Australia let Nauru block refugee medical transfers to preserve ‘relationship’

Australian authorities were unable to send an air ambulance to Nauru for a court-ordered medical transfer after the Nauruan government refused permission, because to do so would affect the “working relationship” on offshore processing, a senior official has said.

At least twice in recent weeks the Nauruan government has refused to give permission for an air ambulance to land and take a refugee to Australia for urgent medical care, despite court orders and doctor recommendations.

The cases have added to growing concerns over inadequate healthcare and the complications of different tiers and standards of care, as well as alleged political motivations interfering with the transfer process.

In the first case, that of a refugee known as ELF18, the refusal came from the Nauruan secretary for multicultural affairs, Barina Waqa, who was “just not convinced” the case was serious. Australian Border Force did not defy the refusal, technically breaching the court order.

“The ambulance therefore had to be cancelled upon which the department will have to pay a cancellation fee,” Vanessa Holben, assistant commission for ABF’s detention and offshore operations command told the court.

“A non-scheduled landing without approval from the government of Nauru would be unlawful,” Holben said.

“In the basis of my experience in dealing with regional processing matters, I consider that such actions would have significantly adverse consequences in terms of the ongoing working relationship between the commonwealth and the government of Nauru in relation to regional processing.”

Holben said that following the first court order for a transfer and considering “the urgency of the matter”, the department sought urgent approval from Waqa, who refused, insisting the case go through the overseas medical referral process, and requesting a review and report from a psychiatrist. The Nauruan government still refused permission for the air ambulance.

Waqa did not object to the woman leaving on a commercial flight and she and her brother were booked on the last two seats, travelling without medical escort, at a cost of $1,478 each.

The cost of the air ambulance cancellation fee is not known.

Guardian Australia revealed on Saturday the Australian government spent more than $320,000 responding to court applications for urgent medical transfers, and it was expected this year’s costs would be far higher amid a worsening health crisis.

A second federal court case last week heard evidence from the Australian government that there were “ongoing issues” with Nauru’s treatment of medical transfers, prompting the sitting judge to declare it was a problem of Australia’s creation for establishing offshore processing in the first place.

Under the complicated contracts and bilateral agreements there are differing arrangements and obligations for asylum seekers and refugees on Nauru. Asylum seekers are under the care of Australia’s contracted health provider, International Health and Medical Services (IHMS), while refugees are under the care of the Nauruan government, alongside other Nauruan residents and citizens.

The IHMS contract with the Australian government requires that asylum seekers have access to “a level, standard and timeliness [of healthcare] broadly comparable with that available within the Australian community”, while those with refugee status, now legally part of the Nauruan community, have access only to local standards.

A “settlement clinic” to assist people’s transition into the Nauruan community as refugees is contractually obliged to offer “local Nauruan standards”.

Refugees and Nauruans who require urgent medical care unavailable in Nauru can receive overseas medical referrals (OMRs) but Dr Nick Martin, a former senior medical officer on Nauru in 2017, told the federal court he had no confidence in the process which he described as inefficient and driven by political concerns.

He said the “powerful” Nauruan OMR committee was required to approve transfers but often made the decisions in conjunction with Australian Border Force officials.

“The OMR sat irregularly, was poorly minuted, and often cancelled at short notice,” he wrote.

“The OMR often gave contradictory opinions – depending on which doctor was chairing it [and] if a doctor appointed by the government of Nauru was dismissed, which was a frequent occurrence, then the decisions made by that doctor were often revoked.

“While on Nauru, evacuation deadlines which either my staff or I recommended were frequently not met and at times appeared to be ignored by the Australian government,” he said.

“Patients were often in constant pain as their condition worsened.”

Martin said clinical decisions and recommendations were often queried by non-medical staff and on at least six occasions asylum seekers were waiting without treatment for months beyond the the medically recommended timeframes.

The differing arrangements for asylum seekers, refugees and locals revealed moral issues for doctors, and Martin wrote to the IHMS area medical director in February 2017, outlining his concerns.

“If I referred a patient in Australia to a hospital where I knew that no form of clinical notes would be kept, no feedback would be given, and often the referral would be lost or ignored even after repeated attempts to get the patient seen, I would expect to be up before the courts on a culpable negligence charge, along with the hospital,” Martin said in the email, tendered to the court.

The director responded that Martin was not alone in his concerns, and that he had raised the issues with ABF on a number of occasions “without a satisfactory response”.

He said IHMS staff were “caught in the middle of it”, as ABF had over the years put “extreme limitations” on the types of asylum seeker patients IHMS could refer for offshore treatment.