours, hardly sufficient time to subject them to a considered analysis. The haste of the response is also evident in the substance of the letter, with its focus on largely irrelevant technical aspects rather than on the key issue — the legitimate concerns raised about the impact of detention on the mental health of inmates.

Are we to assume from the Minister's silence on this core matter that he acknowledges that the majority of long-term detainees are suffering from severe depression and other disabling emotional disturbances, as described in the article by Sultan and O'Sullivan and supported by other data we cite? The rates of depression reported by Sultan and O'Sullivan represent a roughly eightfold greater prevalence than is found in the general Australian population — if correct, this reflects an epidemic of mental illness among long-term detainees. Until proven otherwise, there is every reason to assume that the mental disorders identified are a direct outgrowth of the conditions of detention. One of the key findings of research in this area is that asylum seekers in detention report similar patterns of abuse and trauma as their refugee counterparts authorised to resettle in Australia. It is paradoxical and contradictory that we provide authorised refugees some of the best rehabilitative services in the world through our national network of services for survivors of torture and trauma, while at the same time creating conditions in detention centres that exacerbate the effects of past trauma in their compatriots.

The claim that detention is humane is extraordinary. From a medical perspective, the obvious test of such a claim is in the health outcomes. Instead of the steady improvement in psychosocial status witnessed in authorised refugee populations after resettlement, there appears to be a progressive deterioration in the mental health of similarly traumatised persons in detention. A policy that in its implementation directly undermines the capacity of displaced persons to recover from the effects of past stresses cannot, by any stretch of the imagination, be humane.

If detention is not punishment, then what is it? We are told repeatedly that detention is a deterrent aimed at discouraging the arrival of asylum seekers. How then does detention act as a deterrent if not by punishing the few to deter the many? Interestingly, punishment, according to many criminologists, is not a good deterrent. This makes the situation even worse — punishing those whose only "crime" is to seek asylum from persecution for a presumed greater benefit that remains unattainable. The practical failure of the "punishment as deterrence" approach is evident in the recent, desperate policy shift to the costly and unsustainable "Pacific solution". What next?

In short, detention is not humane — prolonged detention, in particular, exacts severe costs by undermining the mental health of detainees. The stark reality is that political policy is creating a preventable public health tragedy. If doubts remain about this conclusion, then we should turn to science as the final arbiter. It is now pressing that an independent group of researchers undertake a comprehensive survey of detention centres in Australia and the Pacific to establish once and for all the impact of current policies on the mental health of the detainees.

School of Psychiatry, University of New South Wales, Sydney, NSW.

Derrick M Silove, Psychiatrist; Zachary Steel, Clinical Psychologist. z.steelATunsw.edu.au

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(Received 18 Dec 2001, accepted 18 Dec 2001)

Asylum seekers and healthcare

George Halasz, Michael Block, Leon Petchkovsky and Howard Cooper, and 20 co-signatories (all psychiatrists) *

MJA 2002; 176 (2): 86

To the Editor: We wish to acknowledge Dr Aamer Sultan's courage in carrying out his research as a "participant–observer" into the impact of long-term detention on psychological health of asylum seekers1 at the Villawood Detention Centre, Sydney.

In response to the article, Dr Louise Newman, Fellow of the Royal Australian and New Zealand College of Psychiatrists, called for an urgent assessment of the mental and physical health of asylum seekers in detention. As well, The Australian2 reported that Dr Newman advised members of the College not to accept appointments in detention centres because of serious concerns about how they were run by Australasian Correctional Management.

Dr Sultan inspires the medical profession, at considerable risk to himself, in order to fulfil the obligation of the first aphorism of Hippocrates: "The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate."

  1. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long term detention: a participant–observer account. Med J Aust 2001; 175: 593-596. <eMJA full text>
  2. Walker V, Saunders M. Snub ACM jobs, psychiatrists told. The Australian. 2001; 10 December: 4.

(Received 19 Dec 2001, accepted 19 Dec 2001)

Department of Psychological Medicine, Monash Medical Centre, Clayton, VIC.

George Halasz, MRCPsych, FRANZCP, Honorary Senior Lecturer.

95 Wattletree Road, Armadale, VIC.

Michael Block, Psychiatrist.

University of Queensland, Brisbane, QLD.

Leon Petchkovsky, Senior Lecturer in Psychiatry.

Victorian Child Psychiatry Training Department, Melbourne University, Melbourne, VIC.

Howard Cooper, Director.

GeohalaszATaol.com

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*Co-signatories: Lois Achimovich, Steven Adlard, Eva Balint, Graham Blom, George Bruxner, Jonathan Carne, Robert Chazan, Andrew Firestone, Donald C Grant, Jeanette Lancaster, Jenny Lawrence, David Leonard, David Lonie, Isla Lonie, Fiona McGlade, Harry New, Carolyn Quadrio, Jenny Randles, Suzie Taryan, Peter Wigg.

Asylum seekers and healthcare

Debra Graves

MJA 2002; 176 (2): 86-87

To the Editor: I am writing as a member of the Australian Medical Association, and hence a subscriber to the MJA, to express my concern over the recent publication of the participant–observer account of psychological disturbances in asylum seekers,1 and the subsequent media reporting of the issue as a consequence of the publication.

I would like to say at the outset my views are personal.

Like most healthcare professionals, I consider access to basic medical care, including care for those with mental illness, is a human right. However, I do not support the use of a peer-reviewed journal such as the MJA for political purposes. The right of freedom of speech is fundamental in a democratic society; however, if the AMA wishes to push a political issue then such articles should be published not in the MJA but in Australian Medicine, with appropriate recognition that the issue is medicopolitical and not scientific.

My concerns relate to the responsibility I consider peer-reviewed journals such as the MJA have in ensuring that articles, which include reports of alleged research, are scientifically valid. As can be seen by the media coverage on this issue, the fact that the "research study" was published in the MJA gave the impression to the general public that it was a valid scientific study and should be taken seriously.

I have a number of specific issues of concern in relation to the article.

  • Firstly, there is the fact that the principal author and researcher, in being a detainee with serious concerns over his treatment by the democratically elected government of this country, obviously has considerable potential bias in reporting observational research of this kind.

  • Secondly, there is no attempt to assess the baseline mental health of the detainees before coming to Australia, but an assumption that all the symptoms observed are a result of detention.

  • Thirdly, it would appear that there was no attempt to validate the observational research using more rigorous psychological testing.

  • Finally, the methodology of the survey is not outlined, nor is the sample size discussed from the point of view of statistical validity.

Admittedly, there was an acknowledgement of the survey's limitations; however, I do not consider that this article should have been published in the MJA. It does the Editorial Committee no credit and the Journal less so.

19 Albion Avenue, Paddington, NSW.

Debra Graves, MB BS, MHA, FRACMA, Medical Manager. debragravesATozemail.com.au

AntiSpam note: To avoid spam, authors' email addresses are written with AT in place of the usual symbol, and we have removed "mail to" links. Replace AT with the correct symbol to get a valid address.

(Received 18 Dec 2001, accepted 18 Dec 2001)

  1. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long-term detention: a participant–observer account. Med J Aust 2001; 175: 593-596. <eMJA full text>

(Received 14 Dec 2001, accepted 14 Dec 2001)

In Reply: Asylum seekers and healthcare

Martin B Van Der Weyden, Ruth M Armstrong and Helen M Randall

MJA 2002 176 (2): 87

In reply: The Hon. Philip Ruddock, the Minister for Immigration and Multicultural and Indigenous Affairs, believes that the article by Sultan and O'Sullivan1 makes "several claims that are factually wrong and would not have withstood even cursory examination".

When assessing whether contributions are suitable for publication in the Journal, the editors of the MJA submit them to peer review, which has been defined as "independent assessment of the scientific merit of research by experts having knowledge of the research area equal to that of the performers of the work".2

The article referred to by the Minister posed a dilemma. Those with "equal knowledge of the research area" — representatives of the Department of Immigration and Multicultural Affairs or the Department's provider of security services (Australasian Correctional Management) — would have a patent conflict of interest. The Journal did, however, seek advice as to the accuracy of the article from a person with knowledge of the situation at Villawood, who did not advise as to "errors of fact and distortions", as alleged by the Minister.

The discrepancy between the truth according to the Minister and according to Sultan and O'Sullivan may reflect differing interpretations and perceptions of information conveyed by intermediaries.

Graves implies that detained asylum seekers' mental health and access to healthcare is a medicopolitical issue and that the forum for this debate should be the Australian Medical Association. So it should be! But the MJA has complete editorial independence from the AMA, and we believe that the mental health of asylum seekers transcends medicopolitics and goes to the very core of the ideals of medicine.

Finally, it was very clear from the title of the article, and its authorship, that it represented the perspectives of a detained doctor (one of Graves' concerns) and a former visiting psychologist. However, we believe that our readership is sophisticated enough to interpret the content of such articles. We also believe, contrary to Ruddock and Graves, that the standing of the Journal remains solid, as does its policy of "providing a forum for . . . commentary and informed debate on standards of clinical practice, ethics, social, legal and other issues related to health care in Australia".3

To our knowledge, the information conveyed by Sultan and O'Sullivan's article is the best available data on the mental health of detained asylum seekers in Australia. We look forward to a more rigorous and independent assessment, hopefully initiated by the Minister. The opportunity is his.

Medical Journal of Australia, North Sydney, NSW.

Martin B Van Der Weyden, Editor; Ruth M Armstrong, Deputy Editor; Helen M Randall, Senior Assistant Editor.

Correspondence: Dr Martin B Van Der Weyden, Medical Journal of Australia, Private Bag 901, North Sydney, NSW 2059.

  1. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long term detention: a participant–observer account. Med J Aust 2001; 175: 593-596. <eMJA full text>
  2. Office of Basic Energy Sciences [United States]. Review and selection of research projects. http://www.er.doe.gov/production/bes/peerreview.html#pr (accessed December 2001).
  3. Van Der Weyden MB. From the Editor's desk . . . the Journal. Med J Aust 1995; 162: 344.

©The Medical Journal of Australia 2001 www.mja.com.au PRINT ISSN: 0025-729X Online ISSN: 1326-5377

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