December 20, 2013
Exclusive: Fifteen doctors write letter detailing ‘gross departures’ from medical norms towards detainees on Christmas Island.
A group of asylum seekers arrive on Christmas Island in December. Serious concerns have been raised about the medical standards on the island. Photograph: Jon Faulkner/AAP
A group of doctors has revealed the shocking standard of medical care they are made to provide asylum seekers at the Christmas Island detention centre in a 92-page “letter of concern” given to their employer in November.
The forensic report, written by 15 doctors and obtained by Guardian Australia, is the most comprehensive document yet on the failings of medical procedure inside detention centres and is a damning indictment of the Australian government’s care for refugees.
The report documents “numerous unsafe practices and gross departures from generally accepted medical standards which have posed significant risk to patients and caused considerable harm”.
It paints a vivid picture of the indignity of detention through distressing and detailed case studies.
The doctors claim:
• asylum seekers are examined while exhausted, dehydrated and filthy, their clothing “soiled with urine and faeces” because there are no toilets on the boats
• patients are “begging for treatment”
• asylum seekers must queue for up to three hours for medication. Some have to queue four times a day
• antenatal care is unsafe, inadequate and does not comply with Australian standards; there is an ultrasound machine on the island but rarely anyone who knows how to use it
• there is a high risk of depression among children and no effective system for identifying children at risk
• basic medical stocks are low; drugs requested by doctors are not provided
• long delays in transferring patients to mainland hospitals are leading to “risks of life-threatening deterioration”.
The doctors claim their professional integrity has been put at risk and that they are being paid to compromise their medical ethics.
They describe a fundamental conflict of interest between their employer, IHMS (International Health and Medical Services) and the Department of Immigration and Border Protection.
They write: “We have concerns that decisions made by IHMS regarding the provision of care to patients have been compromised by their relationship with the DIBP. As a result, these decisions are not always in the best interest of the patient.”
They fear exposing themselves to possible repercussions for working in such a system. “It is of concern that practitioners working within IHMS may be putting any registration they have with Ahpra [Australian Health Practitioner Regulation Agency] at risk by participating in unethical conduct and in gross departures from clinical standards,” they say.
The report was written in November at the invitation of IHMS, which provides medical care to more than 2,000 asylum seekers detained on Christmas Island and the many thousands of men, women and children processed there on their way to camps on Manus and Nauru.
Glimpses of the medical troubles on Christmas Island have been given in the past by whistleblowers and peak bodies such as the Royal Australasian College of Physicians. But the doctors’ report to IHMS is the most comprehensive account yet of failings in medical care and practice on the island.
They write: “Even when mitigating factors, such as the remote location and the practical limitations imposed by the Department of Immigration and Border Protection are considered, many aspects of the IHMS health service fall well below accepted standards for clinical practice and are unnecessarily dangerous.”
The doctors claim the problems begin the moment asylum seekers reach Christmas Island. They say flaws in initial health assessments are made even worse by the Abbott government’s demand that all asylum seekers who can must depart within 48 hours for Manus or Nauru.
The doctors document with case studies unsafe and inadequate antenatal care; inadequate medical care for children; the risk of life-threatening deterioration in patients waiting to be flown to hospitals on the Australian mainland; shortages of facilities, equipment and medications; unsafe prescribing practices; poor treatment of diabetes; and inadequate programs to prevent the spread of infectious diseases among detainees.
IHMS told Guardian Australia they were taking the letter “seriously” and that senior medical staff had held discussions with “the majority of co-signatories regarding the issues raised”.
The statement continued: “As per the terms of our contract, and recognising the range of issues, we have shared the letter with the Department of Immigration and Border Protection”.
Guardian Australia understands the letter was passed to the department shortly after it was delivered to IHMS in November.
IHMS said they do not accept that is any under a conflict of interest with their obligation to their patients and the department of immigration and border protection.
“IHMS values the contribution of all of our professional medical staff to ensure our care to people in detention remains of the highest standards.”
IHMS identified Dr John-Paul Sanggaran as the principal author of the letter.
IHMS said thatDr Sanggaran was employed on Christmas Island in September and October 2013. “This was during a period of high intensity, with an unprecedented number of arrivals and an increased number of people presenting with a range of significant complex medical conditions.”
They added: “We look forward to working constructively with Dr Sanggaran to review these matters and to resolve his concerns.”
Dr Sanggaran told Guardian Australia: “I’m hopeful that there will be improvements in the care of those detained on Christmas Island and that improvements already made can be maintained.”
Despite repeated requests, the immigration minister, Scott Morrison, would not provide a comment.
Health induction assessments (HIAs) on arrival:
Asylum seekers are examined while exhausted, dehydrated and filthy, their clothing “soiled with urine and faeces” because there are no toilets on the boats.
“The arrivals frequently express their embarrassment at their state. They apologise for the smell and filth they are covered in.”
At busy times the assessment may take as little as five minutes. The doctors report a case of TB that went undiagnosed for 44 days. “Potentially the entire camp has been exposed.”
The asylum seekers’ own medical records have been thrown away. “This is a serious patient safety issue.”
Their medications have also been discarded without being recorded. Glasses, hearing aids and prosthetics are confiscated and often destroyed.
“A single replacement hearing aid has not been seen by any undersigned doctor working for IHMS.”
A number of hitherto standard health checks were abandoned in July and September this year as Canberra demanded faster transfer to Manus and Nauru.
The doctors conclude: “HIAs, as carried out by IHMS, are not fit for purpose and unreliable. They cannot and should not be relied upon for any reasonable assessment of a person’s health.”
The most urgent cases are supposed to be flown to the mainland within two weeks. “Despite this, few category one patients leave before four weeks and some wait at least as long as two months. There have been periods of time where no patients have left the island despite needing immediate tertiary attention.”
Among the case studies in the report are a baby needing heart surgery who waited two months to be flown to the mainland; a child placed on the transfer list for more than two months who was flown instead to Nauru; a man eventually sent to the mainland who returned to the island not having been treated; and others with disabilities and significant injuries still waiting for transfer at the time of the writing of the report.
“Antenatal care provided by IHMS is unsafe and inadequate and does not comply with Australian standards.” The doctors are particularly concerned by the difficulty of conducting ultrasounds. There is a machine at the island hospital. “However, there are usually no ultrasonographers available, as they only visit every few months and cater primarily for local residents.”
A woman with a “very high-risk pregnancy” – thought to be twins by medical authorities in Indonesia and on Christmas Island – was transferred to Nauru. The doctors write: “IHMS management stated to staff the Department of Immigration and Border Protection were ‘setting an example’.”
Backed by the Royal Australasian College of Physicians and UNHCR, the doctors view detention as “unsuitable for children and a contravention of human rights”. They believe their duty of care to children requires “advocating for their immediate removal from the detention environment”.
The doctors say there is inadequate screening for nutritional deficiencies, inadequate testing of sight and hearing and no monitoring of growth and development for the hundreds of children detained on the island.
“None of the scheduled physical and developmental assessments that would normally occur in the community (typically by a maternal child health nurse) occur at Christmas Island immigration detention centre.”
They say there is “no effective system in place” to detect children and adolescents at risk because of “the deleterious effect of indefinite detention” and “no child specific mental health services on the island (i.e. no paediatric psychologist or psychiatrist)”.
“Christmas Island immigration detention centre is unsuitable for any person living with significant intellectual or physical disability. The detention environment exacerbates their burden of care and the facilities and medical services provided are inadequate to accommodate their needs.”
A young woman with cerebral palsy resulting in severe physical disability is wheelchair bound in one of the island compounds. “She was flagged by several medical officers from her arrival as not suitable for the detention environment.” At the time of writing the report, though exhibiting signs of mental distress, she had not been transferred.
Conduct and ethics
The doctors claim they have been complaining about these issues to IHMS for some time, hence the invitation of the health contractor for them to put their complaints in writing.
The doctors see at the heart of the problems on Christmas Island a conflict of interest between the demands placed on IHMS by the Department of Immigration and their own duty of care to their patients.
The doctors reject the view they say was expressed by IHMS management in September that they are “being paid to accept the risk”. The doctors argue that “payment for risk is clearly in conflict with the Australian Health Practitioner Regulation Agency code of conduct for doctors”.
They write: “IHMS must therefore not put its doctors or itself in a situation where financial inducement means that its care for patients is compromised.”
According to the doctors the same IHMS manager told them in September: “There will one day be a royal commission into what is taking place on Christmas Island. He suggested we document well.”
IHMS said they could not confirm the meeting.
With Oliver Laughland