Issue 40 / 15 October 2018

THREE weeks ago, Dr Tony Bartone, President of the Australian Medical Association (AMA), wrote to Prime Minister Scott Morrison calling for the evacuation of refugee and asylum seeker children and their families from Nauru. This letter was swiftly rebuffed.

At the time, over 100 children were still on the island and many of them were critically ill. Just over a dozen children have since been evacuated under order of the Federal Court, which is testament to the seriousness of the health crisis.

It is important for doctors to understand why and how this crisis has occurred, especially as we have tolerated a policy of offshore processing for 5 years.

The Regional Processing Centre in Nauru was opened in 2012. Of the asylum seekers sent to Nauru, over 1000 remain, of whom 800 have been assessed as genuine refugees. Two-hundred are still waiting to have their claims processed.

The Australian Government continues to be responsible for the health care needs of these refugees and asylum seekers. Doctors working with International Health and Medical Services have long provided outpatient medical care, . While we can argue as to whether or not Australia should care for these asylum seekers, or whether there are “worthier” causes in Australia, the reality is that we are legally and morally obliged to care for them, and already spend far more than we would if these people were living in our community and accessing established health services.

Health care services in Nauru are limited by the size and remoteness of this small population. Australian doctors are familiar with the issues around providing care to remote areas, and medical transfer is essential. Doctors in Australia can arrange such transfer based on clinical need and without needing to first apply to a government agency. Nauruan national patients are frequently transferred off-island for complex care.

Increasingly, refugee and asylum seekers patients requirements for medical care not available on Nauru have led to cases being brought to the Federal Court. This has caused significant delays in care, and a huge legal cost to taxpayers. The Federal Court has always found in favour of upholding medical recommendations.

The Nauruan government has also frustrated the delivery of medical care by refusing to issue exit visas to patients whose medical transfer had been ordered by an Australian Federal Court and, more recently, evicting Médecins sans Frontières —  vital providers of quality psychiatric services for both Nauruans and the refugee and asylum seeker population.

The Australian Government has also thus far ignored all offers for independent audit or oversight of the administrative decisions made in Nauru around the health care of refugees and asylum seekers. Both the Royal Australian College of General Practitioners (RACGP) and the AMA have offered independent assessment.

Medical independence and audit of decisions relating to clinical practice and outcomes are essential in any health system. In a setting where two different governments appear to be obstructing delivery of health care and clinical oversight, an inevitable health crisis affecting dozens of people has developed.

Nauru has been billed as a tropical paradise where Nauruan children have no issues. The reality is that the Pacific Islands have extraordinarily high rates of mental illness and double the global rate of suicide. It is impossible to compare the outcomes of Nauruan citizens with those of the asylum seekers and refugees that Australia has transferred there, as the rights, privileges and opportunities accessible by these groups are not comparable.

In rejecting Dr Bartone’s concerns regarding the health of these children, the Prime Minister noted that 1200 people had died at sea before this policy was implemented. We acknowledge that the government has a duty to assess those who seek asylum and to reduce the incidence of deaths at sea. But as a profession, we must reject the notion that denying children their fundamental right to health care is a necessary policy, or the only policy that can achieve those broader goals.

In the past 3 weeks, we have seen an unprecedented response to Prime Minister Scott Morrison’s rejection of Dr Bartone’s call for change. A majority of medical colleges and societies, including the Royal Australasian College of Physicians, the Royal Australian and New Zealand College of Psychiatrists, the Australasian College for Emergency Medicine, the Royal Australasian College of Surgeons, the RACGP, the Australian College of Rural and Remote Medicine, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Australasian Society of Lifestyle Medicine and the Australian Medical Students Association, have publicly voiced their concerns around this health crisis, with many calling for the evacuation of children and their families from Nauru. We are proud to report that over 5000 individual doctors and medical students – almost 5% of the medical workforce in Australia – have, in just 2 weeks, signed an open letter to the Prime Minister also calling for change. This letter has not had widespread institutional support, but has spread via social media, text messages, and email from doctor to doctor because so many in our profession genuinely care about protecting the right to health, regardless of who the patient might be. This unheralded statement from the medical profession will not be easy to ignore.

The failing of successive governments to protect the health of vulnerable children has created a moral vacuum, and the medical profession has both a duty to and a history of wresting leadership in these situations.

Doctors are the custodians of health in this country, and we have both a responsibility and a mandate to demand that our government does not compromise health care standards for some, lest they do so for all.

We are proud to be part of this campaign, which is not only a pressing health care issue, but has clear implications for ongoing health policy in this country.

The open letter to Prime Minister Scott Morrison will be delivered to his office on Monday October 15, but will remain available for any doctors who wish to add their voice to this issue at:


Dr. Neela Janakiramanan is a Plastic and Reconstructive surgeon in Melbourne. She has a Masters in Public Health and believes in the importance of equitable access to healthcare.

Dr Sara Townend is GP in Sydney, with an interest in palliative care.


5 thoughts on “Nauru: a call for immediate action

  1. Anonymous says:

    Well done and I hope it works…..

  2. Greg the Physician says:

    Can the authors please enlighten us as to what other government policies will prevent more deaths at sea once the people smugglers recommence their despicable trade? Could it also be that transferring children and their families to Australia from Nauru will not only stimulate more attempts at illegal migration to Australia, but will also encourage those attempting it to bring children with them on their perilous journeys, putting those children’s lives at risk? Finally, please enlighten us as to why the large number of genuine child refugees languishing in the various UN camps around the world are any less deserving of quality medical care than those on Nauru. 5% of the medical workforce is nothing like a majority; please do not presume to speak for those of us who support the current government policy as very much the lesser of two evils.

  3. Anonymous says:

    From Anonymous365
    Greg, there are policies that were in practice in the Rudd-Gillard years that have been quietly archived, but – once the boats begin to sail again – would, by those who had (wittingly, or unwittingly) engineered the resumption of the flow of refugees, be agitated for. The Australian Navy, in force, would again be asked to sail the breadth of the Indonesian archipelago to rescue boats that had run out of fuel, started taking in water, or became unseaworthy in the rough wind-swept seas. From the air the RAAF would scour the waters looking for these boats in danger, to enable more prompt recovery, and to determine how many boats were on their way at any point in time. Australia would need – on a day by day basis – to plan the resources needed for competent refugee reception. At a later point in time of this process, Department of Immigration officers would need to travel to locations in Asia, the Middle East and Africa, to verify the accounts being given by asylum seekers as to their stories of persecution – and of their personal identities, places and dates of birth. In the past, it was almost the invariant practice for personal identification documents to be dropped overboard during the voyage, by the boat crew, or the refugees themselves. One cannot send a person back to their location of origin if you do not actually know their name, their date of birth, and the location of their community. In many cases, the information given was a fabrication.
    I know, because in the Immigration Detention Centres where I worked, the medical files we created not uncommonly became confusing, as patients abruptly informed us of changes in their name – and their dates of birth. We had to treat this new information as an alias, and continue to identify the medical file of the patient with their originally cited name and date of birth, even though, for the purpose of claiming refugee status, they had become a completely different person.

  4. Vincent Keane says:

    As an Australian physician I worked for near 25 years with UN and international not-for-profit organizations serving refugees, asylum seekers and internally internally displaced persons (IDPs) in the following countries/locations:
    Angola, Bangladesh, Bosnia, Cambodia, Christmas Island, Croatia, Cuba (Guantanamo Bay), East Timor, Ghana, Hong Kong, Indonesia, Ivory Coast, Jordan, Kenya, Macau, Malaysia, Moldova, Mozambique, Myanmar, Nauru, New Guinea (Manus Island), Philippines (Bataan & Palawan), Russia, Rwanda, Saudi Arabia, Singapore, South Africa, Somalia, Senegal, Sudan, Switzerland, Tanzania, Thailand, Ukraine, Vietnam, Zaire and Zimbabwe.
    During my postings on Manus, Nauru and Christmas Island I was impressed by how well the asylum-seekers were treated
    Lobby groups have described the ‘concentration camp’ conditions and stoked asylum-seekers to riot, self-harm and threaten all manner of retribution for injustices they suffer.
    My experience in working in this area in many countries leaves me with the view that the Australian off-shore facilities are second-to-none, i.e. ‘5-star’, described by an experienced colleague whom I worked with in Manus as “refugees for beginners”
    One would think that those so committed to addressing injustice in the management of the displaced would be aware of the global reality and make it their business to focus on a more deserving cohort.
    The “outrage” demonstrated by Australian supporters of those in Australian offshore detention is an insult to the millions of lost and forgotten souls who will never have a voice, will never have the means to travel half-way round the world, will never transit numerous countries without seeking asylum in those countries, and will never have the means to pay thousands of dollars to reach their preferred destination, Australia. For them the safety, security and access to basic comforts is a dream that will never be realized. Nauru, Manus and Christmas Island would prove a haven.
    Selective compassion and outrage is indeed the easy route, the real deal is where it gets tough!

  5. Tony says:

    Shame, Australia, Shame.

    Who has used the wholesale crime,
    “Concentration Camps” before our time?
    Before one fifty years ‘twas Spain.
    Then the Americans did the same.

    Again the British ’gainst the Boers
    Were murderers on S.A. tours.
    And of course as we all know
    The Nazis caused the greatest woe.

    It’s been wrong, of course, each time.
    Against Humanity the crime.
    But now we have it here once more!
    Just as evil as before!

    If it’s now a different name,
    Will it really be the same?
    “Detention Centre” ‘tis this time
    But that is still a heinous crime.

    A crime ‘gainst all humanity.
    A crime for all the world to see.
    We can all pretend no more!
    Whether here or now, off shore.

    Oh! Such cruelty we do inflict!
    But for us fools, it hasn’t clicked!
    You must not harm the human mind
    Outside the laws of human kind.

    You cannot say it’s for the best
    Or say sub-humans are a pest.
    Torturing some can never be
    The way to stop the boats at sea.

    It’s torture still and that’s a crime.
    It’s just as bad in our own time.
    Australians now the torturers are.
    The victims travel from afar.

    We inflict injustice grave
    On those who only kindness crave.
    They flee a world of dark despair.
    We lock them up and that’s not fair.

    Concentration Camps were there before,
    Created by the men of war.
    Now we inflict this heinous crime,
    But have ourselves no war this time.

    We can never innocence claim.
    These Torture Farms are in our name.

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