AMA Speech - Prof Owler, AMA Asylum Seeker Health Forum
SPEECH TO AMA FORUM ON HEALTH OF ASYLUM SEEKERS
SUNDAY 21 FEBRUARY
AMA PRESIDENT PROFESSOR BRIAN OWLER
***Check Against Delivery
Welcome. I acknowledge the traditional owners of the land on which we meet, and pay my respects to their elders, past and present.
There are times, in any nation, where the medical profession must act in the interests not only of our patients as individuals, or for patients in a health system, but it must act in the national interest.
Doctors, along with nurses, lawyers and others, must lead a debate on an issue of national importance.
I believe that is the case when it comes to the issue of children in detention and Australia’s provision of health care to asylum seekers.
Each of our presenters today has demonstrated clearly why there is a need for the medical profession, and others, to speak up and to advocate to remove children from detention.
I want to thank each of you not only for your presentations here today, but also for your candour, your conviction, and your courage in taking the approach that you have.
I am proud to be the President of the AMA. When I see the commitment that so many of you have shown by attending today it makes me even more so.
We should all be proud of the stand that our colleagues have taken.
Doctors at the Royal Children’s Hospital in Melbourne and, of course, more recently at the Lady Cilento Hospital in Brisbane have refused to release children from hospital because they would be returned to detention.
Some commentators have seen this as a form of political protest. But as a doctor working in a paediatric hospital, who deals with the consequences of physical abuse, I know that there is no reasonable other option for these doctors and nurses to take.
There is an absolute ethical, not to mention moral, obligation to that patient who is in their care. The obligation is to not release a child back into a situation where they have reason to believe that there is a risk of harm, whether that be physical or psychological.
Let me say that it is not an issue of denying someone else a bed for elective procedure. The obligation of that hospital, of those doctors, and nurses, is to the patient that is under their care.
To those doctors and nurses, and indeed, the State Governments and hospital administrators who have supported them, let me say you have our support.
Last night I became aware that lawyers for Baby Asha had been refused access to her mother. This communication blackout usually precedes a transfer.
It was reported that guards were to forcibly remove Baby Asha from Lady Cilento Hospital against medical advice.
I was shocked. I made a number of calls. Bill Shorten did call Prime Minister Turnbull to seek reassurance that this would not happen.
As I said last night, security guards entering a hospital to forcibly remove a patient would be unprecedented in this country.
It a line that cannot be crossed. If crossed, there is no return.
Although there was reassurance nothing would happen last night, it seems that the reprieve may be temporary.
You have to ask why the Department of Immigration and Border Protection is pulling apart the moral fabric of this country!
So, is there is a reason to believe that a child would be at risk? Well, that question has already been answered.
The 2014 Report of the Human Rights Commission: The Forgotten Children clearly documents the harms that children experience as a result of mandatory detention.
On that note, I acknowledge the presence here today of Professor Gillian Triggs and acknowledge the work that the Commission has done to highlight these issues.
The Report documents that the rates of mental health disorders were significantly higher compared with children in the Australian community. These findings included cases of self-harm by young children.
Children being detained on Nauru are suffering from extreme levels of physical, emotional, psychological, and developmental distress.
The results of this national inquiry could not be more clear.
As noted in the Report, both former and current Ministers at that time agreed that holding children for prolonged periods in detention does not deter people smugglers.
I acknowledge that the then Minister for Immigration, Scott Morrison, did reduce the number of children in detention significantly.
But today there are still 67 children on Nauru.
What is just as concerning is the plight of 80 other children, including 37 babies who, as a result of the recent High Court decision, are inexplicably about to be sent back to Nauru.
And inexplicable it is. In fact, the Human Rights Commission Report noted that there was no rational explanation for the prolonged detention of children.
The fact of the matter is that prolonged detention of children is a State-sanctioned form of child abuse - and we call for it to stop.
Immigration has enriched our society. That includes those who have come by boat, those who have fled wars and persecution.
I know of one young boy who fled his country by boat - stuffed on an overloaded boat, he became unwell and almost died.
The boat was seized and he was returned to his homeland, where he and his family were jailed. They fled again by boat, reaching Australia, where he and his family this time were sponsored by a local family.
This is a story that is similar to any of those children who are in detention now. The difference here is that he was Vietnamese and it was the 1970s. He and his family were embraced by Australia.
He grew up to become an anaesthetist. I am proud to have had him as my anaesthetist for 10 years.
There are many other examples of the contribution that asylum seekers have made to Australian society.
In the theatre next to mine at Norwest Hospital is a man who started his journey as a young Iraqi doctor working in Iraq during the Saddam Hussein regime.
He fled Iraq when his senior doctor was shot dead in the car park by soldiers for refusing to cut the ears off deserting soldiers.
He fled to Malaysia and then Indonesia, and came here by boat. He spent months in Curtin detention Centre, where he was treated appallingly.
When he was finally released, he completed his orthopaedic training and joined our defence force.
He is an expert in osseous integration, and has given many British soldiers, who are double amputees as a result of military injuries, the ability to walk again.
In fact, when Prince Harry was here recently, he made a special visit to him and to see his work. I am proud to call him a colleague and friend.
I am aware of many others who are among the brightest and the best of our profession who did not start life with privilege, but fled in fear of their lives seeking asylum in Australia, where they found safety and made a home.
They have enriched our country, and we should be proud to have them as Australian citizens.
Detention is not just harmful to children.
The same psychological consequences occur for adults, particularly when detention is prolonged and seemingly indefinite.
When people are detained for whatever reason, they have a right to the provision of an appropriate level of health care.
The AMA’s policy is clear.
It is the AMA position that all asylum seekers and refugees under Australian care should have access to the same level of health care as Australian citizens.
In addition, it should be ensured that their special needs, including their cultural, linguistic, and health-related needs, are addressed.
In October last year, at its 66th Annual Assembly in Moscow, the World Medical Association issued a Resolution on the Global Refugee Crisis.
It emphasised the damage to one’s health imposed by becoming a refugee, and called on nations to play their part in the immediate care and support of these vulnerable people.
You have heard today from our esteemed colleagues how, from their direct experience and observations, Australia’s treatment of asylum seekers could not be considered acceptable.
The defence of this situation, even from the Secretary of the Department of Immigration and Border Protection, has been that there are places in Australia where Indigenous people do not have access to the same level of services.
Actually, having returned from remote communities in Central Australia yesterday, that may be true for Indigenous people living in remote communities.
Even so, it is not a defence; if anything it is an indictment on the health care provided to our own Indigenous people.
As President of the AMA, I have been approached by concerned doctors and advocates about particular cases.
The case of an otherwise healthy 24-year old Iranian asylum seeker who died of a treatable condition stands out.
This man presented with early sepsis while in detention on Manus Island. He had a temperature of over 40C, he was tachycardic, and hypotensive.
He was started on antibiotics. He developed cellulitis and, over the next 24 hours, another antibiotic was instituted - but his symptoms did not settle.
It was decided that the patient should be transferred for inpatient care at Port Moresby the following day on a commercial flight. He was to be escorted by a doctor who was travelling on the same flight.
The following morning, at 10.30am, the request was made for approval for the transfer, and he was booked on the flight. At 3.30pm, there was still no approval and the transfer was therefore cancelled.
That night, the patient deteriorated and developed septic shock with adult respiratory distress syndrome. He was saturating at only 77 per cent.
An emergency evacuation was arranged through International SOS. He was transferred from Manus Island to PNG Pacific Private via air ambulance.
He was not intubated for reasons that are unclear.
The patient was saturating at 60 per cent, and was unconscious on arrival at the ED at Pacific Private in Port Moresby.
There was apparently no warning to the hospital that the patient was arriving, and a further hour and half passed before the patient was intubated and resuscitated.
By this time, the patient was brain dead. He was transferred to the Mater Hospital in Brisbane where this was confirmed, and treatment was later withdrawn.
The death was referred to the Queensland Coroner. A report was also prepared by the Department of Immigration and Border Protection. This latter report has not been released to the public.
The fact is that this young man should never have died. He should have been treated. If he had had access to appropriate treatment in a timely manner, he would still be alive today.
However, the overall attitude may be summed up by the following report from the Sydney Morning Herald, which quotes a leaked report by a service provider on the Island:
"It is likely some Iranian transferee will spread malicious rumours about GDD059's death to further their own personal agendas, as well as to exploit unrest to further their own agendas and standings amongst their countrymen."
When you have people in isolated tropical locations under these conditions, people will have significant health problems.
It is not possible to provide the level of care that Australian citizens would expect when you are on an island as isolated and remote as Manus Island or Nauru.
Keeping people in such locations when they are sick places these people at risk of death.
More recently, I was asked to look into three different cases about which doctors and advocates had raised concerns.
A 70-year old who had been an inpatient in PNG Pacific Private in Port Moresby for 7 months was returned to Manus Island detention facility where he then waited 20 days for a doctor’s appointment.
His diagnosis was described as being a heart condition with high blood pressure.
His legs, of which I was provided pictures by an advocate, were grossly swollen and oedematous.
He was only able to stand or walk for a few minutes. It turns out that he has TB pericarditis, and he was obviously in gross cardiac failure.
A young man who complained of headaches was investigated and found to have a small pituitary tumour on an MRI performed in Port Moresby.
He has not had a full panel of blood tests as anyone in Australia would normally have. His eyesight reportedly deteriorated, and he complained of more severe headaches.
He was transferred back to Manus Island where he was seen by an endocrinologist by teleconference, who prescribed a two-year course of medication. An eye review by an optometrist was to be conducted within six months.
We were last told that he had not received any medication, because the doctors were unsure if he wanted to take it. Therefore, it had not been ordered for the island.
Finally, another man appears to have deteriorating mental health with PTSD and depression. He was witness to a brutal murder, for which two former detention facility workers have been charged.
He remains in the same environment where the event occurred that started his PTSD. Is not removing him from such an environment the most logical and basic step that could be taken to assist this man?
It is not appropriate to keep these patients on Manus Island or Nauru. They need proper investigation and treatment. They need health care.
I have written to Minister Dutton in relation to these cases, and I have met with Dr John Brayley, who is the Chief Medical Officer and Surgeon General of the Australian Border Force.
Dr Brayley was unaware of most of the cases we raised with him.
And, consistent with the culture of secrecy that I have described, at every step of the process there were barriers and obstacles imposed that made transparent health care almost impossible.
First, these asylum seekers needed to provide me with a signed and scanned consent form, but the Department couldn’t tell me if they have access to scanners on Manus Island.
Their own health records were eventually provided to the detainees after some delays, but they were on computer discs. The Department couldn’t tell me if they had access to the appropriate IT to read them.
When I was eventually provided with these heath records, they were also on a disc. Only it was password protected - and the Department didn’t supply the password.
As a result of this process and our intervention, I am pleased to say that Dr Brayley recommend urgent transfer of the man with TB pericarditis to the mainland.
I want to say that I believe Dr Brayley is a good man. He has done great work in his previous roles, but he is clearly in an impossible situation.
It took a week of emails and calls, but this sick man was eventually transferred. I don’t know where to, or what the outcomes are, but I am told that he has been removed from Manus Island.
The concerns about the other patients remain, but this process also highlighted two other major concerns.
First, it took the President of the AMA to write to the Minister for Immigration, arrange an appointment with the Chief Medical Officer, and provide health records and photographic evidence, before action was taken. That is not open, transparent, and appropriate health care.
It is also absolutely wrong that the decision on transferring this asylum seeker for urgent treatment was not made by medical practitioners, but by IHMS.
It was not the ABF’s Chief Medical Officer who made the decision. He could only make the recommendation.
So, when the Government and the Minister say asylum seekers enjoy the same level of health care as ordinary Australians, that is simply not true.
In Australia, when a doctor makes a clinical recommendation, including medical transfers involving significant distances, a request does not need to be made to the Department of Health for clearance.
Recently, the Department of Immigration told the Senate Estimates hearing that they decide who is transferred, not the Chief Medical Officer, or the treating physician.
Doctors should not only exercise their professional judgment in the care and treatment of their patients, but they must be able to speak out about unjust, unethical maltreatment of asylum seekers without persecution or prosecution.
Rather than a culture of clinical independence and transparency, we have the Border Force Act – a piece of legislation that was passed with the support of both the Coalition and Labor, but opposed by the Greens.
The AMA is rightly concerned about the restrictions contained in the Border Force Act.
Despite the Government’s claims that the intent of the Border Force Act is not to prevent doctors from reporting publicly on conditions in detention and regional processing facilities, the AMA has received legal advice that does not reassure us.
There are provisions in the Border Force Act that are unnecessary and shouldn’t apply to healthcare workers.
The legislation must be amended to make it absolutely clear that it does not apply to doctors or nurses working in detention facilities.
It is imperative that medical practitioners working with asylum seekers and refugees put their patients’ health needs first. And, to do this, we must have professional autonomy and clinical independence without undue outside pressure.
Apart from the Border Force Act, in December 2013, the Abbott Government disbanded the Immigration Health Advisory Group.
This group, known as IHAG, consisted of independent doctors who were able to access and assess the medical care of asylum seekers in detention. It was transparent, and provided advice to Government.
There has been no replacement. Instead, when this was raised with the previous Minister, we were flatly told that internal advice was available, and there would be no such group established.
The AMA has continued to call for the establishment of an independent panel of doctors and other health professionals who can provide independent advice to Parliament, and who can report in a transparent manner on health-related issues.
At the end of the day, if Minister Dutton and the Department of Immigration and Border Protection believe that the care and treatment of asylum seekers is at a level that is appropriate, then why should they oppose this level of transparency?
Let me say that the game is up when the Nauruan Government cancels tourist visas for Australians and New Zealanders because they might see something that could be reported.
Refugee and asylum seeker policy is complex. It is also highly political. Both the Coalition and the ALP know that elections have been won and lost on this issue.
A narrative that creates fear among the public by confusing the plight of asylum seekers with the issues of security and terrorism has helped to reinforce support for the Government’s policy.
The dehumanisation of the asylum seekers by Minister Dutton and others referring to these people as ‘illegals’, combined with cloaking them in secrecy in offshore processing, has made it more difficult for the Australian public to identify with these people.
The predominance of mental health conditions among the problems of detainees, including among children, does not seem to convey the same sense of seriousness as it might if the problems were physical.
A question has to be asked about the apparent pervasive indifference to mental health conditions despite the promotion, discussion and apparent progress that has been made in this area.
Somehow, these asylum seekers seem less worthy. The Syrian asylum seekers that we can see arriving in Europe or waiting in Turkish refugee camps seem more human and in need of help.
I was pleased at the announcement that Australia was accepting 12,000 more Syrian refugees, but disappointed that the same indifference to the asylum seekers in offshore processing centres remains.
It should be noted that only 26 of the 12,000 refugees have actually been accepted.
There is no doubt that hundreds of people died at sea while trying to reach Australia. No one wants that situation to arise again.
But, as I mentioned previously, there is widespread acknowledgement that the detention of children has no impact on the actions of people smugglers.
It is also no excuse for the lack of transparency and inadequate provision of health care to the asylum seekers for whom Australia has a responsibility.
The issue of a boycott in terms of providing services to detention facilities by Australian doctors has been raised a number of times.
I don’t agree that is the way forward, not just because IHMS will recruit from overseas, as it is already doing, but for simple reasons.
Provision of medical treatment to asylum seekers is not condoning the system or being complicit. Far from it. Rather, it is what doctors and nurses always do. They put the patient first.
As I said at the National Press Club last year, it would not matter what we said on this issue. Doctors would go and care for these people because that is what doctors do.
If we want to change the Government’s approach, it must be through the weight of public opinion.
Australians need to understand that this is not an argument based on political ideology.
Rather, it is an argument based on our Australian identity, not just in terms of how the rest of the world sees us, but how we see ourselves.
It is based on the prevention of harm, the welfare of our patients as people but, most importantly, it is based on compassion. It is the right thing to do.
There will be some who might wonder why the AMA has spoken out so strongly on this issue.
As doctors, we care for all people, without regard to race or creed, without regard to where they come from. That is a basic moral tenet of our profession.
My message to the Government and to the Labor Party is this: You need to listen to doctors, nurses, and other health practitioners - particularly the experts in the fields of psychiatry and children’s health.
The AMA is calling for the following:
One - a moratorium on asylum seeker children being sent back to detention centres.
Two - the immediate release of all children from both offshore and onshore detention centres into the community where they can be properly cared for.
Three - the establishment of a transparent, national statutory body of clinical experts, independent of government, with the power to investigate and report to the Parliament on the health and welfare of asylum seekers and refugees.
And, four - if the Government or Opposition cannot provide satisfactory health care to people seeking asylum, then their policies should be revisited.
Australia, to me, represents democracy, freedom, openness, and accountability. A fair go and honesty are sources of national pride.
The reality is that children, and adults, are being subjected to physical and emotional harm.
People are being moved in the middle of the night without notice; under a cloak of secrecy and intimidation.
Denying people access to the legal representatives.
Threatening to forcibly remove a baby from Hospital against medical advice.
Our colleagues are being intimidated.
It is being done by the Australian Government, and it is being done in our name.
This is happening now. It is occurring during our time.
It’s time for all of us to listen to our conscience. To give a voice to our better angels.
It’s time to say that this is not what Australia is, it is not what Australia stands for, and we want it to stop.
Colleagues and friends, it is a simple truth that asylum seekers are people like me, like you.
They are no different. Just as our friends and colleagues came here seeking asylum for themselves and their families, to escape persecution and death, so are these people.
But, just like all of the other wrongs, Australia’s detention of children and our treatment of asylum seekers is indefensible because it fails the one true test.
That test is how we love and care for our fellow man and woman, and particularly how we love, care, and nurture the children of this world.
21 February 2016
CONTACT: John Flannery 02 6270 5477 / 0419 494 761
Kirsty Waterford 02 6270 5464 / 0427 209 753
Published: 21 Feb 2016