Breaking their bodies
Paying for their own health care
Increasingly, refugees and people seeking asylum are being denied the health care they need because they have to pay for their own medications, medical records and after-hours care, but cannot afford to do so. Refugees have told RCOA that some of their medical costs are only affordable because they are being paid for in part through donations from private individuals in Australia.
Refugees and people seeking asylum on Manus Island told RCOA that they are now often required to pay for their own medication at the only pharmacy in town, and even then the pharmacy often runs out of the medication they require. The hospital can at times provide some prescribed medications without a fee. The ELTC clinic provides Panadol and some general medications free of charge.
Those on Port Moresby report needing to pay for their own health care after hours. They often go to Port Moresby General Hospital as it is cheaper than PIH. Although some people have negotiated to be admitted for free after hours, the process appears to be arbitrary and inconsistent.
People also have to pay to get their medical records. This now costs around 600 kina (about $AU250). This makes it difficult to seek a second opinion and to ensure adequate health care.Even before the closure of the RPC, there were serious concerns about the availability of health care services, some of which was detailed in a Senate inquiry. For example, the inquiry received evidence that other refugees had complained to IHMS about its treatment of a man who collapsed in Manus RPC on 22 December 2016 and died a day later in a Brisbane hospital. According to that evidence, he had been sick for at least six months before the collapse, with stomach upsets, high blood pressure, fevers, and heart problems.
The failures of health care on Manus Island were dramatically revealed by the coroner’s inquest in July 2018 into the death of Hamid Khazaei. Mr Khazaei died in September 2014 in a Brisbane hospital from a sepsis infection, three weeks after he cut his foot on Manus Island. The coroner found that the death was preventable and the cumulative result of a series of clinical errors, bureaucratic delays and shortcomings.
These included: a lack of antibiotics on Manus Island; a failure by Australian immigration officials to act promptly on a doctor’s request to urgently transfer Mr Khazaei to Australia; and the lack of clinical skills and delays at PIH — the place where people are now being sent for the most critical of conditions. The coroner recommended that there be “independent judicial investigation of the deaths” of those sent offshore, and a written policy on medical transfers, which would allow doctors to make the final decision to transfer people in urgent cases.
It should be noted that PIH chose not to give evidence or be cross examined in this hearing, but provided submissions in writing to the Coroner, including outlining how its facilities had been expanded in Port Moresby since the time of Mr Khazaei’s death.
Cutting health services on Manus
Since the closure of the RPC and the transfer of the contract from IHMS, it has become even harder for those sent to Manus to receive the health care they need. In November 2017, UNHCR found that the clinic at the ELTC is much smaller, less well-equipped and has fewer staff than the clinic that was previously run at the RPC. The clinic at ELTC did not include services such as dental care, optometry and physiotherapy or specialist medical clinics. There was no ambulance, or after-hours patient transport.
The clinic also operates only during business hours and on Saturday mornings.82 People need to submit a request to see someone in the clinic, and in some cases it has taken weeks for an appointment. The clinic only offers services on site, and people living in the other two centres must rely on the transport services provided by Paladin Security or make their own way.
When Amnesty published its report on the effect of these cuts in May 2018, Australian officials gave an overview of medical facilities that was inconsistent with that described by UNHCR and others who had visited the centre, stating that health care is comparable with that provided in Australia. However, they did acknowledge that the clinic would be smaller than it had been previously, have less equipment, not include a pharmacy, and only operate for certain hours. No explanation was given as to why the Australian government now considers reduced health care services appropriate for refugees who remain trapped in the country and under its effective control.
Many people are referred from the ELTC clinic to the Lorengau General Hospital (which also treats them after hours and provides emergency care and a ‘surge service’ in the event of any major health crisis). After visiting Lorengau General Hospital in November 2017, UNHCR noted that:
The hospital was 33% over-capacity, while 50% of medical specialist positions (surgeon, anaesthetist and obstetrician) and 43% of nursing positions were unfilled. The hospital lacked crucial medical infrastructure (ventilators, medical incinerator) and was in need of basic products, such as intravenous fluids.
The hospital also did not have a reliable ambulance service or interpreters, according to UNHCR following its visit to PNG in November 2017. Those on Manus have confirmed that there is still no interpreter (there or elsewhere in the health care system), so those with better command of English often need to travel with their friends to interpret.
Making it harder to get care outside Manus
If people’s health conditions cannot be treated on Manus Island, they are transferred to Port Moresby. It can take between four to six months to transfer them there (although emergency transfers are are available for those with life-threatening conditions). As of October 2018, we understand there are over 70 people in Port Moresby for medical treatment. Many have been there for over six months.
There are people with hernia, stomach and gastric issues, vision impairment, and severe mental health issues. One man was suffering from such severe and prolonged stomach pain that he punched a wall, injuring his knuckles. Several others have had injuries to their tissues and bones which required surgery, but their treatment had been complicated by delays in being transferred to Port Moresby.
Those in Port Moresby can receive medical care during business hours either from PIH’s private hospital or, for after hours or emergency care, from Port Moresby General. While the private PIH hospital is better equipped than general hospitals in PNG, it does not have enough specialists and relies on visiting medical specialists. In November 2017, the hospital confirmed that it did not have an oncologist or neurosurgeon and had only a visiting psychiatrist. As mentioned, with no interpreter available, refugees with better command of English are often required to interpret for others. This increases the risks of misdiagnosis, as well as making it harder to ensure informed consent and appropriate follow-up care.
In October and November 2017, Amnesty International visited Port Moresby and spoke to 30 refugees or people seeking asylum who were there for medical treatment. They were suffering from suspected cancer lumps, gastric issues, vision impairment and mental health problems. Some were still receiving treatment for physical injuries sustained during the February 2014 attack on Manus Island RPC.
Some of these people had been told by medical professionals that their conditions could not be treated in PNG because of the lack of specialists and required transfers to Australia. They remained in Port Moresby with no information on when and where they will be transferred to get treatment. UNHCR raised particular concern about this group:
A subgroup of these patients with complex conditions is awaiting transfer to overseas hospitals and treatment services, since there are no appropriate services for these patients in Port Moresby … It can be anticipated unless urgent action is taken to provide suitable treatment, that permanent dysfunction will occur for a number of these cases.
In the last few years, the number of refugees and people seeking asylum that have been transferred to Australia from PNG has been declining (see Figure 1). Between 1 January 2017 and 30 July 2018, there were only nine transfers from Manus to Australia, in comparison to 180 transfers from Manus to Port Moresby and 40 transfers from Nauru to Australia. There does not appear to be an agreement with any third country for provision of medical care to people in PNG. (There is an agreement with Taiwan, although this only appears to be for refugees on Nauru).