Fear and Hypocrisy in Australia: Immigration Detention and Free Speech

It was not long ago that the Abbott government vowed to champion free speech, pledging to amend Section 18C of the Racial Discrimination Act, a section of the act that made almost completely useless speech illegal. This commitment was re-affirmed a number of times, including again in early 2015 after the Charlie Hebdo massacre. It seems however the government’s commitment to free speech is largely selective, actively working to keep the marginalised and powerless out of the debate, happy to gag and attack those who dissent.

The recently introduced Border Force Act has raised the ire of a number of individuals and professional bodies, gaining significant media attention with a possible two year prison sentence for speaking about the conditions in immigration detention. Much has been said about how this will impact on the ability of health professionals to report abuse and advocate for patients, however less has been said about how this will only further silence those who are genuinely voiceless.

Silencing the Silenced

The stories we hear from within detention centres are often told through third parties, with many former employees feeling compelled to speak on behalf of those who could not. For all the noise surrounding immigration detention policies, how many of those voices are refugees or asylum seekers?
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Hannah Arendt explored this powerlessness in The Origins of Totalitarianism, she argued that even though human rights are proclaimed to be universal, asylum seekers and stateless persons were left with nothing to protect their rights, effectively in limbo, no longer a member of a community where their rights could be enforced. This precarious situation has often been referred to as “the right to have rights”.

“… but it turned out that the moment human beings lacked their own government and had to fall back upon their minimum rights, no authority was left to protect them and no institution was willing to guarantee them.”

She emphasised how this stripped away the right to make oneself heard and opinions matter.

“The fundamental deprivation of human rights is manifested first and above all in the deprivation of a place in the world which makes opinions significant and actions effective… They are deprived, not of the right to freedom, but of the right to action; not of the right to think whatever they please, but of the right to have an opinion”

Managing and processing the powerless

Immigration detention in Australia compounds this powerlessness by further limiting asylum seekers ability to control their own lives and speak candidly about their circumstances. Andre Dao reminds us that this powerlessness can manifest in asylum seekers gambling on their bodies, a symbolic way to regain some control, to be heard. As Dao puts it “you are no longer a human being with free will. Instead, you’re a problem to be managed, an object to be processed.” Few better statements sum this up than these words recalled by an ex-detainee on a hunger strike who was being spoken to by a department employee.

“You understand that your life is in our hands. Your death is also in our hands because we won’t let you die.”

Although a number of asylum seekers have spoken out over the years, their voices rarely make it to the mainstream. Furthermore there remains the expectation of silence both during and after detention, it is not until permanent residency has been gained and families reunited that many feel safe to speak about their experiences.

Silenced subjects and misinformation

Maintaining this silence is key to maintaining our current approach to asylum seekers. The system has been built around rhetoric and misinformation, from children overboard to the present day. Most people can bark back three word slogans, but fewer could tell you what percentage of the world’s asylum seekers arrive on our shores or begin to explain the trauma and torture many have faced before finding safety.

The voices we most need in our debates around asylum seeker policy in Australia are absent, not only that, they are actively excluded. So as well as threatening professionals with gaol time, the Border Force Act only further ensures that that we never get to hear these stories, it ensures that we don’t know who we are locking up or for what reason.

It’s not obvious how the Border Force Act serves to “stop the boats” or “smash the people smugglers business model”, taking into account the boats stopped a long time ago. In attempting to justify this legislation however, the rhetoric has boiled down to a very familiar means justifying the ends rationale, something we should all be careful of and something where it seems appropriate to leave the last words with Hannah Arendt.

“The crimes against human rights, which have become a speciality of totalitarian regimes, can always be justified by the pretext that right is equivalent to being good or useful for the whole in distinction to its parts.”

Ryan Essex

PhD Candidate, The University of Sydney.

Profiting from asylum-seeker detention: Time to divest

Christopher Mayes and Ian Kerridge

On the 25th May 2015 the Royal Australasian College of Physicians (RACP) called on the Australian Government to end mandatory detention and release asylum seekers from offshore processing centres. President of the RACP, Laureate Professor Nicholas Talley outlined the College’s Refugee and Asylum Seeker Health Position Statement, which calls for:

  • more rigorous health assessments for asylum seekers on arrival;
  • better access to healthcare for asylum seekers and refugees in the community;
  • increased support services for refugees; and
  • an immediate end to mandatory detention and the release of all asylum seekers into the Australian community.

Physicians and health care professionals have witnessed first-hand the trauma of asylum-seekers in detention and have repeatedly made public the insufficient medical care available in these facilities. Professor Talley states that “Our Fellows have been inside the detention facilities. We have treated refugees and asylum seekers during their detention and after their release into the community…These people are not numbers, they are our patients.”

A time to boycott?

In September 2014 the Medical Journal of Australia published an article questioning whether the asylum-seeker policy and conditions were so bad that health professionals should boycott working in them. This article was widely reported in the mainstream media and raised awareness of the ethical and medical compromises forced upon health professionals.

Accommodation in the Nauru offshore processing facility.

Accommodation in the Nauru offshore processing facility. Source: Wikimedia Commons, licensed under the Creative Commons Attribution 2.0 Generic

As others have argued, however, while a targeted boycott campaign should be considered, refusing to provide medical care to asylum seekers would only harm the already harmed. health professionals have an ethical obligation to their patients. As Professor Talley notes “we are duty bound to speak on behalf of our patients – especially since their human rights are increasingly seen as optional.” And it may be only when health professionals see for themselves the conditions in which asylum seekers are kept, and the standards of health care they receive, that they will be motivated to speak out against injustice and advocate for better and more humane care.

Time to divest

Compounding the ethical and medical harms resulting from mandatory detention is the fact that the Australian Government spends $3.3 billion a year to maintain this policy. This money is used to pay contractors and publicly listed companies to run and operate detention facilities.

Of these, the greatest beneficiary is Transfield Services. Transfield Services’s share price spiked after it was awarded a new contract to run the detention facilities on Manus Islands. Although the share price soon declined, mandatory detention makes companies like Transfield Services appear like a good investment option.

The superannuation fund, HESTA, invests in Transfield Services. At present HESTA is a significant shareholder in Transfield Services.[1] Considering that HESTA is the superannuation for the health and community services industry it is troubling that they are using the retirement savings of physicians, nurses, allied health practitioners and social workers to invest in a company that profits from the mandatory detention of asylum seekers.

Fifteen of Australia’s peak health organisations have publicly condemned the Australian Government’s asylum-seeker policy. Yet, many of the members of these organizations may unwittingly be financially entangled with the very system they condemn. Rather than calling for health professionals to boycott working in detention centres, there is a campaign for health professionals with their super with HESTA to call on HESTA to divest from Transfield Services.

A multi-pronged strategy is needed to resist and disrupt the detention industry. Political and ethical arguments are essential to convince politicians and the public that mandatory detention should be abandoned. However, it is also important to recognize that detention is a business – that profits and financial gains are being made through the asylum seeker polices and that we may be unknowingly supporting and profiting from these businesses and policies ourselves.

It is time to divest.

[1] As of 27 February 2015, HESTA holds just under 5% of shares in Transfield Services with over 23.5 million shares. http://asxcomnewspdfs.fairfaxmedia.com.au/2015/03/02/01604569-575220267.pdf

Let’s stop the bullying of trainee doctors – for patients’ sake

Kimberley Ivory, University of Sydney and Karen Scott, University of Sydney

Size matters. At least, that seems to be the media’s belief when it comes to analysing social problems. The grimmer the stories, the uglier the experience, the more bodies at the bottom of the cliff, the better.

And last night’s episode of ABC TV’s Four Corners didn’t disappoint, with its expose on bullying among surgeons and the devastating consequences this entrenched practice has for its victims, both in the short and long term.

Despite casting their net wide, the show’s producers found only three medical professionals who haven’t spoken out about this issue before, and only two chose to be identified. Imogen Ibbett and Vyom Sharma have now joined the growing ranks of doctors, such as Dr Caroline Tan and Dr Talia Steed, in breaking the silence around the destruction of careers and health that doctors cause among their own.

But noticing the growing pile of bodies at the bottom of the cliff is only helpful if it triggers the essential questions – who or what is pushing them off and what can be done to stop it?

Not just surgeons

The program notes that this is not just a problem for women, or surgeons or even just the medical profession; it’s a public health issue that demands action. Indeed, women can also be perpetrators as Imogen Ibbett’s allegations against Helen Maroulis clearly demonstrate.

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But most significantly, the show highlights the risk bullying, scalpel-throwing surgeons, misogynist physicians, and harassed and cowered trainee doctors pose to the lives of patients.

The problem starts early, in medical school; both local and international research persistently show most medical students experience mistreatment during clinical placements in hospitals.

Our recent – about to be published – research found 74% of Australian medical students experienced mistreatment during clinical placements and even more witnessed it. Similarly, a 2014 US study found 83% of medical students experienced some form of mistreatment during medical training in hospitals.

A large number of students reported use of “pimping”, an aggressive form of questioning based on an abuse of the Socratic teaching method, described in Four Corners, which is used to shame students for their lack of knowledge. Studies have also highlighted negative environments involving belittlement, disrespect and being “constantly ignored and told to disappear.”

Although student reports of mistreatment may be interpreted by some senior staff as just over-sensitivity, research shows students perceive negative events in a similar way to physicians and nurses. Unsurprisingly, under-reporting is common.

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Mistreatment of medical students is at odds with the explicit teaching about professionalism in medical training, leaving many confused. But some others become medical teachers who “mete unto others what was perpetrated against them”. The effects of all this “teaching by humiliation” can be profound and enduring.

Medical students’ mental health has been shown to decline throughout medical training. And this can lead to poor self-confidence and burnout, binge drinking, stress and depression, and substance abuse, broken relationships, suicide and early exit from the profession.

Mistreatment can create cynicism and reduce empathy, which may directly affect patient care. Students are also distressed when they see doctors mistreating or being disrespectful to, or about, patients.

Impact on patients

Patients can clearly be directly affected by the way the autocratic medical culture affects working practices and ineffective communication causes health-care errors and poor patient safety outcomes.

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In fact, this kind of culture poses an extreme threat to patient care, like the notorious “Butcher of Bega”, Graeme Reeves. After 35 formal complaints of bullying and harassment were made about Reeves by other doctors, nurses and patients over a 15-year period starting in 1985, he was deemed “a person unfit to remain on the register of medical practitioners” in 2004. Behind him lay a trail of dead and mutilated patients and aggrieved and frustrated doctors and other staff.

But much bullying and harassment is subtle, insidious and harder to prove and act upon. Indeed, Four Corners shows how one doctor’s tormentor can be another’s mentor. Dr Imogen Ibbet finds Dr Tan’s tormentor, Chris Xenos to be professional and respectable, for instance, but feels very differently about Dr Helen Maroulis’ behaviour.

And all the bad behaviour is difficult to police because mistreatment is often so subtle and secretive it can be impossible to deal with, especially when the victim is made to feel both responsible and powerless.

In the program’s attempt to look for solutions, it’s confronted by the apparent buck-passing of responsibility between the Australian Medical Association (AMA), the professional colleges and the workplaces where bullied doctors work.

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Four Corners and BeyondBlue have nailed the problem that’s pushing people over the cliff: workplaces that have allowed a culture of humiliation, bullying and harassment to prosper with inadequate pathways for action. And the fence that’s needed at the top of the cliff to prevent the falls is now also becoming apparent.

If bullying is a workplace issue, and the workplace is funded on the public dollar, then the public needs more say in hiring and firing practices. Nothing can change until young doctors are safe in the knowledge that the people they need to complain about no longer have absolute control over their careers. And there’s an example that can be followed.

Training to become a specialist in general practice is no longer directly under the control of either of the general practice colleges. Rather it’s contracted out to 17 regional training providers. The role of the general practice colleges now is to improve practice quality as a whole, build collegial relationships, and provide continuing education and opportunities for its fellows and members.

This may be a model we need to emulate for all medical speciality training. While it will never be possible to completely remove the apprenticeship model from medical education, it’s possible to ensure progression decisions are made by those at arm’s length from training and that merit, not nepotism, prevails.

The Conversation

Kimberley Ivory is Senior Lecturer, Population Medicine and Sub-dean Student Support, Sydney Medical School at University of Sydney.
Karen Scott is Senior Lecturer, Education, Discipline of Pediatrics and Child Health at University of Sydney.

This article was originally published on The Conversation.
Read the original article.

Asylum seeker’s ‘brain death’ shows failure of care and of democracy

By Ian Kerridge, University of Sydney and David Isaacs, University of Sydney

The news that Hamid Kehazaei, a 24-year-old Iranian asylum seeker detained on Manus Island, has been diagnosed as brain dead following his transfer to the Mater Hospital in Brisbane is a tragedy. That it is a tragedy for this young man and his family is unquestionable – but the extent of this tragedy may be much more pervasive than we realise.

If the emerging details of his case are correct, Kehazaei developed septicaemia as a complication of cellulitis (skin and soft-tissue infection) arising from a cut in his foot. This, in itself, is disturbing.

Severe infection can result in brain death – either from infection of the brain itself (meningitis, encephalitis or brain abscess), or from brain injury due to a lack of oxygen resulting from cardiac arrest (as appears to be the case here), or from reduced blood supply to the brain. Yet it is very uncommon, especially in a young, previously healthy man.

Such a case could occur in Australia and has been described in 2012 in young Indigenous adults in Central Australia. Nevertheless, severe sepsis resulting from a foot infection is preventable. And a case like this occurring in an Australian national would raise serious questions about the appropriateness of the antibiotics used and the timeliness of care.

Most cases of brain death result from traumatic brain injury, stroke or lack of oxygen to the brain following asphyxia, near-drowning, or prolonged cardiopulmonary resuscitation.

What happened to Hamid Kehazaei raises concerns about the adequacy of care provided to him during initial treatment, including wound care and antibiotics, and how soon he was transferred to expert medical care, first to Port Moresby and subsequently to Brisbane.

If this young man became ill and had his brain die while seeking asylum in Australia and while in our care, then we must examine the details of his case and ask ourselves not only whether it was preventable but whether our policies and processes actually contributed to his death.

But how can we even begin to ask these types of questions when we know so little about the circumstances in which he became ill, and his subsequent care?

Continue reading

Why care about the health and well-being of asylum seekers?

By Stacy Carter, University of Sydney and Ian Kerridge, University of Sydney

A report on the refugee detention centre in Nauru by five independent clinical experts posted online by The Guardian on Friday paints a bleak picture of life on the island, particularly for children. But why should we care about how these people are being treated?

The report describes the now-familiar wretched conditions of refugee detention. Tents that leak in the rain and become unbearably hot and humid by 10am. Burning white rocks underfoot, little natural shade, dust everywhere, only electric fans for cooling in most areas of the camp.

Mosquitoes that prevent sleep and may carry diseases. Overwhelming boredom. And the hopelessness, helplessness, frustration and despair that accompany radical uncertainty about the future.

The authors detail the effects of this environment on the physical and mental health of asylum seekers. And, not unexpectedly, they recommend changes to the detention centre. This implies, of course, that current conditions should change; that the damage we are doing to these adults and children is unacceptable.

But the Australian government disagrees. It claims current policy is justified because it prevents asylum seekers from dying at sea. Let’s assume for a moment that this is truly the purpose of offshore mandatory detention. The goal – preventing deaths – is worthy, but what means are justified to reach it? Continue reading