Healthcare on Nauru and Manus comes a distant third to deterrence and profit, experts argue, which puts doctors asked to work there in an impossible position

“Abyan”, “Golestan”, “Nazanin”. These people are unknown to us, save for the single pseudonyms with which they’ve been appellated.

Hamid Kehazaei’s name we at least know, even if we know little about the life he led before he came to be within the bailiwick of Australia’s offshore detention regime, under the care of which he would die.



We know, too, Reza Barati’s name and history. Onshore, we know about Mohammad Nasim Najafi and Fazel Chegeni. Because they died in detention, too.



But of those still within Australia’s arcane immigration detention regime, much less is known. Secrecy is a cornerstone of the regime.



Access to Papua New Guinea’s Manus facility is routinely denied. The government in Nauru (with one infamous exception) refuses visas to all independent journalists to even visit the country. Communications with people held in detention without charge is heavily restricted, and closely monitored.



The people who work in those detention centres face prison if they speak out about the abuses they see.



The offshore detention centres used by Australia are clearly ‘black sites’ Dr David Isaacs

But despite this cultivated concealment, the failures in Australia’s care are known: beyond the deaths, the systemic abuse; the instances of rape and sexual predation; the violence by guards; the corporal punishment; the deprivations; the delays in moving acutely ill people to appropriate care; the dereliction of police investigations and prosecutions.



All have been comprehensively documented, by the media, in parliamentary inquiries and in government reports.



Invariably, when people are assaulted, or raped, or die, the problems are explained as tragic accidents, aberrant “terrible incidents”, or breakdowns in operating procedures.



But many of the medical professionals who work within this system have told Guardian Australia that they do not believe the damage to asylum seekers and refugees held is accidental or an unhappy, unintended side-effect of detention.



They argue that the detention centres are “designed to damage” people, and that the illnesses, injuries, and deaths are the predictable, expected outcomes of the regime.



Detention damages people because it is supposed to.



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Guardian Australia has spoken with more than a dozen doctors and medical professionals who have worked in immigration detention offshore and within Australia. Many would only speak anonymously, because of continuing employment within immigration or fears of prosecution.

Two key themes emerged from almost every interview: that immigration detention is designed to harm people held within it, and; that secrecy is paramount.



In a peer-reviewed paper published in the BMJ’s Journal of Medical Ethics in December, Dr David Isaacs asked: “Are healthcare professionals working in Australia’s immigration detention centres condoning torture?”



Isaacs, who worked as a doctor on Nauru, argued that Australia’s offshore detention centres – built in remote places offshore, secretive, and inaccessible – were “reminiscent of Guantanamo Bay”.



“The offshore detention centres used by Australia are clearly ‘black sites’.”



“Secrecy, which characterises recent Australian government policy on people seeking asylum, itself creates ethical issues for healthcare professionals. If they speak up to expose harms to health caused by immigration detention, they will no longer be employed and thus unable to directly improve patient health. They may even face imprisonment.”



Clinical practice is demoted below ideological outcomes Senior doctor

“Each individual practitioner faces the moral dilemma of whether to work in immigration detention at all and effectively condone what amounts to torture, and if they do work there, they must decide for how long and to what extent they report on harms.”



Dr Peter Young, who was formerly the director of mental health services at International Health and Medical Services (IHMS) – the company contracted to provide medical services to people in immigration detention within Australia and offshore – says detention is designed to be “an aversive experience for people”, a regime akin to torture.

“If we take the definition of torture to be the deliberate harming of people in order to coerce them into a desired outcome, I think it does fulfil that definition.

“This detention is created in such a way as to act as a deterrent, to encourage people to return [to their homeland], and to stop other people trying to seek asylum. The harmfulness is a ‘designed-in’ feature.”



Young argues detention’s secrecy is not an adjunct to the detention centre regime, or an exercise of political convenience, but a fundamental tenet.



“You can’t allow transparency, if what you’re trying to do is inflict suffering. Secrecy is necessary because these places are designed to damage.”



In a forthcoming paper, academics Suvendrini Perera and Joseph Pugliese argue that the failures of care in offshore detention are neither aberrant or accidental, rather they are the result of the system working exactly as it is designed.



“At work in Australia’s immigration policies and practices is the intertwining of militarism and punishment working hand-in-hand with the compromising of detainees’ healthcare by the drive to secure profits,” they write. “This nefarious mix results in nothing less than a ‘grotesque faux caring’ exercise that, in effect, is tantamount to torture for Australia’s refugees.”



Prioritising perceived security and profit above duty of care constitutes ... ‘damage by design’ Suvendrini Perera and Joseph Pugliese

Perera and Pugliese argue the outsourcing of health care in detention centres to a multinational firm is a fundamental conflict of interest. Companies have an obligation to shareholders to maximise profits. Australia’s policy of offshore detention is specifically designed as one of deterrence. This leaves patient care a distant third priority.

“Prioritising perceived security and profit above duty of care constitutes what we would term ‘damage by design’. The politics of compromising a detainee’s health thus becomes a ‘structural outcome’ of maintaining a punitive regime in the name of security in order to increase profits.”



Last year a Guardian Australia investigation outlined the structural conflicts faced by IHMS. The company, part of a complex, multinational corporate entity, also lists the US military as one of its largest clients.



Leaked documents from within IHMS show the company is acutely aware of its competing – often contrary –priorities in detention healthcare.



A presentation slide for senior staff said: “Mostly performance is measured in terms of deadlines. Combined with high performance thresholds, that means: conflict between clinical objectives and contractual objectives.”



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This week Guardian Australia revealed IHMS documents showing that children suffer mental illness most acutely in detention, that the mental harm of detention continues long after release. The documents also show that the immigration department was told the offshore detention population experiences “severe mental distress” at rates more than four times higher than the general Australian population.



The complaint of most asylum seekers and refugees in detention is in the minutiae – the delays in seeing doctors and dentists, the harried prescription of Panadol and water regardless of the illness. But the structural deficiencies become most apparent at times when acute care is required.



Hamid Kehazaei was suffering an infected wound on his leg, that could have been cured if the correct antibiotics were easily available. They were not and, because of bureaucratic delays in granting him a visa to travel, he was critically ill by the time he was moved. He arrived in Brisbane on life support. He died there.



When “Golestan” was due to have her baby on Nauru, the country’s only hospital was not properly equipped to handle the complexities of her delivery.



The day before she was due to give birth, Aspen Medical – a health services provider to Nauru hospital – took to searching LinkedIn for a neonatologist to fly in to oversee the delivery. Several doctors refused, arguing the best clinical decision would be to transfer Golestan. Golestan ultimately had the baby by caesarean on Nauru.



Such critical incidents are not isolated but are predictable outcomes created by the medical architecture that is established in Australia’s offshore detention centres, where in the words of one senior doctor, “clinical practice is demoted below ideological outcomes”.



Doctors who wish to use their skills to assist vulnerable people are being placed in an invidious position.



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Several have told Guardian Australia they feel they are being asked to be part of something fundamentally wrong, something designed to be damaging, in order that they might make it a little less bad.



And where they see fault, they cannot speak out. The Border Force Act carries the risk of jail for “disclosure”, even if that disclosure is in the interests of saving lives.



Many doctors also feel they are being used and manipulated for political ends.



Their participation in a system that is deliberately punitive – one that is not designed to heal but to damage – validates the regime, giving it a veneer of legitimacy it does not, on any objective assessment, deserve.

They have the skills to alleviate suffering, they have dedicated their professional lives to that cause, and they see an opportunity to do that for vulnerable people in immigration detention centres.



But they can see too, that it is the centres themselves that are causing the suffering, because that is what they are designed to do.

