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.
- 1. Kerr A. A federation in these seas: an account of the acquisition by Australia of its external territories, with selected documents. Canberra: Attorney General's Department, 2009. https://www.infrastructure.gov.au/department/media/publications/federation‐these‐seas‐account‐acquisition‐australia‐its‐external‐territories‐alan‐kerr (viewed Aug 2022).
- 2. Department of External Affairs. Agreement between the Government of the Commonwealth of Australia and the Government of the State of Singapore concerning the Provision of Treatment in Singapore Hospitals for Asian Residents of Christmas Island. Australian Treaty Series 1963 No. 15. http://www.austlii.edu.au/au/other/dfat/treaties/ATS/1963/15.html (viewed Apr 2023).
- 3. Department of External Affairs. Exchange of Notes constituting an Agreement between Australia and Malaysia relating to the Assumption by Malaysia of the Responsibilities of Singapore under the Agreement between Australia and Singapore concerning the Provision of Treatment in Singapore Hospitals for Asian Residents of Christmas Island of 6 June 1963, and for the Extension of the Operation of the Agreement. Australian Treaty Series 1965 No. 10. http://www.austlii.edu.au/au/other/dfat/treaties/ATS/1965/10.html (viewed Apr 2023).
- 4. Department of External Affairs. Agreement between the Government of the Commonwealth of Australia and the Government of the Republic of Singapore concerning the Provision of Treatment in Singapore Hospitals for Asian Residents of Christmas Island. Australian Treaty Series 1968 No. 13. http://www.austlii.edu.au/au/other/dfat/treaties/ATS/1968/13.html (viewed Apr 2023).
- 5. Department of Foreign Affairs. Exchange of Notes constituting an Agreement between the Government of Australia and the Government of the Republic of Singapore to amend the Agreement concerning the Provision of Treatment in Singapore Hospitals for Asian Residents of Christmas Island of 27 June 1968. Australian Treaty Series 1982 No. 6. http://www.austlii.edu.au/au/other/dfat/treaties/ATS/1982/16.html (viewed Apr 2023).
- 6. Department of Foreign Affairs. Exchange of Notes constituting an Agreement between the Government of Australia and the Government of the Republic of Singapore to terminate the Agreement concerning the Provision of Treatment in Singapore Hospitals for Asian Residents of Christmas Island of 27 June 1968. Australian Treaty Series 1985 No. 31. http://www.austlii.edu.au/au/other/dfat/treaties/ATS/1985/31.html (viewed Apr 2023).
- 7. Department of Home Affairs. Territory of Christmas Island: Report for period 1 January 1977 to 30 June 1978. Parliamentary Paper No. 425/1978. Canberra: Commonwealth of Australia, 1978. https://nla.gov.au/nla.obj‐1363897216/view?sectionId=nla.obj‐1503062335&partId=nla.obj‐1370196628#page/n8/mode/1up (viewed Apr 2023).
- 8. The Parliament of the Commonwealth of Australia. Christmas Island: Report of the Commission of Inquiry into the viability of the Christmas Island phosphate industry. Parliamentary Paper No. 36/1980. Canberra: Commonwealth of Australia, 1980. https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22publications%2Ftabledpapers%2FHPP032016007272%22 (viewed June 2023).
- 9. Australian Government, NSW Department of Education. Institutional racism. https://racismnoway.com.au/about‐racism/understanding‐racism/institutional‐racism (viewed June 2023).
- 10. United Nations Office of the High Commissioner for Human Rights. International Convention on the Elimination of All Forms of Racial Discrimination. Adopted 21 December 1965 by UN General Assembly resolution 2106 (XX). Entry into force: 4 January 1969, in accordance with Article 19. https://www.ohchr.org/en/instruments‐mechanisms/instruments/international‐convention‐elimination‐all‐forms‐racial (viewed May 2023).
- 11. Koziol M. Expansion of Christmas Island medical facilities to cater or up to 500 refugees. Sydney Morning Herald, 7 Mar 2019. https://www.smh.com.au/politics/federal/expansion‐of‐christmas‐island‐medical‐facilities‐to‐cater‐for‐up‐to‐500‐refugees‐20190306‐p51297.html (viewed Aug 2022).
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.