Australia: Appalling Abuse, Neglect of Refugees on Nauru

About 1,200 men, women, and children who sought refuge in Australia and were forcibly transferred to the remote Pacific island nation of Nauru suffer severe abuse, inhumane treatment, and neglect, Human Rights Watch and Amnesty International said today. The Australian government's failure to address serious abuses appears to be a deliberate policy to deter further asylum seekers from arriving in the country by boat.

Refugees and asylum seekers on Nauru, most of whom have been held there for three years, routinely face neglect by health workers and other service providers who have been hired by the Australian government, as well as frequent unpunished assaults by local Nauruans. They endure unnecessary delays and at times denial of medical care, even for life-threatening conditions. Many have dire mental health problems and suffer overwhelming despair – self-harm and suicide attempts are frequent. All face prolonged uncertainty about their future.

"Australia's policy of exiling asylum seekers who arrive by boat is cruel in the extreme," said Anna Neistat, senior director for research at Amnesty International, who conducted the investigation on the island for the organization. "Few other countries go to such lengths to deliberately inflict suffering on people seeking safety and freedom."

Australian authorities are well aware of the abuses on Nauru. The Australian Human Rights Commission (AHRC), the Office of the United Nations High Commissioner for Refugees (UNHCR), a Senate Select Committee, and a government-appointed independent expert have each highlighted many of these practices, and called on the government to change them. The Australian government's persistent failure to address abuses committed under its authority on Nauru strongly suggests that they are adopted or condoned as a matter of policy.

By forcibly transferring refugees and people seeking asylum to Nauru, detaining them for prolonged periods in inhuman conditions, denying them appropriate medical care, and in other ways structuring its operations so that many experience a serious degradation of their mental health, the Australian government has violated the rights to be free from torture and other ill-treatment, and from arbitrary detention, as well as other fundamental protections, Human Rights Watch and Amnesty International said.

"Australia's atrocious treatment of the refugees on Nauru over the past three years has taken an enormous toll on their well-being," said Michael Bochenek, senior counsel on children's rights at Human Rights Watch who conducted the investigation on the island for the organization. "Driving adult and even child refugees to the breaking point with sustained abuse appears to be one of Australia's aims on Nauru."

Australia and Nauru impose strict secrecy on the processing of asylum seekers on Nauru and refuse most requests to visit from journalists or researchers. Nevertheless, an Amnesty International researcher and a Human Rights Watch researcher were able to enter Nauru legally and remain for a total of 12 days in July 2016. They were not asked about their organizational affiliations when they completed entry formalities. They interviewed 84 refugees and asylum seekers from Iran, Iraq, Pakistan, Somalia, Bangladesh, Kuwait, and Afghanistan, including stateless Kurds who had been living in Iran or Iraq. Twenty-nine were women. Five were girls, and four were boys. The researchers also interviewed several service providers, who agreed to share information despite risking prosecution for providing information.

Nauru, a tiny, impoverished island of 21 square kilometers, or eight square miles, is smaller than Melbourne's airport. The population is 10,000. The island's interior, devastated by 40 years of phosphate mining, is mostly uninhabitable and uncultivable. Employment opportunities are scarce, and basic services, such as health and education, are largely inadequate.

Australia has been forcibly transferring families with children, unaccompanied children, and single men and women to Nauru since September 2012, under Memorandums of Understanding between the two countries. Australia agreed to cover all costs associated with the offshore detention and processing of the asylum seekers and refugees. The Australian government spent 415 million Australian dollars (US$314 million) on its Nauru operations in the fiscal year ending on April 30, 2015, nearly $350,000 for each person held on the island in that year alone.

Those transferred to Nauru initially spent a year or more housed in cramped vinyl tents in a detention facility called the "Regional Processing Centre" (RPC), with temperatures indoors regularly reaching 45 to 50 degrees Celsius (113 to 122 degrees Fahrenheit), and torrential rains and flooding.

Refugees and asylum seekers described conditions in these detention camps as "prison-like," with regular searches of their tents by the guards, confiscation of "prohibited" items – including food and sewing needles – two-minute showers, and filthy toilets.

The RPC is run by a private company hired by the Australian government, which has effective control of the facility and is responsible for ensuring the health and welfare of the asylum seekers detained there. Australia shares responsibility with Nauru for human rights violations committed against the refugees and asylum seekers.

Those the Australian and Nauru governments recognize as refugees are generally provided accommodation in open camps or other housing throughout the island. Families are generally assigned prefabricated units or converted containers, and single men are placed in rooms with space only for a bed and a small shelf. About one-third of the 1,200 refugees and asylum seekers on Nauru remain in the tents, people interviewed said.

Since October 2015, Nauru has allowed asylum seekers greater freedom of movement around the island, a step widely interpreted as a response to litigation in Australia challenging the lawfulness of asylum seekers' detention. But those who remain in the tents may not bring smartphones into the center, are monitored by guards, and face other restrictions on their liberty.

Prolonged detention in appalling conditions exacerbated the trauma many had suffered from persecution in their home countries and the abuses and other hazards they faced on their journeys to Australia, as the Australian Human Rights Commission and UNHCR, among others, have found.

Refugees and asylum seekers interviewed said they have developed severe anxiety, inability to sleep, mood swings, prolonged depression, and short-term memory loss on the island. Children have begun to wet their beds, suffered from nightmares, and engaged in disruptive and other troubling behavior. Adults and children spoke openly of having wanted to end their lives. However, refugees on Nauru do not receive adequate support or mental health treatment.

The standard of medical care for refugees and asylum seekers on Nauru is also poor. Medical equipment is rudimentary, and specialist medical attention is not regularly available. Dental services are largely limited to tooth extraction.

Refugees and asylum seekers described long delays on seeing specialists for serious conditions or for being transferred to medical facilities outside Nauru for care not available there. Under new policies, those transferred to Australia for care must go without their family members in most cases, an apparent attempt to force them to return to Nauru.

When Amnesty International and Human Rights Watch put these concerns about medical care to International Health and Medical Services, the company hired by the Australian government to provide medical services on Nauru, senior staff denied that care was poor.

The physical safety of those held on Nauru is a serious concern, Human Rights Watch and Amnesty International said. Many asylum seekers had been beaten and robbed. Every woman interviewed said she could not go out alone. Interviewees said that local police made little or no effort to investigate attacks against them.

Children who attend local schools described frequent bullying and harassment from Nauruan students, who tell them to go back to their home countries. Many have stopped attending classes altogether.

Some refugees and asylum seekers said that the abuses they endured gave them little option but to accept or request return to countries where they face a real risk of persecution or other serious harm.

The Australian government should immediately resettle the refugees in Australia and close the Nauru offshore processing center. While refugees and asylum seekers remain on Nauru, Australia should ensure that they receive quality medical and mental health care. Nauru should allow independent human rights monitors and journalists access to the island, and Australia should do likewise for its "processing centers" for asylum seekers.

A Wall of Secrecy
The Australian government's offshore operation on Nauru is surrounded by a wall of secrecy, with both Australia and Nauru going to great lengths to prevent the flow of information off the island. Service providers and others who work on the island face criminal charges and civil penalties under Australian law if they disclose information about conditions for asylum seekers and refugees held offshore. Nauru has banned Facebook on the island and has enacted vaguely worded laws against threats to public order that legal experts fear could be used to criminalize protests by refugees and asylum seekers.

Journalists in particular face severe restrictions on entry, with an $8,000 non-refundable visa fee and a protracted application process. Nauru has granted visas to just two media outlets since January 2014. Other requests have been rebuffed or met with no response. UN officials have been denied entry or in some cases have concluded that a visit would be impractical due to severe limitations on their access.

Human Rights Watch and Amnesty International documented cases in which Nauruans, alone or in groups, assaulted and robbed refugees and asylum seekers, sometimes at knifepoint, during daylight or in the evening. In all, more than 20 of those we interviewed said they had been attacked by Nauruans.

A refugee from Bangladesh suffered serious head trauma in May 2016, when a Nauruan man threw a large rock at him, kicked the refugee off his motorbike, and beat him after he fell. A Somali woman reported that several Nauruan men attacked her husband in March, hitting him on the head with a machete. The following night, a group of Nauruans tried to break into the family's housing. A Somali man said a Nauruan man robbed him when he attempted to hitchhike to a store.

Many others spoke of being attacked by Nauruan men, who stole their money, mobile phones, and motorbikes, as the refugees went to work or bought food. A service provider confirmed that such assaults happen "several times a week, especially over the weekend."

As a result, refugees and asylum seekers said they were afraid to leave their accommodations, particularly at night. Women said they almost never left the camps and then only in groups, or with male companions.

Six women described sexual assault or harassment, including groping, touching, explicit threats, demands for sex, and attempted rape. One woman said that on two occasions Nauruan men tried to drive her to the jungle when she was catching a ride with them, clearly intending to rape her. She also said that at one point she got a job at a shop on the island but had to quit after the first day because other employees kept touching her.

One young woman said she married for protection after being released into the community:

After I left the camp, I felt very unsafe, I could not go out. I decided to marry a man who is 15 years older, just to have protection. If you are alone, everything is a struggle. At least he could go shopping or accompany me. Now he is in the hospital, and I have to rely on my case manager if I need to go out of the house.

Another woman said:

We are always scared, all the time. I am always checking the door to see if it is locked. We can't go out alone. A lot of times, some Nauruans get drunk and come near the entrance by the road and shout at us.

Refugees and asylum seekers said that Nauruan police disregard their complaints and sometimes discourage them from filing reports. Police have dismissed some complaints as "made for media exposure only," a news report said. Several refugees provided Human Rights Watch and Amnesty International with copies of reports they filed with local police following the attacks, saying that police had done nothing to investigate or apprehend the attackers, even if the victims were able to identify them. Service providers, who said they often have to accompany refugees to file police reports, confirmed these statements.

Nauru's former chief justice, Geoffrey Eames, QC, testified before an Australian Senate Select Committee in July 2015, that "there is a serious question about [police] independence and about their willingness to investigate allegations against Nauruans who are charged with assaults of non-Nauruans." (Eames, an Australian national, was forced out of office after Nauruan authorities revoked his visa in January 2014.)

Medical Care
International Health and Medical Services (IHMS), a company hired by the Australian government, is the main health service provider for refugees and asylum seekers. Some of its staff have publicly condemned the appalling treatment of refugees on Nauru, raising concerns about the company's operations there. Specialized medical equipment and staff are not available on Nauru; Nauruans who require more than basic medical care are sent to Australia or Fiji. Refugees and asylum seekers reported that the hospital lacks even basic supplies, such as bandages or sterile gloves.

Refugees and asylum seekers reported that both the IHMS medical staff and Nauru's hospital often refuse to take their complaints seriously and, in most cases reported to Human Rights Watch and Amnesty International, prescribe nothing but painkillers. Some of those interviewed said that they had developed serious medical problems in Nauru and that they had received virtually no specialized medical attention. They had heart and kidney diseases; diabetes accompanied by weight loss and rapidly deteriorating eyesight; and back problems leading to reduced mobility, among other conditions. When Amnesty International and Human Rights Watch raised these concerns with senior IHMS staff in Australia, they "strongly refuted" allegations of poor quality medical care.

Parents were particularly critical of services available to women during pregnancy and childbirth and said that newborns suffered from persistent infections and other medical conditions.

An asylum seeker described conditions while his wife was in labor:

I saw my wife lying under the bed. The bed didn't have a mattress…. I saw the nurse, an Australian nurse, playing on her tablet. My wife was crying. I said, "Please do something for my wife. This is like a jail, not a delivery room." The bathroom didn't have tissue or handwashing liquid. I went out to buy handwashing liquid and rolls of tissue.

Because they cannot leave the island without authorization, they are completely dependent on the Australian authorities and service providers to arrange for them to be transferred to medical facilities outside Nauru. Interviewees described long delays while suffering with serious conditions, without any information, before eventually being transferred to hospitals in Papua New Guinea or Australia for tests or surgery.

One father said:

My son has kidney problems. We have been visiting IHMS for two years now, and they keep promising he would see a regular doctor, but it hasn't happened. They just take tests, but do not prescribe any treatment. My daughter has been having such problems with her eyesight that she cannot see the blackboard in school and has to ask her classmates for help – but there is no way to get glasses, or even get her eyesight properly tested here.

A young man with diabetes said that after he lost 27 kilograms (60 pounds), he went to the IHMS manager. The manager told him that such weight loss is "normal" and that he only would be "moderately worried" if the weight loss continued. The family recorded the conversation on a mobile phone and provided a copy to researchers.

A young woman who had been forced to undergo genital mutilation in her home country said that as a result, she was experiencing severe pain and was not able to have sexual intercourse. She has received no treatment for her condition in her time on Nauru. She said:

For five months, they just kept referring me to a mental health specialist. I had no idea what was wrong with me, and just kept blaming myself for everything. I've been able to see a gynecologist a few times since, but there is nothing they can do here for my condition, and for a year and [a] half now they keep telling me that I need to be transferred for treatment, but so far it has not happened.

Refugees and asylum seekers reported multiple situations in which they tried calling an ambulance when their friends or family members needed urgent help, but the hospital refused to send one. A service provider confirmed these accounts:

When people call [an] ambulance, or even when we call, they sometimes come, and sometimes not, sometimes in 20 minutes and sometimes in three hours. But we are also not allowed to call ambulances for our clients, or transport them to the hospital in our vehicles – because it is considered "advocacy," and we are supposed to help our clients be "independent." We often have people discharged while they are still sick, sometimes half-conscious; once a patient still had needles in the hands. We are not allowed to ask the hospital why they are being discharged, or what medication they've been prescribed, or for their medical records.

Even getting a pair of glasses can be an ordeal; one woman reported that she waited nine months for her prescription to be filled from Australia.

Denial of Access to Medical Records
At least five refugees and asylum seekers reported that their personal requests for their medical records have been denied or have yielded partial records – lacking information on surgery they had undergone, for example. In some instances, they received pages that were blank except for their name and age and the doctor's initials.

In several of the cases Human Rights Watch and Amnesty International reviewed, doctors made written requests in medical reports for overseas treatment for refugees and asylum seekers because the hospital lacked the necessary expertise or equipment. Those referred for overseas treatment may wait for months before they are transferred.

Medical Transfers to Australia, Papua New Guinea
Medical transfers are frequently carried out with little notice, often separating family members. In one case, a man was told that his wife would need prolonged specialized treatment for her mental health condition, which they asked him to authorize without giving him any information about when she would be transferred:

The next thing I heard was, "Oh, we sent your wife to Australia on an emergency flight." That was the next day. My son took it very bad. He was in shock. He wasn't able to say goodbye to his mother. [On arrival in Australia] my wife woke up, and she didn't have any information; she didn't even know she was in Australia....

I am really worried about my son. For the last 40 days, he hasn't left his room. He had a special relationship with his mother. Now he doesn't talk. He's very angry, and he doesn't talk. I can't control his behavior. Everything has changed about him.

His 13-year-old son was having nightmares, had begun wetting his bed, and was hostile to and refused to interact with anybody other than his father, the man said.

Returns to Nauru following medical care in Australia are even more abrupt, and are sometimes carried out in a deeply humiliating and traumatizing way. A man who had been in Brisbane with his wife while she gave birth said:

They handcuffed my wife and me and said we had to go back to Nauru. My wife wasn't ready. She wasn't dressed. She was sleeping. It was not good. Why did they need to do it like this? If we have to go back to Nauru, that's not a big deal. Why early in the morning, and with handcuffs? They took us from the room at 7 a.m. and took the baby from us. We didn't see the baby until after 7 p.m.

In another case, a woman said:

I was sound asleep, and the door was locked. Suddenly there was an officer in front of my face, with a camera. He said, "Wake up!" I couldn't move. I didn't know where I was. There was an officer on each side of me holding my arms, and more officers behind me. My legs were shaking. My heart was pounding. I lost my footing, but they dragged me into a room. They didn't even allow me to put on my glasses. They didn't care about what the doctor had to say. They put me on the airplane. I'm still scared. When I try to sleep, I'm still remembering this.

Some said they were brought back to Nauru even though doctors had advised immigration authorities that they should not travel in their condition.

Others described having serious chronic conditions requiring transfers for treatment, which has sometimes been cut short by their forcible return to Nauru. In one such case, a young woman who developed lumps in her breasts, throat, and uterus, and was also diagnosed with ulcers, said that she was sent for treatment first to Australia and later to Papua New Guinea:

When I was in Australia, my doctor told immigration that I needed surgery for my breasts, but they still sent me back. My problems deteriorated, and a year later they sent me to Papua New Guinea for endoscopy and colonoscopy, but then returned me again. They gave me some pills, but they are not working, and I am in constant pain and cannot eat anything.

In another case, a man who suffered a heart attack after a year on the island was eventually sent to Australia, where he stayed for four months:

When they came to take me back to Nauru, IHMS people were there, and I tried to plead with them and the security, but they just took me and my family. I was scared, because the doctors found a blood clot in my heart, and clogged arteries, and said it was very dangerous. When I arrived, an IHMS doctor saw my file and said, "I cannot be responsible for you, they should not have sent you back." I had another heart attack since, and the doctors keep saying that they cannot do anything here, that I need professional treatment and a proper hospital.

When Amnesty International and Human Rights Watch asked IHMS if they had any medical concerns about the timing and manner of transfers, senior medical staff replied that the organizations would have to ask the Australian Department of Immigration about this issue.

Beginning in February 2016, Australian immigration authorities have insisted on medical transfers to Papua New Guinea rather than Australia, service providers said. In cases in which the transfer to Australia is still deemed necessary, Australian immigration officials usually authorize transfer of the patient alone. Service providers said that this new practice was introduced after lawyers in Australia were successful in preventing the returns of some of the refugees to Nauru following medical treatment. "Now that their families remain on the island, they have no choice but to return," one said.

Mental Health
Refugees and asylum seekers suffering psychological trauma and severe mental health conditions do not receive adequate support or treatment. Only two types of mental health services are available. International Health and Medical Services (IHMS), the private contractor hired by the Australian government which is the main health service provider for refugees and asylum seekers, appears to make heavy use of strong sedative and anti-psychotic medication – for children as well as adults – to address mental health issues. Refugees and asylum seekers said that these medications have severe side effects but provide little relief. IHMS senior staff in Australia "strongly refuted" allegations of poor quality care, including the charge that prescriptions were inappropriate, when Amnesty International and Human Rights Watch spoke with them in advance of publication.

Another agency, Offshore Service for Survivors of Torture and Trauma (OSSTT), officially deals only with previous trauma.

Families can wait for months to have their children seen by a visiting specialist.

Nearly all interviewees reported mental health issues of some kind – high levels of anxiety, trouble sleeping, mood swings, and feelings of listlessness and despondency were most commonly mentioned – that they said began when they were transferred to Nauru. In many cases, the consequences appeared to be severe; they repeatedly self-harmed, cutting their hands or banging their heads against the wall, did not speak to anybody for months, did not recognize their relatives, and stayed in bed for weeks, refusing to go outside or take showers. One woman told researchers that during her time on Nauru she had begun to wash her hands compulsively, hundreds of times a day.

Family members said that children also began to wet their beds, suffer nightmares, act out, and in some instances had stopped interacting with or even speaking to people outside of their immediate families.

Even so, refugees and asylum seekers sometimes received diagnoses that were not reached on the basis of full psychiatric evaluations and did not appear to take into account their experiences of trauma in their home countries, their prolonged detention on Nauru, and their uncertainty about their future.

Many of the interviewees said that when they reported their own or their relatives' mental problems to the IHMS, the complaints were often dismissed, and in some cases they were accused of acting and "mimicking" the conditions that they had seen in other asylum seekers and refugees who have been transferred to Australia for mental health treatments.

Moreover, patients whose mental health issues were apparently severe enough to justify their transfer to Australia were returned several months later into the same conditions that doctors had identified as contributing to their trauma.

A service provider reported being aware of more than 20 such cases, some of which led to tragedy. For example, Hodan Yasin, a Somali woman who was considered suicidal, was admitted to a hospital in Australia for several months, then forcibly returned to Nauru. She was still considered highly suicidal and placed in a special ward in one of the camps, which was supposed to have 24-hour observation. However, she managed to escape, buy gasoline, and set herself on fire, burning 86 percent of her body.

More than a dozen of the adults interviewed said they had tried to kill themselves by overdosing on medication; swallowing bleach, other cleaning products, or razors; hanging or strangling themselves; or setting themselves on fire; many more said that they had seriously considered ending their lives. Some children had injured themselves with lighters, razor blades, or in other ways.

Nearly all made references to Omid Masoulmali, a 23-year-old Iranian man who died in May after setting himself alight, and to Yasin, who set herself on fire the following week. "I have the oil ready," one man stated matter-of-factly. "I'm tired of my life," said a 15-year-old girl, who said she had tried to commit suicide twice.

A woman whose husband had been transferred to Australia for urgent medical treatment said that their 9-year-old son had repeatedly talked about suicide after the family had been separated: "Two weeks ago, my son took the lighter. He said, 'I want to burn myself. Why should I be alive? I want my daddy. I miss my daddy.' I look in his eyes and I see sadness."

Conditions in the Processing Center
For months and sometimes years after their arrival in Nauru, asylum seekers have been held in prison-like camps in the Nauru Regional Processing Centre (RPC), surrounded by fences and guarded by security services. They live in crowded tents where the heat is unbearable, even after some basic fans were installed. With humidity between 75 and 90 percent, mold grows quickly on tent walls and ceilings, and skin rashes and other infections spread rapidly. Sudden, torrential rains flood roads and pool on the tent floors. On several occasions, rains have also uncovered unexploded World War II ordnance on the detention center grounds.

Food is distributed at set times, and no one is allowed to bring any food into the tents, even for young children. Living conditions in the RPC improved after October 2015, when Nauru allowed most of those housed there greater freedom of movement.

Until early 2015, the asylum seekers could take one two-minute shower a day. Several of the women we interviewed cried recalling how guards forced them out of the shower after two minutes, shampoo still in their hair. There were long lines for toilets that quickly became so dirty that cleaners refused to clean them. They could use the Internet once a week at most, and could not leave the camp.

Most of the approximately 400 refugees and asylum seekers who remain in the RPC are allowed to leave during the day, although they are subject to monitoring by guards and other restrictions on their liberty. Smartphones are prohibited inside the camp.

One male asylum seeker said:

When we came to this place, we found tents in a jungle. They put eight families together, with six kids, young kids, under one tent. Every day, every night, we had no rest. No sleep. Every day, the kids would fight because they were so close together. Most of the day, they kept the water locked up. They just gave us a small amount. It wasn't enough, with the strong sun. Sometimes we couldn't shower for two or three days. The kids started getting bad skin. We suffered these problems for two years.

A woman recalled:

The tents were terrible. It was too hot, so hot you felt you couldn't breathe. The children always felt bad because it was too hot for them. There wasn't enough water to drink. For the shower, we had a specific time. If the children needed to take a shower at a different time, they couldn't. Security wouldn't let them take showers except at the specific time. After three years, children in that bad situation have mental problems. Bedwetting. Nightmares.

At the end of May 2016, according to Australia's Department of Immigration and Border Protection, 466 people, including 50 children, were housed in the RPC. Most, if not all, continued to be housed in tents, asylum seekers said.

Immigration Department records say that the agency had completed refugee status determinations for 1,194 people held on the island, of whom 915 were recognized as refugees. The remaining 279 received negative determinations. Most recognized refugees are now housed in other camps or in houses in the community, Human Rights Watch heard from refugees and asylum seekers, but some remain in the camp while they await housing assignments. Most of those rejected for refugee status are still on the island and in the tents, although refugees and asylum seekers reported that a handful had accepted return to their home countries.

Bullying, Harassment in School
Parents and children reported that students from families of refugees and asylum seekers are frequently bullied by Nauruan students. A 15-year-old girl said that she stopped going to school because Nauruan children always tried to pull off her headscarf and constantly taunted her.

One mother said:

When they go to school, the Nauruan children call our children "refugee," not by name. People have names. They say, "Why are you here? This is our country. You should leave. We don't like you staying here."

A 10-year-old girl gave a similar account:

All the kids at school, they say, "Refugee, refugee, refugee." They don't say our names. They hit us. And when we try to talk to the teachers, they don't say, "Why are you Nauruan kids hitting the other kids?" They say to us, "Why are you fighting with the Nauruan kids?" We try to explain, but they don't listen.

Two brothers, 13 and 14 years old, said they went to school for a month initially, but then stopped and haven't attended school for almost three years. The older brother said:

Local kids kept attacking us, and even throwing stones. When we complained to the principal, the kids were made to say "sorry" to us. But when we left the principal's office, they got even angrier at us.

Save the Children Australia estimates that 85 percent of asylum seeker and refugee children on Nauru do not attend local schools, in part because of the prevalence of bullying and harassment.

Corporate Responsibility for Abuse
Australia's operations on Nauru rely on private companies and service providers. These service providers face penalties if they speak out, and some staff members have taken a considerable risk to do so to expose the conditions on the island. The companies that provide services on Nauru are aware of the situation and the impact on refugees and asylum seekers. The companies' involvement facilitates the continuation of the abusive situation. The Australian and Nauruan governments would have great difficulty maintaining their Memorandum of Understanding and the offshore processing center without their services. Most are working directly on behalf of the Australian Department of Immigration and Border Protection.

Amnesty International and Human Rights Watch sought comment from the two key companies contracted by the Australian government to provide services for its Nauru operation: Broadspectrum, the company that runs the RPC, and IHMS, the main medical service provider. Broadspectrum responded to Amnesty International and Human Rights Watch's summary of findings that it "firmly rejected" any suggestion that the company did not respect human rights. IHMS stated that its role was to deliver services, and not to engage in Australian government policy, and "strongly refuted" the allegations put to it by Amnesty International and Human Rights Watch.

Dr. Peter Young, a psychiatrist who was until July 2014 IHMS's director of mental health, commented:

It is a basic ethical requirement for doctors and other health care workers to advocate for the best health interests of their patients and to speak out against policies and practices that do harm to health. The Australian government has followed a deliberate policy to cause suffering to asylum seekers coming to Australia by boat. Being subject to abuses, lack of health services, delays in treatment, and inhumane procedures are necessary components of coercing returns and deterring others.

Health providers who accept this and do not speak out, collude with secrecy and harmful practices causing harm to health. They are caught in an irresolvable conflict of interest, breach their ethical obligations and fail to provide a satisfactory standard of care. Full clinical independence, public reporting of health data and proper independent oversight are necessary minimum standards to provide safe and ethical services.

Amnesty International and Human Rights Watch believe that their ongoing involvement in the Nauru center amounts to complicity in violations of the rights of refugees and asylum seekers. These businesses are profiting from an abusive context, and based on Amnesty International and Human Rights Watch's investigations on the island, some are directly responsible for serious abuse and the failure to provide appropriate medical care.

An Uncertain Future
All of the refugees and asylum seekers interviewed reported that when they were sent to Nauru, immigration authorities told them they were being transferred for "processing" and would be then resettled in a third country. They said that Australian immigration authorities' description of the time they would be held on Nauru has changed frequently since August 2013 – with every new version of the timetable accompanied by a denial that Australian officials had ever announced a different version.

At this point, even those who have received positive refugee status determinations have no idea what to expect and are unable to receive any clear answers from Nauruan or Australian authorities. They have no way of leaving the island, even if they have financial means to do so, and even when they have been issued "travel documents." Researchers saw travel documents issued by the government of Nauru to some refugees. These papers described the nationality of the individuals as "refugee," and refugees who have tried to apply for visas to go to other countries are rejected.

One man said:

They didn't say how long we have refugee status for. When I came to Nauru, they said it would be five years maximum. They said within that time we would go to another country. Not Australia. After two years, they said, "You will stay in Nauru for 10 years or go to Cambodia."

Another man said:

Even if they had said when I came to Nauru that it would be 10 years, no problem. But they said it would be a maximum of five years and then we would go to another country. Which country, I don't know. But after two years in Nauru, the government said 10 years here or Cambodia or return home.

Another man said:

Refugee status in Nauru is not permanent. The government has only offered us temporary resettlement. They give us a travel document which is useless, because we cannot leave here. We are still in prison. We cannot leave this island.

And a woman said:

People here don't have a real life. We are just surviving. We are dead souls in living bodies. We are just husks. We don't have any hope or motivation.