Submission to the Senate Legal and Constitutional Affairs Committee inquiry into the Migration Amendment (Repairing Medical Transfers) Bill 2019 by Dr Tanya McIntyre, 15 August 2019

Submission overview and concerns

This submission outlines my views on refugees and asylum seekers 1 in need of medical evacuation from and Nauru to , as enabled by the Home Affairs Legislation Amendment (Miscellaneous Measures) Act 2019 , referred to herein as the “medevac law”.

I am concerned that people who are physically and mentally unwell are denied medical treatment. I am appalled that this is done to uphold government policy that is explicit in its aim to inflict ongoing harm on one group of people to try to compel them to return to the harm they fled as refugees, and to warn others of the harm they would also suffer if they try to seek refuge in Australia.

I am concerned about this brutal and inhumane treatment of refugees. It does not befit the fair, democratic and compassionate principles that we like to think underpin Australian society and polity.

My experience with refugees in Australia’s offshore detention regime

In 2012 I began visiting refugees in Australian immigration detention.

In 2014 I completed a Graduate Certificate in Australian Migration Law and Practice. My other credentials include a PhD in Asian studies.

Since 2014 I have met and communicated with refugees detained by Australia on Nauru and after 19 July 2013 when offshore detention became more than a temporary processing regime and became a feature of the practice of permanent exile of people who sought protection in Australia.

In 2015 I registered as a migration agent and began providing migration assistance to refugees in Australia’s immigration detention network.

Since 2015, I have been a member of Darwin Asylum Seeker Support and Advocacy Network (DASSAN) through which I assisted sending e-books to refugees on Manus Island and Nauru and distributing a hardship fund to refugees, including in Papua New Guinea.

In 2017 I lived in in Papua New Guinea for several months. I worked for a local non- government organisation to establish monitoring and evaluation systems for a project that supports market vendors, who were mainly women, to elevate the status of their work into the formal economy as a regulated and safe working environment.

1 The terms ‘refugee’ and ‘asylum seeker’ generally refer to, respectively, people found to be refugees through a refugee determination process and people seeking asylum but not found to be refugees either through a refugee determination process or not having yet undergone or completed a refugee determination process. However, in this submission, I hereon refer to both groups as refugees. This is for ease of reference and to not distract from the subject of medical needs by delving into immigration status issues. It also acknowledgement that many people in Papua New Guinea and Nauru not yet found to be refugees are still requesting their refugee claims be assessed or reviewed according to the principles of the UN Refugee Convention and the UN guidelines on determining refugee status.

Submission to Senate Committee by Dr Tanya McIntyre Medevac Law Page 1 of 5 While living in Wewak in 2017, I made two trips to Manus Island, for approximately two weeks on each occasion, and met some of the refugees held there since 2013.

In April-May 2019, I visited Manus Island for approximately three weeks, and for approximately a week. I was devastated to see everyone I had met on Manus Island in 2017 suffering further and sharp decline in their health and wellbeing. In 2017, people I met on Manus Island had descended to a level of despair and hopelessness lower than I have ever seen in the years I have interacted with refugees. Yet by 2019, the same people had crashed to unimaginably gut wrenching pits of despair and hopelessness. Whereas in 2017 people were relatively engaged and welcomed the opportunity to exchange stories and experiences, by 2019 the same people apologetically struggled to even go out of their guarded accommodation due to their incapacity to cope with life.

In recent months, I have been assisting more than 20 refugees with their applications under the medevac law. This involves gathering their medical records and contextual information about factors affecting their health and wellbeing, responding to emergencies including suicide attempts, and referring to appropriate services where possible.

Observations of Wewak medical services – a comparative example of regional Papua New Guinea

Medical services in the regional town of Wewak may be loosely compared to that of Lorengau on Manus Island. However, Wewak is not as remote as Manus Island. Wewak is situated on the north coast of the main island of Papua New Guinea, and is larger and better-resourced than Lorengau. Wewak population is around 30,000. Lorengau population is around 7,000. Wewak medical services, although substandard, are likely better than medical services in Lorengau. Moreover, Wewak is not overwhelmed by a population of ‘foreigners’. Whereas the large number of refugees in Lorengau in recent years has placed additional demand on already substandard medical services.

While living in Wewak, I visited a patient at the Wewak Hospital. I also knew two Australians who worked at Wewak Hospital – one in administration and another as a surgeon.

The patient I visited at Wewak Hospital was my co-worker’s father from a nearby village. He was a fit, lean and strong man in his mid-fifties who developed diabetes undiagnosed until some of his toes fell off after rotting from a small, infected wound. Through several weeks in a ward of about 40 patients in one large room, while one of his daughters slept on the floor of the hospital by his bed and provided necessary care for him that the hospital could not provide, he underwent two amputations of his leg – the first below the knee and the second above the knee. Shortly after the second amputation he died, as the infection was not contained.

The Australian administrative worker I knew at Wewak Hospital told me about the impact of funding constraints. For example, a doctor employed to deliver outreach services to the villages around Wewak was only funded for wages but not for travel or program support so the doctor could not deliver any services. Additionally, when administrative staff were not paid wages for months, they did not attend work, or attended but failed to undertake duties.

The Australian surgeon I knew at Wewak Hospital told me that, despite the commendable skills and commitment of medical professionals, the hospital was extremely under-resourced of both equipment and medical expertise. For example, the hospital had no independent electricity supply, so during frequent power blackouts doctors used torches and mobile phone lights to see as they completed surgery in the dark. Further, doctors worked extremely long hours and were constantly challenged to perform procedures that stretched their competencies. Patients routinely died preventable deaths that

Submission to Senate Committee by Dr Tanya McIntyre Medevac Law Page 2 of 5 in Australia would invoke full investigation yet no follow up in Wewak Hospital ever occurred. There was no scrutiny of medical or systemic failure.

I also knew of a disabilities service in Wewak that did not pay its employees for months, so instead of attending work, physiotherapists and other professionals resorted to selling garden produce in local markets to make ends meet. I bought some of their produce.

General observations about the health of refugees held in Papua New Guinea

All the refugees I met in Papua New Guinea suffered chronic physical complaints for years, and struggled increasingly with serious mental health conditions. Their treatment was mainly ineffective medication. Doctors often say and write reports that their illnesses are caused or exacerbated by stress and anxiety, resulting from their being held in Papua Guinea indefinitely. Medications are often changed due to lack of availability and for trial – this has particularly detrimental effect on refugees taking psychotropic medications. Food quality and diet is poor, increasingly so since Australia withdrew in October 2017 from directly operating the centres. Activities have declined since Australian operational withdrawal, for example with closure of prayer spaces and gyms. Almost all refugees I met had eating and sleeping disorders due to chronic pain, gastro issues and mental health issues, and were taking pain killers and tranquilisers. Some refugees suffered complex conditions that required surgery. Some had suffered botched surgery, resulting in disability. Some suffered injuries from assaults, resulting in disability and mental ill health. At least half the refugees I met reluctantly admitted to self-harming or attempting suicide – I suspect higher actual incidence.

Individual cases of refugees and medical evacuation

I outline below three cases of refugees I know and have assisted in their efforts to be medically evacuated to Australia. These three cases exemplify the need for medevac law to be retained. The first case is about a refugee evacuated before introduction of the medevac law. The second case is about a refugee evacuated under the medevac law. The third case is about a refugee remaining in Port Morseby whose application under the medevac law is pending.

Case 1: Refugee evacuated from Nauru prior to medevac law

A refugee on Nauru who I communicated with for about a year suffers multiple serious physical and mental health conditions. He lived in a tent on Nauru for most of five years. He suffers extreme loneliness and longing for family and community that he is now forever separated from.

He has serious neurological and heart conditions, and severe anxiety and depression, for which he was not treated on Nauru. Moreover, his mental health issues were caused by being held on Nauru in a physically and emotionally exhausting environment that did not relent.

In the latter half of 2018, he gave up and virtually stopped eating and drinking. As he became weaker and more disoriented, he stopped taking medication without which he could die. He told me he did not decide not to eat, drink or take medicine but when he tried he just could not do it. His mind and body were shutting down. He lost control. He did not care that he could die. He had no will or hope left.

Late 2018, lawyers commenced action for his medical evacuation. When his court case was filed, he was evacuated. Since arriving to Australia, his condition stabilised to some extent. He now has

Submission to Senate Committee by Dr Tanya McIntyre Medevac Law Page 3 of 5 ongoing specialist medical care, and a healthy living environment with regular meals and activity. However, his conditions had become so serious that his recovery is slow.

Had the medevac law been in place earlier, he would have been evacuated and received the treatment he needed much earlier and would likely not experience such a slow recovery.

Case 2: Refugee recently evacuated from Papua New Guinea under medevac law

A refugee who was on Manus Island for almost six years has multiple physical and mental health issues. I communicated with him since 2016 and we met on my visits to Manus Island.

He is a strong person and despite the odds he tried to retain his good health and fitness. He expresses deep love and longing for his family, especially his mother, who he tries to shield from his harsh reality. He tries to put on a bit of weight before taking a photo to send home.

He suffers chronic pain and discomfort from stomach and kidney problems, an eye problem, and a muscular-skeletal condition that developed since being on Manus. He has not slept well since refugee Reza Barati was murdered inside the detention centre in February 2014. During most of his years in Papua New Guinea, he suffered nightmares of violence in detention on Manus Island and trauma he fled as a refugee. He had several infections from minor sores that took months, or even a year, to heal. He constantly took many medications, which he hated, including antibiotics, pain killers, for gastro, anti-depressants and tranquilisers.

About two years ago, due to his complaints, he stopped physical fitness activities, and his overall health declined more sharply. He self-harmed and suffered an injury resulting in a permanent disability. He also suffered injury from a serious assault in the detention centre.

During the last year, he was in constant pain, barely left his room, could not sleep, vomited daily after eating, and was prescribed psychotropic medications. These medications were constantly changed due to lack of supply or trial of different medications. Although he barely digested food, he put on about 10 kilos – apparently a side effect of psychotropic medication.

Early 2019, he was transferred from Manus Island to Port Moresby for medical treatment. He hoped treatment would be better than on Manus Island, yet it was much the same in Port Moresby and his health declined further, particularly his mental health. He attempted suicide a number of times. He virtually stopped talking and eating and did not leave his room except to get medication. He lost a lot of weight. He told friends not to see or talk to him. He did not respond to messages. He refused contact with family for months, and said they would soon forget about him after he died. The guards brought food to his room that he could not eat.

Throughout the last year when his mental health was in sharpest decline, no local counselling services were available, and remote counselling could not be reached at times of crisis.

He was recently medically evacuated to Australia under the medevac law. Since then, with doctors’ consultation he is gradually withdrawing from most medications. He is talking to family and friends, and has started mild exercise again. His pain and anxiety is diminishing.

His life was saved by the medevac law – he has begun to recover since his medical evacuation. Had the medevac law been in place earlier, much of his pain and suffering could have been prevented. If there was no medevac law he may have died by now.

Submission to Senate Committee by Dr Tanya McIntyre Medevac Law Page 4 of 5 Case 3: Refugee awaiting evacuation from Papua New Guinea under medevac law at August 2019

A refugee who has been in Papua New Guinea for approximately six years remains in Port Moresby, where I met him. He has serious medical conditions for which he has been transferred between Manus Island and Port Moresby a number of times. He has been hospitalised several times and constantly undergoes medical tests. He has spent approximately three years in total in Port Moresby for medical treatment. He suffers extreme pain almost all the time. Ongoing medical maltreatment and lack of appropriate treatment has contributed greatly to his deteriorating mental health.

He was diagnosed about four years ago with an illness that doctors advised could be terminal if he did not have surgery to a vital part of his body. He was encouraged to talk to his family urgently on advice he may not live long. So although he was afraid, he agreed to surgery. After the surgery, it became evident he had been wrongly diagnosed, the unnecessary surgery resulted in a permanent disability, and his severe chronic pain moved to another part of his body. His condition remains untreated. He is victim of extreme medical malpractice. He feels tortured by this, and the torture extends to his family anticipating his death in their absence and inability to even comfort him.

He has since been advised to have surgery for another condition. However, he will not agree to surgery again in Papua New Guinea after his previous experience.

As a result of the trauma of his medical treatment and chronic pain, he suffers constant anxiety, depression and sleeping and eating disorders. He often does not leave his room for days. He cannot exercise anymore. He often does not communicate with anyone. He avoids medical treatment despite being very ill. He contemplates suicide and says his life is nothing.

If the medevac law is not necessary, as the government says, why has the government failed to transfer this refugee to Australia for medical treatment until now? It has been evident for literally years that he needs medical treatment that he cannot get in Papua New Guinea and that his life is at risk while he remains there without appropriate medical treatment.

He is in the process of applying for medical evacuation under the medevac law. His application is pending. If he is not medically evacuated, his life is at risk. The medevac law can save his life.

Summary and recommendations

In the Second Reading Speech in support of the Migration Amendment (Repairing Medical Transfers) Bill 2019 on 4 July 2019 the Minister for Home Affairs somewhat ironically said the “medevac law … was passed by parliament in February on a lie. There is no medical emergency on Manus or Nauru.” It is submitted that ample evidence shows that the latter part of this quote is a lie and that there is a medical emergency on Nauru and Manus Island, as well as in Port Morseby.

It is submitted that it is unconscionable conduct of the Government, Minister and Department, while privy to all the details of the medical emergency in Papua New Guinea and Nauru, to perpetuate circumstances creating this medical emergency and fail to act upon it unless compelled by law.

I therefore recommend:

1. That the Committee ensures the medevac law is upheld; and 2. That the Committee does not support the repeal of the medevac law.

Submission to Senate Committee by Dr Tanya McIntyre Medevac Law Page 5 of 5