Malaria on Manus Island: a threat to human rights

This post was originally published on ABC’s The Drum.

International health and human rights lawyer Alexandra Phelan argues that by exposing asylum seekers to the risk of malaria on Manus Island, the Government could be violating human rights conventions.

When the Australian officials head to Port Moresby this week to discuss the reopening of the Manus Island detention centre, their risk of contracting malaria on a short-term visit to Port Moresby (according to the Government’s own Smart Traveller website) is relatively low.

However, if the officials make their way to Manus Island, located north of Papua New Guinea to inspect the detention centre site, their health professionals would likely advise that they take prophylactic antimalarial drugs.

Given this visit is part of a government-related mission, the cost of these antimalarials would most likely, and rightly so, be covered by tax-payer funding.

Malaria is contracted by the bite of a mosquito infected with one of the five species of Plasmodium parasite. The parasite travels to your liver, where it multiplies and then ruptures liver cells, spreading to your red blood cells and then throughout your body. This process causes fever, shivering, headache, and vomiting. In the case of Plasmodium falciparum (the cause of 90 per cent of Papua New Guinea malaria cases), if not treated within 24 hours, the infection proceeds to severe malaria resulting in coma and death, especially in young children and pregnant women. In malaria endemic areas, local populations may develop partial immunity, meaning that individuals who have not grown up in the endemic area are at greatest risk.

There is currently no vaccine for malaria – prevention is through the use of antimalarials, which require important medical consideration of each patient’s age, weight, pregnancy status, underlying illnesses, the risk of side-effects and the increasing prevalence of the parasite’s antimalarial resistance.

Papua New Guinea is a malaria endemic country; in the World Health Organization’s (WHO)2011 World Malaria Report, the WHO concluded that 94 per cent of Papua New Guinea’s population is at high risk of malaria infection, with the remaining 6 per cent of the population at low risk. No person in Papua New Guinea is deemed by the WHO to be risk-free of malaria. In 2010, there were 1.4 million suspected malaria cases in Papua New Guinea, out of a total population of 6.9 million. In 2010, there were 616 reported deaths attributed to malaria, six times more than any other country in the Western Pacific Region.

Papua New Guinea is clearly the highest risk country in the entire Western Pacific Region for malaria. But to make matters worse, the WHO categorises Manus Island, where the Government proposes to send asylum seekers, as having the highest numbers of probable and confirmed malaria cases in all of Papua New Guinea.

The Manus Island detention centre was initially established in 2001 under the Howard government’s Pacific Solution policy. In February 2002, an outbreak of malaria affected at least 15 asylum seekers detained at Manus Island, a claim denied by then-minister Philip Ruddock, but supported by local doctors on Manus Island.

In response to the outbreak, the Royal Australasian College of Physicians (RACP) called for asylum seekers detained at Manus Island to be immediately removed. Then-president of the RACP, Richard Larkins, said that:

“[G]iven the medical evidence about the prevalence of malaria, in particular the chloroquine [an anti-malarial] resistant strains, on Manus Island, the responsible course of action is to immediately evacuate the detention centre. This is the only truly effective way people at risk can be protected, especially pregnant women and children, but also any others with low immunity.”

The Manus Island detention centre was closed in mid-2004, after asylum was granted to Aladdin Sisalem, who had been the sole detainee at the centre for the previous 10 months.

If plans to re-establish Manus Island are followed through, Australia will most definitely risk violating a number of the asylum seekers’ human rights and protections under international law, in particular, the asylum seekers’ right to health under article 12 of the International Covenant on Economic, Social and Cultural Rights, and possibly, their right to life.

The right to health provides that everyone has the right to a standard of living adequate for the health and wellbeing of themselves and their family. It imposes obligations on countries to take steps to prevent, treat and control disease. The principle of non-regression prevents countries from “going-backwards” in the realisation of the right to health. It is also arguable that by sending individuals to a country where their health is knowingly at risk so substantially as to risk their lives, the protections of their right to life under the International Covenant on Civil and Political Rights could be engaged.

These rights are universal, regardless of an individual’s status under a piece of Australian legislation. Even more so, due to their circumstances, asylum seekers are especially vulnerable and at risk of having their rights violated. Sending asylum seekers offshore to Manus Island where malaria is endemic, and present in its most deadly strain (Plasmodium falciparum), risks violation of the asylum seekers’ rights and contravention of Australia’s obligations under international law.

There are only two ethical options left for the Australian Government. The first option is to invest Australian tax payers’ money in improving the facilities on Manus Island, providing mosquito nets, and supplying universal medical prophylaxis and healthcare with informed consent to detainees (which may be impossible with pregnant women, children and those most vulnerable to malaria). The second option is to immediately abandon any plans the Government has to send asylum seekers to Manus Island.

When Australian Government officials on Manus Island this week take their medically-assessed and freely consented to antimalarials, don their long shirts and pants, spray their insect repellent, and don’t have to worry about closing their mosquito nets securely around their hotel beds thanks to the air-con, perhaps they can take a moment to consider whether it would be conscionable for the Australian Government to expose persons in its custody and care to the conditions on Manus Island.

Alexandra Phelan is an Australian international health and human rights lawyer, and was involved in writing a book chapter on a human rights based approach to malaria at the World Health Organization, to be released later this year. View her full profile here.

Advertisements

Reflections from the US environment: Zoe’s Law

Yesterday, the NSW lower house passed the Crimes Amendment (Zoe’s Law) Bill (No. 2) 2013 to amend the Crimes Act 1900 (NSW).  This version of Zoe’s Law establishes a separate offence for actions that cause serious harm to or the destruction of a foetus. There are a wide range of legitimate criticisms of Zoe’s Law that need examination before becoming law, as the Bill will still need to pass the NSW upper house early next year.

The history of Zoe’s Law actually provides a little insight into where the criticisms of this piece of legislation stem from. When looking for the original text of the Bill, I came across three different Bills before the NSW parliament this year purporting to be a “Zoe’s Law”.

The one that passed yesterday, as you can see above, is the (No. 2), and was sponsored by Chris Spence MP, a Liberal Party MP. There are some interesting facts about Spence in his Wikipedia entry and its references. Before joining the Liberal Party, Spence was a member of One Nation and president of the One Nation Youth Wing, standing twice as a One Nation candidate in elections. Since joining the Liberal Party, Spence has said that his involvement in One Nation was a mistake. As an interesting aside, Spence was also the electoral officer of “Liberal powerbroker” Chris Hartcher, who provided the paperwork for and witnessed the statutory declarations against Belinda Neal and John Della Bosca in the “Iguanagate” scandal. What brings Spence to the party on this mater however is that he is the local MP for Brodie Donegan, a woman who lost her 32-week old foetus after being hit by a driver under the influence of drugs.

Before the law that passed the lower house existed, here were two previous versions of “Zoe’s Law”, sponsored not by Chris Spence, but by Fred Nile MP. Yes, that Fred Nile – aka Reverend Fred Nile of the Christian Democratic Party – a very vocal advocate against gay marriage and homosexuality. The Christian Democratic Party policy platform includes strong opposition to abortion and believes that it should be banned, and that abstinence only sex-education is the only acceptable form of sex-ed in schools. Fred Nile’s version was developed with no consultation or consent from Brodie Donegan.

In the previous Fred Nile version of “Zoe’s Law” available (the “No.1”), the language of the Bill is telling. The object of that Bill was to “establish a separate offence for conduct causing serious harm to or the destruction of a child in utero”. The use of the term “child” here, that is, “a young human being”, rather than “foetus”, immediately denotes a state of personhood. Using this term makes the only difference of a child before birth and after birth is its location, not its viability or its capacity to survive outside the mother’s uterus. As a result, the term “in utero” is required to designate the particular location of the “child”. As a contrast, “foetus” however denotes reliance on the mother’s body for life, it does not possess its own personhood and information about its location is superfluous.

While the latest version of “Zoe’s Law” changes the term “child” to “foetus”, however (and this is a big however), it clearly states that:

an unborn child is taken to be a living person despite any rule of law to the contrary

An unborn child is defined as the foetus of a pregnant woman that is at least “20 weeks’ gestation” or, where gestational age cannot be determined, has a body mass of least 400 grams.  This immediately creates personhood in law for a foetus that has a gestational age of 20 weeks or more. Why this figure? Why 20 weeks?

It’s no coincidence that 20 weeks is also the point at which some of the most extreme anti-abortion laws put forward by Republican Party politicians over the last three years in the US come into effect. This is one measure used by the GOP Tea Party to skirt around the Constitutionally protected right of US women to an abortion before “viability”. Viability means the ability for a foetus to exist on its own outside of the uterus PROVIDED that substantial medical assistance is provided. To put this into context, actual viability is typically deemed to be about 28 weeks (or seven months) without substantial intervention, and this was the definition of viability accepted by the US Supreme Court in Row v Wade.

At 20 weeks, chance of viability is considered to be 0%. If a baby is born before 22 weeks, resuscitation generally does not occur due to major disability. When I completed my Bachelor of Biomedical Science a couple of years ago, contemporary medical science stipulated 24 weeks as the absolute minimum of survival of a baby born, however this was survival with significant disabilities and substantial medical intervention. To put it simply, the foetus’ organ development is just not advanced enough for survival before these dates. Even slightly premature babies suffer health difficulties. I was born premature at around 8 months and spent my first days in an incubator, and have chronic asthma (the only one in my family) correlated with preterm birth.

incubator pic

Me in an incubator (c) lexsanitas

So, when Zoe’s Law defines an unborn child at 20 weeks, I find it scary. I find it scary for women’s rights to access reproductive health services, such as abortions, and I find it scary when I think about attempts to redefine viability by politicians rather than experts, such as neonatal physicians and doctors.

Now, Zoe’s Law Mk II, does include the following provision:

This section does not apply to or in relation to: (a) anything done in the course of a medical procedure or medical treatment, or (b) anything done by, or with the consent of, the pregnant woman concerned.

On its face, this provision is comforting. It reiterates the notion that Zoe’s Law is intended to give some sort of acknowledgement of the loss of a potential baby as a result of an attack (deliberate, reckless or negligent, such as with dangerous driving) to a pregnant woman. I remember when I was studying criminal law, and I felt torn by the notion that a pregnant woman who loses her baby as a result of an attack, in particular, for example domestic violence against the mother, has no additional criminal recourse against the attacker beyond a criminal assault charge and other crimes specifically against the mother. I get this. I can completely understand Brodie Donegan’s perspective, when she called for this legislation to be introduced. I think Brodie Donegan makes a compelling argument as to the validity of this law. And I get it. I know that I agree with the desire to have one’s loss recognised. I just don’t think that this is the way to do it.

Introducing this law is incredibly risky to women’s rights. I know that these provisions attempt to cover all bases and protect women’s reproductive rights. But it puts criminalising the destruction of or injury to a foetus on the table; making amendments a pen stroke closer than a law that isn’t there at all. Such amendments could include changing the definition of viability, removing the protections for medical treatments, or, as may be possible, extrapolating the creation of personhood in this law to other criminal laws against women.

Creating foetal personhood is not the answer to this horrible situation experienced by Brodie Donegan and other women. It is medically and scientifically faulty law. Legal personhood should not be extended to a baby in utero. A feotus in utero is not capable of surviving on its own, and furthermore, exists solely within the pregnant woman’s body, covered by her legal personhood. Birth is the point of separation – where the baby is no longer a foetus, no longer a part of the mother’s body, but becomes a separate individual. Defining personhood before birth completely obfuscates and ignores the existence of a woman’s body between the baby and any third party.

By giving the foetus legal personhood, you are also giving the foetus rights against its mother. With the pregnant woman’s consent one of the pivotal “safeguards” in this law, the right of that person to give consent, can then be challenged. The autonomy of the pregnant woman becomes second to the personhood of the foetus.

That is why I disagree with this law. Any legal challenges brought on behalf of a foetus’ legal personhood risks a woman having to continue a pregnancy beyond the point at which she no longer can access reproductive services over her own body and violates her bodily integrity.

As an alternative solution, I agree with Hannah Robert’s proposal: a law that is focused on criminalising a violation of a pregnant woman’s right to continue with a pregnancy against her will. Such a law focuses on the mother, and the right of the mother to bodily autonomy. It attempts to criminalise any person that deliberately, recklessly or negligently violates a woman’s right to reproductive autonomy, to keeping her pregnancy, and having a child. This is the sort of right that is engaged in arguments against China’s previous one-child-policy, or a government attempt to control a woman’s reproductive rights and violate a woman’s bodily autonomy, such as forced abortions.

This is a more ethical construction, focused on the woman – an individual human being with existing legal rights –  and a more ethical example of how the law clumsily tries to give people resolution of their loss. The law can only do so much in this respect, which makes ethics the most important guidance in this process.

From a medical, scientific and ethical perspective, protecting the reproductive autonomy of a pregnant woman – not constructing personhood for a foetus – is the best answer.