What I witnessed on Nauru

03 Jan 2019

Psychiatrist Dr Beth O’Connor, from Christchurch, treated asylum seekers and refugees on Nauru for 11 months, until the forced exit of Médecins Sans Frontières (MSF) from the island in October. 


Dr Beth O’Connor (right) and psychologist Dr Christine Rufener speak at an MSF press conference in Sydney in October 2018, following the forced exit of MSF from Nauru. © Meredith Schofield / MSF 

Several of the refugees I treated on Nauru described their depression by comparing it to water in a glass. They would say the water represented sorrow and depressed thoughts, and that the glass could only be filled to the top – like themselves. "I can't keep getting filled, I don't know what I will do,” they would tell me. "I am a human being and we all have limits.”

On Nauru, I was part of the MSF team providing mental health care to asylum seekers, refugees and local Nauruans. Over the 11 months I spent on the island, I witnessed shocking levels of depression, post-traumatic stress disorder, anxiety, self-harm, suicidal thoughts and suicide attempts among our asylum seeker and refugee patients, and severely unwell Nauruans with chronic psychotic disorders.

“As a doctor, I believe I have a professional duty to advocate for my patients; to address the cause of their mental health decline rather than continuing to simply provide individual treatment.”

During consultations with asylum seeker and refugee men, women and children, I began to understand the psychological damage they suffer from not knowing their future. The indefinite time frame of their ‘processing’ on Nauru, now at five years, has created a deep uncertainty for these people. They exist in limbo, with limited control over their lives and no ability to make decisions about their future. Patients also spoke about the injustice of their situation. Most people have been recognised as refugees, yet while they have been told there are processes to resettlement, the criteria are unclear. People try to learn the ‘rules’ of the system, but the rules keep changing. They realise it is impossible to help themselves.


Downward spiral of hopelessness

There were people we treated who, when we arrived, were managing. But over the next year, they lost the capacity to do basic daily tasks like cook, shower, or properly care for their families. Children who had once been chatty and playful deteriorated to the point of being bedridden, unable to talk or eat: a condition referred to as traumatic withdrawal syndrome or resignation syndrome.


View of the hospital and housing on Nauru. © MSF

Our team saw a significant decline in the mental health of the community in the middle of last year. More than 70 people were rejected from the US resettlement deal, leaving them with little prospect of leaving Nauru. Patients presented as increasingly hopeless – even those who didn’t get a negative response. In a small community that has spent five years together, events have a wide impact. In June, there was the suspected suicide of a young and well-respected asylum seeker. These events contributed to further despair, and the community struggled to have the resources to support each other. There was a similar effect in family units: when one person was sick, we would see the whole family collapse.

Many patients had been separated from family members which led to a significant deterioration of their mental health. While some people were evacuated to Australia for urgent medical care not available on the island, the rest of the family was not usually permitted to join them. Women were flown to Australia to give birth, their husbands forced to stay behind. Family separation was particularly distressing for children who were separated from one parent.

“Patients presented as increasingly hopeless . . . in a small community that has spent five years together, events have a wide impact.”

A responsibility to speak out

Asylum seekers and refugees on Nauru have generally experienced trauma in their home country or during their migration journey, and often again when they reached Nauru, in detention and in the community. This includes violence and sexual assault. Nauru is not an environment that enables recovery from these traumas. Instead, I witnessed a system that shatters people’s resilience, identity and hope. People say if they stayed at home they would have been killed – but in Nauru, they feel like they’re being killed every day.

It is extremely concerning that our patients remain on Nauru, with no access to independent mental health services. As a doctor, I believe I have a professional duty to advocate for my patients; to address the cause of their mental health decline rather than continuing to simply provide individual treatment. It is irresponsible to work on an ‘ambulance at the bottom of the cliff’ model – we need to address what’s going on at the top of the cliff, rather than waiting until everyone falls down.


A group of refugees leave Nauru for resettlement in the US in 2018. © MSF

There aren’t medicines and therapies that can help our asylum seeker and refugee patients on Nauru to fully recover. While we could sometimes help people develop coping mechanisms, ultimately, the environment in which they are trapped continues to cause deterioration in their mental health. It is our medical opinion that our patients need to be brought to a safe place, where they can regain hope for their future and a meaningful life.