Take two and see your doctor

2015-09-02

Dr R Pryor

Like many doctors in Australian public hospitals, I'm used to treating patients who are 'socioeconomically disadvantaged'. In normal speak, these are patients who are poorer and less educated, from families who can't afford private health insurance. They are often the working class, the unemployed, the chronically ill or the disabled. In our hospital, they are often the immigrants: Vietnamese, Indian, Sri Lankan, East African and Middle Eastern, to name a few. 

Unsurprisingly, these are not the people you see on MasterChef or Sunrise. They're not the darlings of Australian commercial media. But in their own way, they are as dignified and mainstream as anyone. And even to a single doctor's observations, they highlight the power of the conditions into which people are born, grow, work and age, and the wider set of systems which shape the conditions of daily life. 

These systems include economic and social policies, as well as development agendas and political structures. In public health speak, they are called the 'social determinants of health'. They are the subject of much research, undeniably powerful in their effects, and largely out of the control of many of us.

By this reasoning, many of my patients are inheritors of negative social circumstances. They start life on the back foot, have shorter life expectancies and higher rates of illness. Their disparities in health, from those of us in the middle or at the top of the tree, are largely predetermined. And that's before straying into the special, extreme conditions reserved for our Indigenous and remote communities.  

A whole lot of inequality, for sure. No medals for spotting that or crying about it. Because after all, we're all Australian citizens, living in a secure country at a prosperous time, with a safety net of sorts for those at the bottom. All in all, still a lucky club, some would argue, right?

Some are more equal than others

So what of asylum seekers and refugees, those not yet in the club? You can't witness Australian media without hearing something about them. To a doctor, the stories that jump out are often those with a health twist. What are their chances for good health, given their backgrounds and journeys? What are their social determinants, and how do they change once they hit our shores?

Occasionally, stories touching on some of these issues crack the headlines. 

Most recently, there is the story of Nazanin Bagheri, a 23-year-old Iranian asylum seeker who was raped and beaten by locals on Nauru in May of this year. Medical staff on the island immediately requested her transfer to Australia for specialist, inpatient care. These requests were repeatedly denied by the Australian government, while Nazanin proceeded to deteriorate, physically and psychologically. 

This culminated in Nazanin becoming catatonic, unresponsive to even her family, and unable to eat or drink. The accompanying electrolyte disturbances and kidney failure required intravenous nutrition. Nazanin was evacuated to Australia on August 20th, 2015, as her condition was approaching critical, some four months after she was assaulted.

While Nazanin's story is only one headline, it drew me in. Naturally, I questioned how things were allowed to get so bad. Plus, what else is happening, health-wise, to asylum seekers on Nauru and Manus Island?  What was learnt (and changed) after the deaths of young asylum seekers, Reza Berati (from violent trauma) and Hamid Khazaei (from infection)?  What about other health issues, such as: 

  • The health impact of long-term detention on babies, infants and children.
  • Perinatal care for pregnant women and young mothers in detention.
  • Treatment and immunisation for infectious diseases such as malaria, hepatitis, tuberculosis and sexually transmitted infections.
  • The prevalence of non-communicable diseases, such as malnutrition, anaemia, lead poisoning and cardiovascular health.
  • The impact of indefinite detention on mental health, including post-traumatic stress disorder, anxiety and depression.
  • The current provision of medical and allied health services, through a Federal government contract with International Health Medical Services (IHMS).

Time to pay attention

Members of the Australian medical community seem to be on high alert to these and other questions. Last year, in an article published in the Medical Journal of Australia, 139 Australian paediatricians voiced their perception of mandatory detention as a form of child abuse. Psychiatrists in Australia and New Zealand have similarly issued guidelines, critical of the government's current policies, especially for children and families in detention. 

Earlier this year, the Australian Medical Association (AMA) ramped up its lobbying, citing concerns about 'toxic environments' and 'on-going damage' in immigration detention centres.  This came on the heels of the Border Force Act, quietly passed by both major parties on May 14th. This new Act threatens doctors, nurses and teachers with up to two years imprisonment, for publicly reporting on the details of their experiences in detention centres. 

Over the coming months, in a number of reports, I'll attempt to unravel some of the facts, myths and unknowns around the state of refugee health in Australia. The 1951 Refugee Convention, to which Australia is a signatory, states that refugees should enjoy access to health services equivalent to that of the host population.  Just how are we tracking in meeting this mark?  

Due to the risks involved in identification, the author is using a pseudonym. He is a medical doctor and a Greens member. The image is a stock image and is not intended to resemble any person currently living in Australia.