“Tough on borders”: how Australia’s immigration detention system fails refugee and asylum seeker health

Facilitating medical advocacy at individual and systemic levels to improve health and living conditions of people in immigration detention

Health care professionals attempting to advocate for individuals held in Australian immigration detention face a myriad of barriers. These range from difficulties in securing medical transfers, pressures to discharge patients to unsafe destinations, and poor communication between the federal government and their contracted companies about improving care for deteriorating patients in detention facilities. During the coronavirus disease 2019 (COVID-19) pandemic, substandard infection control measures in immigration have seen preventable outbreaks of the virus unfold among medically vulnerable individuals. With a history of border politics and deterrence strategies underpinning bipartisan federal government’s refugee and immigration policies, when it comes to refugee and asylum seeker health, politics can no longer be removed from advocacy.

Australia’s current system of immigration detention

Successive governments have used Manus Island and Nauru as detention facilities for thousands of asylum seekers attempting to seek safety in Australia.1 Under the Migration Act 1958,2 4183 individuals have been detained in regional offshore detention centres since the commencement of this system in 2012.1 Forty‐six deaths have occurred in detention facilities since 2013, 14 of those in offshore detention; multiple Australian refugee advocates have cited the conditions of detention as direct contributors.3 These include indefinite detention; lack of access to medical care, including appropriate mental health care; multiple cases of abuse; and living and hygiene conditions well below the expected.4,5,6 The coronial inquest into the death of Hamid Kehazaei from septic shock in the setting of a foot wound, found his death preventable in the setting of a 2‐day transfer delay to an Australian hospital.6 The detention of the (now freed) Australian‐born child Tharnicaa Murugappan resulted in her admission to hospital due to bacteraemia in the setting of untreated pneumonia.7 Multiple cases of physical and sexual assault have been reported, some inflicted on children.4,5,8

Detention facilities are managed by privately contracted companies such as Canstruct, to which the former Coalition government granted a $221 million contract to from January to June 2021.9,10 International Health and Medical Services (IHMS), tasked with the medical care of detainees, has been paid $138.8 million over the past 5years.9 However, there has been criticism that their medical care in detention facilities falls under the jurisdiction of Commonwealth immigration law and operates outside the scrutiny of state and territory health policies.11

Almost 1400 individuals remain in immigration detention in Australia in facilities such as the Villawood Detention Centre as well as alternative places of detention onshore.8 Ten of these individuals were initially transferred from offshore facilities under the now defunct Medevac legislation in 2019 and remain detained in alternative places of detention.8 Public Interest Advocacy Centre reports have found that adequate health care had not been delivered to Medevac refugees, particularly regarding mental health care services and mitigating transmission risks during the COVID‐19 pandemic.8 Many of these individuals had been detained indefinitely for up to 9years, with documented cases of exacerbated symptoms of trauma and suicide attempts. COVID‐19 outbreaks have been documented at the Park hotel and Villawood Detention Centre in the past 6 months.12,13 The Australasian Society for Infectious Diseases and many refugee health advocacy groups have called for the release of medically vulnerable individuals into the community and for a reduction in the number of people detained in densely crowded facilities.14,15 Vaccine administration has been well below that of the general public, with only 55% of detainees having received two doses of the COVID‐19 vaccine by February 2022.8

Prolonged and indefinite detention is recognised as a form of torture, and there is documented evidence that it compounds pre‐existing mental health illness in individuals who are torture and trauma survivors.16,17 As a signatory to the United Nations Refugee Convention and the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, the Australian Government is not fulfilling these responsibilities.18,19 UN member states, at a review of Australia’s human rights record in 2021, emphasised Australia’s ongoing violation of international law when it came to the offshore immigration processing system and indefinite detention.18,19

The way forward

What is medical advocacy and how does it pertain to refugee and asylum seeker health?

Physician advocacy has been defined as “action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well‐being”.20 Medical advocacy can be divided (broadly) into two categories:

• individual patients level, which includes actions taken in everyday practice to ensure patients receive appropriate interventions and care delivery that have a positive impact on their health;20,21 and
• systemic level, which includes actions taken to address the social determinants of health and remove barriers to appropriate health care access and delivery at a societal platform. This may involve appealing for hospital or governmental policy change, educational programs, and direct collaborative action involving marginalised or disadvantaged groups.20,21

The systemic form is crucial to bettering access to appropriate health care and improving living conditions of individuals held in immigration detention. Lobbying for legislative reform in this area often involves actions such as, but not restricted to, petitioning the government, peaceful protests, and the public support of medical associations, hospitals and practices.21

What are the barriers to medical advocacy in this area?

There is opposition to advocacy, particularly political, becoming the professional role of physicians.22 It has been outlined that the civic responsibilities of advocacy should not be included in the traditional definition of medical professionalism.22 More recent medical literature reflects that although most doctors are socially engaged, they are much less able to participate in systemic advocacy, citing time and knowledge as barriers.20,23 Doctors have also expressed that teaching surrounding systemic advocacy is lacking from a junior level of training and in medical school curricula.23

When doctors do wish to speak out, there are several issues that complicate the process. Many health care providers employed by the Department of Immigration and Border Protection and IHMS report conflicting interests in speaking out about the conditions of immigration detention, poor health screening and medical negligence.24,25 There are many cases of recommendations for medical transfers and referrals to specialists being ignored by IHMS and the federal government.6,7,8,24,25 Historically, whistleblowing in health care has not been welcomed on a systemic level when it comes to immigration detention, as was the case in the now repealed Australian Border Force Act 2015.8,11,25,26,27

Discharging refugees and asylum seekers from inpatient hospital settings to detention facilities has presented clinicians with further dilemmas. There have been instances of pressures exerted by the federal government and the Australian Border Force to discharge patients once inpatient care has been completed, despite concerns that adequate safety and continuity of care in detention has not been guaranteed.8,12 The Australian Medical Association (AMA) has also stated that doctors should have “reasonable professional autonomy and clinical independence without undue external influence”.16

Normalising and promoting medical advocacy for refugees and asylum seekers

Despite the recommendations of multiple peak medical bodies (including the AMA and the Royal Australian and New Zealand College of Psychiatrists) to improve the health care provision in immigration detention, the federal government’s policies (founded, arguably, in a history of border politics as an election tool) have demonstrated that our current system of immigration detention is damaging to refugee and asylum seekers health.16,17,28

There is a strong argument to be made for the professional responsibility doctors and health care providers hold in speaking out when governing politics obstruct an individual’s right to universal health care.8,20,21,23,24,28

How do we normalise medical advocacy for refugee and asylum seeker welfare? Facilitating medical advocacy projects and formal advocacy training in medical schools and during prevocational training is an important first step.20,23,26 Learning what legislation at a local, state and federal level exists that supports and undermines vulnerable groups such as refugees and asylum seekers is vital. Subsequently, this can be centred on learning about engagement with Members of Parliament (MPs), how to support and start petitions, and the different forms of protest in which health practitioners can be involved to support improved conditions in immigration detention and ending indefinite detention.20,23,26 A long‐touted example is that medical professionals boycott working in Australian immigration settings.24,25 The power of medical protest has been significant. The refusal of doctors working at the Lady Cilento Hospital in 2016 to discharge asylum seeker baby Asha to Nauru (from where she was transferred with burns sustained in detention) was a striking movement at the centre of public protest that resulted in her release into community detention.29 Then AMA President Brian Owler’s statement calling on doctors to condemn inhumane treatment of asylum seekers in the national interest was a galvanising moment of medical advocacy and leadership.29 More than 170000 individuals signed the petition as part of the subsequent “Kids off Nauru” campaign.29

When refugees and asylum seekers are transferred to hospitals from detention facilities, medical professionals should be able to deliver inpatient care and independently make decisions about the safety of a discharge destination.16,30 Organisations such as Doctors4Refugees have outlined that a thorough risk assessment of the living conditions within an immigration detention centre should occur, with special regard to the likelihood for deterioration of one’s mental health, before approving discharge.30 This would require a multidisciplinary meeting with hospital administrators to deliver a unified stance, and to extend models of care to incorporate patients from immigration detention.30 When refugees and asylum seekers are admitted to hospitals or other health care settings, comprehensive medical screening with respect to communicable diseases, immunisation schedules and their psychosocial history should be completed.16,30

Finally, accountability for medical care delivered to refugees and asylum seekers in detention has not been addressed. Before 2013, the Immigration Health Advisory Group, consisting of specialists in areas including psychiatry and public health, advised the Department of Immigration and Border Protection to ensure that an appropriate standard of health care was implemented in immigration detention.11 Following its disbanding in 2013, the independent oversight into the medical care of detainees is lacking. There needs to be renewed calls by more medical professionals, reinforcing the AMA request for an independent panel of experts who regularly review the conditions and medical care delivered by IHMS in immigration detention.11,16 We must ensure that where government policy has overridden provision of health care commensurate to that of the Australian public, investigation into medical negligence in immigration detention is undertaken.