Nauru

https://meanjin.com.au/essays/the-nauru-diaries/

'The Nauru Diaries

Nick Martin

Autumn 2018

For those who’ve come across the seas…

It doesn’t take long to break a man. You can do it in a second, in one punch, one judgment handed down, one small gesture. I’ve seen it happen: a sudden crumpling of the features, a devastating blow. I’ve remembered those occasions, viewed them as significant; to watch someone once full of life die, to be replaced by a shattered husk, is humbling.

To watch someone break over a period of months was a different thing altogether. To see eyes go from shining to dull, to watch shoulders slowly droop and hang, as if the arms themselves were too heavy. To hear the tone of bored resignation slowly take over a voice, dulling it until only a monosyllabic version of the previous incantation remained; for a man to become a hopeless case, no longer even angry enough to fight against the injustice of it all, was something I’d never seen. That’s what I saw as a doctor on Nauru working for International Health and Medical Services (IHMS).

Weariness became king in the camps, watched over by an indifferent crowd of faintly menacing guards, attended by various helpers from myriad agencies, all with the same basic goal: to stop people from killing themselves, and to stop bad news leaving the island. Weariness, helped by a stifling heat, by a hundred petty rules and regulations, by the interminable indignities of closely managed living. No money, queues, carefully timetabled buses that never ran on time, appointments cancelled arbitrarily, interpreters unavailable, petty bickering between people forced to sleep next to each other for years on end in tents or leaking portacabins.

There were times when I would get uptight in meetings, raise my voice in indignation, rail against the idiocy or downright incompetence of the system that kept these people stuck here and denied them the care they needed. The sheer pig-headedness of some of the decisions, and indeed of the people tasked with parroting them, caused my pulse to accelerate, my anger to rise. I used to feel that maybe people would see that we were all complicit; that it wasn’t good enough to sit idly by and watch these processes slowly destroy any hope that our patients had. I used to feel that perhaps my anger would help fire-up others too, might start a shift in attitudes so that I no longer felt like the sole troublemaker.

After about four months it suddenly dawned on me: learned helplessness didn’t apply only to the patients. It affected the staff too. You could see it on the faces of those who didn’t look indignant when their failure to speak up or to comment on another poor decision, their complicity in propping up this inhumane system, was pointed out. They had ceased to care, reduced to automata, ticking boxes furiously to satisfy an administrator in Sydney or Canberra and ignoring the simple fact that while people were dying in front of us, we failed to express anything beyond what you might give to a nature documentary when a not particularly cute animal died peacefully.

I looked at the latest email. An update from a patient who had finally been transferred for care. Not to Australia, though that would have been the best for him, there was no question about that. However, as he was an asylum seeker, he had to be kept as far away from the glare of publicity as possible. The solution offered was Papua New Guinea. A substandard hospital, roundly derided by patients who had been there, and often the cause of many questioning emails from Sydney, responding to claims of poor results, hygiene, staffing and standards. It had taken him ten months of waiting, in pain with kidney stones, requests for transfer ignored as a matter of routine, and increasingly insistent enquiries from the staff here, before he’d been bundled off to have his much needed operation.

I read the update. Of course, there had been complications and he was in difficulty. I sat back and exhaled. What the hell had I expected? I had not been there to give him false reassurance, I refused to go along with that. Had I been complicit? No. I searched my memory and couldn’t think of a lie I’d told him about where he would likely be sent. I had consistently said ‘a third country’, so as to keep all options open, to divorce myself from the decision-making process. I had done the initial referral, the rest was outside my control. It wouldn’t stop him blaming me, along with anyone else he could think of once he was sent back here, with a huge scar and maybe some residual surgical problems. Hell, not a great email to read, but not exactly unexpected.

I buried my face in my hands. Earlier the daily meeting had taken place, all the staff members in the same room, discussing patients of concern. It was the same old people, the patients whom we were trying to prevent killing themselves. Two names stuck in my mind, both head injuries, both needed to be in specialist units, both being left to rot while emails flurried about them, with each person passing the buck. What needed to happen was for them to be transferred, to be just put on a plane. What happened instead was the equivalent of going to a shop for food when you’re starving and for the staff to try to sell you a new carrier bag. It made people look like they were doing things, while ignoring the fact that the position of the Australian government was to prevent anyone coming to Australia at all costs. The increasing pleas, clinical reports, incident reports, specialist meetings, risk management meetings, targeted interventions and mental health reviews all fell on deaf ears.

At what point do you throw your hands up, admit defeat, accept that the system can’t be beaten? The monolith of the government was behind this, inflexible, unswerving, shameless. What could I do? Send off yet another email? Hadn’t someone defined insanity as the art of doing the same thing over and over expecting a different response? Something like that. Christ, this was soul destroying.

Time to try a different approach then. Emails were all very well, but it was all about accountability. As I saw it, nobody wanted to be the one on the dock when it all went wrong and there was an inquiry, an inquest or a journalist on a mission with an audience. If that was the case, I reasoned, then people would not like to be seen as responsible for a hold up in getting patients off the island when they need further care. I could see already a cycle of ‘no, the delay is with the hospital … with the government … with border force … not enough information from IHMS … they’re refugees …’. It was easy enough for people to pass on the responsibility ad infinitum while the patients stayed where they were.

What a conundrum. How best to change that? Who had the power? Australia, surely? They would hide behind the Nauru government—a line I had often seen was that refugees were the responsibility of the government of Nauru. Although clearly a legal loophole to avoid court cases and publicity, yet it was stated time and again, to Senate committees and any other organisation you could mention—the UN springs to mind. It was a complete fallacy, but it was the excuse that they’d use. The Nauru government would blame the hospital for not telling them. The hospital would blame us, and so the cycle would repeat.

With this in mind, I set about finding a way to work within this system. It seemed like one of those Escher drawings, where you went up a series of staircases and arrived back where you’d started. How to shine a light on the situation? Time for a coffee, pen, paper and some lateral thinking.

Nothing happens without the Australian Border Force allowing it. They were where delays came from: ABF had held up evacuations for my critically-ill patients before. They seemed to work in committees. There was never a name you could pin things on. They used terms such as ‘the delegate’ or ‘the committee’ to guarantee anonymity and avoid accountability. I had the name of their chief medical officer. I had met him, he was amicable enough. I wasn’t sure if they listened to him, but he was a contact at least. I knew my bosses in Sydney spoke with him regularly. I had his email address, but to contact him without going up the chain would be seen very dimly. Was there an alternative? How could I make sure that he was singled out, so he had no plausible deniability?

Should I aim higher? Find some way of telling the minister, circumvent all the layers that were set up beneath him to ensure that he could blithely spout his lies on TV and be untouchable when it came to apportioning blame? Maybe. How to approach him? Would I need a journalist? A lawyer? Another doctor? This was absolutely against the rules. I’d be out of a job, would have breached the confidentiality agreements I had signed.

I sighed again. This was predictably depressing. I felt a hollow desperation. I was stuck, and needed to change the script. How to change things? How to get people to do something?

The realisation came slowly but with a certainty I was reluctant to acknowledge. This system would not change. It had been honed by respective governments, reshuffles, rebrandings and reorganisation to work like this, to keep people from speaking out, to keep patients here, and to grind them down. So, if there were to be change, it had to be me: leave the job and speak as an outsider, or stay and attempt to change it from within.

Back to the pen and paper. Writing down the roadblocks and the myriad arrows involved in stopping people getting off, from the initial request by me or my staff seemed to help focus my mind a little. I looked at my notepad; it was full of circles, question marks and big X’s marking delays and bottlenecks. So many delays and blocks. This would keep a bureaucrat in business for years. In a way I admired those who had allowed, either by direction or neglect, this system to remain in place and indeed defended it. It was impressively Byzantine.

I knew ordinary Australians didn’t care. How could they? This place was a testament to canny PR, disinformation and politicising of the refugee/asylum seeker agenda. It seemed to be an irrelevance to most of the population back home. Every time I heard Peter Dutton blithely trot out the same old lies and half-truths and accusations it drove the point home: these guys were good at this, and they would have a dozen prepared answers to any technical questions posed to them: ‘it’s a matter for Nauru’, ‘won’t comment on individual cases’, ‘a matter for the department’, ‘subject to security regulations’, ‘the fault of the previous government’ … I had heard them all. To make people sit up and take notice, the story had to be about individuals, about people whom you could picture, whom you could sympathise with, imagine being in their shoes. This was going to be tricky.

I walked out of my office, past a guard slumped in his chair, quietly snoring. He didn’t stir as I walked by. We were told to report sleeping guards, but everyone knew you’d be on a plane the next day if the guard had influential relatives. On an island of 10 000 it was fair to say everyone knew every-one. So, we all played the game of ignore and carry on.

I moved through the ‘goldfish bowl’—the main area where the receptionists sat, shielded by panes of glass from the people who came in—and on to the staff coffee area. I needed a caffeine hit to keep my motivation up. Some out-of-date instant coffee went into my mug. Small talk with one of the admin guys and back past the dozing guard into my room. At least the aircon was working. It was 30° plus outside, sticky and heavy, with no wind. At my desk I checked the computer to see who was coming in.

The next patient was already ten minutes late. It wasn’t fair to blame them for lateness: the bus service was unreliable and slow, and they had to wait in the heat for it, and then suffer the indignities of a search and ID check at the camp gates. They were invariably referred to by their boat numbers, a horrible practice that officially didn’t exist and yet was widespread. There would be a further delay at the reception desk and then the wait for an interpreter. Some of the doctors deliberately booked their troublesome patients in at nine in the morning knowing that they were unlikely to show. People’s daily routines usually led to them rising late and staying up half the night, trying to kill time, and as a way of beating the worst of the heat, especially if they were still living in tents.

I remembered the patient. He was a nice guy, well spoken, polite and made an effort with his appearance. He spoke pretty good English and was a refugee. How he came here, I didn’t know. He would have had to tell his story to many people over the years. I knew he’d been picked up off a boat and transferred four years ago from Christmas Island. He didn’t have any family with him; his parents were presumed dead somewhere in Afghanistan. He lived in a tent and seemed to be quite popular. He often applied for jobs locally, but so far had been unsuccessful. He played soccer and took a lot of time over his hair; your typical young man I guess. A glance at the screen showed me he was supposed to be taking an antidepressant but wasn’t very good at remembering to. He hadn’t tried to kill himself and wasn’t assessed as high risk from that point of view. There were no other warnings I could see.

I walked down the corridor past the guard who was now awake and scrolling through his phone. In the waiting area I spotted the interpreter and my patient. I felt for the interpreters. They had to sit and listen to misery all day, every day, and some clearly did not enjoy this; why would you? It was a vital job but sometimes you could see the effects of what they were relating. Hearing someone’s story firsthand and trying to relay it in a matter-of-fact way was a routine that would threaten the thickest skin.

The problem my patient had was fairly typical; he had injured his leg, and it wasn’t getting better. He most likely needed a scan, an orthopaedic surgeon to sort out the probable ligament damage. This would be straightforward enough in Australia. Yes, there would be delays but his injury and the effect it had on him would warrant a fairly prompt response: a scan in a few weeks and a surgeon within six at the most. This man was looking at years of waiting, if he was lucky. His best hope for an operation was in Papua New Guinea, to see a surgeon who may or may not be able to fix his knee. His relatively simple case would now consign him to being added to a list of patients whom I needed to convince the local hospital committee to consider, before throwing him to the mercy of the Border Force, who would again delay his move for reasons known to them alone, regardless of my recommendations.

Knowing this, I had to explain the process to him as I understood it, leaving out mention of what I knew would be very long delays. On paper the system looked reasonable; in reality it was completely unworkable. I had long ago stopped defending it: that was morally impossible.

I said something like, ‘This all takes some time, and you may get frustrated at the delays, but I will try my best.’ This seemed to have a slight effect on him, but he understood that this was not going to be sorted out in a few weeks. For me, it was a lot of email referrals and checking on spreadsheets now. For him it was just another obstacle to his daily life. My worry was that this could be the final straw: after four years of this people cracked at the smallest or largest things. Was it worth making sure he saw the mental health team? I tried to bring it up as a topic.

‘You mean, I will be so upset that I will kill myself?’

I was taken aback a bit by his bluntness but at least we were addressing it. ‘Not really, it’s just I know that you have a lot to deal with anyway, and this is one more thing for you to worry about.’

He inclined his head to acknowledge the point. ‘I will see. What can they do? Give me more medicines? No, I will see.’

We finished up and he walked away, obviously in some discomfort.

I sat back and started typing up the referrals, and starting the ball rolling on a process that would take months and was reliant on a load of rotating staff to keep the momentum, or else it would be lost again. I had calculated an average of four referrals that were needed to get a patient seen once at the Nauru hospital and then only one in four after the patient was seen would have any kind of clinical report or note on file that I could then use to convince their committee that the patient needed transfer. Who the hell had been responsible for this system?

Responsibility was a thorny topic. It was, I felt, a concept that underpinned so much of what happened here. Who was responsible for these people, who would be held accountable in cases of injury or death? Refugees were the responsibility of the Republic of Nauru. I had heard that being spouted by politicians almost every time they got a question about Nauru in an interview. Not our problem, not the right question, now move on please.

If they weren’t Australia’s responsibility, what the hell was I doing here? All the Australian contractors, Australian Border Force officers who hung around? Who was paying billions of dollars for the camps? It was all Australia. Legally it might have washed once, but time and again it failed every pub, sniff or common sense test. I rolled my eyes every time I heard it, and any respect for the politicians who defended the policy further disintegrated. I was no left-wing social justice warrior; years in the forces and a solidly middle-class upbringing ensured that. But I could spot legal bullshit being flung around with relative ease.

There was a break before my next patient. I had a list of jobs to do to help me make sense of what was going on with all the patients. Primarily, I had a duty to ensure that those people who needed to be reviewed and treated off the island were followed up. Time and again, though, I would come across a patient who was waiting for an appointment date to come through, only to discover that they were not on this list. Having two different computer patient databases as well as a separate system for refugees, and the division of primary health and mental health … it was a recipe for chaos, especially when you factored in that the hospital did not use our notes anyway, rarely wrote anything down and rarely shared it with us when they did. Each time I returned to the island I spent hours trying to determine whether the spreadsheets and patient lists I had painstakingly compiled were anywhere near current; they never were despite my requests for others to help keep them up to date.

Boring work, and not what I’d signed up for, but it was essential if people were to get the help they needed. If someone had told me at medical school that Excel spreadsheets would be a mainstay of what I did, I would have laughed at them. Unfortunately our local staff were incapable of doing the job—I had sounded one of them out and he looked in horror at what I was suggesting. I figured it was best to do it myself; then I could show my bosses in Sydney that my requests for treatment were being ignored and so push to change things.

Each name became just another entry on a spreadsheet, but behind each name was a story—of hours pleading for help in a hostile, unforgiving place. From operations on backs and knees, to kidney stones, to giving reassurance that their breast lumps weren’t cancerous: they were all here, a long list of people in Nauru who were now being denied what people in Australia took for granted.

I’d had a few small wins here and there, but at the expense of hours cajoling, shaming, pleading, pushing and harassing people to at least sign a report I’d prepared for them, hours waiting for uninterested doctors at the hospital to sign off on a request, and emails and phone calls after a meeting in an effort to ensure that they would do what they’d said they would do. It was a massively inefficient system and everybody knew it. From border force there was no incentive to change this; why would they willingly be making it easier for patients to get treatment?

• • •

Mohammad, ‘She sees you’, coffee on paper, 29 x 41 cm. Image reproduced with the assistance of Refugee Art Project

One of the nurses came in with an update on a patient we had sent to the hospital. A young man whom we had seen five days ago with a very low blood count. He was bleeding from somewhere, most likely his upper bowel. This in Australia would be pretty straightforward. If the bleeding man had been a member of staff here he would have been on a plane the next day, back to a shiny hospital with staff who could give him the scope he needed, to see the source of the bleed and then fix it. He had been sitting in his bed for four days now without treatment or blood tests. He’d had two units of blood, which was a bit like topping up a bucket of water that had a big hole in the
bottom of it.

I wasn’t sure why he hadn’t been diagnosed. Was it a lack of equipment, of staff or of interest? Maybe a combination of all three. We were in a difficult position. To interfere would be viewed very dimly, and would result in a plane ride home the next day, visa cancelled. To suggest or push was a masterclass in diplomacy. I had failed miserably at this before. That morning I had enquired in as off-handed a way as possible about him, and received a very evasive reply. He was officially a refugee and so was to be treated as a Nauruan. I was not supposed to get involved, if you believed the ABF rhetoric. But we were invariably called in to sort out disasters—when distraught relatives begged my staff to intervene it was impossible to sit back and watch them being treated as second-class citizens in the hospital.

I took the precaution of requesting some more blood from Australia so that when we got the phone call at least we’d be prepared for it. We were in a precarious position, watching a patient decline but knowing that interfering would result in us being deported. Where did our duty of care finish? Did we have one? Morally yes, I felt we had a duty. Legally maybe not, but it was not right to remain silent and watch someone potentially die when you had a way of intervening and saving them.

I decided to go and see him the next day and bring some kit that the hospital had asked us for, as a bargaining chip. Maybe that way I could have a halfway reasonable conversation with the doctors treating him. Better to have all the facts, and in this place with people keen on wild exaggeration, it was wise to find out for yourself.

• • •

News came in via email. A change in policy, courtesy of ABF. Refugee women who needed terminations, who beforehand had seen our gynaecologist and psychologist and then were referred directly to ABF to sort out their terminations in Australia, were now to be referred to the Nauruan hospital’s overseas medical referral committee.

Abortion was illegal in Nauru. This new direction would place the doctors in the hospital in an impossible situation, effectively asking them to sign off and be complicit in a criminal act. There was no way that would happen. Quite apart from the inefficiencies of the committee, which rarely sat and acted as a bureaucratic roadblock for scores of refugees requiring treatment or investigation overseas, this would effectively deny these women the choice of an abortion. In a country where rape was commonplace, and traumatised women already had almost unbearable pressures on them, this would mean they would be forced to carry on with their pregnancies.

Had ABF thought about this? It was well known that Peter Dutton hated women coming to Australia for terminations: most didn’t come back, regardless of whether they went through with the procedure or not. The clued up ones got in contact with lawyers who started the lengthy process of injunctions and arguments to prevent them being returned to Nauru. ABF tried everything in their power to prevent this happening; ensuring other children did not accompany the mother so she would have to choose between staying in Australia away from her family or returning to Nauru to see her children again. Partners were forbidden to go with them, naturally.

If ABF had done this as a cynical gesture to stop this group of women getting to Australia, it was breathtaking, a manifestly immoral act. If this was based on the mantra of ‘refugee equals Nauruan’, then it was poorly thought out. The email trail did refer to the local officers strongly advising against this as a policy. This advice had been blithely overridden.

I had three patients awaiting termination. Two were married, the other girl was terrified that her father would kill her if he found out that she was pregnant. He had made his views clear, and had previously hit her with a rock to the head when he suspected she was in a relationship. The two other women had massive psychological problems and an unwanted pregnancy would be enough to push them over, either to suicide or to try to take matters into their own hands to end the pregnancy.

How on earth to fight this new development? This was going to get messy really quickly, and time was not on our side. It wasn’t just me. I was gratified to see that other people in IHMS had quickly grasped the severity of the situation, and had made their feelings clear.

I tried to write an email explaining the problems we would now face, and asking for help. The politicians hated bad news, and this would be a big problem if people back home—perhaps the pro-choice lobby or shrewd refugee advocates—got hold of this information. It would be inevitable if the women got turned down and started reaching out to people in Australia who would listen to them and fight their corner. Didn’t ABF realise this? The news black out was pretty effective but these people were desperate, and desperate people would speak with anybody they thought could help them.

A more immediate concern was the welfare of the women in question. We would have to explain to them the delays, the change in the process and the distinct possibility that their request would be denied. As they were already fragile, this might be enough to tip them into drastic measures: self-harm, attempting to abort by medicating, poisoning, or worse still trying to induce an abortion themselves physically, by inserting wires or other gruesome means, all incredibly dangerous. Self-harm attempts were endemic anyway, with detainees swallowing razor blades and pins. These women ran the risk of presenting after an even more drastic attempt. The worst case as ever was suicide, and who knew how the news would be received?

I decided to seek some opinions. The mental health team leaders had plenty of experience in this, and might know how best to offer support to the women, and detect signs of a woman preparing to take matters into her own hands. At the same time, they could help me repeat the arguments to ABF about our concerns over the new policy’s impact.

How much of this was driven by self-preservation I do not know. I was personally ambivalent about terminations. I did not see it as my right to tell a woman what to do with her body; in that regard I was pro-choice. It was an area of medicine that I usually dealt with by referring on and trying to distance myself. Who was I to dictate to someone? Previously the women had quietly gone overseas where it was out of sight and the problem solved. Now it had the potential to blow up in everybody’s face, quite apart from the devastating impact on the women affected. I did feel an obligation to make my position clear to my bosses: this was not the right thing to do. If nobody else was going to tell ABF then we needed to.

With all these issues, remaining dispassionate was important. Traditionally, doctors always advocated for their patients. It was surely possible to keep that distinction, and do one’s best for the patient while remaining apolitical. Listening to some of the staff here, that did not appear to be the case. Advocacy was cited as an easy way to lose your job, to be threatened with gagging orders and to have your reputation trashed.

A darker part of me wanted something awful to happen or at least for people to sit up and take notice. This was tempered by the realisation that after multiple deaths and countless protests, whistleblowers, articles, the leaked Nauru files, occasional interviews, invariably the answer was the same: sticking to a much discredited, hollow, ‘lives at sea’ argument. It was as if the government had backed itself into a corner and then refused to budge, fearing that any softening or change was an admission that they were fundamentally wrong, that what was happening here was inhumane and utterly un-Australian.

Would another death by immolation change things? A man had just been found dead on Manus Island, and again there were headlines and silence, repeated stonewalling, referrals to the local government and then general obfuscation. The government wanted ‘off shore’ to mean so much more than ‘out of sight’. This was the intention, and so far it seemed to be working.

If anything I had seen happen were occurring in a medical facility in Australia, the centre would be shut down amid an outcry and indignation. Here it seemed to be left to a few left-wing reporters and activists, people who were routinely dismissed as bleeding heart do-gooders who consistently lied or exaggerated to suit their political agendas. The same words were used against the refugees. Routinely I saw the terms ‘illegal immigrants’, ‘economic migrants’, ‘terrorists’ and ‘radicals’ used interchangeably. The language used was controlled, the press coverage was severely restricted, and the issues were dodged, ignored or just brazened out.

With all this in mind, I decided to concentrate on what would be happening in front of us. That the news of the change to abortion policy would get out I had no doubt; the refugees were increasingly well connected with people, and this kind of decision had significant ramifications for future pregnancies as well as the ones affected now. Leave the uproar or murmours to other people, I thought. Worry about what was going to happen to the affected women.

All we could do for now was to try to offer more visits, more brief interventions, to mitigate any risks. It seemed a wholly inadequate response to address what these women were about to be told, but it was all we had. At least we knew this was happening and could try to pre-empt any suicide or self-harm attempts.

• • •

I had a chat with one of the paramedics. He’d been called in to the hospital to help with a ten-year-old local girl who was in some difficulty. He had gone down with one of the other nurses, and had been presented with a confused and chaotic situation that ultimately resulted in the girl dying, surrounded by her family. He was fairly pragmatic about it, and said that he was okay—it was important to recognise that these things happened routinely to all of us, and we had different ways of coping, but these circumstances sounded particularly horrific. I asked him to try to write a narrative or a timeline of the events, so we could see if there was anything that we could do differently next time.

An hour later he sent it to me, and I read it in my office. It was awful: an unemotional description of what must have been an absolutely dreadful scenario. The number of things that were done incorrectly, ignored, just plain screwed up, due to incompetence and ignorance, wilful or otherwise, was astounding. It painted a picture of a hospital utterly ill-equipped to deal with what should have been a fairly straightforward emergency presentation.

The paramedic had listed ten things that he felt contributed to the girl dying. They were damning; in any other hospital in Australia there would have been a coronial inquest or a post-event discussion to see whether things could have been done differently. Here there would be nothing, unless the girl’s family were well connected or particularly vocal. The stark contrast between Nauru and Australia was laid bare over three sides of A4 paper.

This was the hospital that the Australian government was relying on to give emergency and secondary care to the refugees and indeed asylum seekers it had placed on Nauru. The hospital was a completely unsuitable place to be treated, for locals and refugees alike. In no way could I recommend it as a suitable, safe or competent facility, and to say otherwise would be a blatant lie. It seemed that although this was common knowledge here, the message was not being acknowledged in Canberra. Was this an opportunity to raise it again? Could I really sit idly by?

I wrote an email to my bosses in Sydney. I attached the paramedic’s account and a covering letter explaining the situation and asking where our duty of care started and ended. I asked them to raise this with ABF, and to answer my questions and concerns from an ethical point of view. To knowingly refer patients to such a facility was, I felt, morally wrong and needed to be addressed.

I did not expect a reply, and did not offer any suggestions—they would only have been to close the bloody place down or bring in a completely new hospital team and equipment for them to use—but rather asked that if we were not responsible for refugees and that yes, this was the standard of care Nauruans routinely received, then this should be made clear. At present we were left with the dilemma of being responsible for refugees in primary care, and were expected to refer to the RoN hospital routinely, in the knowledge that it was a fundamentally unsuitable facility.

Sending emails like this was not going to make me popular in IHMS. At this point, after four tours on Nauru, and with a growing sense of helplessness, I didn’t care. I had long wrestled with the ethical dilemmas that came with the job, and concluded that many reports like this were suppressed or otherwise minimised, so the plausible deniability exercised by the politicians confronted with information like this could continue.

I could not remain silent. It would be more than just morally indefensible: in a court of law I would be ripped apart and I could see there would be a royal commission or inquiry once this whole sorry debacle was over. As one of the visiting psychiatrists had said, ‘The lawyers are circling.’

There had already been a fairly well publicised legal action that had been settled before the court case went ahead. The government had paid millions in the settlement. My impression was that this was to avoid going to court where the minutiae of offshore detention would be laid bare for all to see, with no news blackouts or sanctions against reporters. The government had spun it as a cost effective measure; better to spend some money now than to face a protracted legal battle. No admission of guilt or wrongdoing, it was the greedy lawyers who were at fault here. I didn’t buy that for a second. This was about covering up and media management.

• • •

Mohammad, ‘Protection’, coffee on paper, 41 x 29 cm. Image reproduced with the assistance of Refugee Art Project

My days merged into one long wade through treacle. I spent hours in an air-conditioned office, avoiding the bleaching sun, the phosphate dust and the unremitting humidity. The asylum seekers and refugees had put up with this for years, in mouldy tents or, if they were lucky, portacabins. Conditions inside the two main accommodation centres were basic at best, primitive and unpleasant at worst. Every little thing seemed to be designed to control and corral the people, whom the bored guards viewed with suspicion and occasionally overt hostility.

Outside the camps, the accommodation was also incredibly basic. Portacabins, shoved together into little shanty towns, with intermittent water and power supplies, seen as easy pickings for bored or aggressive locals to help themselves to belongings, to intimidate the refugees, sometimes to fight them and also on many occasions to rape them. The sheer weight of these stories was extraordinary. A refugee raped with a bottle by a group of local men was too terrified to leave his portacabin, and had persistent nightmares. A young Farsi woman was repeatedly beaten up by her Nauruan boyfriend.

The one time she sought help, the local police turned up and she was confronted by the policewoman who happened to be her boyfriend’s cousin. No charges were brought. The woman then went on to have a miscarriage after her boyfriend repeatedly kicked her in the stomach when he found out she was pregnant. Refugee kids presented as school refusers; when asked why, they reported being hit by the local teachers, punched and spat on by the local kids on the school bus. Walking around the island was fraught with danger: from being spat on or hit by a bunch of disaffected local lads to the risk of being bitten by any one of the roaming packs of feral dogs. The refugees often felt that their safety was perversely greater inside the camp fence, even though that carried with it its own indignities.

The stories just kept on coming. I would hear them or read them in the patients’ files, horrible stories reported blandly as incident reports tucked away in their medical notes, followed by assurances that their medications would be increased or a report would be lodged. After more than four years stuck on the island, people did not expect any action to be taken. They had moved by and large into a state of learned helplessness. Some called it detention fatigue, which seemed an apposite term for it. The American deal was mentioned frequently by our staff, almost as a potential prize, and generally the response was the same: It’s a lie, a delaying tactic, a way of keeping us quiet. The people here felt abandoned, and it wasn’t hard
to see why.

I spent most of my clinical time trying to explain why someone’s referral had not happened, why they were still waiting to learn when they might get the treatment that they needed. It was soul destroying. The refugees usually conflated IHMS with border force, seeing us basically as the same entity.

We lived alongside the Nauruans but rarely got close to them. I couldn’t speak much more than the basic greetings, despite writing the words and trying them out on some of the local medical centre staff. I had been told to not offend them if at all possible: this was their island, and they did not take kindly to being patronised or criticised. That seemed entirely reasonable. I would have hated it if a bunch of foreigners turned up in my home town and started throwing their weight around and judging me and my lifestyle.

The history of Nauru had a special interest for me; my grandfather had died on Nauru, after being posted there before the Second World War. He was still remembered on a memorial outside government house as one of the few Europeans who didn’t leave and stayed to face what they knew was an almost certain death at the hands of the coming Japanese. I had read his story with fascination, and spoken with my own father who had lived for eight years on Nauru before the war. He had given me an insight into this tiny island, so used and abused over the years, a warning tale from history of how a land could go from obscurity to the richest nation in the world and then to sink back to abject poverty over two generations.

I had chatted to a few Nauruans and found many of them to be kind, proud and welcoming; but I had also seen the casual violence among the kids, large-scale brawls, drunken crowds shouting abuse at each other, and I had moved away quickly when a group started to get leery with some of the nurses at a local bar. It was hard sometimes to reconcile the gentle islander image with the bruises, drunken shouts and scared accounts from refugees. Add in the absolute abuses of power by the government that I saw first-hand, and then the measures against reporting and free speech and you began to feel paranoid.

They had even banned Facebook, although this ban was widely flouted by everyone I knew, by using VPNs.

It was not surprising that Nauruans viewed the large number of foreign contract workers with suspicion. To be known for being little more than a penal colony would be upsetting to anyone who was fiercely proud of their nation. The refugees, with their wildly different customs, appearances and behaviours, were tolerated at best and roundly abused at worst. The refugees didn’t want to be there, the Nauruans didn’t want them there, and although a few Nauruans profited from the camps, the average Nauruan saw no advantage in this influx of Australia’s unwanted boat people.

It was also disingenuous to describe all the asylum seekers and refugees as saints. There were many whom I genuinely liked, and would gladly have them as neighbours and friends back in Australia, and there were also some whom I instinctively distrusted, who were aggressive, rude, arrogant and violent. Some were child molesters, others so damn angry at their situation that it was incredibly difficult to see the man underneath. Some were obviously highly educated and cultured, others less so. In short, they were just like us.

Depending on the patient, one could become cynical quickly. They weren’t daft. People knew that getting to Australia via the medical route was usually a quick ticket to an injunction and a temporary protection visa, community detention and then the holy grail of residency later. You had to try to ensure that the people presenting were genuinely in need. It did the IHMS case no good if, for example, a catatonic depressive who hadn’t spoken or moved out of their room for six months was transferred to Australia for treatment, then promptly got up, engaged a lawyer and became as good as new. Whether that was because their symptoms were solely situational or they had been putting it all on in a bid to get on the plane was a moot point, but it bred a feeling of cynicism at ABF when they were presented with a request to move patients overseas.

The same went for self-harm and suicide. After Dutton had come out with his view that refugees were self-harming, self-immolating and attempting suicide in a bid to get to Australia—a breath-takingly cynical viewpoint—it set the tone for any negotiations with ABF. Decisions were made that seemed to the clinicians here to be downright dangerous, and at odds with the recommendations we had made. Further muddying the waters were the actions of some of the refugee activist groups who often engaged well-meaning doctors in Australia who reasonably took the refugee’s comments at face value when I knew that the patient was exaggerating symptoms. I had one little boy who I would see happily running around playing soccer, high-fiving his mates in the camp, who when in my surgery with his parents would report excruciating pains in his arm every day, and report being unable to move it without agony. I tried to be firm but realistic with the family when I explained that this was not the way to go about getting overseas treatment, but sometimes this fell on deaf ears.

It was important not to be viewed as a doctor who cried wolf, and I tried to keep my observations to the purely objective; to things that you couldn’t fake. If I simply didn’t believe them, I would write ‘patient states that …’ in their notes. This didn’t happen very often, but I was wary of it. Conversely, there was the patient for whom I had arranged an air ambulance in the middle of a dengue outbreak, with a dangerously low platelet count and close to death by the time he got onboard. My emergency medical officer and I stayed up with him and monitored for hours, watching his decline in front of us until he was hovering into unconsciousness. That earned me a four-page email criticising my management and asking if an ambulance had really been necessary, as he had subsequently recovered in hospital. This cynicism from the department made for an incredibly difficult referral pathway, with every patient being seen as a malingerer unless one had incontestable proof that they needed urgent care away from Nauru.

Some staff ignored the politics and just dealt with the problems in front of them. I tried to do this at first, but soon realised that so many physical complaints were directly related to the patient being stuck on Nauru for an extended time: skin conditions for example tended to deteriorate in the camp conditions. Some conditions had a significant psychological element: back pains often tended to present more frequently than one would expect; almost everyone had a concurrent mental health diagnosis of insomnia, depression, detention fatigue or sometimes more florid manifestations such as psychotic depression. Self-harm was endemic, suicide attempts frequent. Addictions became more obvious as people looked for ways to pass the time, and illicit drugs were readily available and traded among the refugees. Altogether, it was hard to divorce the condition presenting in front of you from the situation the patient was in.

Other doctors became cynical very quickly. Rumours became facts. When the dengue outbreak was in full swing, people talked of refugees deliberately exposing themselves to mosquitos in order to get infected and encouraging their children to do the same, presumably in a bid to get off the island. When challenged about this, the story petered out into unsubstantiated rumour, and then to one person simply making up the story. It was hard to get to the truth, but you could rely on the more cynical members of staff to repeat these stories as facts.

Likewise, when management made a decision that impacted on the refugees and asylum seekers, some people would readily jump to its defence as a reasonable policy, and an underlying resentment would often bubble to the surface. For example, when it was decided to disallow people to pick up medications for family members—the rationale being that it enabled the patients to take more responsibility for themselves—this was defended vigorously by some staff members. When it was pointed out that in Australia family members routinely picked up drugs for others from the pharmacy, and it would disadvantage people who would then have to make the trip up to the medical centre, with all its attendant annoyances and delays, this fell on deaf ears.

Activism was stamped on incredibly quickly. It was seen as the greatest crime to be considered an advocate; it was to invite a swift cancellation of your visa and non-renewal of your contract. What was meant by ‘advocate’ was never explained. It seemed to me that our primary concern had to be the patient, and to push for the best appropriate treatment for them. If that was advocacy then surely it was what we did every day as doctors or nurses. I had signed an extensive non-disclosure agreement, and the draconian Border Force Act reminded us that speaking to people at home about what we had seen was punishable, possibly with imprisonment. Even when the rules were changed after appeals from pressure groups in Australia, this was never discussed, and to bring it up would have been seen as dangerously subversive.

The use of boat identification was ubiquitous when I started. Patients were referred to by all and sundry as ‘QLA027’ or similar and nobody batted an eyelid. I heard one of the IHMS bosses strenuously deny this practice at a Senate hearing, and laughed out loud at the lie. Later, once I had been in the job for a few months, I sat down with my team and explained that this was never to happen again: that these people were more than just numbers and we were to refrain from using numbers again. This went down surprisingly well, and word soon got around to new arrivals in the medical centre that this practice was now frowned on.

For a few weeks people would begin quoting a boat number, stop suddenly, look slightly flustered and then recheck their piece of paper, and use the patients’ names. I was ridiculously proud to have changed that. The guards persisted in using boat numbers, and I recall one man repeating it, even when I quietly asked him the refugees’ name three times, and then told him: ‘Look, I’m sorry but we just don’t do that any more. He’s got a name, and we thought we’d use it.’ He went through his notebook, and found the man’s name, and stumbled through it. I thanked him and looked up the patient’s records. Maybe it was proving a point, but it had to start somewhere.

To talk about asylum seeker politics was fascinating indeed. Some people held incredibly fixed views, parroting the government’s line about saving lives at sea. This argument rarely had any more substance to it than a few statements, and no factual basis, yet the message put out by successive governments had clearly been accepted. I began enjoying listening to people try to justify the existence of the offshore camps, then realised that for many of the workers it was a genuinely held belief, and they thought they were an integral part of keeping Australia safe from illegal immigrants, boat people, shouty, beardy men and terrorists.

I didn’t see the point in arguing with them; what possible good would it do except mark me down as a dangerous radical and probably a terrorist sympathiser. The comments came through in short soundbites: ‘We don’t really know who they are’; ‘They jumped the queue and they knew that at the time’; ‘They won’t integrate. They’re not what we need in our country.’ Many people never professed an opinion either way, and a fellow doctor advised me early on to be one of them. ‘Don’t make a name for yourself as a refugee lover, for Christ’s sake. They’ll have you on the next plane out of here.’ It seemed sound advice and I tried to keep my opinions to myself.

• • •

Mohammad, ‘Living Life in Limbo’, coffee on paper, 41 x 29 cm. Image reproduced with the assistance of Refugee Art Project

The media blackout was very effective, with no journalists allowed on Nauru. The standard line from ABF and the government was a refusal to comment or a referral to the government of Nauru. This was a ludicrous idea, as they simply didn’t respond. Columnists did often use Nauru and Manus as a stick to hit the government with, but with ongoing bipartisan support for the policy of offshore detention, and an equally large number of journalists or writers happy to parrot the ‘saving lives at sea’ line, it was rare to see any objective reporting. That did annoy me, as I did not feel that Nauru had to be the preserve of the political left or right; the conditions on the island and the treatment of the refugees or asylum seekers spoke for themselves.

And yes, the refugees had food, shelter and water, and were not being shot at. That line was fed to me a few times, and it seemed a straw man argument. They were, however, exposed to conditions that Australians would find absolutely intolerable. The evidence for that was the rising death toll, incredibly high rate of mental illness and self-harm, and every day I saw the results, in depressed people with psychosomatic illnesses. Australia had robbed these people of four years of their lives and reduced them to numbers. For many of them this was the worst thing: at least in prison you know what your crime was and what your sentence is. Here it was not a crime to seek asylum, yet the detention still appeared to be indefinite.

Twice a week I held a clinic for refugees, next to the hospital. We called it the settlement clinic. I had no idea why. I had been told that originally once people achieved refugee status—received a positive refugee status determination (RSD)—they would to all intents and purposes be viewed as Nauruan, with residency for an undefined period of time, and then access to the same services that a Nauruan would have. The concept of GPs was alien to Nauru. If locals got sick, they had a choice of being sorted out at home, going to one of the Chinese shops that sold a variety of medicines and so acted as chemists after a fashion, or attending the emergency department. The IHMS clinic was only envisaged to be around for eight weeks or so to help refugees in this initial transition period. That had been a few years ago, and it was still going strong, a tacit nod to the ongoing need for primary health care for the refugees, and possibly an acknowledgement that the RoN emergency department was in no way comparable to any facility in Australia.

When patients got to see me, I spent some time trying to ascertain what had happened, going through patient files and uncovering a chaotic paper trail of repeated referrals, sent into the ether with no reply, or at best an illegible squiggle, from which we had to see what that meant for the patient. The Holy Grail was for the local specialist to agree that they couldn’t treat the refugee, and so have proof to give the overseas referral committee that the reason we were requesting overseas referral wasn’t from a sense of superiority or arrogance, but simply that the decision had been made by one of their own. Unfortunately, when I sat in the weekly clinical meeting at the RoN and heard the director of medical services ask his staff to write in the notes—as if this were a new concept in patient care that he wanted them to adopt, instead of a basic rule of medicine—I held out little hope of ever getting a straightforward decision from the RoN specialist or committee.

To compare the RoN facility to anything remotely resembling an Australian hospital, even in a remote outback town, was unrealistic. There had been a significant cash injection and a building program, widely lauded by the Australian government. I think more than $26 million had been spent, and you could indeed see the shiny new porta-cabins containing operating theatres, a shiny new pharmacy and office spaces. Visiting officials from the Red Cross, the UNHCR and senior ABF members were shown around these new facilities with pride, an example of ethical foreign investment and a great example of two countries working well together.

It was, of course, only half the story. The emergency department and wards remained in the older buildings, with inadequate equipment, poorly trained staff and creaking infrastructure. The sparkling new pharmacy routinely ran out of basic drugs, not all doctors were medically qualified. There were no pathologists on the island and no way of conducting post-mortems. Any deaths were not investigated, and the deaths I heard about were quickly hushed up, even if serious concerns were raised by our staff. We again ran the risk of being deported if we upset the staff by pointing out any of the glaring mistakes being made.

During the dengue outbreak, I had to listen to the physician explain to me that I did not know what I was doing with the patients, and that the guidelines I was following were nonsense (these were the World Health Organisation ones) and she would continue with her own management as she knew best. Five Nauruans had already died and her response, giving people blood and antibiotics, was lethal to them. I had to bite my tongue, as she made it clear that my opinion on the refugee patients was not welcome.

This state of affairs often placed me and my staff on a collision course with the RoN. Our duty of care to the refugees was never clear cut, with ABF and IHMS shown to be adept at shifting blame between each other when something did go wrong. The young man who died on Manus from sepsis after a fairly innocuous initial infection was a case in point, and the coronial inquest showed both organisations blaming each other. I was under no illusions that if something went badly wrong with one of the refugees when they were in the RoN then the standard excuse of ‘this is a matter for Nauru’ would no longer apply and IHMS and by extension I, as the senior doctor on the island, would be made to account for any inaction.

If the division of responsibility were made clear, I would know where we stood. But frequently we had to get involved and incur the annoyance of the RoN doctors, who saw us as interfering. It was a rotten situation to put people in, and one that hadn’t ever been resolved. To stand idly by was not an option that any reasonable doctor could take, and we constantly tried to walk that diplomatic path, balancing our duties as doctors and avoiding deportation following a complaint.

I could see why the rate of staff turnover at IHMS was so high. This situation made you feel helpless and frustrated a lot of the time. The high ideal of doing some good soon fizzled out when staff realised that these people were simply pawns in a government game. The ever present fudge of hiding behind another country and its rules, although morally indefensible, worked to prevent any real decisions.

• • •

It was the end of the rotation; time to return to the real world outside the goldfish bowl that Nauru had become. I had become increasingly vocal in my criticisms of the delays in treatment and the dreadful standards. The act of speaking up while on Nauru was fraught, and I could see that it simply was not sustainable for me.

I’d been home for a week when the call came from IHMS to go to their head office in Sydney to talk about how things were. All slightly cryptic, but I was hopeful that my repeated emails and conversations were now getting through. If changes were being implemented by IHMS then it was great news; my frustration levels were rising with each tour. Otherwise, to return to the same old situation, the same patients and no progress … I was really excited that a change might be coming.

I was somewhat ambushed at the meeting. Halfway through I realised that they were telling me diplomatically that they could not guarantee my safety on Nauru: my representations were becoming an increasing annoyance either to the Nauruan government or to ABF. I asked to see any evidence showing this. My boss gave me a wry smile. This, I quickly realised, was the politest way IHMS could tell me that I wasn’t going back. They were kind enough to offer me continuing work at other centres. I left in a daze. I had gone in thinking that my efforts had borne fruit, that I would be going back to a more streamlined process, that my complaining had been listened to. Instead, they were moving me aside. Deep down I knew this had a certain inevitability to it. In a system based on secrecy and an abhorrence of scrutiny, with all the journalism bans and non-disclosure clauses, making too much noise was never going to be tolerated.

I had thrown so much of myself into the job, had tried my best to get these poor buggers the help they desperately needed. And now I was outside the tent and felt completely impotent. I had a couple of days to chew it over. Was it time to speak out? I had tried to bring about change from within the system. Now that I saw it from an outsider’s perspective, I realised it was insane. I spoke to my family, to some trusted friends. I was amazed at how much I had normalised, how much that had seemed almost acceptable at the time was clearly inhumane. I just couldn’t walk past it. I made some calls, my indignation rising. I spoke with some people who had blown the whistle before. I spoke with lawyers who were very reassuring. With each call I felt my resolve growing. This crazy, dreadful, inhumane episode had to end one day, and I did not want to have to explain to those who knew me why I had done nothing.

I contacted a journalist who I knew had been involved with the Nauru files leak: the thousands of documents that showed the banality of detention, the depressing collision of bureaucracy and humanity, people’s existence reduced to ticked boxes, documenting the extent of their self-harm, the seriousness of their suicide attempts, the myriad indignities suffered daily. I thought he’d be a good place to start. One final talk with family and friends before I jumped in. Any more delays and I would get cold feet. Was this the right thing to do? It was the only thing to do. How could I look my kids in the eye in years to come otherwise?

Things happened quickly. Television crews, interviews and hours answering questions as honestly as I could, trying to keep it solely medical when of course it would all boil down to politics. I hoped that the ex-military aspect would work in my favour. I’m not your average social justice warrior.

When the story came out, I was away from home doing a locum. My phone started to ring, and then messages started arriving. The media had done a great job as far as I could see. I felt I’d had a chance to get my message across: that medically what was happening was unacceptable, that no matter what your stance on boats, borders and refugees, it was a basic obligation, having locked people up, to look after them.

People got in touch from around the world—former colleagues, people from medical school, old navy mates, distant and close family. It was incredibly touching. I’d been on the ABC’s 7.30 and there was a Buzzfeed article and video that was shared around on Facebook. At last viewing, the online video had been seen more than 260 000 times. For a news video about a topic that generally struggles to get attention in Australia, probably because of press cynicism, general ignorance or lack of interest, this was pretty good. There were lots of kind comments, and a fair smattering of abusive ones, but it helped raise the subject again.

Nauru and Manus seem to crop up time and again now, or maybe it’s just that my awareness has been raised. The whole issue of boats, refugees, asylum seekers and detention seems to bring out the very worst in the media and in politicians. I have been disgusted listening to the moronic mantra of ‘illegal immigrants/we stopped the boats/drowning at sea’. It has made me see how powerful words are; the consistent use of words to dehumanise and belittle, to justify a barbaric, shameful policy that has made a country built on immigration a pariah.

I await the political change and the will necessary for the suffering imposed on these patients to end. I won’t hold my breath. I still think about them: did I do enough? It’s up to the rest of us to keep reminding the politicians who put the asylum seekers there that people do notice and are watching. Australia is better than this. •

Nick Martin is a GP. He trained in the UK, worked around the world with the Royal Navy and now practices as a GP in Australia.'