Treaties for “offshoring” hospital treatment of Asian patients from Christmas Island, 1963–1985: a racist chapter in the history of Australian medical care

Simon Barraclough, Alison Hughes and John Oldroyd
Med J Aust 2023; 219 (2): 57-59. || doi: 10.5694/mja2.52009
Published online: 17 July 2023

The Australian Government's offshoring policy for hospital care of Christmas Island residents classified as “Asian” contradicted the spirit of the United Nations multilateral convention against racial discrimination

Situated about 350 km south of Java, Christmas Island was transferred to Australian sovereignty by the United Kingdom in 1958. Previously, it had been part of the Colony of Singapore. The island's economy was based almost entirely on the mining of phosphate.

Most of the population of the island were Asian people originating from Malaya, Singapore, China and the Cocos Keeling Islands, and were recruited to work as phosphate miners. As part of the transfer negotiations, it was agreed that Australian citizenship would be granted to those born on the island after the transfer. Residents who were British citizens were permitted to become Australian citizens. In 1957, there were about 2000 inhabitants on Christmas Island.1

At the time of the acquisition of Christmas Island, elements of Australian public policy were characterised by overtly racist ideology. Indigenous Australians were not counted in the national census and faced discrimination in many aspects of their lives. The White Australia Policy sought to prevent non‐European immigration.


Offshore hospital treatment: the Australian Government's arrangements with Singapore

A problem for the Australian administrators of this new Indian Ocean territory was the provision of hospital treatment. It was thought to be uneconomical to construct and maintain a major hospital for such a relatively small population. Nor did Australia have a universal national health insurance system. Except for Queensland (which had free public hospitals), charges for treatment in public hospitals were means tested. It was therefore decided in 1963 to finalise a formal treaty with the authorities in Singapore (at that time a British colony) to provide public hospital facilities for Christmas Island residents of Asian descent. The fact that the treaty was based on a racial criterion was no barrier to its acceptance by the United Kingdom Government. The treaty did not define “Asian” or specify how the identity of such persons was to be established.

The treaty was for a period of two years and involved an annual payment to the Singapore Government of “twenty‐five thousand Malayan dollars” for the treatment in Singaporean public hospitals of Asian residents of Christmas Island suffering from “mental disorder, tuberculosis, leprosy, opium addiction or needing orthopaedic or other surgical treatment”.2 Treatment was subject to the availability of beds in Singaporean hospitals and patients would only be transferred if treatment could not be provided on Christmas Island. Patients in the scheme were subject to laws governing immigration and health in Singapore.

The Australian Government undertook to pay the travel costs of patients in the scheme, to provide the medical records of prospective patients and, except for emergency cases, to seek the approval of the Director of Medical Services in Singapore before sending patients for treatment. The opinion of Singapore Government medical officers “as to the desirability or necessity of any particular patient being hospitalised in Singapore”2 would be binding, and patients refused treatment after arrival would have their return transport costs covered by the Australian Government.

In June 1965, it was necessary to renegotiate the treaty with the Government of Malaysia after Singapore's incorporation into the Federation of Malaysia in 1963.3

In 1968, a new treaty containing most of the provisions of the original agreement was agreed with Singapore, which had separated from Malaysia in 1965. This treaty restricted the treatment of Asian residents of Christmas Island to “free‐class wards of Singapore hospitals” and stipulated that “if the patient wishes to be admitted to the paying‐class wards he or she will be accepted as any member of the public and charged at rates chargeable to the public”. It was also agreed that “consultations and out‐patient attendances shall be charged for at current rates”.4

Rising costs of hospital treatment led to a further treaty in 1982. This provided for a 20% increase in the yearly payment from the Australian Government. In addition, the original description of the wards was revised to reflect Singapore's changed policy on charging patients in public hospitals. Free class wards now became C class wards and paying class wards were termed higher class wards.5 By definition, Christmas Island patients would therefore be treated in lower class wards.

It was not until 1985 that the scheme was ended by the final treaty in the series.6 By this time, Australia had established Medicare, a universal national health system open to all permanent residents, including those on Christmas Island.


Reflections on the history of the scheme

The scheme was ostensibly benevolent in intention, having at its core the welfare of the majority of the island's inhabitants by providing them with hospital care. It was also economically rational in that it saved the Australian Government the expense of constructing and maintaining specialist hospital facilities for a small population. It also obviated the need for complex financial administration by negotiating a flat fee‐for‐service with Singapore's authorities. In cases where urgent treatment was necessary, Singapore had the advantage of being about half the distance by air in comparison with Perth, Western Australia. There would also be potential savings for evacuation costs.

Yet, as the title of the treaties made clear, the scheme was unashamedly based upon the racial classification and segregation of patients, although the terms of the agreements did not define “Asian”. Asians were to be treated in Asia. The scheme also had a residual colonial association: Asian patients would be treated in an Asian country that was once part of the same colony as Christmas Island. Moreover, the specific inclusion in the original treaty of leprosy and opium addiction in the types of illness to be treated could be considered as redolent of historical efforts to stigmatise Asians as part of efforts to prevent their immigration to a White Australia. Racial factors were also evident in employment practices for the island's phosphate industry, which was managed by the British Phosphate Commissioners. “Regionally engaged” workers recruited from Asian countries were paid at a lower rate than “mainland engaged” workers and were subject to limited‐stay visas.7 This discriminatory wage policy was ultimately ended after a trade union campaign.8

These formal treaties, resulting in differences in medical management based on race, can be viewed as institutional racism. This is a practice which occurs when “organisations, institutions or governments discriminate, either deliberately or indirectly, against certain groups of people to limit their rights”.9

It is significant that, in this case, treaties based on racial discrimination continued despite Australia embracing the United Nations International Convention on the Elimination of All Forms of Racial Discrimination10 in 1975 and enacting legislation further to this treaty in the same year. Both measures were taken by an Australian Labor Party ministry led by Gough Whitlam.

The Convention's preamble asserted “that the United Nations has condemned colonialism and all practices of segregation and discrimination associated therewith”. However, there were provisions under Article 2 for states to take “concrete measures to ensure the adequate development and protection of certain racial groups or individuals belonging to them”.10

Despite the racial basis of the treaties with Singapore conflicting with the spirit of the UN Convention, the Whitlam ministry did not seek to rescind the agreement. It could be argued that the special provisions for Asian patients in the treaties represented a form of special protection and were therefore permissible under the Convention, although these patients were restricted to lower class wards in Singapore's hospitals.

It is perhaps telling that, in recent years, Christmas Island again featured in medical offshoring policies by the Australian Government. This time, the aim of policy appears to deny asylum seekers held in offshore detention centres in Papua New Guinea and Nauru from receiving medical care on the Australian mainland by detaining them on Christmas Island. This necessitated expanding hospital facilities and increasing staff numbers in the Christmas Island detention centre.11 Once again, racial identity could be considered a factor in health care policy as the asylum seekers were predominantly non‐European.


Provenance: Not commissioned; externally peer reviewed.

  • Simon Barraclough1
  • Alison Hughes2
  • John Oldroyd2

  • 1 La Trobe University, Melbourne, VIC
  • 2 Australian Catholic University, Melbourne, VIC


Open access:

Open access publishing facilitated by Australian Catholic University, as part of the Wiley – Australian Catholic University agreement via the Council of Australian University Librarians.

Competing interests:

No relevant disclosures.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.