Once, on a cold day in Melbourne

Someone called the Clinic the other day and left this message: ‘Alexa Rosa wanted to speak to the doctor who treated her mother a long time ago. And she wanted to buy your book.’ Did I know an Alexa Rosa? I thought somehow I should. A scene came back to me: a cold winter’s day in Melbourne, a young family in a front room, a sick mother, her worried husband, their adult daughter.

If this truly was my Alexa, then her story was strong and bright in my recall. I could never forget it. It was the winter of 1971. I had a new marriage, a new licence
to practise medicine outside of the hospital and a brother about to marry
in the United Kingdom. In order to raise the fares to the wedding I moonlighted as a radio locum. A radio locum installed a two-way
radio in his car and travelled, like a taxi driver, to wherever the job
called. On this occasion the call came to the Migrant Hostel in Kororoit Creek Road Altona. My bride, an able map reader, sat at my side and navigated.


Kororoit Creek Road in Atona was a long drive from everywhere else. When we arrived and parked in a vast car park, Annette (the bride) repeated the Controller’s directions, “Building 19, apartment 5.” I stepped outside.
Here, at Melbourne’s western edge, you could see the setting sun
disappearing beneath the horizon and the world darkening.

I didn’t feel happy leaving Annette there in the dark. I looked beyond the carpark toward the distant buildings. Would Annette be any safer in that lowering mass? Annette said, “I’ll be alright here. Just go.” Troubled, I went. How would I find building Nineteen where someone needed a doctor, someone who was suffering from something, possibly something serious? Having now reached the first of the buildings I could see my search was hopeless. The buildings were all great bulky cuboids of concrete. All were unli. And the dark was cold. I wandered and looked for numbers. No number nineteen anywhere, no five. I knocked on a door to enquire. The door opened, I asked, Can you direct me to Flat Five? A hand flew to the heart. The head shook: I not English. I sorry.

I felt sorry too. I turned dully away. Of course no English, everyone here newly arrived, everyone indoors, appalled, like me, by the cold. Movement in the shadow on
my left. I hailed the shadow: Excuse me, do you speak English? The head
shook no, while the face smiled a wide yes. The shadow, a young man,
beckoned, and signed me to follow. I followed. He moved swiftly along cement paths, in and out between buildings, along corridors, until abruptly he stopped in his tracks, pointing and nodding furiously. The shadow knocked on a door, turning to me, smiling. Pointing towards the door, the shadow said, English! The door opened and a voice spoke: Good evening. How can I help you?
Did you send for a doctor?
No.
Is this Apartment Five?
No. This is seven.
Is this Building Nineteen?
No but I’ll take you to Number Five..

This was someone not lost in language nor in space. Feeling found, I followed. A building or two or three later, my guide stopped and knocked on a door. I noted a large numeral 5 next to the doorway and felt almost
hopeful. The door opened and a pretty young woman appeared. Behind her stood a man, older than she; behind him a couple of small children, curious and fearful, clutched at the man’s legs and peeked. The young woman saw my
medical bag. She told me her name and said, Come in Doctor. Thank you for coming. My mother is sick.

Mother lay on a couch. She did not look well. Her daughter explained: We arrived just today from Spain. During the flight Mother started to cough and it was hard for her to breathe. Now she has a fever. We didn’t know how to call a doctor. Thank you for coming.

I examined the lady. I thought I heard altered breathing sounds in one
lung. I bent and listened hard. The air struggled into one side of the chest, it rattled and squeaked.This was bronchopneumonia. Ordinarily a hospital matter, this called for X-RAY, possibly intravenous treatment as an inpatient. How would this lady get to hospital? Would Medicare cover a new arrival? Would the ambulance take her? Was there another way?

I straightened and addressed the  man through his adult daughter. Mother is sick. She has an infection in her chest. She needs strong antibiotic medicine, she might need to go into  hospital. If you wish I can start some treatment here, now. And with luck she will improve quickly.

The daughter translated for her father. The two spoke with the mother, the three nodded. They had decided. The daughter spoke. Thank you doctor, yes, we would like you to treat her. Thank you doctor…we don’t want hospital.  I fished out some  penicillin – no, mother is not allergic – and gave the lady a hefty dose by injection. I wrote out a prescription for oral penicillin to commence the next day. 

Leaving detailed instructions for a range of eventualities I prepared to take my troubled leave. I wished the lady well, I wished the whole family good health in Australia. The daughter reached for a purse. How much do we pay you, Doctor? I did not want payment. A doctor who deserted his sick patient didn’t deserve payment. I said something like, There is no charge. To myself I said, You have paid me, you’ve paid off my guilt. The young woman protested, No Doctor, we must pay you. We don’t know who sent you. How did you know we needed you? I didn’t know. Once again I wished them well and I left, my ears burning with blessings I could not accept.

Back in the car, I found Annette unharmed. I said, I couldn’t find my patient. And I told her the story.

***

It might have been six months later when I was called to the Delivery Suite for the birth of a baby. Birth was not expected for some weeks. Labour was well advanced when they called me and birth was imminent. I needed the mother to help. ‘Push, hard, push! The mother didn’t speak English. A masked figure at her side coached her, translating my words: Big, long push. Push….The mother pushed, her face turning deep red, the veins standing out on her forehead. Stop pushing now! Don’t push! Breathe, breathe…The mother breathed and with each breath the head advanced. The mother breathed her baby into this life, accompanied by fluids, red and clear and mucoid, and followed by the placenta and cries from the baby and crying from the mother. I counted fingers and toes and other parts and placed the baby on the mother’s chest and wished the new family joy. I pulled off my mask and thanked the person whose interpreting had made the birth smoother. I extended a hand, My name’s Howard. We have met, she said, removing her mask. I am Alexa.

***

Alexa explained she had come to visit her friend, now a new mother, in her ward. Abruptly, labour started and accelerated. The hospital discovered there was no-one to interpret for a Spanish speaker so Alexa volunteered. We chatted. She told me her own mother was well, recovery had gone smoothly. She, Alexa, was working as a wardsperson in this hospital. She told me she hoped to study nursing.

I said, I don’t know if you realised I had been called by an entirely different person on the day you arrived from Spain. I never found that person. I never discovered how I fund your Mum. I know, said Alexa. God sent you.

A few weeks later my father told me a new family had started seeing him as their local doctor. They’re from Spain, he said. They tell me you treated the mother for pneumonia.

***

Forty-nine years passed. Locked down, I’m doing Telehealth from home. A message arrived for me, asking me to contact an Alexa whom I had know years before. I rang the number. Alexa speaking, said a voice. The voice sounded Aussie. I told Alexa who I was. She asked, Do you remember us? If you arrived from Spain in 1971, then yes I do. How could I forget? We did. It was 1971. I guess you were about nineteen then. Exactly. So you’re sixty-eight now? Yes. And I did do nursing. I’m still nursing. We talked for a while. Mum is still alive. She’s ninety-three now. Dad only died last year. Do you remember what you said when you left us that night? What did I say? You said, I wish you health and happiness in this country. You blessed us and your words came true. I reminded Alexa of her words to me in the Delivery suite. You said, ‘God sent you.’ That’s right. God did send you. It’s the only explanation. That was the night I became a believer. I found God in the Hostel.

***

In the few days that have passed since Alexa opened the closed door on half a century, I’ve felt excitement and perturbation. I’m excited that Alexa and I will ‘meet’ again, that I’ll ‘see’ my pneumonia patient again, spry and vital; that I’ll meet the children and their father, that I’ll learn their stories. At the same time, some different, powerful feeling operates and unsettles me. It’s the thought of the power of a word, the reverberation of a small act. Alexa sees the hand of the Divine. Does that make me somehow an instrument in a plan? I cannot begin to recognise anything so lofty. I dismiss any idea of some special mission I might have; I find that sort of belief a burden, an embarrassment; it makes me want to run away.

But I’ve been moved to tears thinking how a simple act might lodge in memory, might germinate as a seed, might influence a life; that somehow, quite without intent or thought or awareness, a simple act could take root, help, lift, encourage, perhaps inspire. That thought brings with it a glow, the sense I have done as I know my father did before me – many times – some act of unwitting goodness that lived on afterwards. I’ve felt overcome with a feeling of blessing, perhaps of being a small link in a long chain that might continue on, in lives undreamed…

Mercedes, aged 92 years
Alexa and son

Reds Under the Bed

This coming Thursday evening, April 6, I plan to attend a meeting to listen to a researcher report on the history of his family in Australia. Following the death of that family’s breadwinner in Russia, his children of twelve years and younger tried to work their father’s small farm. Where their father struggled to feed the family, the children failed. Following a pattern familiar to many in this immigrant country, family members trickled here, arriving as serial migrants through the 1910’s and 1920’s. 

Australian immigration officials looked upon citizens of Russia, a Communist country, with deep suspicion. Very few Russians were admitted during this period. The family in question were accepted on the basis of Letters of Recommendation of the first arrival, who had shown himself an exemplary citizen, winning written and lobbying support from leaders on both sides of Australian politics.

So the family came. Within a generation their children became graduates, rising to positions of distinction in the Law and Medicine. Others started small businesses and prospered. The clan was preponderantly leftist – one at least became a member of the Communist Party of Australia – but all lived the life of the petit bourgeois. 

I haven’t mentioned the family name for one curious reason – the family has never agreed on what they are to be called. Thursday night’s speaker, Michael Komesaroff, has cousins called Komesarook, others are Komisaruk, yet others are Kaye. Komesaroff, the speaker, will present a paper titled ‘Reds Under the Bed’, drawing on the files that ASIO kept on these good citizens. It must be disturbing to discover that the authorities in the country you have come to love (and in some cases, to serve in the forces) mistrusts you sufficiently to spy on you. In the case of the Komesaroff/Komersarook/Komisaruk/Kaye clan there was no sedition but reasonable grounds for suspicion. As is often the case the files show Australia’s spooks to be heavy handed and occasionally laughable.

If the McCarthy era was one of paranoia ours is also a time of anxiety and too-ready accusation. Because mistrust is once again the mood of the day in this country Komesaroff’s scholarship is highly topical. 

The meeting is open to the public.

7.30 PM, Thursday 6 April

Temple Beth Israel, Alma Road, St Kilda

The talk is under the auspices of the Australian Jewish Historical Society 

 

The Voice of Victor

For a few years my daughter lived in England where she met lots of other young mothers, ordinary white middle class women with orderly lives, healthy babies and toddlers. They all had husbands with jobs, all were native English speakers in an English speaking country. They were all OK. Their babies got croup and cradle cap and they saw competent doctors in a timely way and had access to suitable, safe and effective medicines, and soon their babies were OK again; and they were all OK. 

But one day, one of my daughter’s friends saw the papers, watched the TV news and she stopped being OK. The friend’s name is Ros. And although Ros – a person in London with an ordinary life, who abandoned her day job and roused herself and roused one hundred thousand other ordinary English mothers and fathers and children to demonstrate and campaign for refugees, and this led to David Cameron rousing himself and his government, and this roused Britain to admit many whom they previously would have turned away – this story is not about ordinary Ros.
My daughter left England and returned home to Australia. She and Ros remain in touch. Ros sent a photo that broke my daughter’s heart. She wrote me a letter that included the image below:
 

My daughter’s friend Ros sent her this photo in a letter she came across in a camp on the Greek Island of Thessaloniki. In shrinking lettering near the foot of the letter the writer signed his name, “victor”.

 
My daughter says Victor’s is the despairing voice of one refugee so desperate to be heard he writes on the wall of his tent. He knows no-one hears. She says the world has turned its back. My daughter turns to her writer father with a plea of her own: “Maybe your writing could give Victor a voice. I’m just saying it made me think of you. Do with that what you will.”
I read my daughter’s letter. I read Victor’s letter.
Do with that what you will, she says, then adds, “Going to sleep with a heavy heart.”
Days pass and I don’t do anything.
Every time I switch on my computer, my daughter’s letter asks me, what will I do to make Victor’s voice heard? Something indistinct echoes, something about the unheard voice. It is a voice from a cattle car.
WRITTEN IN PENCIL IN THE SEALED RAILWAY-CAR:

here in this carload 

i am eve 

with abel my son 

if you see my other son 

cain son of man 

tell him I

  

What can I do? What can any of us do? We can try to emulate ordinary Ros. We can write to our local Member of Parliament, write to our faith leaders, speak to our friends. We can do as an ordinary friend of mine does – she organises aid packages. (That friend – a lapsed fundamentalist Christian – writes annually to this Jewish friend, seeking donations of Christmas gifts for Muslim refugees.) We can adopt a Victor – there are so, so many – and write to him. We can send him books. We can remind him he is not alone, not forgotten.

 

What good will these ordinary acts do? In the case of Ros they led to the saving of thousands. In Australia, our ordinary voices were raised enough to encourage our very ordinary leaders to find our captives place of safety in the USA. Our leaders are timid. It is for us to lead them.
(You can find out how to emulate ordinary Ros if you visit http://www.swruk.org/ )

Twelve at a Dinner Table

The year was 1938. In November a coordinated series of pogroms across Germany and Austria saw the burning of synagogues and the shops of Jewish people, and the beatings and murders of Jews on a huge scale. The Night of Broken Glass, Kristallnacht, broke more than glass. It saw the destruction of hope among those German Jews who remained hopeful that this madness would soon pass. In its place a realization, completely new, at odds with the eagerness of the Jew for acceptance: They want to kill us all. If we stay they’ll kill us.   

 

Far away in Australia twelve friends enjoyed a convivial dinner. Long after they’d finished eating the friends sat and talked. A relaxed group,intimate and trusted. One pulled from his pocket a sheet of paper. This arrived in the post today. The stamp reads, ‘Osterreich’ – I think that’s German for Austria. The letter seems to be in German; no-one at work can speak or read German. We don’t know what to make of it. It is addressed to us apparently. That is, we think so. The first line uses our company name. The same on the envelope…

 

 

A hand reached across the table. A second voice spoke: Pass it here. I’ll have ago. I did German at school.

A brow furrowed. A quietness fell, the quiet of satiety and comfort among friends. Hey! This is horrible. Terrible – if it’s true. The German scholar translated. The quiet now took on an earnestness, an intensity, as twelve ordinary Australians grappled with facts that would unseat innocence. The reader’s voice slowed as she rendered the closing lines: Honoured Uncle Borer, Unless we can leave Austria, we will die. They will kill us. Unless you sponsor our admission to your country.

 

 

This story was told at my family dinner table towards the end of a recent Festival meal. At the table sat three generations of Jews, all but one of us born after WWII. We too had sat, sated, content, comfortable. It was the voice of my wife’s sister, Robyn telling the story. She continued: ‘This was a family that was desperate. Jews could still get out – if they had a visa. Australia would accept a certain number of Jews if they had a relative here who would sponsor them – that is if the family would guarantee their upkeep.

 

 

That terrified family in Austria recalled an obscure uncle somewhere in Australia. The only detail they recalled was the name the family had known him by, ‘Uncle Borer.’ Was Borer a first name or a family name? They were uncertain even of that. Where in Australia did Uncle settle? Was he still there? Was he alive? Would he help them?

 

 

Armed only with the ardent desire to live, the family somehow procured Australian telephone directories. They searched for the name Borer. Few were the families in Australia that answered to that name. But the family wrote to every Borer they found, explaining their situation and pleading for Uncle to save them. They never heard from Uncle Borer. But the Manager of a small Australian enterprise listed in the telephone directory under ‘White Ant and Borer Exterminating Company’ received a letter written in the German language, which he brought with him that evening to a dinner party in 1938.

 

 

No-one at that dinner table had relatives in Germany or Austria. None of them had friends there. The twelve absorbed the content of the letter. They contemplated its closing lines, they will kill us…and they heard the words that had reached them like a letter in a drifting bottle – unless you sponsor us.’

 

 

Robyn paused. Eleven of us, all Australian by birth, Jewish by heritage, reflected on our families’ stories of arrival. We knew by name those who sponsored us, we knew the dozens of families that our families had sponsored. The twelfth person among us, mother of Robyn and my wife Annette, was born ninety years ago in Danzig. She too arrived in1938. The matriarch at our table, Nana, our treasure, a brand plucked from the fire, was sponsored, saved. Nineteen Australian citizens, Nana’s descendants, are alive today. (A twentieth is expected).

 

 

Robyn resumed: ‘The manager of the borer company sponsored the family. We know that family, they are friends, but I never heard their story until now. And there’s one more thing – everyone at that dinner table sponsored Jews who needed to escape. Apparently forty people – or was it forty families – were saved by the borers and their ordinary Australian friends. Incidentally one of those twelve was a man named Harold Holt.’

 

 

Harold Holt! I remembered the prime minister from my student days. I remembered him as the conservative who sucked up to the USA in Vietnam. ‘All the way with LBJ’, was his catchcry. Harold Holt giving succour to asylum seekers was not how I imagined him. How old was he, I wondered, when he heard that letter to someone’s Uncle Borer? 
 

 

At our table that night I looked around, mentally counting: twelve, yes we too were twelve. Would we, I wondered – would I – sponsor a family of foreigners as that twelve did? But as matters stand, we twelve Australian adults are all impotent under our present laws to sponsor anyone, not even those who have escaped to Manus or to Nauru.

POSTSCRIPT:

So I looked him up in Wikipedia: “Harold Edward Holt, 5 August 1908 – 17 December 1967), was an Australian politician and the 17th Prime Minister of Australia from 1966 to 1967. He was born in Stanmore, New South Wales and won a scholarship to study law at the University of Melbourne. Holt went into business as a solicitor, during which time he joined the United Australia Party (UAP). In 1935, aged just 27, he was elected for Fawkner. Holt spent 32 years in Parliament, including many years as a senior Cabinet Minister, but was Prime Minister for only 22 months before he disappeared in December 1967 while swimming at Cheviot Beach near Portsea, Victoria, and was presumed drowned.
As Minister for Immigration (1949–1956), Holt was responsible for the relaxation of the White Australia policy.”
So here is one ordinary Aussie, aged thirty, a junior politician who acts and does a private good. Eleven years later, in his public capacity as minister for immigration, he recognizes the humanity of those humans whose skin is not white, transforming for the better a largely monochrome country.

The Clinician and Detention

Recently Dr David Isaacs, a courageous Australian paediatrician, returned from a working visit to one of Australia’s offshore immigration centres with distressing reports of the suffering and what he considered to be torture of the detained asylum seekers. He called publicly for doctors and nurses to question whether it is ethically permissible for them to accept employment in such settings. Since Dr Isaacs spoke out doctiors and nurses at Melbourne’s Royal Children’s Hospital have refused to discharge asylum seeker p[atients to island detention where they believe the children would be unsafe.
Dr Isaacs risked imprisonment for speaking out and he donated his earnings to asylum seeker relief. He then published an essay in The Journal of Medical Ethics, whose editor – an Australian medical graduate – asked me to respond. This is what I wrote. It is published here with the kind consent of the editor of the Journal of Medical Ethics, British Medical Journal.
ABSTRACT: An examination of ethical issues encountered in the author’s clinical work with detained patients. The author seeks to clarify in which ways, if any, the detained patient might differ from the generality of patients, and hence to identify any distinct ethical duty of the clinician. Also addressed is the broader question: how – if at all – do medical ethics vary from universal ethics? The author reflects on the distinctive duties of a free human towards a detained one. And finally addresses the topical suggestion that a doctor or a nurse should positively refuse to serve in an immigration detention facility on the grounds that to do so would be to condone or facilitate torture.

BY WAY OF INTRODUCTION

The author is a general practitioner of wide experience, having worked in Australian urban, suburban and country practices over greater than four decades; and having spent about eight weeks a year for the past twenty years working in remote clinics. These ‘outback’ postings have been predominantly in Aboriginal communities, while (in 2009) the writer worked for a time In Alice Springs Correctional Centre, and (in 2010) in an Australian Government Immigration Detention Centre offshore.
 
 
DECLARATION OF INTEREST
 
1. I worked in Alice Gaol for lower than average wages; I worked offshore for inflated wages; I banked all proceeds and I paid tax on them.
2. I tutored the editor of this journal in general practice. Our conversations ran particularly to ethics. I became your editor’s friend, his referee, his failed marathon running mentor.
3. As a result of the foregoing I must accept partial responsibility for any ethical errors in your editor’s writing and in his clinical work.
4. I have written and published elsewhere on these themes and continue to do so. They constitute a substantial element in my forthcoming book, ‘Burned Man’ (in press, Hybrid Publishers, for release in August 2016), to be marketed with mercenary intent (and with the opposite expectation).
5. I signed a confidentiality agreement with my employer prior to working in the island Detention Centre. 
6. I worked in Torres Strait (2008) on behalf of the Department of Customs, charged with medical assessment and initial treatment of illegal fisherman captured in Australian waters.
 
 
MEDICAL ETHICS VS ‘UNIVERSAL ETHICS’
 
I read with interest and admiration ‘Are health professionals working in Australia’s immigration detention centres condoning torture?’ The paper addresses a number of important issues explicitly as well as raising equally significant questions implicitly. As I read that valuable paper I found myself wondering whether any distinction actually exists between medical ethics and human ethics generally. An alternative way of formulating my question runs something like this: Why, and in what ways, should a nurse or a doctor – or any clinician – be answerable differently from any other moral agent?
At first blush there would seem to be no difference: in the encounter between any two humans who find themselves respectively in need of help and in a position to help, their inequality mandates a response. That one is sick and the other is skilled in healing is an accident, a detail. This is the bedrock ethic of the Good Samaritan.
However, if among a number of willing passers-by there be one who is a nurse or a doctor, the twin facts of clinical training and of vocation, demand that person in particular step forward and help.
Similarly, the training of the Surf Life Saver selects her to rescue one washed out to sea; and the paramedic is the one who should commence CPR in case of roadside cardiac arrest; and the infectious diseases physician respond to the Ebola outbreak.
 
Common to all these is a degree of risk to the rescuer; the life saver risks drowning, the paramedic risks injury from passing vehicles or hostile lawyers, the physician risks contracting infection and the asylum-seeker’s clinician risks criminal penalties should she reveal official wrongdoing. Traditionally society expects its ‘rescuer class’ to accept those personal risks. In entering our professions we who are clinicians have implicitly accepted – indeed embraced – those risks. So much so that it was with shock that I first heard the suggestion – made in 1969 – that a doctor should not stop to help a road victim, lest the doctor be sued for an adverse outcome. (That advice was given to doctors in litigious America. The advice was ethically wrong, and in many jurisdictions laws have been passed that protect a clinician who responds ethically.)
 
 
ARE DETAINED PATIENTS DIFFERENT?
 
 
My detained refuge-seeking patients resembled all patients in that they were variously unhappy and anxious; their understanding of their condition was inadequate; and they were sometimes unwell, although not in the way they understood themselves to be.
These were patients (although my employers insisted they were ‘clients’); their complaint, their pathos, was the detained condition, to which more familiar clinical entities were superadded.
 
To a man – and the great majority in my care happened to be adult and male – patients in immigration detention suffered from a spiritual malaise, an affliction I have not seen described and which I struggle to categorise. Its features include an inversion of belief such that the detained person replaced trust in fellow humans with mistrust, an expectation of mendacity and malignity of purpose. Thus the clinician, ostensibly present to help, was felt to be the adversary, present only to frustrate and harm the detained one. Our method of harm was supposed to destroy sanity, literally to drive mad the supplicant for our help. The two protagonists became respectively the anti-patient and the anti-doctor. The inversion of belief was pervasive. Hope, the constitutional belief in life and its goodness, were alien, felt to be elements of the fabulous, not congruent with life as it was now known. In a community of almost one thousand believers the mosque was largely unattended.
 
This inversion of the spiritual substrata of life reminded me of Primo Levi’s descriptions of that distinctive moral universe, the Nazi concentration camp, where the SS intentionally destroyed a world of hope, faith, kindness. I do not suspect any such intent on my island. But the outcomes here are as certain as they are unintended. 
 
An unanticipated hazard was experienced by carers, both among the guards and the clinicians. The hazard was moral in nature. Quickly many came to sense wrongness in the system. The wrongs included treating as criminals persons who had broken no law; imprisoning persons who had shown every desperation to be free; humiliating our patients with a dehumanizing system of identification by boat number rather than by name. All who worked in the Centre understood we were functioning parts of an unkind system: while we were to do no harm we were to delimit our own capacity to do good.
Evidence of the moral hazard, the sense of our violence against our own values, emerged in the behavior of the captors. Doctors drank every night, smoked heavily, suffered nightmares. More than one guard attempted suicide, one successfully.
 
In one more than one instance my medical superior refused my referrals for imaging, apparently on the unspoken grounds such would have to take place outside the Detention Centre. In one case, evidence of acute lumbar disc herniation indicated urgent CT scanning. This would require transfer to the mainland. My boss said: ’No. That can’t be done.’ Knowing that it could be done and it should be done, I asked, ‘Why can’t it be done?’
Displeased by my insubordination she stepped forward, stopped half a pace from me and shouted, ‘You can’t ask that question!’
 
For months following my return to the mainland, my reunion with friends and family, my resumption of normal medical work, I experienced nightmares. In those dreams I was a member of a tribunal, sitting in judgement on refugees’ pleas for asylum. In those dreams no voice was heard; supplicants argued mutely; mutely, we judges refused their pleas. The whole was an accusation against my implicated self, against my silent self.
 
 
CRIMINAL DETENTION VS IMMIGRATION DETENTION VS CUSTOMS DETENTION
 
 
The author of ‘Condoning Torture?’ refers to both criminal detention and immigration detention. I have worked in both categories as well as in compulsory detention for Customs. In all three cases detained persons are held inside locked areas behind high fencing in locations beyond view of the public. These arrangements serve to ensure ‘security’, an idea with more than one understanding: ‘security’ has evolved from the safety of the detained person and of the community to security of secrets. Briefly put, locked behind a series of heavy steel doors, detained persons remain invisible to outsiders and hence vulnerable to abuse. These are the settings which some refer to as Black Sites.
 
In the case of my island Detention Centre, the detained resided in their quarters, out of reach and sight of clinicians, who saw and treated them only when they were admitted to the Clinic located in a second secured area. The communicating door between the broader compound and the clinic was manned by the bulkiest of the male guards, charged with selecting and admitting our patients according to acuity of need. In practice these selections were opaque; we clinicians could never know who was excluded from our view and on what basis.
 
Offshore detainees manifest a critical and unique pattern of behaviour which distinguishes them from the great majority of patients of my clinical experience in other settings: they see it in their interest to achieve, demonstrate and maintain the worst health possible. The purpose – or the function – of this ‘poor health’ is to qualify for urgent transfer to ‘the mainland’, a location endowed with a mythic access to liberty in Australia proper. Thus the asylum seeker will exaggerate or fabulate to save himself. The clinician is mistrusted (like all in authority, for all have ‘lied’, and lied maliciously to drive the poor patient mad); in turn the clinician is unable to take symptoms at face value. Trust, the substrate of every decent clinical encounter, is shattered. For the clinician and the imprisoned person have opposite objectives.
 
Quite different are the assumptions in Alice Springs Correction Centre where eighty percent of prisoners are Aboriginal. Here transparency is a cardinal virtue. Prompted by blackfella outrage and whitefella shame, and by the political hazard of failing to care well for imprisoned indigenous people, authorities hasten to identify risk of harm to their charges and to act upon it. Often warders and clinicians over react, such are the anxiety and the dread of misreading need through the clinician’s cultural subliteracy.  
 
 
SHOULD A DOCTOR ACCEPT WORK WITH DETAINED PERSONS OFFSHORE?
 
 
This question arises because of the apprehended possibility that a doctor will participate in or facilitate wrongdoing; and having witnessed harm to patients will be constrained from ‘whistleblowing’ against that wrong. The apprehended risks are real. Under new Australian legislation a clinician who speaks out is open to prosecution and if convicted, to imprisonment for up to two years, for revealing secret information. An additional constraint is the Confidentiality Agreement employees are required to sign as a condition of employment.
 
The author of “Condoning Torture” suggests Australia’s treatment offshore of detained refugees constitutes torture. The writer adduces evidence for that suggestion but stops short of declaring categorically that such treatment is torture. At the same time he acknowledges the clinical needs for care of the refugees. He writes: Australian health professional thus face a major ethical dilemmas. Individual health professionals need to decide whether or not to work in immigration centres. If they do so, they need to decide for how long and to what extent restrictive contracts and gagging laws will constrain them from advocating for closing detention centres.
 
I find the author’s formulation of those questions helpful in pointing a clear ethical path. He authorizes each individual to forge a personal response. This seems to recognize the moral autonomy of the individual practitioner, as well as the individual responsibility of the individual. As the Mishnaic sage Hillel taught: if not me, then who? If not now, then when?
The author breaks the decision into two or three parts:
1. Will I work there? (Do I have the right to do so? Do I have the right to decline?)
2. If I do accept that work, I must do so provisionally, ceasing when I form a judgement that to continue more offends ethically than to desist.
3. In answering the second question I must consider how much my gags prevent me from doing needed good?

The argument allows me to approach the questions as follows: Here, in the offshore ‘facility’ – a black site or a blackish site or at the very least a grey site – we have sick human beings. Our government, their custodians, seeks to employ doctors, nurses, psychologists, mental health nurses, to attend to clinical need. The employer presents the qualified clinical professional with a contract to perform professional duties and to treat the conditions of the workplace confidentially. The government does not stipulate, ‘You must agree to torture your patient’.
 
On the basis of my own experiences, where I was not required to do positive harm but I was constrained from doing some needed good, I could sign the contract and enter upon my employment in good faith and in the assumption of my employer’s good faith. After all, I was employed a medical professional. That profession implies first and foremost a refusal to do no harm. If and when I form the belief my employment required me to do harm, I must refuse and make clear my reasons for doing so, both to my superiors and to my peers. Where possible I must make this clear also to the detained person. Should my employer dismiss me I must make public my employer’s wrongful instruction and my actions and the circumstances of my dismissal. I run a risk in doing this, the risk of incarceration. That is my lifesaver, my paramedic, my infectious disease specialist moment, my moment of familiar medical hazard. A hazard, yes, but in our relatively non-totalitarian system, a hazard without risk of death. Safer far than the ebola risk. Safer than the choices of a psychiatrist in the Soviet Union, safer than those of doctors under the Third Reich. A hazard but not a mortal hazard. 
 
On the other hand if no objectionable command requires me to take a self-sacrificial stand I remain free to work, to watch, to listen and to consider. And upon making my judgement I should speak out. If all is kosher, if detained persons are treated with full human dignity and compassion, then I must cry it from the rooftops. And conversely, if I find my hypothetical centres to be objectionable I must call for their improvement or their closure.
 
Those are equally clear ethical imperatives – not matters of narrow medical judgement but the call of every citizen. In the end the doctor, the nurse, the guard, the journalist, the therapist, the pharmacist, the interpreter, the public servant all answer to an ethic which is universal. Medical ethics represents but one corner of that wide universe.

I No Longer Know my Country

I Left Home a Few Days ago and When I Returned it wasn’t there

Australia is my home; it has been since adventurous forebears from England and France arrived in the 1840’s and 1850’s, and desperate forebears came in the 1890’s. Nowadays we might call these people economic migrants and queue jumpers.
I flew from my home country last Thursday and returned yesterday morning. I read the paper and I knew I was no longer at home. My home had gone. I might never get it back. What had changed?

Border Force to have up to 6000 armed officers

Border Force in Australia sbs.com.au

Border Force in Australia sbs.com.au

I read the headline. I didn’t understand it. This Border Force would be deployed not on the border but inside my home. Most of its officers would be armed, many already are ‘trained for use-of-force operations.’ I sat and I wondered: what ‘operations’ inside our borders do they contemplate? Against whom are they armed? Who is the enemy within?

In the home where I used to live people trusted each other. We were different and we were OK. Some of us were very different indeed: in the small country town of my boyhood a sole Jewish family lived, trusted and trusting. That family was my own. Trust was rewarded, we were neighbours, we became friends, we knew each other and we were citizens together.

In the home where I became a father I met a man who was extremely different. He was the son of a Muslim cleric who went on to become Mufti of Australia. The father worked for amity and respect between communities and became a Member of the Order of Australia. The son, a ratbag or scallywag or black sheep or white sheep, became my friend and danced at my daughter’s wedding with the then President of the Zionist Council of Australia.

All that took place in Australia, which used to be my home.

On September 11, 2001 the world changed. Three days later the Melbourne ‘Age’ reprinted an article by respected Israeli journalist and novelist, David Grossman. Grossman had witnessed the effects of terror within his own community. He wrote that terror’s greatest victim is trust between citizens. When you believe your neighbour might wish to hurt you, you cease to trust her; you cannot afford to trust. Grossman predicted in 2001 we would see that erosion of communal trust, that injury to community.

Grossman’s prophecy has well and truly come to pass. Ironically, in Australia’s case, the principal destroyers of trust have been politicians who promote fear recklessly. We have a government led by a man who acts like a boy who swoons at the sight of a uniform.
Little by little, day by day, our masters in government – as well as the odd mistress – attack trust. The headline in the paper on the day of my return to my homeland appears below another: Transfield to remain at Nauru;
and alongside a third headline: Yongah Hill detainee hurt after incident of self-harm

All of this is relegated to Page 8. In this country that used to so welcome the stranger it is no longer big news that a private corporation be rewarded (at a daily cost of $1500 per head) for its systematic unkindness to inmates. This is not news. This is policy. As is ‘turn back the boats’, the policy that hath made my name to stink upon the earth.
In this place that used to be a home a man who cut his throat in detention is hospitalised, then returned to that place of detention where he ‘is receiving appropriate medical and mental health support and care.’ In that place his doctors and mental health carers risk two years of gaol if they report on that ‘appropriate’ medical care. I know detention. I sewed my lips, I accepted overpayment and I worked as a doctor in detention.

But in the place that used to be a home nothing like this is news.

Ogholotse and Adam

This blog has seen me leap into print recently in a familiar posture of righteous urging on the subjects of the public humiliation of a footballer and the plight of a lady with a disability. Brace yourself for more righteousness.

I wrote of my schoolmate, Hilary, a social worker and ceramicist – did I mention Hilary’s ceramics? – who works from home, counseling the lost and confused, supervising tribes of fellow therapists, contributing to the health of persons and, through her taxpaying, to the health of the economy. Hilary is an agent for good. She is not a leaner. Financially stringent governments should love Hilaries.

This particular Hilary has a couple of disabilities, however: she is not young and she has a touch of quadriplegia. She needs carers around the clock. She pays these persons from her earnings and they in turn pay taxes. No leaners here.

One of Hilary’s two carers, Ilaisaane – called Saane – is not a citizen of this country. A skilled person (she’s a State Enrolled Nurse), Saane comes from Tonga. She’s allowed to stay here as the spouse of another person, who holds a skilled immigrant visa. That person, Ogholotse, is highly skilled. A graduate of Melbourne’s esteemed RMIT University, OG as he’s called, holds both Bachelor and Masters degrees in multimedia. (As an unimaginative unimedium person I am bemused that such a skill might exist.) However, exist it does and an employer exists who needed someone with Ogholotse’s skill. So the someone employed him, he came into the country, he worked and he paid his taxes. Another non-leaner. Everyone is happy. Ilaisaane cares expertly, intimately, tenderly for Hilary in a relationship rich in mutual respect.

Everyone’s a winner.

So far so good. But hard times struck the employer and OG was let go. He has sought alternative employment in his sanctioned area of skill, but he has not found it.

Now Australia will let OG go and with him Immigration rules we must let Ilaisaane go. Being near-indispensible, once Ilaisaane goes, Hilary just might go too: Hilary’s going would be into institutional care, into a life of dependency, of expensive involuntary leaning.

Everyone loses.

There’s a simple solution: OG needs to find a job. RMIT graduates are the most work-ready, highly employable skilled persons in industry. Employers love RMIT graduates, seeking them out and hiring them even in times of deep economic recession. At present we don’t have a recession. Skilled jobs exist. Odd that Ogholotse doesn’t have one. He’s strong and healthy and clever, he’s experienced, willing and personable. And as you’ll see from the photo, he enjoys that unfair advantage in job-seeking of being good looking.

  
What can be his problem? Sure, he’s black. That couldn’t be his problem, surely. Not here, not in Australia. We aren’t racists. Ask Adam Goodes.
Postcript:

If you happen to be or to know a colour blind employer who needs a person skilled in multimedia, please write urgently to Hilary at quincetree@gmail.com. Time is very short.
Previous post on Hilary’s story http://wp.me/p2QU0B-Mg