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Standing Committee on Health and Ageing - 21/11/2012 - International cross border health initiatives

GOGNA, Dr Parbodh Chandar, Area Medical Director Christmas Island, International Health and Medical Services

GRAHAM, Dr Julie Leanne, Director of Public Health and Medicine, Indian Ocean Territories Health Service

LEE, Councillor Kelvin Kok Bin, Shire of Christmas Island

McCAUGHAN, Mrs Julie, Health Services Manager, International Health and Medical Services

SCHAFFNER, Mr Maurice, Health Liaison Officer, Department of Immigration and Citizenship

SOKOLOFF, Mr Troy, Deputy Regional Manager, Department of Immigration and Citizenship

WINDSOR, Mr Paul, Assistant Secretary Detention Health Services, Department of Immigration and Citizenship

Committee met at 13:24

CHAIR ( Mr S Georganas ): I declare open this public discussion on health issues across international borders. Thank you for providing a tour of the health facilities on Christmas Island this morning.

The purpose of this round table is to discuss the health services provided to people who are placed in immigration detention on Christmas Island, specifically those services related to the identification of and treatment of infectious diseases.

Although the committee does not require you to give evidence under oath, this discussion is a formal proceeding of the parliament and warrants the same respect as proceedings of the parliament itself. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament.

Would you like to make an opening statement? You are not obliged to make an opening statement but you may if you wish to. We will then open discussion.

Mr Windsor : I did make a statement to the committee at the previous round table in Canberra so I am not proposing to add to that statement.

Dr Graham : As an introduction, Indian Ocean Territories Health Services provides primary health care to the community of Christmas Island and Cocos-Keeling Islands. We also provide emergency care and in-patient care for those in immigration detention on both Cocos-Keeling and Christmas Island. As part of that, we have a large role in public health issues both for those in immigration detention and those who are working out at the centre on a fly-in fly-out basis. From a community aspect, we are the coordinators of public health efforts on the island. If a public health response is required to any disease process, we are the ones who will coordinate it in collaboration with the shire and in collaboration with other organisations on the island.

Dr Gogna : First of all I would like to thank you for the opportunity to contribute to this important inquiry into health issues across borders. As the area medical director for IHMS on Christmas Island, I provide medical oversight of the services provided here and the more limited screening conducted on Cocos Island. This morning you met with my colleague, Julie McCaughan, who is the IHMS Christmas Island site manager. She has had a distinguished career in nursing, clinical governance and health service administration. Julie, with myself, leads the team of health professionals in the design and delivery of health services across six sites on Christmas Island and Cocos Island, some of which you have visited this morning. In August Paul Windsor and my colleague, Dr Mark Parish, spoke with you in Canberra about the work of IHMS and this morning you had a chance to see those services being exacted. I will confirm only briefly that IHMS is contracted to provide extended primary health care services and mental health services for people in immigration detention.

In this region this includes public health screening and induction health assessments upon arrival, vaccinations and ongoing health care while people are on island and fit-to-transfer assessments for those scheduled to leave. Clients requiring hospitalisation are referred to the Christmas Island hospital, and we greatly appreciate the professional cooperation Dr Julie Graham and her staff provide. Where we identify infectious diseases we work very closely with the Communicable Disease Control Directorate of Western Australia, as well as the Christmas Island hospital. To manage the care of these patients, we do contact tracing and additional screening when required. These arrangements depend on the cooperation of all parties, which has worked well to date. Despite infectious diseases being a normal part of the health profile of new arrivals, we have not had known instances of transmission between clients in the detention network or between clients and the Australian community. We look forward to answering your questions on these matters today.

CHAIR: Is there anything anyone wants to add before we open up for discussion? Then I might start off. What I would like to hear more about—if someone can just walk us through—the process that takes place when a boat arrives. Once you have walked us through that, what happens with the people who are diagnosed with an infectious disease?

Ms McCaughan : I will walk you through that process. When the clients arrive on the jetty we attend for observation and clinical assessment of the clients. We are generally looking for clinical signs that the client has a diagnosis or an issue that we need to address acutely and quickly. Following that, they are transported up to the induction centre where we conduct a public health consent. We have a set questionnaire that we ask the clients through interpretation and then we get their consent to be able to deliver their healthcare needs. That is the whole gamut from induction right through the system while they are in detention.

At the same time we talked to them about immunisation and vaccination to prepare them so that, when they seek the doctor, they can respond to the doctor's questions in terms of their own immunisation status. Should the client through our public health assessment require any additional treatment such as isolation or should we determine that they may have symptoms that we want to investigate further, we may isolate them or start additional investigations of them. Should a client also present clinically, we can also fast-track them to have a chest X-ray, as an example, and take additional specimens there so that we can send them off and get the results as quickly as possible. Until we get a diagnosis, it is quite difficult for us to determine whether a client needs hospitalisation or full isolation, but we do take the necessary steps to ensure that they are quarantined if need be.

Ms HALL: Could you detail for us what the health check involves? We saw what was happening this morning, but could you put it on the record?

Mrs McCaughan : Do you mean the public health questions that we asked?

Ms HALL: Yes. When people come in, they have blood tests, for instance—the process.

Mrs McCaughan : Our process includes a public health screening, which is the questionnaire; consenting for treatment; urine tests; clinical observations; pathology screening; chest X-ray; GP induction or assessment; and a mini mental health screening as well.

Mr IRONS: Is that on that sheet that we saw where all those things are ticked through? Could we get a copy of that sheet?

Mrs McCaughan : Sure.

CHAIR: We discussed this earlier and we will be getting one. What is the impact resulting from the large number of unauthorised boat arrivals that have been coming?

Mrs McCaughan : The impact relates more to the level of activity. It does stretch resources that enable us to attend to clients in a timely manner; however, I think that our processes are efficient enough for us to be able to identify and fast-track clients as required. The other impact is that, when you have a large number of people, it is harder to quarantine them separate to all boats. So we might have to quarantine together boats that have not finished all of their processes.

CHAIR: Has there been any impact on health issues and the services that are provided to the residents of Christmas Island?

Mrs McCaughan : It might be more for Dr Graham to answer that question.

Dr Graham : There has certainly been an increased usage of the health service. That is across the board, not only from those in immigration detention but also with the workers associated. Since the 2006 census to the 2011 census there has been an increase of 81 per cent in the 20-to-65-year-old age group. In numbers, that is about an extra 800 people on the island, so in a sense that has an impact on resources within the health service and provision of services to the community. We also deal with the perceptions of the community when we have more resources put to refugees or treating, transferring and screening, but we try to maintain adequate services as much as possible. But certainly the workload has increased.

CHAIR: Has it had an impact on the local community?

Dr Graham : Not from an infectious disease point of view. There has been no recorded spread of infectious diseases from immigration detention clients through to the community.

CHAIR: Excellent. In discussions with some of the people on the island yesterday when we arrived, they said that they are seeing more refugees who are seeking health services—people who are, perhaps, amputees or who have a whole range of illnesses, and people who are making the journey specifically for the health services that they can get. What can you tell us about that?

Dr Graham : I defer that one to Dr Gogna. We see a very small percentage of them.

Dr Gogna : As you all know IHMS provide all the primary care to the refugees, as well as the induction screening. It would be an important analysis to do. It is important to collect these statistics and analyse them carefully. We do report them through to the Department of Immigration and Citizenship, and a complex disease register, as well as a tuberculosis register, is maintained, and those statistics are provided through the department. The department will disclose those at Senate estimates, I believe.

There is significant evidence to point towards people coming to Christmas Island and Australia for medical treatment, and we are seeing the Tamils taking the three-week journey to Christmas Island from either points of departure in Sri Lanka or southern India who have had amputations due to trauma, and people would advise that would have occurred in the civil war. Some are due to accidents as well. We have also had people with ovarian cancer that have had chemotherapy in eastern countries, then travelled to middle eastern countries for further chemotherapy, and then were advised to travel across for further input. The question is: is it anecdotal? I do not have a reference or a standard range to compare with. We had 4,700 arrivals last year, compared with something over 11,000 this year.

We are seeing people taking a longer journey as opposed to the transmigration from Afghanistan, Iran and Burma via Indonesia through into Australia. To answer your question, we do see a tangible increase in people requiring specialist medical care. The vast majority usually bypass the hospital because they are chronically unwell. Some will have cardiac murmurs, some will have diabetes that is uncontrolled, some will have had coronary artery bypass grafting done in other countries, and because these clients may be unstable—not unwell enough to require acute admission into the hospital, or acute transfer via the RFDS—we will transfer them by charter, with the help of Morris, the health liaison officer. We will prioritise them for mainland transfers and then specialist care.

Obviously there is a whole gamut of TB management that occurs with latent tuberculosis as opposed to acute infectious tuberculosis. Julie would have pointed out the blood tests that were done today. People are sometimes unaware that they have been infected with hepatitis B or hepatitis C, and we will do screening tests for HIV also. For the last month, we probably would have had six confirmed cases of HIV.

CHAIR: Earlier, when we were at the detention centre—I forget which one it was—

Mr WINDSOR: North West Point.

CHAIR: We asked whether people, when they present—and they have to go through the procedure to determine whether they are refugees—are asked a whole range of questions. Some say, 'We are here to work', so you know that they do not qualify as refugees and they are sent back, or whatever. In terms of health issues—and it might be better suited for Troy—when they are asked the question, 'What is the reason you are here?' and people say, 'We are seeking health services or medical treatment for this, that or the other,' are you seeing any cases specifically?

Mr Sokoloff : It has not been reported to us. As we were talking about earlier, that was in relation to Sri Lankan clients that are returning to Colombo. In terms of our interactions with them, I am not aware of any clients stating that during the interview. Obviously we look at whether they fit the criteria for the refugee convention, and often a lot of the ones that we have been having recently are stating it is for economic purposes.

CHAIR: Thank you. Will everyone please feel free to jump in at any point if you want to add to or clarify something that someone has said.

Mr IRONS: Dr Graham, thanks for the tour this morning of the hospital. I think if I was ever going to go into the hospital at Christmas Island I would want to do it on a Wednesday morning. It was quite relaxed and there was a minimal amount of work to be done there. If the government achieves a reduction in people-smuggling, would that have an effect on your resources? Have you had to ramp up your services to accommodate the extra inflow of people smugglers?

Dr Graham : In 2010 we increased our number of medical officers from two to three and of full-time equivalent nurses, RNs, from 10 to 11. They are the only additional resources in clinical capacity that the hospital has put on since the introduction of refugees coming to the island. The other resources that have been increased are mainly to deal with immigration services, our torture and trauma services, which are funded by DIAC, and our medical scientist is funded by DIAC. Other than that we have not had an increase in resources to the health service in that time. We are struggling.

Mr IRONS: In relation to the processes you laid out for us before, with immunisation status, do we promote the idea that people should be given immunisation if they have not had it? If we do, what sort of reaction do we get to that? Or do we process them and send them to Australia without having been immunised?

Mrs McCaughan : Because our throughput of clients is very fast in terms of their on island these days, we do not immunise everybody. We offer vaccination to everybody and then, when they are going to another receiving site, it is noted in their medical record that they have agreed to continue with vaccination. We immunise all school-age children as a priority so that they can go to school. So everybody is offered immunisation and that continues through the system regardless of which detention centre they are at.

Ms HALL: First of all, I wondered what your job was, Maurice, as health liaison officer.

Mr Schaffner : As the title says, I am basically the focal point for immigration and our health service providers. I make sure that any issues on a daily basis that prevent the appropriate patient care or resources issues are addressed and highlighted to our managers and I ensure that any contractual obligations are being are being met on a daily basis.

Ms HALL: Is there any follow-on when people leave the island? Do you have any role then, or is your role only liaising with them whilst on the island?

Mr Schaffner : I do liaise with my colleagues within the detention network, specifically when we facilitate medical transfers. We ensure that they are provided with enough information and advice to ensure that they continue the appropriate care of that client at the detention centre.

Mr Windsor : We have a network of liaison officers, so Maurice's role is duplicated elsewhere around the country. He would also liaise with his colleague HLOs where people are being transferred from one—

CHAIR: It is not just—

Mr Windsor : It is not just in CI.

Ms HALL: That was one of the things I was trying to ascertain.

Mr Schaffner : It is basically to provide a nationally consistent approach and ensure that DIAC fulfil their duty of care.

Ms HALL: One thing that impressed me this morning was the consistent, streamlined, approach that you have and the fact that it would be very difficult for someone with some sort of communicable disease or any other illness to fall through the cracks. Would you like to comment on that for me?

Mr Sokoloff : We work as a multidisciplinary team in terms of managing the clients through the process. Obviously our health contractors have their role and Immigration and Serco have their roles as well. So when we make decisions around transferring we make sure that we consult with all of our colleagues and contractors. There are stringent processes in place and we are very keen to ensure that, with our duty of care, we maintain that and do not endanger anyone's health. We have strict processes in place around client movements from this island. We also have our own internal policies and procedures for maintaining the safety of those within the facility. So we do work very strongly together and as a network.

Ms HALL: I would now like to go to mental health. I see this as a communicable disease, because if you have somebody with a mental illness it can be transferred when they are associating with and living with others. I wonder if you could tell us about your mental health program—the counselling, support and options available for people in detention—and how you deal with a situation where somebody has a significant mental illness that is going to impact on others in the detention centre.

Dr Gogna : We take mental health very seriously. As you all know, people being in incarceration and also going through traumatic events in their lives will predispose them to having quite significant mental health issues. To mitigate that, the government has put into place, through DIAC, IHMS's role in providing psychiatrists who visit Christmas Island. We have a strong team of mental health specialist nurses. We also have psychologists on staff and we have very clear screening tools in place. We do mental state examinations at regular intervals, which we are contracted to provide. That being said, once we actually highlight a problem there is an escalation process that goes on. We also have general practitioners who will then review. Mental health will be made a priority.

It will be treated as a multidisciplinary illness that requires multidisciplinary support. So we will end up with programs—not only the medications but also the psychology review, the ongoing mental health review—to help improve that person's welfare within detention. Obviously we are very concerned about people tipping into severe depression and suicidal tendencies. Unfortunately it is sometimes a by-product of people's lives, but it is something we see as a very high priority. We have a psychological support program that we report on every day, at the operational meeting, to flag high-risk clients. We use that in a very inclusive way, to make sure that the right people are getting the right level of support in a timely manner.

Ms HALL: Could you talk us through the psychological support program?

Dr Gogna : Julie McCaughan is the operational manager so she will talk about that.

Mrs McCaughan : The program outlines guidelines so that all staff are fully aware of people who should be flagged, or need to be flagged, and how we manage them. Everybody gets an individual assessment, and what management and treatment we offer them depends on the level of risk they are presenting to us. If clients are at high risk and they are demonstrating or verbalising some self-harm ideas then we will put them on a closer observation program that will include continuous meetings, on a daily basis, with DIAC, the case managers, Serco and the officers so that as a team we are closely monitoring and supporting them, the clients.

It is quite a complex program because it is individually tailored. What I can say is that through the communication process all stakeholders who have a part to play in the client's welfare throughout the 24-hour period are involved in meeting, communicating, sharing, reporting and feeding back. That is the program in a nutshell.

Ms HALL: Is there a different program for children? How are children dealt with?

Mrs McCaughan : We have had some children who have demonstrated some difficulties. A lot of it is related to the trauma they may have experienced in their early years already. We often will keep a closer eye on the children who demonstrate these problems by doing family groups. Because the parents are with the children most of the time, we do tend to bring the family in and do group work so that the children are always feeling supported. What you will find with children is that it is not a one-on-one with the mental health provider but more group work with the family and on a more regular basis.

Ms HALL: If a person is diagnosed with the communicable disease or a mental illness, what sort of support services do you have in place in the detention centre for the families, carers or other significant people in that person's life?

Dr Gogna : We never isolate people individually. We always consider the family unit. We look at individual needs for the isolation and we will try and put a package of care together leveraging on all the nursing that is available, the mental health nursing that is available and the psychology teams that are available. Packages are tailored.

The other thing is that we are an island with limited resources. As you have heard today, we are struggling with accommodation. We also have significant numbers. You saw the marquees that are being erected on our facilities. It is important to realise that we have a finite ability to do things. One thing we spoke about was the psychological support program. It is also important to realise the strong input that the trauma and torture psychological unit at the hospital provides, an independent specialised service, which we see as highly valuable. The difficulty for us is that we have a very high throughput of clients now through Christmas Island and it is very difficult to engage quickly. We do a risk assessment to see whether they are high, medium or low risk. But sometimes that end use of care has to be a more sustainable position—that is, the person is going to be in that position for bit longer. There is significant work that needs to be done with post-traumatic stress and other related psychological illnesses.

Mr IRONS: Is there any evidence of dementia in any of the people who are arriving? How do you deal with it if there is?

Dr Gogna : We do see patients present with syphilis. Syphilis can have all kinds of different presentations from the initial illness right through to a tertiary disease, which can give you those symptoms. We have not seen any of those formalised in a young patient but we have seen people with brain trauma, for example. We have seen patients not specifically with dementia but we are seeing an older cohort. We have had a significant number of arrivals where people have come off the jetty and gone straight to hospital due to heart failure. It was quite surprising they were able to make even a short ocean-going voyage.

As my colleague Dr Graham receives these patients on an acute basis, she will also be able to see that trend that is occurring. I think a statistic that Maurice discussed the other day is that we are medivacking virtually one person per week off the island. Would you confirm that, Maurice?

Mr Schaffner : Yes, that is correct.

Dr Gogna : Will we see more degenerative diseases? Absolutely, Mr Irons.

Mr IRONS: With the trip, the dehydration can bring on dementia-like symptoms.

Dr Gogna : Absolutely. There are cases where people have been on boats where the water has run out a week ago. There are also people that you have obviously discussed regarding typhoid. If you are doing a three-week voyage with vats of water, as soon as those vats become contaminated it becomes a risky affair. We have had people who have been based in Indonesia for a prolonged period of time and they have had chronic diarrhoea, and that can be anything from food intolerance through to an infectious cause, which is obviously the remit that you are interested in.

Mr IRONS: Have you had any cases where you suspect child abuse at all? How do you deal with that?

Dr Gogna : We have a social worker on the island. We use the Western Australian resources that are available to us. We are also aware of mandatory reporting in the state of Western Australia, and we adopt the WA state laws. We escalate these cases through to Princess Margaret if need be. We had cases when the Malaysia solution was discussed and food withdrawal to children from their parents. On my desk sits, quite clearly, physical abuse versus psychological abuse to children. It is an absolute minefield because the legalities are important to map through. We have social workers on the island and we have a mental health senior clinical team leader who is very au fait with the process. Also, the minister has a strong input into cases, such as voluntary starvation for example, so if these get escalated over time then we have a trigger mechanism, because the child's safety is paramount.

CHAIR: Just before I crossover to my colleagues, I know we have touched on mental illness and whole range of things, even though the terms of reference specifically talk about infectious diseases. We might veer off a little bit occasionally, but forgive us for that.

Mr WYATT: My first question is to Mr Windsor. In relation to the table provided to us with the infectious diseases, is that from DIAC?

Mr Windsor : Yes.

Mr WYATT: I will come back to a question for Ms McCaughan in a moment. We had 4,700 people here last year and 11,000 this year, giving us a total of 15,700. If we consider a couple of the categories in terms of infectious diseases—tuberculosis, typhoid and HIV/AIDS—then amongst all of those columns over that two-year period there were 93 of the boat people only who had infectious diseases that would be of some risk to Australians. Given that figure of 93 against a total of 15,700, it is not a significant issue amongst the asylum seekers.

Mr Windsor : I think the numbers that we are seeing are small in light of the overall numbers arriving. My understanding is that, with conditions like TB, we believe that the levels we are seeing are broadly comparable with the source countries from which the people have originated. So, if they are clients who have made the journey ex-Indonesia, then they are broadly comparable with levels in Indonesia. Similarly, if they are coming directly from Sri Lanka, then they are comparable with the levels found there.

Mr WYATT: Given the small number, are there any other infectious diseases on this list that are not included?

Mr Windsor : I am not aware of any other infectious diseases of concern that are not included on the list.

Mr WYATT: Can we go back to the period pre July 2010? The numbers would probably be commensurate in terms of the number of people arriving prior to 2010 as well, would they not?

Mr Windsor : I would expect that would be the case, but I do not have the figures.

Mr WYATT: That is understandable. In one sense, one of the key messages that needs to come from this committee, or be included in the committee's report, is that some Australians should not be captured by the media headlines in portraying that we have this significant infectious disease issue coming from the illegal boat people and that it probably stems from other areas in which Australians travel to countries with infections or infectious diseases that could become problematic through the regular and increasing volumes of air travel.

Mr Windsor : I agree with that assessment and I reiterate and reinforce the point that was made both by Dr Gogna and Dr Graham earlier that there have not been cases of people coming to Christmas Island with infectious diseases which have resulted in transmission of that infectious disease to others.

Ms HALL: I think that is a very important point.

Mr WYATT: I would like to move that the table provided by DIAC be included not in the papers but in our published report.

CHAIR: Can we get some advice from the secretariat. We do not need to formally accept it. It will be included in that.

Mr WYATT: So we can include it in our report.

Ms HALL: On that, I wonder whether you might be able to give us a little bit more detail by showing what percentage of people that arrive here have some sort of communicable disease. You could do it over a period of time, saying: we might have a few more people arriving with those diseases now, but there are more people, so therefore it is still a fairly low figure and it is a stable figure.

Mr Windsor : If I could take that on notice.

Ms HALL: Absolutely.

Mr Windsor : I will talk to the people who provide the statistics. I am sure that we could provide something which goes to what you are asking.

CHAIR: If you could send it through the secretariat, that would be great.

Mr Windsor : The proportions, rather than the absolute numbers.

Dr Gogna : Can I make a comment to Mr Wyatt. The incidence, as you said, is low. But it must be taken into account that it is an incarcerated community. We use a communicable disease guideline that is produced by the public health unit in Western Australia. Communicable diseases can be chickenpox, for example. One case of chickenpox can shut down an entire camp. We had a boat from Sri Lanka that came in earlier. A client had chickenpox on the boat. We pushed it into a public health program which contained the outbreak. We screened the Tamil population and 30 per cent of the population had not had chickenpox before. The children were immunised immediately because that confers some benefits quickly. We were putting all of the adults that had not got antibodies to chickenpox on medication. Obviously, I work very closely with Dr Graham because of the workers at the detention centres—and this refers to your communicable disease question: has it had an impact on the community? If you are a pregnant person in your first trimester and a worker in our facility, who has possibly been exposed to chickenpox and not had any immunity, then it becomes a significant issue for Dr Graham. Things that we take for granted in our normal communities, such as scabies and head lice, are all communicable diseases. Therefore, your gamut of diseases is huge, apart from the big ticket items that we talk about regarding HIV, that then will go onto an AIDS-related complex or AIDS-related diseases. This is what we face on a daily basis, but it does not get as much traction as some of the hepatitis Bs and Cs, HIV, tuberculosis, syphilis, gonorrhoea and chlamydia that we talk about.

Mr WYATT: Your point is well made.

Dr Graham : Another issue that comes in is not actually in the communicable diseases themselves but in the possible vectors that are also being introduced into the community of Christmas Island.

CHAIR: Sorry?

Dr Graham : Vectors—that is, mosquitoes. Any water source or water container that comes in on a boat that comes close to shore has the possibility of transferring the mosquito vector for both malaria and dengue fever. Dengue is the main one that is of concern in this region. Our AQIS personnel have detected the Anopheles mosquito, which is the dengue vector which has come from water containers that have been on these boats. We have had imported cases of dengue come back to the island from Bali, Malaysia and Indonesia If these vectors get into this confined community with its large mosquito population, there could be potential for quite a serious outbreak.

Ms Hall : Those people who came back from Bali and Malaysia, they were Christmas Island residents who had travelled away and come back rather than people coming in with those diseases—is that correct?

Dr Graham : Yes, that is correct.

Mr Wyatt : Do we still have a vector issue within that?

Dr Graham : It is more the vector issue than the actual—

Mr Wyatt : On Friday, 24 August, Mr Windsor, you gave evidence to the committee. You made a comment about a framework based on five core principles. You said:

Fifthly, decision making in this space should be evidence based and should utilise research or expert advice from external professional bodies, including a specialist advisory group.

Has DIAC done any research in terms of extolling the virtues of the process of screening and the effectiveness of that, or on some of those other potential issues that may arise, such as vectors that are within the water that is being brought into the country?

Mr Windsor : I do not think we have done any research. I am not aware that we have done any research into vectors. That might be something that would fall within the responsibilities of AQIS rather than DIAC. I think there are measures that are in place. Troy, you might be able to comment on that in terms of how close the boats generally come to shore and the measures that AQIS and Customs and Border Protection Service take in terms of destruction of boats to ensure that appropriate quarantine measures are in place.

The department does commission research in relation to health related matters. We have had a review of the effectiveness of the implementation of the Psychological Support Program, which we were discussing earlier. We currently have an audit being undertaken by a firm called Protiviti around this very topic that this committee is considering—the risk of transfer of communicable diseases. They are also currently undertaking research.

Dr Gogna : I would just like to add a bit more to that. DIAC is collecting a tuberculosis register. We are also collecting information that, as the healthcare provider, we are required to supply on latent tuberculosis and the people we are collecting sputum from to look for acid-fast bacillus, the tuberculous bacilli. If they are negative, those samples will go for culture and it can take up to eight weeks. DIAC is collecting information that we are supplying. That has been an initiative that DIAC has led over the last few months. It clearly gives a line of sight from induction chest X-ray to induction public health questioning of symptomatology. 'Have you had a cough for greater than two to three weeks?' It helps to join the dots between an abnormal X-ray and public health questioning. If somebody has weight loss and is not thriving or has a very low body mass index, that can lead to the questioning as to whether they harbouring tuberculosis. Then we consider how can we go about tracking this person right the way through our system. DIAC obviously asks IHMS to carefully track that person right to the point before any visas are issued to allow these people to go into the community. At the very end point, IHMS are required to refer that client to a communicable disease centre.

For example, we carefully work with Prof. Justin Waring who is a respiratory physician at the Anita Clayton Centre which is the refugee medicine centre in Perth.

Mr WYATT: Have we had any cases of antibiotic-resistant communicable or infectious disease?

Dr Gogna : I believe we have had one case of multidrug-resistant tuberculosis, but the cultures were still pending on that patient. I do not have any other evidence. We do see patients coming through our doors with multiple sores. We will swab these lesions and they do come back as methicillin-resistant staphylococcus aureus which is MRSA. Methicillin is not an antibiotic. It is a biological product, a chemical product, used in a lab as an antibiotic. We are finding that people are growing organisms that we talk about mainly with hospital environments where they have had MRSA outbreaks. Obviously very few antibiotics are able to treat those types of problems, but once again it is a product of poor hygiene. Whether it is a reflection of being on a fibreglass hulled vessel for three to four weeks with very poor nutrition before and after while ducking the authorities—it is difficult to extrapolate what went on in their lives before we receive them.

Mr LYONS: Ken talked about the limited number and I acknowledge what you said about one case potentially being difficult for the community. Have there been any procedural changes or treatment changes as a result of Manus and Nauru? Are there any protocol differences?

Dr Gogna : Our protocols have been very much firmed up in the last year. Our tuberculosis protocols have been very firmed up. There is very clear guidance on who we collect sputum samples from and who we do not, and how people are followed up for abnormalities on chest X-rays. We now have clear follow-up regarding what we will do with somebody that is hepatitis C positive and what will happen with people with HIV positive initial screening blood results, and what other tests we will do.

For the Manus and Nauru transfers, obviously the authorities in Manus and Nauru do not want to have any communicable diseases sent to them, so we have to carefully screen them with dipstick urine you saw at the induction shed this morning, and we will not send carriers of hepatitis B or people infected with hepatitis C. They need specialist intervention and they are given first-world care on the mainland. Patients with HIV we are unable to send. We will not send people with active tuberculosis. Is it business as usual and has it changed ostensibly? Not really. We are mindful that these are remote locations, so it is not suitable for people with complex care needs or for people who are chronically sick or who within a three-month period might require medivac if they have unstable cardiac conditions or their angina is worsening.

Mr LYONS: Roughly how many a year get transferred off for diseases that you cannot adequately treat here?

Dr Gogna : I would defer that to Maurice because he gets our emails to say we would like to put them on priority transfer. How many do you have on your list at the moment, Maurice?

Mr Schaffner : I do not have those figures at hand but I could provide them.

Mr LYONS: How many go to the mainland treatment for something that we need to clear up before it gets into the Australian community? It could be an interesting figure to get.

Dr Gogna : It is usually not communicable diseases, because we have very strictly enforced levels of fitness to fly.

CHAIR: What about tuberculosis?

Dr Gogna : We use the World Health Organization's guidelines on tuberculosis and being fit to fly. We will also be very wary of introducing unknown illness into a commercial airliner, for example, or introducing it into a charter to the mainland. Invariably if somebody is very sick, we take whatever opportunity we have. As you can see, we are in the summer months at the moment, but when the wet comes in it is sometimes very hard for planes to land on the island. There are other things that are done on the island, such as procedures. We are a classic example of remote and rural medicine and people managing.

The RFDS jet takes, on average, six to seven hours to get here in an acute emergency, if they are able to land.

Mr LYONS: In terms of how you look after staff, can you give us some sort of indication of what precautions, what testing you do?

Dr Gogna : There will obviously be the predeployment type of activity that we will do. We will also ensure that people have their vaccinations and immunisations checked before they arrive. Hepatitis A is a vaccine-preventable disease. Hepatitis B is vaccine preventable if you serum convert and there is still evidence that, even if you do not serum convert, you still have immunity from hepatitis B. Obviously, with respect to HIV we have no breakthroughs, apart from very good needle stick sort of care and Sharps awareness. We run programs on all of those. We also make sure that staff are reasonably fit and well to do these deployments.

Unfortunately, like all good organisations we do not pry into people's private information. Dr Graham will probably have more information on Serco employees, IHMS employees and DIAC employees who may come with incumbent illnesses or produce a burden. But they may not be communicable diseases.

Mr LYONS: What proportion of your patients—

Dr Graham : This is not infectious-disease related but a third of our GP consultations are with staff related to the detention centre. One issue we have is that some organisations are better in their predeployment testing and pre-island vaccination program, so we often get a lot of staff coming onto the island who have not been vaccinated, who will then present to our health service looking for vaccines. Or organisations on the island then, as a knee-jerk reaction, in some instances look for vaccination programs for their staff. We have been pushing for several years to have better predeployment medical screening with regard to (1) vaccine status and (2) medical conditions that are really unsuitable for people to be on the island with. That is something we will continue to press.

CHAIR: In terms of departments and firms which are contracted here to provide services, do a lot not require their staff to have their vaccinations before they are deployed here? Does DIAC get their staff to have vaccinations—

Mr Windsor : I think it is recommended but not mandatory.

Mr Sokoloff : That is correct. They have a physical health check and also a resilience check, if you like, to make sure that they will be suited to working in such a busy and operational environment in a remote area. They are certainly offered the opportunity to have those vaccinations at the department's expense prior to their deployment. But, obviously, we cannot make someone. It is not mandatory.

Mr LYONS: What sort of risk does that impose on the community if we are importing people who have not had vaccinations who potentially are dealing with people who may have some communicable disease and we have not—to me, it seems a bit weird.

Dr Graham : I certainly cannot quantify that risk for you, but it is certainly an issue we have been pushing and we have been upfront in offering vaccination programs to staff. We see it as an important issue that people coming onto the island could be protected against vaccine-preventable illnesses who have not been in predeployment medical checks.

Mr LYONS: Is there any reason, Mr Windsor, why the department would not insist on their contractors having vaccinations?

Mr Windsor : I think the view has been taken that we make people aware of the benefits of vaccination. This is coming at it from a perspective of, I guess, guarding the individual's health rather than the perspective of a possible link in the transmission of an infectious disease. So it is from an occupational health and safety perspective to make sure people are informed about the risks and make an informed choice about whether they take the vaccination measures at departmental expense to protect themselves.

In terms of the broader risk, I go back to the point that we made earlier—that is, we have not had evidence of transmission through staff or through service providers. I think the way in which we screen arrivals for communicable diseases and manage that has been managing that risk. So our focus has been on the individual protecting themselves.

Mr Sokoloff : We have a work health and safety committee, which comprises representatives from our contractors and the department, that meets monthly as well. These sorts of issues are considered and we put in the relevant precautions should they be necessary. Our staff are constantly reminded of the work health and safety arrangements and they are encouraged regarding basic hygiene and the like when they are working with clients. So I think the strong arrangements that we have in place also help with that sort of situation as well.

CHAIR: How many of your staff would take on the vaccinations?

Mr Windsor : I do not have that data.

Mr Sokoloff : We would not have that information. Obviously it is their private medical information. Unless they disclose that to us, we would not have it.

CHAIR: Do you drug testing of staff up here?

Mr Sokoloff : No, we do not.

Ms HALL: There are privacy issues.

Mr LYONS: Do you provide free vaccinations through the department before they come?

Mr Sokoloff : Certainly. They have full access to that before they come. There is a deployment guide given to them which outlines the health aspects of their pre-deployment checks. So they are aware of the risks, the environment they are coming to and what is available to them. We also ensure that our staff are inducted and, of course, we have assistance on island in terms of our employee assistance program. We have a permanent presence of a mental health professional here as well for our staff.

Mr LYONS: To make this a perfect world, we need to recommend something in our report. What would you suggest that we put in our report?

Dr Gogna : If you are talking purely on communicable diseases, I think you put the gamut wide and you actually say 'Communicable diseases include all of these.' They include head lice. They include diseases that we have not seen in Australia for many a year. It is the historical types of typhoid outbreaks, such as the Worthing one in England in the 1900s that killed 200 people. We are fortunate that we have potent antibiotics right now. We are getting significant ciprofloxacin resistant salmonella coming from South-East Asia, because you can walk into a shop in Bali and buy ciprofloxacin. So the antibiotic resistant point that was made earlier was very, very pertinent. The recommendation is that we need to be evidence based. We need to look at not only communicable diseases but also communicable diseases within an incarcerated environment. Not only have you got people hoarded together; there are the prospects of it jumping from person to person.

Regarding your vaccination and immunisation question, it is very pertinent to look at the route of transmission of these illnesses. Hepatitis B is sera, blood and body fluids. Hepatitis A is faecal oral. Hepatitis C can live outside on a needle for a lot longer than HIV can. So it is a question of risk stratification. If your remit is purely communicable diseases, that would be an area that I would focus on given the opportunity.

We are in an operational tempo that is significant at the moment. Not only do we induct people; we also arrange people for rapid transfer off island. There is also the removal of people directly back to their origin country. There is the backdrop of general practice going on as well.

Dr Graham : My recommendation would be the follow-up of those individuals who are moved into the community. We know the latent form of TB stays in the system for your life exposure.

Statistics show that the risk of reactivation of TB becomes more prominent in the first 12 months when someone has resettled in a country and certainly state-based TB programs have had funding cuts to them and so reduced their ability to follow up those individuals who have latent TB or new arrivals into the system. That produces a risk. We know that the rates of TB in the areas that these people are coming from are higher than the rates in Australia. We have seen it before in the Northern Territory where we had people coming down from Timor. Twelve months into that settlement program we were seeing increased rates. So, it is continuing those ongoing healthcare services to these in-settlement programs on the mainland for an extended period of time.

Mr LYONS: There would be some medical staff who would not have seen some of these diseases. In terms of medical training perhaps we need to—

Dr Gogna : Absolutely. We are seeing these illnesses sadly in remote Aboriginal communities and so we have immunology clinics and remote HIV clinics to these communities. It is very sad. It is a terrible statistic for a first world nation, but once again because of the resistance of TB the failure of the vaccination program which has become less effective as the years have progressed. We had virtually got to the point where we had near eradicated a lot of this, but due to poor conditions and poor hygiene areas of south-east London, for example, with high immigration we are seeing significant levels of tuberculosis reactivation. Dr Graham's points are very clear that if you go onto any immune suppressive therapy your TB could flare back up. So, these people will require lifelong screening with drugs that if not taken on a regular basis will end up creating even more failure rates and more resistant forms of TB. It is something we are on the precipice of. We have not even talked about flu pandemics and SARS or even bioterrorism, which are very communicable in these areas.

Mr WYATT: Just on that point, the committee has canvassed enough locations for the transmissions of SARS, HIV and the like through the broader travelling population. The ones we have focused on here are those that have been reported to us and hence the narrower scope of the discussion. I appreciate the fact that measles and some of the simpler things also have an impact if a population has not been exposed to them. There is a risk factor for them as well.

CHAIR: If I could ask a question of Dr Graham. You mentioned that you would like to see a system in place where there is long-term monitoring of people with TB because they need, as we heard, care for the rest of their lives. You also spoke about some state based cuts to funding. Can you explain that a bit more and how it is affecting the monitoring of people?

Dr Graham : With TB, as I said, once you have been exposed to it, the bug lies dormant in your system and can be in the system lifelong. There is also the risk of exposure from an acute case in a confined environment over a long period of time—which happens within our centres here and in the centres on the mainland. The initial contact tracing process should be established for a two-year period because the data shows that that is when reactivation of TB is the most likely to occur. In some states that has been reduced down to 12 months.

CHAIR: That period of time has been reduced and that means the money spent on it has been reduced as well. Therefore you are only monitoring for 12 months.

Dr Graham : Yes, and in some places they are not monitoring.

Mr LYONS: Monitoring involves chest x-rays—

Dr Graham : Chest x-rays and clinical review.

Mr LYONS: Are they available free on the mainland for people with TB?

Dr Graham : Within some regions. Certainly, both the Northern Territory and WA have state TB facilities where people are monitored, traced and treated for latent TB if necessary.

Mr LYONS: States used to monitor for more than 10 years at one stage.

Dr Graham : Yes. It has been reduced and certainly the statistics are showing that there are increasing rates of tuberculosis Australia wide.

CHAIR: Do you put that down to that period, or is it something else where we are seeing a greater influx of the disease, or—

Dr Graham : We have TB in our Indigenous population; that certainly creates a spike. And with the increase in migration to the area from high-prevalence countries we are going to see increased rates as well.

CHAIR: And what sort of effect will the lessening of that period from two years to 12 months have?

Dr Graham : Part of the issue was brought up by Mr Lyons before, in the education processes. These are diseases that are not common in Australia, and so symptom recognition by a GP in urban Melbourne may be a prolonged process. By that stage this person may have been sick for quite a while and may have been through several health facilities. Those with lowered immunity are at risk, and so the chance of spread there is an option.

Ms HALL: I will ask a question first-off that came up whilst you were giving evidence. What is the incidence of head lice and scabies in detainees?

Dr Gogna : It is very variable. We have people from different socioeconomic backgrounds travelling to Australia. At the moment we have seen one boat that has had head lice, and we go through our normal head lice protocols. Scabies, obviously, is a burrowing mite and so it can be a chronic infestation. We have probably seen it in two or three boats in the last three months.

So, not huge numbers—not a level that is huge. We still have the same scabies issues in our communities, and also head lice. As you can see with the proprietary brands that are available from the chemist, it is a huge issue. If you talk to some mums they will say, 'We could never get rid of it for ages'. Maybe a haircut like mine!

Ms HALL: I have heard that that is the best treatment!

Dr Gogna : Can I just speak to Mr Lyons's previous question? He brings some very important points up.

You have a very poor socioeconomic group; so not only regarding Dr Graham's point about when you interact with the doctor but getting these guys to the doctor if they are on a Centrelink payment, which is very low, makes it really difficult for them to be followed up. If you make that a mandatory process—and I am not aware of the Centrelink payment or levels—once people are unable to work, are in the community and getting from A to B they ask, 'Would you rather have a full belly today or pay the bus fare?' Those are the dilemmas. But it was a very good point.

CHAIR: It is an interesting point that you make. I live in an area that has a high migrant population and the clinic that I go to is full of new arrivals and refugees. Sometimes I say to my doctor, 'You work very hard and you are here until seven o'clock'. He says 'What can I do? I can't turn people away and everyone who comes in is a high-need patient'. Many of them are refugees. He is always asking me if there is any assistance or help from government. Are you aware of any particular programs that do assist doctors out in the community to be able to deal with these issues, which are very complex issues—unlike some of the leafy suburbs where doctors have an easier time?

Dr Gogna : We have not had a cohesive approach. There have been some major steps forward recently. IHMS have been contracted to provide a community detention medical director and staff who will be involved in taking calls. We all have significant medical information. We had a delegation from Dandenong Hospital come to the island just recently with a collection of GPs and an infectious disease specialist. Dandenong is a place where Hazaras are now migrating to. It is becoming the place where their communities are all forming. Their food habits and things such as the interpreter service and the infectious disease units—the CDCs—are the great links, but there is no definitive, central, well-informed, evidence-based body. It is a bit of a piecemeal approach, considering that we may have significant numbers for a long period of time.

Dr Graham and I deal with the coalface but it is very important that our patients have good quality continuity of care.

What would normally take your GP 15 minutes would take him 30 to 45 minutes per consultation. That is the difficulty with refugee health. Somebody who is culturally naive to yourself is also verbally naive and cannot really take hold of your non-verbal communication. All the quality things taught in general practice for delivering a good interaction are getting lost, well and truly. It becomes mechanical.

Ms HALL: I next want to concentrate on the health services provided within the detention centres and those health services that are provided within the community. What is the interaction between the two health services, when are the crossovers and how do the two work together?

Dr Gogna : We work very closely with Dr Graham and her team at the hospital. We are fortunate to have doctors of the calibre that we have at the Indian Ocean Territories Health Service. For example, the capsized boat has prompted significant debate on refugee issues. We work very collaboratively under the disaster plan dealing with patients who were injured but we work very closely on multiple levels. We feel very guilty that we give patients of ours to Dr Graham and create a burden there. So we try to manage as many things as we can within the detention health service, even though—as I mentioned in my opening remarks—we are a slightly extended primary care facility.

There are very few primary care facilities putting intravenous drips in, taking blood, giving IV antibiotics and sending bloods off to the hospital. Our level of clinical activity is significant. We also know that they are a space limited facility. When tuberculosis was significant and the hospital had run out of beds we managed tuberculosis patients in isolation there. Commonly, the hospital will do the first couple of weeks of treatment and we will then take that patient back and have them in isolation. The relationship is very close. It has to be, in a small community like this.

Dr Graham : We actually work very hard on that relationship, for the points that Dr Gogna pointed out but also because we have limited resources on the island. We provide services to those in immigration detention. Dr Gogna has provided services and assistance to those in the community who have needed it. We all have our own individual skills and if we are not accessing that skill base because of a breakdown in communications or relationships then it is the patient who suffers in the long run. We have a good working relationship. We communicate regularly. We troubleshoot if we need to, to make sure our resources are managed appropriately. We get angry at each other when we cannot work out something! I think it is something we pride ourselves on. Those relationships might not have been strong previously but we have worked hard to build those relationships and we will do everything to maintain that relationship. We have a close working relationship with DIAC as well.

Ms HALL: Are there pathology services?

Dr Graham : We are the pathology service, so that encompasses that relationship.

Ms HALL: What other services do you provide and are there any other services provided by the detention centres that are not available within the public sector or your sector?

Dr Graham : The services that the centre provides for us are more on an individual basis. For example, there is a recent trauma case where Dr Gogna provided his expertise for the patient, who was a community member. The reverse is that we provide pathology, we provide X-ray facilities for non-screening chest X-rays, we provide inpatient services and we also provide the torture and trauma service. That generally covers what we do.

Ms HALL: That shows the strength of the relationship. If a situation arrives where there is a health crisis relating to a disease or some other health crisis, who would be the lead agency and how would it work?

Dr Gogna : It has been pretty clear with the capsized boat. There is an emergency disaster plan that is activated by the hospital. I sit on the disaster preparedness unit in Western Australia, dealing with events such as CHOGM, Banda Aceh and the Bali bombings, for example.

It is crystal clear to us the lead agency is the Indian Ocean Territories Health Service. They are very inclusive of us, but what we require in medical resources and nursing resources will fall under their care. We get a seat at the top table. So we are not compromised in any way and we willingly help.

Dr Graham : We have activated that process twice. The SIEV221 was a joint effort between IOTHS and IHMS, as well as the boat crisis recently. So the clear lead role is with the Indian Ocean Territories Health Service. We have the main facilities on the island as far as emergency care goes, and we have resources within that to access the IHMS staff resources, IV drugs, IV fluids and whatever else we need. So it is a very well structured plan we have in place and it has worked very well twice.

Dr Gogna : DIAC have been very supportive. We used the induction centre for medical management with the people from the capsized boat who had swallowed diesel, swallowed lots of seawater and been in the water for greater than 14 hours. Rather than burden the hospital with semi-acute patients we were able to use our facilities in a very agile manner.

CHAIR: Just before you go I would like to welcome Mr Jon Stanhope, the administrator of the island territories.

Mr WYATT: Dr Graham, you made a comment about tuberculosis lying dormant within the body for, fundamentally, a lifelong period. If we consider the socioeconomic determinants, what conditions, illness or treatment could be a precursor to a person coming out of that remission phase?

Dr Graham : Anything that reduces or in any way immunocompromises the system. Chronic diseases are the main one, along with diabetes and renal disease. We then have lifestyle issues like alcoholism and drug use or abuse. One of the other factors that is not taken into consideration largely is that stress can also reduce the immune system. We have seen previously in resettlement of refugees into areas that the first 12 months, which is generally a stressful period, sees the highest reactivation rate. Stress or treatments can cause reactivation. Steroids used for chronic conditions like arthritis, asthma and things like that can cause reactivation.

Mr WYATT: On that basis, it seems logic to extend the period beyond 12 months and to monitor with greater rigour than we currently do.

Dr Graham : It is also looking at the treatment of latent TB. Latent TB can be treated with a six- to nine-month course of one of the medications we use for active tuberculosis. That requires again a structured tuberculosis program in a state or territory to monitor that, to follow up. Again, if we are using these drugs without follow up and supervision we run the risk of developing resistance to them. Isoniazid, which is the drug we use, is the main focus of treatment for TB.

Mr WYATT: Going back to a previous comment made by you, Doctor, the issue will be those who make the choice to use their Centrelink payment to pay for their rent and food as opposed to continuation of compliance with their treatment. That would compound the problem, so there is a need to seriously consider what options we have to ensure that we do not have a recurrent, let alone an antibiotic resistant or drug resistant, tuberculosis.

Dr Graham : Some states and territories have a more rigorous program. The Northern Territory has a very rigorous TB control program and provides free treatment. Just to qualify that, TB treatment and treatment for latent tuberculosis is provided free by the states. But, again, it is that program that needs to be in place to implement the treatment, follow up and ongoing care of these people.

Mr WYATT: What you are really arguing for is a national approach that is consistent in each of the states and territories. I want to refer to a comment you made earlier. Do you see the need for a CDC that is centralised and coordinates an Australia-wide approach?

Dr Gogna : A CDC centrally would give significant levels of help regarding communicable diseases. It would also give a central point for advice for SARS, for example, or bioterrorism or agents that come across our border. Focusing back onto tuberculosis, we need a consistent standard. We have state health departments that have their bailiwick and we have federal health departments that have their bailiwick, but you can now easily transport these diseases across borders.

Dr Graham mentioned an important point regarding the difference between the Northern Territory's protocols and the Western Australian protocols. We need to have a single body that is giving consistent advice. IHMS as an organisation and DIAC as an organisation have 22 plus immigration detention centres across the whole nation, and we are trying to have protocols and guidelines for our staff that are consistent. It is very hard to do that when a CDC in a different state or territory gives you a differing opinion. For example, with latent TB in the Northern Territory the CDC there will ask for sputum to be collected, looked at under a microscope and cultured. That is not what Western Australia is currently advising us to do.

Obviously, being on an island we have our own restrictions on doing that many samples, and that is why we have careful public health questioning. The nicety is to safety net a lot of that with a chest X-ray, because tuberculosis in the respiratory system will have some definitive changes. We have had patients with tuberculosis in other parts of their body who have presented with acute problems that have required removal off-island, so we have to see tuberculosis as a whole in that it can go anywhere throughout the body, but that its infectivity is moderated when in different parts of the body.

CHAIR: Mr Windsor, in the previous inquiry you were presented with some questions about how you get through so many people who are currently coming to the island in terms of checks and balances in health. The term you used was that at that moment you had 'surge staffing capacity'. Is that permanent staff or do you bring staff in, and are we still at that stage or have we gone into a difficult level where it has settled with the correct number of people et cetera? If you recall, back then the numbers were just starting to rise. It was earlier on in the time.

Mr Windsor : It goes to our contractual arrangements with IHMS, where we have different bandwidths based on our assessment, looking forward, of likely client numbers on the island. It is very difficult to project forward because you are trying to make a prediction as to the efficacy of the policies or whether they are having the intended effect. We want to see a decrease in the tempo of arrivals; we are not seeing that currently but we are hopeful that we will see that shortly.

We have one mechanism which looks at the forward projections and determines what bandwidth IHMS's staffing might be at, but in acknowledgement of the particular point-in-time pressures we have approved what we call 'surge staffing', which is additional short-term staffing for IHMS. Currently, on-island, IHMS has 84 staff. The staffing at the top of our band for IHMS is 87, so they are very close to the maximum staffing that would be provided under our current contract arrangements.

CHAIR: Going back through the Hansard of the previous inquiry, there was a particular doctor from the Northern Territory who made a statement in regard to follow-up checks on the arrivals. That doctor said that at best it was ad hoc. Do you know why someone would make a statement like that? What are your views on that particular statement?

Mr Windsor : The Northern Territory have the most rigorous, if you like, protocols. They recommend or insist upon antibiotic drug treatment for people who present with latent TB. My understanding—I may be wrong; I am not a clinician—is that they are the only state or territory that mandates that. They set the bar higher than others, and that may be the perspective that they are bringing to bear when they make that comment.

You were talking earlier about TB and differences around the states. Again, I preface my remarks by saying I am not a clinician, and it would have been useful if Dr Paul Douglas, who attended an earlier roundtable, were here because he is a member of NTAC. My understanding is that the National Tuberculosis Advisory Council is seeking to bring that overarching view and to drive consistency among the different state and territory jurisdictions to get more agreement about uniformity of approach, so there is that mechanism there.

Dr Graham : There is NTAC and there is also CDNA, the Communicable Diseases Network Australia, which sits above NTAC and provides guidelines and resources. In a sense, CDNA would be the central CDC of Australia. Each state and territory has its own public health legislation and public health acts, and that is where it becomes difficult across borders.

Dr Gogna : That is an important question and one that is pertinent in our own communities if patients move from one GP to another GP. The things that can be involved with it are patient factors—if patients do not front up or patients do not communicate information easily, succinctly and clearly. This is a cohort that suddenly speak English. There is also an onus to provide good medical records so the transfer of medical information from one health practitioner to the other is crystal clear. This is something that has been seen as a deficit, where the community detention area medical director was brought in line and there are support systems that have been put in place. Also, getting the other organisations that are delivering health care to the people in the community once they leave detention gives them a clear line of sight as to how they can plug into IHMS to be able to get some of this information.

We are contracted to provide a level of health discharge assessment information for the community, but there is a richness there that cannot be transposed in a small document and it is more important to provide that richness. So it is multifactorial as to why the person would make such a statement. But am I surprised that a statement like that would be made? Not at all, because we lose patients to follow up all the time. If we have them on a recall register, by law we have to make two phone calls and then send a letter to be able to say that we have discharged our medical legal responsibility. There are lots of reasons why that could fail: addresses change, people move, they get lost to follow-up. Your melanoma that you had excised that you should have regular checks on gets missed over a period of time. It requires robust systems in place for recall and, obviously, resources to maintain those registers.

CHAIR: Councillor Kelvin Lee and the administrator, Mr Jon Stanhope, have joined us and have been following the proceedings. If you would like to add anything, you are quite welcome.

Councillor Lee : Two of my colleagues were supposed to come, but unfortunately they had to send their apologies. They might put in a written submission. Also, our CEO and the president are at a meeting. When they come back, they will put something in writing for the committee.

Ms HALL: From a community perspective, what do you think are the issues surrounding communicable diseases and the relationship between the community and the detention centre?

Councillor Lee : Definitely, when the boatloads of people come in here and when they have the tuberculosis detected, it does create some situations where people are fearful. In our community it has been the case for a long time that we have not come across this sort of disease, so it is a bit frightening for a majority of them. Also, in the early days, when the boat people went to school and they mixed with our kids, they were fearful that it might just carry over to them.

CHAIR: So are you saying previously to the mix there were fewer fears in the community—

Ms HALL: No, there was more fear. The fear that exists in the community is that the community is at risk of getting diseases that do not exist within the community—that did not exist within the community previously. Is that what you are saying?

Councillor Lee : Yes. That is right.

Ms HALL: Have yours fears been found to be accurate? Has there been any increase in communicable diseases?

Councillor Lee : From my experience, I think tuberculosis is a curable disease, especially when Julie Graham puts out some information to the community at large. One of our residents has contracted this disease too, somehow, but it seems that he is all right now. To me, it is nothing.

Ms HALL: If you had better information and education provided to people within the community, and maybe better interaction between the detention centre and the community at a liaison level—not necessarily the people in the detention centre—would that help?

Councillor Lee : To me it would help if the communicators from the detention centre, especially from those people who are in charge on the other end, could work together with our local doctor in order to provide more information to the community at large; it would lessen the fear.

Mr WYATT: Dr Gogna, you made an important point that the patient-doctor relationship is always based on an understanding that you both understand the words you use, and that language is considered critical. What advice would you give us with respect to people who leave Christmas Island and have been given Australian citizenship yet will be left to fend for themselves? Are there gender issues in relation to a doctor-patient relationship, given the cultural make-up of the groups?

Dr Gogna : Very important points. We constantly have at least two to three female doctors on staff because, even if you have a well-experienced obstetrics gynaecological doctor who is male, by preference those clients will not want to go to him, either on a cultural basis or on a 'this is my preference' basis. As the vice-chairman for the Rural Workforce Agency in a previous time in Western Australia, I can say that culturally-specific training would be appropriate. It is giving people bolt-on modules so that they can take these skills forward.

It is also understanding. We are not talking about a homogenous group. We are talking about Burmese, Nepalese, Sri Lankan, Tamil, Sinhalese, Iranian—even some of the rarer ones that we do not often see coming to Australia such as the Vietnamese population. Some of the European nationalities that have not been here for a long time may be resurging.

My advice would be to work with the professional colleges. There are elements of the Royal Australian College of GPs which are devising specific refugee training programs: being able to engage, cultural awareness and culture specific issues. We have had to put a doctors' handbook together to make sure people understand what languages people speak. How does Farsi relate to Hazaragi? How does it relate to Urdu? People's knowledge of these areas needs to be built up. We do not want to be immersed completely in one culture but be able to do enough to ensure that how we approach a situation is construed clearly—and that is your point exactly. I think it can only be met with specific training and by using the people that are related to standards in our medical profession, which are the royal colleges, to help put the standards together and then we can educate on those.

Mr WYATT: On that answer, with the recall system of two letters and a phone call, is somebody who does not read English or who does not understand the meaning of the letter likely to fall through the cracks and remain untreated?

Dr Gogna : Any interaction with authority was construed as a fearsome activity. They may see this as, 'Is my visa going to go?' Currently in our facilities there is lots of fear and innuendo going around. You do not know if one minute you are going to Nauru or one minute you are going to the mainland or what is happening with you. Does that fear transpose into when somebody settles into the community? Absolutely, it is only human nature. Whether they have had an affluent existence or a traumatic existence coming from there to here, lots of things can be lost in translation. The question is: what other additional supports do we put in place? Do we get someone from the same language group? Do we try and get community leaders to fly the banner of 'this is sensible health care' and 'this is what you should be doing'? We should not become a nanny state. We should also give the leaders the and the healthcare workers the tools but then give people the choice as well. They have a choice of whether they want or need to turn up.

Mr IRONS: On the TB returning within the 12 months issue, I know in Western Australia a lot of clinics are turning patients away saying 'we are not taking new patients on'. If someone who has achieved a visa or citizenship status rings up, they are likely never to follow up on the issue. They might have TB again. I know there is no cure or silver bullet but we have to protect the community in some way from those diseases. How do we do that in this situation? Do we find a way of getting these people to public hospitals?

You talk about choice but I do not think they should have a choice about whether they go or do not go to a doctor if there is a chance they are going to get that disease again within 12 months. We need to be able to get those people to some sort of treatment.

Dr Gogna : The health department of Western Australia merged the Anita Clayton Centre some years ago. That encapsulates not only the old Perth chest clinic but also a refugee health component, which is a whole section of the Anita Clayton Centre. I do not understand the funding model of where it comes from but there is obviously a significant component from state health. Specific units are what is being proposed at Dandenong health as well.

As a doctor, I know that getting people treated is going to give the best possible health outcome to the individual and the community so you have me on-board.

Do I grab cigarettes out of people's mouths when I walk past them? I would like to but I know I cannot. Your points are very well made. It is about finding a medium that respects individuals and our proud nation.

Mr LYONS: Many communities now have refugee health centres. Even in Launceston, in the new ICC, they have a refugee health clinic. You would do a discharge plan and give it to the person. That seems to me to be a bit haphazard as to whether that gets handed on in treatment. Is there a way of communicating with the area to which they are going inside refugee health, of passing on some of that detail?

Ms HALL: Was that not the role that Mr Schaffner identified? When they leave your centre you then pass it on to the next person.

Mr Schaffner : If they remain in immigration detention. However, if they are granted some form of visa it is a separate issue, and I do not think it falls within our area.

Dr Gogna : We have an extra program in which the level of services that we provide to released clients depends on the type of visa they have. If they are in community detention they are supported by a DIAC case manager. We also have organisations contracted to the department who will assist our clients in attending health appointments. That includes taking them to appointments if necessary if they have any issues going to those. Clients who remain in our care or through community detention et cetera are supported, and clients who are released on permanent visas et cetera obviously have access to the settlement program and a variety of migrant resource centres around the country, and people will help with those issues as well. They are the sorts of services that we provide as a department. The case manager would be the person whom that information would travel through.

Mr Windsor : The person who is granted a visa may also be granted a visa with a health undertaking which obliges them—

Ms HALL: How many people are granted visas from Christmas Island?

Mr Sokoloff : Not many these days. Predominantly, our clients are transferred to a centre on the mainland where they will either be granted a visa or go through a process there.

Ms HALL: That is what I thought the process was.

Dr Gogna : Just so the point is very clear, mainly we will transfer our patients back into the network onto the mainland or, now, to the regional processing sites on Nauru or Manus. There will be patients who are being repatriated directly back to Sri Lanka; obviously, we do not have a point of contact for those. For the clients who are up the end, you are alluding to how we get that information across. You have heard about the health undertaking and the responsibility, but we are also contracted to provide a health discharge assessment. Has it had the richness in the past that colleagues are requesting? It is getting better and better as we speak. We are a system that has grown substantially over time. I first arrived here in January and, while I am acutely aware of protocols for collecting sputum and doing chest X-rays, what is contractually required from IHMS versus what is gold standard medicine is what we have been moving to. We need to protect our staff, we need to protect our patients and we need to protect the clients that interact with those patients.

Mr Sokoloff : I would like to add to the points on the issue raised by the councillor in terms of our committee engagement. I take the points on board about engaging more in health issues, but I point out that we have a very strong program of engagement and inclusion with the community. We have a community reference group which meets monthly. We also have representatives from the council and shire invited to our daily morning meetings where we discuss issues. We also have regular bulletins that we put out.

I just wanted to say that we work very strongly with the community here and have a very good relationship but we are always looking for feedback and are always keen to improve our communications where we can. Certainly on the part of the department we have a very strong sense of working with the community and we are always open to hearing any feedback or responding to any concerns people have. We have a dedicated officer within our team whose primary responsibility is dealing with that. She does a very capable job.

CHAIR: Thank you very much. On that note, this brings this round table to a close. I thank all of you for participating and for your very informative discussion on this issue and for the valuable contribution and insight to our inquiry.

If there is anything further you wish to add to the comments you made today feel free to feed that through to the secretariat, and vice versa—if there is something, for whatever reason, that we did not raise today that we might think of later, we may be in touch with you as well, to get that feedback. Thank you to all the members for attending, to the members of the public who are here, to my colleagues Alison Clegg and Renee Toy and to Peter Treloar from Broadcasting for putting this together, and especially to you guys for giving up your busy schedules. It is a busy time. I know you had to take a couple of hours giving us a tour of the hospitals and centres. We really appreciate it. Thank you very much. I would also like to thank Mr Stanhope, the administrator, who is here with us, and Mr Lee who is representing the Christmas Island shire.

Resolved (on motion by Mr Irons):

That this committee authorises publication of the transcript of the evidence given before it at public hearing this day.

Committee adjourned at 15:17