So you think you know what it's like on Nauru? A doctor tells his alarming story

GP Dr Nick Martin details his experience treating asylum-seekers and refugees during his eight-month stint on Nauru

Dr Nick Martin is a GP. He trained in the UK, worked around the world with the Royal Navy and now practices as a GP in Australia. Between November 2016 to August 2017 he was one of the doctors who worked in the asylum-seeker detention camps on the island of Nauru. This is the story of what he witnessed.

For a man to become a hopeless case, no longer angry enough to fight against the injustice of it all, was something I’d never seen until I worked as a doctor on Nauru for International Health and Medical Services (IHMS).

Weariness became king in the refugee camps, watched over by faintly menacing guards, and helpers from myriad agencies, all with the same basic goal: to stop people from killing themselves and stop bad news leaving the island. 

After four months it dawned on me: it wasn’t only the refugees who had learned helplessness. It affected the staff too. They had ceased to care, reduced to automata, ticking boxes to satisfy administrators in Sydney or Canberra while people were dying in front of us. 

Many workers believed they were an integral part of keeping Australia safe from illegal immigrants, boat people and terrorists.

Others never professed an opinion either way, and a fellow doctor advised me early on to be one of them.

‘Don’t make a name for yourself as a refugee lover, for Christ’s sake,' he said. 'They’ll have you on the next plane out of here.’

It seemed sound advice.

I had signed an extensive non-disclosure agreement, and the draconian Border Force Act reminded us that speaking to people at home about what we had seen was punishable, possibly with imprisonment.

It was important not to be viewed as a doctor who cried wolf, a dangerous radical, or terrorist sympathiser. But I saw the results of conditions that Australians would find absolutely intolerable every day. My primary concern had to be the patient and to push for appropriate treatment. 

Achieving that was nigh impossible at the Republic of Nauru Hospital (RONH), the island’s only hospital.

I spoke with a paramedic after he’d been called to emergency to help a 10-year-old local girl. He met with chaos and the girl died, surrounded by her family. I asked him to write a timeline of events, to see if we could do anything differently.

An hour later he sent me the result.

It was awful: an unemotional description of a dreadful scenario. The number of things done incorrectly, ignored, just plain screwed up, due to incompetence and ignorance was astounding.

It painted a picture of a hospital utterly ill-equipped to deal with what should have been a fairly straightforward emergency presentation. 

The paramedic listed 10 things that contributed to the girl’s death.

They were damning; in Australia it would have led to a coronial inquest or at least a post-event discussion. Here, nothing. The stark contrast between Nauru and Australia was laid bare over three A4 pages.

The emergency department and wards remained in the RONH’s older buildings, with inadequate equipment, poorly trained staff and creaking infrastructure. The sparkling new pharmacy routinely ran out of basic drugs. Not all doctors were medically qualified and there were no pathologists.

And there was no way of conducting post-mortems. Deaths were not investigated, and the deaths I heard about were quickly hushed up, even when our staff raised serious concerns. 

During the dengue outbreak, a RONH physician told me the World Health Organisation guidelines I was following were nonsense and I didn’t know what I was doing.

Five Nauruan patients had already died under her care, as their approach – giving people blood and antibiotics – was lethal.

I had to bite my tongue, as they made it clear that my opinion on refugee patients was not welcome. We ran the risk of being deported if we upset staff by pointing out glaring mistakes.

We sent one refugee, a young man who was bleeding, most likely from his upper bowel, to the RONH with a very low blood count.

Five days later he’d still had no treatment or blood tests. He’d been given two units of blood; a bit like topping up a bucket with a big hole in it.

Why hadn’t he been diagnosed? Was it a lack of equipment, staff or interest?

I made a casual enquiry and received an evasive reply. I requested more blood from Australia and headed to the hospital with a kit they needed as a bargaining chip.

He ended up going to Australia for surgery after weeks of waiting in the Nauru hospital getting transfusions.

He lives in the US now.

We were in a difficult position treating refugees as our duty of care was never clear. Once they achieved a positive refugee status determination they were considered Naruan, with residency and access to local services.

The Australian Government’s mantra was Nauru was responsible for the refugees, which was a complete fallacy.

If the refugees weren’t Australia’s responsibility, what the hell was I doing here?

I was not supposed to get involved, but we were invariably called in to sort out disasters by distraught relatives who begged my staff to intervene. 

When something did go wrong, the Australian Border Force (ABF) and IHMS played a game of blame shifting. I knew that if something went wrong with a refugee in the RONH, then the line – ‘this is a matter for Nauru’ – would no longer apply. 

As the island’s senior IHMS doctor, I would be held accountable.

So we walked a difficult diplomatic path, balancing our moral and ethical duties as doctors while trying to avoid deportation.

Twice a week I held the IHMS settlement clinic for refugees, next to the hospital.

I had no idea why; it made no sense given these people were supposed to be Nauruan now.

The clinic was initially set up as a temporary measure to help refugees during the first eight weeks after they left the camp.

But it was still providing services for these people several years later; a tacit nod to the ongoing need for primary health care on an island with no GPs.

I spent most of my clinical time trying to explain why someone’s referral had not happened, why they were still waiting to learn when they might get the treatment that they needed. It was soul destroying. 

But I did have a few small wins here and there, after hours of cajoling, shaming, pleading, pushing and harassing people to sign a report I’d prepared for them, waiting for uninterested doctors at the hospital to sign a request, sending emails and making calls after a meeting to try and get people to do what they said they’d do.

I got one patient finally transferred for care after a 10-months wait, in pain with kidney stones.

He’d been bundled off to have his much-needed operation, but not to Australia. As an asylum seeker, he had to be kept away from the glare of publicity and so went to a sub-standard hospital in Papua New Guinea. It was notorious for poor results, hygiene, staffing and standards.

I received an email update saying there had been complications and he was in difficulty. I buried my face in my hands.

Dr Nick Martin: 'Some conditions had a significant psychological element: almost everyone had a concurrent mental health diagnosis'
Dr Nick Martin: 'Some conditions had a significant psychological element: almost everyone had a concurrent mental health diagnosis'

The same day of that email update, we’d had all the staff members in the same room, discussing the patients at risk of killing themselves. Two names stuck in my mind; both had head injuries, both needed to be in specialist units and both were being left to rot while buck-passing emails flurried about them.

They needed to be transferred by plane, but the Australian Government’s position was to prevent anyone coming to Australia at all costs. The increasing pleas, clinical reports, incident reports, specialist meetings, risk management meetings, targeted interventions and mental health reviews all fell on deaf ears.

We were in a precarious position when we were left watching a patient decline, but knowing that interfering would result in us being deported. Where did our duty of care finish? Did we have one? I couldn’t remain silent and watch someone potentially die when there was a way of intervening and saving them.

A cycle of buck-passing – from the hospital, to government, to border force to IHMS – left patients right where they were. 

Nothing happened without the ABF and they were ultimately where delays came from: they’d held up evacuations for my critically-ill patients before. They seemed to work in committees. There was never a name you could pin things on.

They used terms such as ‘the delegate’ or ‘the committee’ to guarantee anonymity and avoid accountability. 

I arranged an air ambulance in the middle of a dengue outbreak for a patient with a dangerously low platelet count. He was close to death by the time he got onboard. My emergency medical officer and I stayed up with him and monitored for hours, watching his decline in front of us until he was hovering into unconsciousness.

That earned me a four-page email criticising my management and asking if an ambulance had really been necessary, as he had subsequently recovered in hospital.

This cynicism from the department made for an incredibly difficult referral pathway, with every patient being seen as a malingerer unless one had incontestable proof that they needed urgent care away from Nauru.

Some staff ignored the politics and just dealt with the problems in front of them.

I tried to do this at first, but soon realised it was hard to divorce the presenting condition from the situation the patient was in. Skin conditions deteriorated in the camp conditions.

Some conditions had a significant psychological element: almost everyone had a concurrent mental health diagnosis of insomnia, depression, detention fatigue or sometimes more florid manifestations such as psychotic depression. Self-harm was endemic, suicide attempts frequent. Illicit drugs were readily available.

I also had three patients awaiting terminations.

Two were married, the other girl was terrified that her father would kill her if he found out that she was pregnant. He had made his views clear, and had previously hit her with a rock to the head when he suspected she was in a relationship.

The two other women had massive psychological problems and an unwanted pregnancy would be enough to push them over, either to suicide or try to end the pregnancy themselves.

Then came the policy change which meant refugee women who needed terminations were to be referred to the hospital’s overseas medical referral committee.

Abortion is illegal in Nauru. It placed hospital doctors in an impossible situation; being complicit in a criminal act and there was no way it would happen.

It effectively denied women from being able to have an abortion, in a country where rape was commonplace and traumatised women already had unbearable pressures on them.

How on earth to fight this?

I had no doubt news of the changed policy would get out. Leave the uproar to other people, I thought. Worry about what was going to happen to the affected women. At least we knew this was happening and could try to pre-empt any suicide or self-harm attempts.

At what point do you throw your hands up, admit defeat, accept that the system can’t be beaten? The monolith of the government was behind this, inflexible, unswerving, shameless. What could I do? Send off another email? It was soul destroying.

I felt a hollow desperation. I was stuck, and needed to change the script. How to change things? How to get people to do something?

The realisation came slowly but with a certainty I was reluctant to acknowledge. This system would not change. It had been honed to work like this, to keep people from speaking out, to keep patients here, and to grind them down.

My days merged into one long wade through treacle. I spent hours in an air-conditioned office, avoiding the bleaching sun, the phosphate dust and the unremitting humidity.

The asylum seekers and refugees had put up with this for years, in mouldy tents or, if they were lucky, portacabins. Every little thing seemed to be designed to control and corral the people, whom the bored guards viewed with suspicion and occasionally overt hostility.

Outside the camps, refugee accommodation was also incredibly basic.

Portacabins, shoved together into little shanty towns, with intermittent water and power supplies, seen as easy pickings for bored or aggressive locals. They helped themselves to belongings and intimidated the refugees, sometimes to fight them and on many occasions to rape them.

Read more:

A refugee raped with a bottle by a group of local men was too terrified to leave his portacabin, and had persistent nightmares.

A young Farsi woman was repeatedly beaten up by her Nauruan boyfriend. Once, she sought help. The policewoman who turned up was her boyfriend’s cousin.

No charges were brought and she had a miscarriage after her boyfriend learned of her pregnancy and repeatedly kicked her in the stomach.  

Refugee kids reported being hit by the local teachers, punched and spat on by the local kids. Walking around the island was fraught with danger: from being spat on or hit by a bunch of disaffected local lads to being bitten by any one of the roaming packs of feral dogs. Perversely, the refugees often felt safer inside the camp fence, despite its indignities.

I found many Nauruans to be kind, proud and welcoming; but I had also seen the casual violence among the kids, large-scale brawls, drunken crowds shouting abuse at each other.

It was hard to reconcile the gentle islander image with the bruises, drunken shouts and scared accounts from refugees.

Asylum-seekers and refugees were not all saints. There were many I liked and would gladly have as neighbours and friends back in Australia.

There were also some I distrusted, who were aggressive, rude, arrogant and violent.

Some were child molesters, others so damn angry about their situation it was difficult to see the man underneath. Some were obviously highly educated and cultured, others less so. In short, they were just like us.

It was the end of the rotation; time to leave Nauru and return to the real world.

I’d been home for a week when IHMS called, asking me to meet at their head office in Sydney to talk. All slightly cryptic, but I hoped I’d maybe achieved cut through. If IHMS was making changes, that was great news. 

But I was ambushed and caught off guard. They said they could not guarantee my safety on Nauru: my representations were becoming an increasing annoyance to the Nauruan government and the ABF. I asked to see evidence. My boss gave me a wry smile. I realised he was telling me I wasn’t going back. 

I left in a daze. I had gone in thinking my efforts had borne fruit and they were moving me aside. Deep down I knew it was inevitable. Too much noise was never going to be tolerated.

I had thrown so much of myself into the job, had tried my best to get these poor buggers the help they desperately needed. And now I was outside the tent and felt completely impotent. 

I had a couple of days to chew it over. Was it time to speak out? I had tried to bring about change from within the system. Now that I saw it from an outsider’s perspective, I realised it was insane. 

I contacted a journalist who I knew had been involved in leaking thousands of documents about Nauru.

Things happened quickly. Television crews, interviews and hours answering questions as honestly as I could, trying to keep it solely medical when of course it would all boil down to politics.

I was on the ABC’s 7.30 and a Buzzfeed article and video achieved more than 260,000 views.

I got my message across: that medically what was happening was unacceptable. No matter what your stance on boats, borders and refugees, if you lock people up you have a basic obligation to look after them.

I await the political will necessary for the suffering imposed on these patients to end. I'm happy that the children are finally being transferred. But I fear the  appetite for people to advocate for all the others detained on that island to be taken to a place of safety just isn't there.

I hear the anti-refugee rhetoric from the usual suspects every day.

People will be left to rot on Nauru for years to come which is a scandal.

I still think about my patients: did I do enough?

We all need to keep reminding our politicians that we are watching and that we care.

That Australia is better than this.

This is an edited and updated version of an article that originally appeared in Meanjin.