family health assessment

Organisational Study

Order Description

Assessment 1 gives you an opportunity to demonstrate the application of knowledge in organisation theory on a specific organisational setting. To allow for uniformity in assessment, this assignment will be based on a common case – the organisations involved in the detention of asylum seekers as portrayed in the following article:
Briskman, L., Zion, D., & Loff, B. (2012). Care or collusion in asylum seeker detention, Ethics and Social Welfare, 6(1), 37-55.

Assignment 1 is in two parts. Use the headings below.

Part A: Profile of the Organisations [Use half the words allocated]
Using clues that can be gleaned from the accounts of workers’ experiences in the article, provide a profile of the human service organisations in terms of:

1,How recipients of services are conceptualised
2.How workers are conceptualised
3.Governance and decision making structures

Part B: Influence of the External Environment [Use half the words allocated]

Critically consider the role of the external environment – particularly the societal politics behind the issue and the funding relationships these organisations have – in shaping the development of the culture within those organisation represented by how recipients of services and workers are conceptualised and the governance and decision making structures.

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Care or Collusion in Asylum Seeker
Detention
Linda Briskman, Deborah Zion & Bebe Loff
Version of record first published: 13 Jul 2011
To cite this article: Linda Briskman, Deborah Zion & Bebe Loff (2012): Care or Collusion in Asylum
Seeker Detention, Ethics and Social Welfare, 6:1, 37-55
To link to this article: http://dx.doi.org/10.1080/17496535.2011.575383
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Care or Collusion in Asylum Seeker
Detention
Linda Briskman, Deborah Zion and Bebe Loff
This paper explores ethical questions arising from the work of health practitioners
in immigration detention centres in Australia. It raises questions about
the roles of professional disciplines and the ways in which they confront dual
loyalty issues. The exploration is guided by interviews conducted with health
professionals who have worked in asylum seeker detention and an examination
of the outsider advocacy role undertaken by the social work profession. The
paper discusses the stance taken by individuals and professional associations on
participation in controlled settings, including as participant, bystander and
advocate, and asks when the provision of care becomes collusion with
oppression.
Keywords Immigration Detention; Health Provision; Dual Loyalty; Ethical
Dilemmas
When it comes to health and human rights more often than not asylum seekers do
not count. (Correa-Velez & Gifford 2007, p. 278)
Introduction
Professional practice can be undermined in sites where services are dispensed
in controlled settings. This article discusses the ethical issues that arise in
professional practice with asylum seekers in immigration detention centres in
Australia. Discussion is based on interviews conducted with health service
providers, and an analysis of the advocacy of refugee advocates with health
ISSN 1749-6535 print/1749-6543 online/12/010037-19

2012 Taylor & Francis

http://dx.doi.org/10.1080/17496535.2011.575383
Linda Briskman is a social worker and Chair of Human Rights Education at Curtin University, Australia.
She conducts research, advocates and writes on asylum seeker issues in Australia. Deborah Zion
teaches medical ethics at Monash University, and has published widely on issues related to the health
of asylum seekers, clinical research and issues related to HIV/AIDS. She led the project ‘‘Caring for
Asylum Seekers. Human Rights and Bioethics,’’ which was funded by the Australian research council.
Bebe Loff is a lawyer and Director of the Michael Kirby Centre for Public Health and Human Rights in
the School of Public Health and Preventive Medicine at Monash University, Australia. Correspondence
to: Deborah Zion, International Public Health Unit, School of Public Health & Preventive Medicine,
Monash University, 3rd Floor Burnet Building, Alfred Hospital, Melbourne 3004, Australia; Email:
deborah.zion@med.monash.edu.au
ETHICS AND SOCIAL WELFARE VOLUME 6 NUMBER 1 (MARCH 2012)
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and human services backgrounds, drawing on literature that contributes to an
explanation of the ethical terrain. To provide context, the article presents an
overview of immigration detention in Australia, a synopsis of the research and
project methodologies and findings, followed by discussion of the debates on the
delivery of services in environments of social control.
Asylum Seeker Well-being
Asylum seeking is a global phenomenon. War, violence and persecution have
resulted in people fleeing their home countries to seek safe haven. Australia has
stood out as one of the harshest regimes in the industrialised world in its
treatment of asylum seekers. The focal point of the attempt to make Australia an
impenetrable fortress is mandatory detention, the relevant legislation introduced
by a Labor government in 1992. With mandatory detention:
. . . refugees have been criminalised through their incarceration in prison-like
institutions, where the daily imperatives of control and management systematically
undermine detainees’ decision making capacity; their ability to engage in
the wider polity; and their access to proper legal advice, care and protection.
(Grewcock 2009, p. 196)
As the asylum seeker flow increased from 1999, particularly from Afghanistan,
Iraq and Iran, increasingly harsh measures were put in place including the now
defunct Temporary Protection Visa (TPV) that created uncertainty and barred
family reunion, and the ‘Pacific Solution’ which saw asylum seekers placed in
detention camps on Nauru and Manus Island (Papua New Guinea). Under the
conservative government of Prime Minister John Howard (19962007), the main
sites of detention in Australia itself were remote locations in Western Australia,
South Australia and Christmas Island, with many people languishing for years in
the facilities. In each site concerns arose about the quality of health care, and
the role of healthcare professionals. Although overall responsibility for the
policies and practices rested with the Immigration Department (now known as
the Department of Immigration and Citizenship*DIAC), a changeable and
complex web of privatisation of detention and the services within detention
facilities resulted in limited accountability and transparency, posing additional
barriers to the creation of an environment conducive to acceptable health
practice. Despite the evidence that many practitioners working within immigration
detention centres colluded with processes amounting to inhuman and
degrading treatment, including participating in force feeding and chemically
constraining people for deportation (Briskman et al. 2010b), we acknowledge the
courage of those who stood up against these practices and spoke out about what
they witnessed.
The findings documented in this article refer mainly to the period up to mid-
2008, after which the Labor government that came to power in November of the
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preceding year introduced a range of reforms based on its newly devised
Detention Values, including abolishing the Pacific Solution. Despite some changes
at this time, once the boats started arriving more regularly from 2009, the
government became increasingly tough in its border protection measures,
including immigration detention. The concerns outlined in this paper have
changed only minimally since the research was conducted.
The following two case studies illustrate the nature of health concerns which
led to the professional advocacy in Australia that is profiled in this paper. The
first relates to the death of a woman detained on remote Christmas Island and
the second refers to the consequences of detaining a child in immigration
detention.
Case Study One: Fatima Erfani
The folly of maintaining detention in a remote location has had serious
consequences. In 2003, Fatima Erfani, an Afghan asylum seeker and mother of
three young children, was detained on Christmas Island. Ms Erfani was diagnosed
with high blood pressure that increased rapidly. After several days of blinding
headaches she was taken to the Christmas Island Hospital where she was
diagnosed with migraine. Upon returning to the hospital when her condition
became worse, she collapsed and did not regain consciousness. By the time she
was flown to Perth, 2,600 kilometres away, she was brain-dead and her life
support was switched off in the presence of her traumatised husband.
Case Study Two: Shayan Badraei
The case of five-year-old Shayan Badraei, despite exposing the damage that
could be inflicted on children, did not influence policy change. Shayan had
become increasingly withdrawn in detention and developed a range of disturbing
symptoms including refusal to eat, night terrors and inability to speak. Although
hospitalised many times, he was continually returned to an immigration
detention centre. Following his eventual release from detention and the
relentless advocacy of his supporters, he and his family received an out-of-court
settlement that recognised the harms that had been inflicted.
In time, tragic scenarios began to receive attention in the media and also
captured the concern of advocates, including health professionals, particularly in
the sphere of mental health. The main question that arose for us as researchers
and advocates was how health and mental health practitioners working within
the restrictive detention environments articulated their ethical obligations. This
led to the research project titled ‘Caring for Asylum Seekers in Australia:
Bioethics and Human Rights’. An Australian Research Council grant enabled the
conduct of interviews with health professionals who had worked in immigration
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detention facilities during the time of Prime Minister John Howard’s government.
The semi-structured interviews focused on ethical dilemmas of working in a
securitised detention environment and were conducted with nurses (the majority
of respondents), psychologists, psychiatrists and general practitioners who had
worked mainly in immigration detention centres between 2000 and 2006. A total
of 40 interviews took place Australia-wide. The people who agreed to speak out
were those who found the environment problematic and we are aware that there
are others who were able to fulfil the duties required of them by the government
and private security companies. An unknown number of people who could not
cope silently relinquished their employment, choosing not to go public with their
concerns. Using grounded theory and thematic analysis, the overall findings
centred on the concepts of human rights, dual loyalty and professional ethics.
The interview narratives that follow illustrate the interconnected themes arising
from the broad concepts: the decision to take positions, coping mechanisms,
dehumanisation, standards of care and securitisation. Some of the interviewees
had previously aired their concerns publicly, in open forums or with the media,
but there were others who had not previously spoken out. Respondents were
chosen either because of our knowledge of their public advocacy or through a
snowballing approach.
The second project that will be discussed is the People’s Inquiry into
Detention, which was a response by academic social workers who had previously
raised their disquiet with immigration officials, but to no avail. Although not a
profession that was specifically involved in immigration detention settings, the
Australian Council of Heads of Schools of Social Work (ACHSSW) saw itself as
having a professional obligation to expose injustices in immigration detention.
Taking a different slant to the bioethics research, the People’s Inquiry is
discussed not through a focus on the ethics of working in detention but
articulates how the social work academics enacted an ethical mandate to expose
the policies and practice that constituted human rights violations. The stimulus
for the Inquiry was the following case scenario.
Case Study Three: Cornelia Rau
The People’s Inquiry arose in response to the cruelty shown to one woman,
Cornelia Rau.
In February 2005, a mentally ill Australian was ‘discovered’ inside the highsecurity
Baxter Immigration Detention Centre in rural South Australia. She was
initially identified as a German named ‘Anna’ before her true identity was
established. Prior to her incarceration in Baxter, Rau had been held in a
Queensland jail after found wandering in a disturbed manner (Briskman &
Goddard 2007). Two social work academics (Goddard & Liddell 2005) wrote that
what happened to her ‘exposed the darkest corners of our lives’. Although the
government ran an inquiry into the circumstances of her detention, it refused,
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despite pressure from detainees and refugee advocates, to widen its terms of
reference to inquire into the treatment of all detainees. Prominent QC and
refugee advocate Julian Burnside (2005) asked: ‘Why is it acceptable to treat
asylum seekers this way, but shocking when it is done to one of us’?
The ACHSSW conducted the People’s Inquiry into Detention. The Inquiry had a
dual role to influence policies and to place the stories of immigration detention
on the public record for the future of the nation. Professional responsibility arose
from social work ethics and from the knowledge base and experience of social
workers, which fostered a positioning as practice ethnographers (Briskman 2010)
through understanding the harms that arise through institutional racism and
malevolent policies. In these ways the ACHSSW adopted the stance described by
Fraser and Briskman (2005) that social work cannot be apolitical or neutral but is
a profession engaged with the political context. An advantage of an academic
group taking the lead was the existence of academic freedom, as universities:
. . . are essential for producing educated, informed and questioning citizens with
some capacity to scrutinise government decisions. The academics who staff
these institutions require a high level of academic freedom to pursue research
that may, at times, challenge a government’s values and agenda. (Hamilton &
Madison 2007, p. 13)
The methods of inquiry included holding 10 public hearings in urban and regional
areas and inviting written submissions. With very little financial backing, the
Inquiry attracted volunteers from all walks of life. More than 200 people gave
verbal evidence, including health professionals, faith groups, lawyers and
migration agents and asylum seeker advocates and activists. Almost one-third
of those testifying had been previously incarcerated in immigration detention
facilities. Another 200 organisations and individuals presented written submissions.
The evidence received was supported by formal documents including court
hearings and parliamentary debates. The Inquiry was joined by volunteers who
assisted in every facet of the organising including media activity, panel
membership, transcription, promotion of the Inquiry and liaison with witnesses.
Both projects had at their core concerns about the detention of men, women
and children, particularly how human rights violations inflicted harm on people
exercising their right to seek asylum. In the absence of comprehensive official
data which were not officially collected, the projects made a contribution to
asylum seeker advocacy by rigorously exposing issues and in highlighting
professional responses which had been absent from the wider literature on the
topic. By gathering a substantial number of testimonies, the systemic and
institutionalised nature of the human rights violations was exposed.
We now turn to outline the findings of the bioethics and human rights project
prior to examining in more detail the ethical issues that arise from the provision
of services in sites of control.
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Findings: Bioethics and Human Rights Research
One of the first questions that confronted some of those we interviewed was the
question of the ethics of working in an immigration setting. ‘Hannah’, a
psychologist, stated: ‘The biggest ethical dilemma was being an employee in
there. Taking a pay.’ ‘Max’, a nurse, although stating he was ‘on the side of the
detainees’ put it simply, stating that he worked in detention as it paid well and
he wanted a different experience. ‘Susan’, another nurse, raised the further
question of showing people kindness, posing the question: ‘Shouldn’t I stay and
continue to do that? And what about hope? One person said to me, and it sticks in
my mind absolutely clearly: ‘‘Are you just a kind lady or can you really help us?’’
Susan responded with: ‘I don’t know that I can help you any more than how I’ve
helped you here, but I will keep trying to help you. That I promise you, I will.’
‘Louise’ discussed how she responded to hostility about working as a nurse ‘in a
place like that’:
On the inside there’s nobody who’s on their side so I saw myself as a person who
was privileged to sit in their room, privileged to hear their stories because that’s
what people on the outside, no matter how well intentioned, were not able to
do. Sometimes I was able to facilitate their linking with the outside world. I just
felt there was a role for us there, as long as I tried to be true to myself. I suppose
too, guards learnt very quickly there was no point hanging shit on detainees in
front of me because I would argue with them or say ‘that’s not on, you can’t say
that, that’s illegal, I can report you’.
‘John’, a psychiatrist, saw the situation somewhat differently in relation to
medical personnel and presented the way he saw the problem of enacting
medical practice in isolated conditions:
But my concern is every doctor in Australia has the opportunity of peer review of
some sort or another, except them. That lack of peer review plus the nature of
the way those doctors get employed in the first place, they tend to see people
that work in the prison system, who are perhaps a little bit out of mainstream
medicine as they may not see the ethical issues in the same way we would. And I
can see that there is an issue. They would just say ‘Look, I’m a doctor and I’m
doing my best when I see the patient, and that’s that’. I know they’re reasonable
doctors and I know that they’re trying to do a good job for these patients but they
don’t have a broader perspective of where they’re in the system that they’re in.
They haven’t got the contact with the outside medical world to see what they’re
missing.
Nonetheless there were others who stayed within the system not just to be ‘good’
health practitioners, but to also be advocates. Advocacy was important for
‘William’, a psychiatrist, and he described as nonsense the idea expressed by some
of his peers that medical care and advocacy could not be enacted simultaneously.
Respondents spoke further about how they coped with working in detention,
particular maintaining their ethical stance and enacting a duty of care. A common
theme arising was the idea that being somewhat subversive and adjusting the rules
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was an appropriate response, a phenomena that Bill Jordan (1990) refers to as
‘isolated acts of banditry’. In her nursing role, ‘Susan’ explained that to survive
and be effective in that environment required both adaptive and subversive
behaviour when acting from humanity rather than inappropriate rules:
I needed to be surreptitious about what I was doing which to the organisation was
probably quite subversive and not being open about what I was doing with the
detainees.
Using a specific example, ‘Max’ said he ignored the rules when he felt it was in
the interests of the detainees, including the dispensing of the morning drugs. He
explained he felt sorry for the refugees as they had to queue up outside a hut and
wait for their medications. ‘We were asked to check them off to make sure they
were taking their tablets, the thing that I didn’t agree with and didn’t do.’
The theme of dehumanisation has been a recurring one in immigration
detention regimes and one of the main responses in the research was concern
about the use of identification numbers rather than names. ‘Max’ spoke about
the number system and said that this had an impact on the keeping of medical
notes:
You see the problem was they weren’t given names; as they got off the boat they
were given three letters and three numbers.
‘Simone’, a nurse, discussed how the dehumanised environment became normalised:
We would actually refer to people by their number rather than by their names . . .
I wasn’t conscious of it. And eventually I must say I think it was much easier as it
turned out, and people themselves actually identified by that number.
The dehumanisation process of using identity numbers continues today. The
Australian Human Rights Commission (2010) states that its members observed the
practices of calling people by numbers in the detention centre on Christmas
Island, and, as one detainee told the visiting representatives, it made people feel
like a flock of sheep (AHRC 2010). One of the authors also witnessed this practice
(Briskman et al. 2010a), commenting in a report to the immigration authorities
that the practice breaches DIAC’s Detention Values which specify that the
conditions of detention will ensure the inherent dignity of the human person.
A further anomaly for those used to providing health care on an equitable basis
was that lesser services were provided than for people outside the detention
environment; poor and discriminatory quality of care was a recurring theme in
the interviews. This included some comments about comparisons with other
environments of social control such as prisons where there was more equitable
healthcare provision than in immigration detention. ‘Simone’ referred to one
medical practitioner who stood out by challenging the expectation of low-level
health care:
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She said to me that she got hauled over the coals because she ordered an
ultrasound to test the person for kidney stones. And see again, because it’s a
detention situation, you never ever do the ultrasound. The ultrasound would
have involved a transport from Woomera to Port August, 180 kilometres each
way. It would take two prison guards out of circulation, plus of course the costs.
Overnight costs maybe for the person, for the two guards. So viewed in that
context, it really does escalate the costs. And so the doctor then got into trouble
for ordering too many ultrasounds. ‘Why do you order more than the other doctor
does?’ And she said ‘I like to treat my patients all the same regardless of where
they’re coming from.’
‘Anna’, a psychiatrist, explained that working in the public system where
detainees were sent for treatment, she was told not to refer to matters like
immigration and visas. However, she made it clear that she would not
recommend that people return to detention. Her community discharge plans
were rejected by the authorities. She said:
Politics came into play. People could be sent back to detention against
professional judgment. That was the real crunch for me.
‘Max’ spoke of the shock of seeing the health centre when he first arrived,
describing it as ‘disgraceful’:
There was no opportunity for sterilising things. It was all done with hot water.
The clinic was, because we were in the desert, always dirty. Babies’ bottles were
washed at the same sink where urine was tested. It was horrible.
‘Louise’ spoke of inadequate access to the one medical doctor in the Curtin
detention centre in remote Western Australia and a rotating system by compound,
which meant that it was less than a day a week that access was possible. This rule
was applied even when people needed immediate medical treatment.
Despite relentless criticisms that continue into both physical and mental
health care in immigration detention facilities (see Briskman et al. 2008), the
Australian government maintains that:
All people in immigration detention are provided access to health care at a
standard generally comparable to the health care available to the Australian
community. Health care services are provided by qualified health professionals
and take into account the diverse and potentially complex health care needs of
people in immigration detention. (DIAC n.d., p. 1)
‘John’s’ response spans the issue of equity of health provision and dehumanisation.
He described one visit to a detainee:
For example, when I went to see my first patient, they were expecting me, I
didn’t have too much trouble getting in the door, and I was offered the file to
review before I went to see the patient. The patient was brought in handcuffs
into a room and the room I was given was the size of this room (about 5 2 m
wide) it had light-blue walls which were just painted large concrete blocks with
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bright lights at the top and that’s it (and a carpet). There was no table no chair,
no examination couch, no nothing. He and I are sitting on the floor, having a chat
and I’m trying to examine the patient on the floor. Although . . . there were no
nasty words said by the guards to the detainee, there was nothing like ‘You stupid
bastard go in there’, there was nothing like that at all. It was ‘these are the rules,
this is the room that you’ve got, that’s it’. It struck me as the most depersonalised
system I could possibly imagine.
Although under-explored in the immigration detention literature, healthcare and
therapeutic relationships have been severely compromised by security considerations.
As asylum seekers are not ‘criminals’ but still held in what are
effectively private prisons, abuses can occur through the employment of security
personnel who may engage in practices that clash with those who uphold ethical
care as the main imperative. Yet without the accountability and peer review
referred to by ‘John’ that are the norm in most healthcare settings (Zion et al.
2009), ethical concerns for service providers continually emerged, as told to us
by interview participants.
As with John, ‘William’ told of people coming to appointments in handcuffs
with guards, which he tried to dispute. ‘Susan’ spoke of her difficulties as a nurse
in dispensing strong medication in the medical centre with guards present. When
she raised her concerns it was suggested that she should leave. To survive and be
effective in that environment required acting from humanity rather than
inappropriate rules. She spoke further about the ethical dilemmas:
One of the biggest problems was that the guards decided that they would become
the triage nurse, so they would determine who got through the gate and who
didn’t. So they’d ask what the problem was and if the person said: ‘I’ve got a
headache’, well the guard would say that’s not a good enough excuse to see the
nurse. I had to say to some of the refugees: ‘If you want to get through the gate,
tell them you’ve got chest pain and they have a duty of care to let you through.’
‘Max’ spent time reprimanding the guards for their behaviour towards the
refugees; some of the things they did were ‘quite abominable, it was appalling’:
I would hear guards talk about how ‘I gave LOC46 a good thumping today, a good
smack in the mouth, he spoke back at me’ or something like that. The guards
would totally abuse their power.
‘Max’ tried to speak out within the system and wrote official reports and even to
the Minister but he did not get responses:
The dilemma was that I was supposed to report to the supervisors, the guards,
ACM,1 anyone who was suicidal, they’d be on 24 hour watch and deprived of all
liberties. The problem is that they would be punished if they were deemed to be
suicidal . . . in actual fact the consequences of being suicidal made them more suicidal.
1. Australian Correctional Management was the private detention provider until 2004, followed by
G4S and now Serco.
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To deal with this ‘Max’ told them that he would not tell anyone but asked them to
promise not to hurt themselves because of the consequences and said he would
review them the next day.
Professional Issues in Detention Health
What do these research data suggest about traversing the complex terrain that
surrounds health care in immigration detention settings? Robust sociological
critiques directed at the helping professions argue that they generate an ideology
that perpetuates the dominant power of the professionals over groups they are
ostensibly helping (Fook 1993, pp. 56). Themes of social control have
characterised appraisals of professionalism, particularly where practitioners
may be expected to provide the contradictory roles of care agent and control
agent. The social work literature is one body of knowledge that has grappled with
this conundrum, pointing out that practitioners must balance the competing
demands of a society that wants both to help and to control the disadvantaged,
usually at the same time (Ife 1997). Critics from within social work argue that
there are unresolvable dilemmas between the values of casework practice and
those of the society in which it is practised (Fook 1993, p. 6). Once we
understand the core of the tensions underpinning working within an immigration
detention environment there is the prospect of grappling with what Fook sees as
intractable. One explanation is the issue of dual loyalty.
Dual loyalty issues arise where the loyalty of a health or welfare professional
to the patient/client is compromised by obligation to the employing body, which
may represent the interests of the state. Historically, the ethical obligations of
health and welfare professionals have privileged the need for loyalty to patients
and clients. Increasingly, however, health professionals may be in settings where
they are asked to weigh their devotion to patients against their obligations to
government employers or third-party employers acting on behalf of government
(London et al. 2006, pp. 38182). As employees, those within the care
professions are expected to follow agency rules and policies (Carniol 1990, p.
61), and these rules may be both explicit and tacit. In the case of immigration
detention, dual loyalty considerations may create potential for the violation of
human rights through collaboration which can be either active or passive (Gready
2007, p. 417). It is not always clear as to the extent to which health professionals
in these contexts are bound by employment, bureaucratic, political and
economic constraints (Fook 1993, p. 30) and part of the problem may lie outside
the employment contract, with health professionals colluding with the dominant
discourse in their societies, which may be unevenly challenged by their training
institutions or their professional bodies. This means that beyond day-to-day
practice there is a danger that professional groups may contribute to the social
control function by abiding with a dominant and repressive order. This is nowhere
clearer than in the case of asylum seekers, where governments have successfully
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convinced the wider populace of the risks associated with receiving strangers
who arrive ‘uninvited’. Here an imagined threat has a potency that was
exacerbated after the attacks in New York on 11 September 2001. As Tascon
(2010, p. 289) asserts:
Fear of the outside, fear of ‘the other’ that is outside, of invasion by that other,
who pervades the unknown outside is consistently present in Australia as an
island because the way to breach the physical border is by boat. The boat
becomes an iconic symbol that represents the possibility of such an invasion most
patently and hence became deeply central in the easy acceptance by the wider
population of the border protection measures taken after 2001.
Disturbingly, those working within detention are no more immune to the
political and media attack against boatpeople2 than health and social workers
were under National Socialism in Germany (Georges & Benedict 2006), the
apartheid regime in South Africa (Gready 2007) or those involved in torture in
Guantanamo Bay (Woolf 2007). Ahmed (2004, p. 1) speaks of how narratives arise
that espouse that the ‘other’ or those who are ‘not us’ are seen as endangering
what is ‘ours’. Health professionals may become socialised to environments that
permit abuse. By failing to confront abusive acts they may sustain those
environments. This is enacted through both their silence and the failure to use
their professional authority in defence of patient well-being (Allen et al. 2006).
Consistent with the views of interview participants about normalisation of
practices within detention, journalist Sushi Das writes:
So, how do you attract people to run camps, such as Baxter, where a detainee’s
human rights are abused through indefinite incarceration; where the disciplinary
process, which includes solitary confinement, appears to be arbitrary; and where
demoralised and depressed detainees resort to aggression, roof-top protest,
barricades and hunger strikes in anguished pleas for help? One way to do it, is to
make everything look normal. Corporate, bureaucratic or technical language is
often employed to provide a normalising effect.
She notes that when cruelty is organised, systematic and routine, it starts to
appear normal. There is also the misleading propaganda of the immigration
authorities that states that detention is not about punishment but about duty of
care, good order and safety (Das 2005).
Health professionals may witness severe abuses that have enormous health
consequences (International Dual Loyalty Working Group 2002, p. 48). They
may well believe they are powerless to do anything; others believe that
speaking out is not their professional concern. They may be contractually
prohibited from speaking out, and their supervisors are likely to be nonmedical
administrators with duties unrelated to health care (International Dual
Loyalty Working Group 2002, pp. 47, 48) and with little understanding of the
2. The term ‘boatpeople’ has entered the Australian lexicon to describe asylum seekers who arrive by
sea without travel documents.
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professional requirements of health practice. In Australian immigration
detention, nurses were one front-line group who often found themselves
directly confronted with dual loyalty conflicts, where legal obligations to their
employers could subsume their professional obligations (Zion et al. 2009). This
frequently resulted in their having to work against the interests of their
patients.
Despite the constraints, many health professionals tried to provide extra care
beyond that mandated by the authorities in places of detention. This could be
simple acts of the giving of appropriate food, humane ways of administering
medicine or offering the hand of friendship (Zion et al. 2009). In this way the
health professionals embraced an ethics of care, a morality based upon empathy.
However, neither such mild acts of benevolent defiance nor empathic care served
to challenge the conditions of detention. What was largely absent was the act of
speaking out and a political analysis framed by advocacy. For this group, caring
and relationships were preferred to confronting questions of justice and rights
(Zion et al. 2009). Well-known American community organiser Saul Alinsky
distinguishes between those who are prepared to fight for the rights of the
‘under-dog’ and those who are morally indignant but not prepared to act on their
concern. He argues that without active opposition, we perpetuate existing
unequal social and political relations (cited in Kenny 1999, p. 21), an argument
that echoes the troubling collusion that pervaded much professional activity in
immigration detention settings.
The People’s Inquiry project did not confront the question of collusion as it
was undertaken through an ‘outsider’ role. In undertaking this form of advocacy,
the social work academic group avoided taking on a ‘bystander’ position to act
beyond the moral indignation approach criticised by Alinsky. Before examining
the ethics that guided the project, an overview of some of the findings is
presented to reveal the abuses that the People’s Inquiry uncovered. Those
highlighted are by no means unique, and a major strength of the Inquiry was that
through a rigorous collection of narratives, the systemic institutional abuses were
exposed.
Findings: The People’s Inquiry into Detention
The People’s Inquiry into Detention documented testimony that revealed the
injustices and harms created by the asylum seeker system in Australia across four
thematic areas: journeys into detention, the processing of claims, life inside
detention facilities and the aftermath of detention. Although all four areas
revealed serious abuse by a range of actors working within the asylum and
immigration detention system, among the most compelling of the evidence
presented were the testimonies and written submissions that told of the
malevolent practices within the detention centres. Evidence was collected
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from professional groups outside the health and welfare domain, such as lawyers,
migration agents and faith group representatives. Health concerns featured
prominently in both the verbal evidence and submissions from health providers,
former immigration detainees and advocates focusing on physical and mental
health issues. One mental health professional stated:
You could have the Rolls-Royce of mental health services in Baxter and I don’t
think it would make a scrap of difference, because the environment is so toxic
that you can’t treat anything meaningfully. I think that half a dozen of the most
damaged people that I’ve ever seen are the adults I’ve seen in Baxter and
Woomera detention centres, both parents and single men.
An early childhood worker told about witnessing the treatment of children in
detention:
If I saw the same level of abuse, neglect and distress in the children in the
service in which I work, and I failed to make a mandatory notification, I could
be prosecuted. Yet, I have made mandatory notifications on so many children in
detention and they have gone nowhere. I will never, ever forgive them for what
they have done. There have been children emotionally murdered in detention.
A visitor to detention said:
We . . . do our best but nothing bloody well changes. And while we do our best, we
watch people get very, very, very sick trying to kill themselves and wish they
were dead.
Former detainees raised issues of the unhealthy conditions in immigration
detention centres. On Nauru, part of the now defunct ‘Pacific Solution’, a
witness told the People’s Inquiry:
I have never seen such a place in my entire life. It was scorching hot; you couldn’t
even see trees. There wasn’t enough drinking water and the water itself was
completely sour. The windows were covered by plastic, no electricity, not enough
food and we couldn’t see anything except stone.
A detention worker from a remote rural detention centre told of how:
Eighteen hundred detainees arrived in a couple of weeks. We had to allocate
them places to live. Bessa block buildings fit for one person and on many
occasions there would be six people in one. There was no air conditioning, the
temperature would range from easily high 40s and my shirt would be covered
head to toe with flies. There were scorpions, snakes, lizards. There were eight
toilets for 1800 people. There were two taps in the compound.
Although the People’s Inquiry did not delve into the ethics of health provider
collusion, it documented clear breaches to the right to health, particularly
exclusion from the provision afforded to those designated as ‘citizens’. This is
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by no means exclusive to Australia, for as the group Medical Justice (2007) has
stated in the United Kingdom, unmet health needs are a major problem among
immigration detainees and detention itself is frequently damaging to the
health of detainees, and sometimes profoundly so. Other commentators argue
that privatisation is a key problem, for once granted entry into this state function
the endeavour of contractors to maximise their profits can lead to abuses in
detention sites (Flynn & Cannon 2009). One group of psychiatrists explicate the
dilemmas faced by practitioners once they enter the detention environment (Steel
et al. 2004):
When we enter the world of detention . . . we enter a zone where usual
conceptions of human rights and obligations to others do not apply . . . The role
of doctor and clinical advocate is altered by ‘crossing over’ . . . the social
contract, as we usually experience it, does not apply here.
Responses into the Future
There are a number of avenues open for professional action. Professional
advocacy is one pathway to respond to the harms of immigration detention.
Although social work academics have ceased their role in convening the People’s
Inquiry, the findings that were documented in Human Rights Overboard: Seeking
Asylum in Australia came to public prominence with the awarding of the
Australian Human Rights Commission award for literature in 2008. Furthermore,
social work academics are among those who continue to work as advocates,
commentators and researchers in the field of immigration detention.
The immigration detention authorities in Australia have now adopted a ‘case
management’ role for people in immigration detention facilities and some
employed are social workers. Up until now there has been silence from the
case managers, but their observations may become apparent in the years ahead
as it is likely that some may draw on their experiences to advocate for change.
But professional advocacy is by no means the norm, and the perplexing
question remains as to how professionals can withstand the pressure to
participate in organisational dictates that are antithetical to their professional
identification, values and norms. Amanda Sinclair (1996) discusses the significance
of whistle-blowing when the organisational ethos conflicts with conscience,
leading individuals to reject organisational norms despite the pressure
placed on them. It is important, she argues, to maintain a personal sense of what
is right. In relation to health and welfare, Soldatic and Fiske (2009) point to the
medical discourse, which carries with it a claimed ‘objective’ knowledge and
‘scientific truth’. They posit that the use of a medical discourse needs to be read
alongside the ideological aims of the speakers, as evident in the statement by the
immigration authorities on health equity within detention.
In encouraging more robust professional responses it is important not to diminish
the difficulty confronting practitioners for it takes courage and determination to
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engage in resistance or to speak out in the name of a profession. Ministers of religion
have been told to stick to the pulpit and not lurch into politics; health professionals
have been told that their role is to dispense direct care and not to be advocates; and
the legal profession has smeared activist lawyers.
Professional organisations have a role. Although some professional bodies have
made statements against detention, they have stopped short of making recommendations
about whether their members should work in immigration detention
environments. The Royal Australian and New Zealand College of Psychiatrists
(RANZCP) issued a statement on the provision of mental health services to asylum
seekers. Although it expressed concern about the plight of asylum seekers and
called for the full provision of mental health services and research (RANZCP n.d.),
an advocacy approach was not suggested. A position statement of the Australian
Medical Association (AMA 2005) affirms that those seeking asylum within Australia
have the right to receive appropriate medical care without discrimination,
regardless of citizenship, visa status, or ability to pay. Like all seeking health
care, those seeking asylum in Australia, says the AMA, should be treated with
compassion, respect, and dignity. The statement adds:
Australia must find an alternative solution to prolonged, indeterminate detention
as a matter of urgency.
The Australian Association of Social Workers (AASW) supported the People’s
Inquiry into Detention. Its Code of Ethics (AASW 1999) calls upon social
workers to strive to challenge policies and practices that are oppressive. The
AASW Code emphasises that the social work professions subscribe to the values
and aspiration of the 1948 Universal Declaration of Human Rights, a directive
that can be a sound basis for asylum seeker advocacy. Organisational
constraints against speaking out against perceived abuse beset social work as
much as other professions. Although it is not known how many social workers
have been employed in any capacity within detention, those on the outside
also face advocacy difficulties if working in government or publicly funded
organisations.
Child psychiatrist Sarah Mares (2007, p. 222) reflects on her professional role,
arguing that moral indifference fast becomes complicity. This raises the question
of how professions refute a climate where, in relation to asylum seekers, service
delivery has reached a point where it is almost accepted without question that
existing arrangements are satisfactory and where the professions are uncritical
and complicit (Hayes 2005, p. 191). South African social worker Tiamelo Mmatli
(2008, p. 306) provides some leads for the professions, telling us that it is a dereliction
of professional duty not to comply with what Canadian academic Bob Mullaly (1997)
refers to as the promotion of political will to develop a humanised society.
Professional groups, particular social workers who work with the most
vulnerable people, can invoke their practice wisdom as experience in a range
of fields of practice demonstrates the harm of policies that are antithetical to
our common humanity. The knowledge base of the professions can open our
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eyes to the impact of subjugation, oppression, racism and structural
disadvantage. Beyond direct health and welfare practice we can propose an
ethics of responsibility where we locate ourselves in relation to others,
including strangers (Stratton & McCann 2002) and challenge the pervasive fear
of asylum seekers that permeates Western societies.
Another pathway to assisting practitioners in resolving the dilemmas is by
ensuring that health and welfare education has a strong ethical component that
goes beyond direct and individual practice to an understanding of the political
domain. This remains unfinished business in the competition for curriculum space
that confronts many disciplines, but without such foundations the quest for
justice in the care professions will be more difficult.
Postscript
The final comments in this paper reflect a degree of pessimism as developments
within immigration detention in Australia continue apace. At the time of writing
in late 2010 there are more than 5,000 people detained in immigration detention
sites in Australia, including 900 children. The case of Christmas Island illuminates
the ongoing problem.
In late 2008, the Labor government opened a maximum-security immigration
detention facility on Christmas Island to house single male asylum seekers. There
are now more than 2,000 asylum seekers on the island, including families and
children who are housed in an alternative detention facility known as Construction
Camp, as it was designed as temporary accommodation for the workers who
built the maximum security centre. Christmas Island is 2,600 miles from the
Australian mainland state of Perth, with the detention industry supported by flyin,
fly-out service contractors. As the numbers of asylum seekers expand on the
island, access to health and mental health services diminishes. The island cannot
cope effectively with medical emergencies or the level of distress within the
detention facilities. In 2010 an anonymous source working within Christmas Island
health services said ‘there’s better medical treatment available in Indonesia than
there is on Christmas Island . . . Christmas Island does not have the facilities to
cope with complicated medical conditions, with no surgeons or anaesthetists on
hand’ (cited in Collerton 2010). This assertion was confirmed in December 2010
when an asylum seeker boat arriving on Christmas Island smashed against rocks,
killing up to 50 people. This tragedy was exacerbated by the need to fly out
seriously injured survivors and to fly in trauma counsellors to deal with the grief.
Concern extends beyond the remote sites. In the last three months of 2010,
there were three suicides of detainees in Sydney’s Villawood detention centre
despite the constant advocacy by mental health providers and other advocates
who express concerns about the level of despair and desperation created by
detention. As psychiatrist Derrick Silove (2005, p. 29) states:
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The evidence that prolonged detention under harsh conditions damages the
mental health of previously traumatised refugees places a heavy burden on all of
us. It confronts us with a stark reality that the social policies, we, as citizens,
entrust in policy-makers will determine whether traumatised refugees become
healthy, productive citizens or, conversely, chronically mentally disturbed
persons with mounting disabilities.
The People’s Inquiry into Detention made three broad recommendations: to
remove racism, restore human rights and reinstate accountability. Such principles
are the gateway not just for governments but for morally active
practitioners to be freed from the tyranny of organisational practice in cruel
and unjust settings. These cannot be seen as the responsibility of governments
alone but arguably the health and care professions have a role in both ensuring
their practitioners adhere to such principles and that they challenge human rights
violations as individuals and collectively through professional advocacy.
When accepting the prestigious award of Australian of the Year granted by
Prime Minister Kevin Rudd in 2010, psychiatrist Patrick McGorry demonstrated the
type of leadership that is a model for the professions. He used the occasion to
describe detention centres for asylum seekers as factories for producing mental
illness and said he would lobby the prime minister to process asylum seeker
claims while they were residing in the community instead of detention (cited in
Overington 2010). The quest for justice for asylum seekers continues with health
(and other) advocates continuing to strive to influence change. The words of UK
Prison Ombudsman Stephen Shaw, which resonate with the Australian experience,
conclude this work.
The strength of a liberal democracy is measured not by how it treats the majority
but by how it cares for minorities and those on the margins of society. The best
tests for humanity and decency are conducted in prisons, psychiatric hospitals,
and in institutions for failed asylum-seekers and other migrants. (Cited in Medical
Justice 2007)
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