Seven years of offshore processing. Enough is enough.

For 11 months from November 2017 until October 2018, MSF provided free psychological and psychiatric treatment on Nauru to refugees and asylum seekers, as well as to Nauruan nationals, under an official agreement with the Nauruan government. 

• Of 285 patients, 73% were refugees or asylum seekers and 22% were Nauruan nationals (the rest were foreign workers or had unknown status).
• Of the refugee and asylum seeker patients, 193 (93%) were recognised refugees while 15 (7%) were asylum seekers. 
• MSF also worked on building local capacity in treating mental health disorders, increasing mental health awareness, and decreasing stigmatisation of mental illness. 

In October 2018, the Nauruan government forced the closure of MSF’s mental health activities on the island, advising that our services were “no longer required”. In February 2019 the Nauruan government prohibited telemedicine in Nauru, again preventing patients and their families from accessing our services.  This came after MSF had raised the alarm about the mental health crisis on the island, as described below. 

In late 2017, MSF attempted to assess medical needs among refugees and asylum within the regional processing centre on Manus Island, Papua New Guinea. However, despite receiving official authorisation, the team was never granted access to the centre or nearby transit centres. 

In December 2019, MSF commenced tele-mental health services for refugees and asylum seekers held in Port Moresby, who had been transferred from Manus Island. MSF psychologists and cultural mediators conducted over 140 tele-health counselling sessions for 18 patients over the three-month program, with activities concluding in March 2020.  

The project aimed to prevent further mental health deterioration among asylum seekers and refugees after the repeal of the Medevac bill, which had given independent doctors more decision-making power on medical transfers to Australia. 

As well as these mental health projects, MSF has also provided medical administrative support to assist with patient assessments for people seeking medical transfer. We have also continued to advocate to the Australian government that asylum seekers and refugees held on Nauru and PNG need to be permanently resettled because of the impact of indefinite ‘processing’ on their mental health.  

MSF analysed our medical data from Nauru in a report called Indefinite Despair. 

This analysis found that the mental health suffering on Nauru is among the worst MSF has ever seen, including in projects providing care for victims of torture. One of the key factors contributing to the mental health distress was the lengthy and indefinite time period of the ‘processing’: people simply had no idea how long they would be held offshore.

Other factors included the lack of control that people felt over any aspect of their lives, the separation from family members and violence they had experienced in Nauru. 

Of the 208 refugees and asylum seekers MSF treated in Nauru, 124 patients (60%) had suicidal thoughts and 63 patients (30%) attempted suicide. Almost two-thirds of our refugee and asylum seeker patients were diagnosed with moderate or severe depression. A total of 12 adults and children were diagnosed with resignation syndrome, a rare psychiatric condition where people enter a comatose state. 

Our team also found that the local Nauruan health system was ill-equipped to manage the mental health crisis, with insufficient staffing and no inpatient facilities. 

All the patients in Port Moresby that we supported through tele-mental health counselling met the criteria for depression and at least one other diagnosis. Ninety per cent of our patients had experienced suicidal thoughts, and 50 per cent had attempted suicide prior to the tele-health program. 

“In offshore detention, for hundreds of people who were only seeking a peaceful life, a life free of persecution, there is no end. I witnessed people become immobilised by depression and helplessness.”
—Sue Mitchell, Mental Health Activity Manager, Port Moresby tele-mental health program. 

The case histories of our patients revealed that their mental health had deteriorated from moderate to severe mental health disorders over the years of the policy. Many now had such poor psychological health that they were effectively incapable of engaging with the processes required to apply for resettlement.  Many also raised concerns about the quality of healthcare they were able to access in Port Moresby. 

“I have no energy to think or make a decision. They make decisions for me, they think for me."
—Refugee, Port Moresby, 2020. 

These poor mental health outcomes are tragically not surprising, as the effects of detention and family separation are well documented by mental health research. As long as refugees and asylum seekers remain in limbo, their mental health is likely to further deteriorate.