Borderline health: complexities of the Torres Strait treaty

The treaty between Australia and Papua New Guinea (PNG) referred to as the “Torres Strait treaty” entered into force in February 1985.1 The treaty’s purpose is to provide certainty of the sovereignty and maritime boundaries between the two countries, including in the Torres Strait, where there are over 200 islands. The three major inhabited Australian islands of Boigu, Dauan and Saibai are situated several kilometres off the coast of the South Fly District of PNG’s Western Province (Box 1).2

In September 2009, the Australian Senate requested that the Foreign Affairs, Defence and Trade References Committee inquire into and report on matters related to the region and the treaty,3 including the administration and management of public health in and around the Torres Strait. Although the treaty excludes health access as a justification for travel, its free-movement provisions have contributed to a situation where access to Australian health services by people from PNG and public health issues — particularly those related to tuberculosis (TB), HIV/AIDS, cholera, dengue and malaria — have become major concerns.

We present our analysis of the committee’s November 2010 report and highlight the increasing immigration, health, socioeconomic, cultural and human complexities that exist in the region. Such complexities require collaborative commitment between state and national governments from both sides of the border in formulating policy and providing resources.

The Torres Strait treaty established a Torres Strait Protected Zone. Within the protected zone, people who live in the coastal areas of PNG and Australians who are Torres Strait Islanders are permitted to travel across the border in accordance with their way of life as the traditional inhabitants of the region.

Australia and PNG are divergent in wealth and development, and this divide has grown in the past 20 years. PNG has one of the poorest health records in the Pacific region and is unlikely to meet any of its health-related Millennium Development Goals.4 Communicable diseases are the major cause of death and illness across all age groups; life expectancy is 57 years;5 and 30% of children in PNG are considered to be moderately to severely malnourished.6

The health system in the remote Western Province is particularly poor.7 This area’s main health facility is Daru Island Hospital, which operates with poor infrastructure as well as ongoing staff and clinical supply shortages.8 The hospital lacks capacity to support rural areas in clinical outreach services.9

Western Province has been described as the “most economically depressed region of PNG”.10,11 Poor sanitation and water quality and limited disease-control activities result in outbreaks of infectious diseases such as malaria, HIV/AIDS and other sexually transmissible infections, TB and multidrug-resistant TB (MDR-TB).8

Unsurprisingly, the international border provides a bridge for emerging infectious diseases.9,12,13 To counter this, the treaty allows for border integrity as a public health priority — under its provisions, Australian or PNG authorities can close the border to limit or prevent free movement.14 All cross-border travel was restricted in 2009 because of the H1N1 influenza epidemic,15 and again in 2010 because of a cholera outbreak in Daru that killed 30 people.16 There is increasing alarm over the potential for a major public health crisis on Australian shores, such as MDR-TB spreading into vulnerable Aboriginal communities in north Queensland.9,12

Traditional inhabitants were exempt from usual immigration health checks at the Australian border in the Torres Strait: This exemption, under the treaty’s freedom of movement provisions, aroused locals’ “fear of likely transmission of serious diseases”. The committee highlighted that

PNG residents traversed the border for Australian health care services: Although access to health services is not classified as a traditional activity pursuant to the treaty, the reality was that people from PNG frequently travelled into Australia to receive treatment at Queensland Health clinics, particularly those located on the islands of Saibai and Boigu.17

Demand for Queensland Health services was increasing: Although data on the number of people from PNG who sought medical assistance in the Torres Strait were incomplete, there were “significant” and rising numbers receiving Queensland Health services. This caused a strain on Queensland Health services and subsequent access difficulties for Australian Torres Strait residents that contributed to local unease and tension.17

The committee found that the situation was complex, with “very strong push and pull factors” driving the trend for PNG residents to seek Queensland Health services.17

The factors included:

• A lack of health care services and resources in Western Province, and particular paucity in the South Fly District adjacent to Torres Strait.

• The proximity of Australian medical facilities for South Fly District residents. Queensland Health clinics on Saibai and Boigu islands are a 15–30-minute boat trip, costing about A$60 return for fuel, which was subsidised by the clinics.9 Daru hospital is a 2-hour boat ride, for which the cost of the fuel ranged from $180 to $240.

• Provision of health care by Queensland Health, with the support of the Australian federal government, to PNG residents who required urgent medical attention. This occurred on humanitarian and public health grounds, especially to prevent the spread of infectious diseases into Australia and throughout Western Province. Australia’s “level of care” extended to medical evacuations of people from PNG to the Australian mainland and Thursday Island Hospital,17 outside the Torres Strait Protected Zone. Only patients with acute life-threatening conditions were admitted (Box 2).15

Support for PNG health care initiatives by the Australian Government: The aim of this recommendation is that PNG residents will eventually not need to seek Queensland Health services in the Torres Strait region. The committee acknowledged the long road ahead, particularly in the remote Western Province. While AusAID supports development of PNG’s health system substantially through cooperative capacity-building exercises, the differential between health services in Australia and PNG will persist into the foreseeable future.

Reframing the health issues as a collaborative cross-border approach: Development assistance is primarily framed around a host nation’s needs. However, the Torres Strait situation warrants reframing as a regional cross-border issue and a specific project targeting the needs of both countries. This would need to move beyond the current model wherein the Torres Strait Health Issues Committee (known as the HIC), meeting twice yearly, examines health issues associated with the free border movement of PNG residents and Torres Strait islanders.7 Rather than the HIC, an adequately resourced, targeted project that deals with cross-border issues on both sides is needed, and one that particularly includes consultation with both PNG and Australian communicable disease physicians who work in the region.

Increased monitoring of Australian development projects in Western Province: While the committee’s recommendation for greater accountability over how Australian development funding is spent appears to be reasonable, what is needed is a greater focus on results and mutual accountability over the outcomes that would result from a harmonised approach to this cross-border issue.

Collaboration between all government agencies: The committee recognises that investment in health infrastructure by both the PNG and Australian governments in Western Province is insufficient. Continuing financial support is needed for maintenance so that the benefits of initial aid outlays are not lost — a recognition that is consistent with the redefining of sustainability in development.18 The committee encourages all agencies to work together in the use of resources, so “projects on both sides of the border should complement and strengthen each other”. The recognition that this is an “atypical jurisdiction” invites innovative solutions: the Torres Strait situation could be framed as a regional trans-border issue, and health authorities of Australia, Australian states, the Torres Strait, Western Province and PNG, as well as other stakeholders, could be invited to collaborate on developing a network of cross-border services, with defined objectives that address specific shared concerns. Given a long and continuing history of migration to the Torres Strait region from Asia and Melanesia,10 a broader regional approach could be justified. Experience from Australia’s tristate Aboriginal health services in Central Australia19 and from Mekong cross-border development collaborations20 provides appropriate models.

Continued provision of services by Queensland Health to PNG residents in the foreseeable future: On humanitarian and public health grounds, the committee stated its full support for Queensland Health. Yet Queensland Health will need to be better resourced by the federal government as part of a collaborative strategy for health care services at this regional interface. Failure to recognise this as an international obligation will see Queensland Health’s commitment to communicable disease control compromised. The economic and public health implications for Australia of reducing current cross-border communicable disease strategies warrant urgent attention. This is already a demonstrable concern for Australian health professionals working in the region, with Queensland Health’s recent decision, on financial grounds, to close its TB clinics on Saibai Island.

Review of Australian Government funding to Queensland to ensure it is commensurate with actual costs incurred: In view of the previous recommendation, it is unsurprising that the committee made this additional comment. Developing a cross-border project would enable clear costing of and responsibility for the agreed strategies, while building communicable disease control capacity within PNG and safeguarding Australian public health interests.

Current Queensland Health policy regarding access for PNG residents to health services from Australian health clinics — to provide acute services only — is in tension with public health imperatives and the long-term management of some chronic infectious diseases. Problems are compounded by the number of agencies and levels of government responsible for interlinked funding and health care provision bridging the border. Solving the problems demands a collaborative but innovative approach, with improved health services for the people of PNG in their own country as the long-term goal. In the interim, the Foreign Affairs, Defence and Trade References Committee report identifies a range of strategies and makes clear recommendations that will guide progress.

These recommendations are enmeshed with concepts of health diplomacy, as international health issues have now achieved foreign policy priority.21 The risk of cross-border disease transmission in the Torres Strait is a clear demonstration that health is a global, rather than a local, agenda.

People from PNG will continue to challenge the treaty provisions and seek lifesaving health services that are unattainable in their own country. A mother from Western Province making the 20-minute dinghy trip to a Queensland Health clinic seeking treatment for her young child with TB is unaware of any potential concerns of the Australian public — her need is urgent, and Australia has comparatively unlimited resources. This is the human side of the Torres Strait quandary, reminding us how intensely personal public health is, and how health and human rights arguments intersect.22,23

1 Map of the Torres Strait region, showing the boundaries between Australian and Papua New Guinean territory