Won’t someone think of the horses?

In the effort to make things simpler, sometimes the media reaches for a simple analogy. Metadata is just about the envelope. Flapping butterflies are making hurricanes. That drug called ketamine is just for horses and underground rave parties. Or both together.

Which is why it might not be so easy at first to grasp that ketamine is about to be discussed at the UN in the sort of context that could make millions of people around the world less safe when they need surgery.

Yep. Special K is a human rights issue.

A Bit About Horse Drugs

Ketamine is used for horses and it is used by some for recreational purposes. But overwhelmingly it’s used in human anaesthesia and as a pain reliever. Particularly in the developing world. It’s probably the world’s number one anaesthetic agent and there’s a bunch of good reasons.

As an anaesthetic agent, ketamine is quite different to most of the other agents we use. The reflex is to think that all anaesthetic agents are about suppressing activity in the brain. And it’s true that many agents interact with receptors (GABA receptors) that have the primary job of making neurones in parts of the brain fire less.

Ketamine is not the same beast. It is an antagonist at N-methyl-D-aspartate (NMDA) receptors and the patient who has received a dose looks entirely different. They enter a “dissociative” state and instead of just looking sleepy they classically get a slightly glazed look, eyes flicking like they’re watching trains rolling across the landscape. Talk to them and you’ll get no response. They are unaware of all of this.

For a long time explaining this ability to produce anaesthesia while not “looking” like anaesthesia has confounded those looking for the unifying theory of how anaesthesia works. There is some evidence now that it does produce similar effects in communication between brain areas as the agents we’re more accustomed to using. It just has a few bonus effects on the way.

Ketamine also provides excellent pain relief and when used to produce anaesthesia, patients tend to keep breathing pretty well and their blood pressure remains stable. This isn’t the case for some of our other anaesthetic agents and it adds in a bit of a safety margin not apparent in the other options. All these different qualities give ketamine serious advantages when you’re going to give surgical care in a clinic somewhere in west Africa.

That’s why it is such an important drug worldwide. Because it is the most widely available agent that can deliver what should be a human right – freedom from the suffering of surgery while you’re fully aware. It is the agent available more often than not in all those spots around the world where people need an operation, or a woman really needs surgery to deliver a baby but the surgical care amounts to a couple of passionate individuals, not a whole health system. That’s why it is used millions of times every year.

Sounds Good

So that should be where the story finishes, right? Science found a drug that generally provides excellent pain relief and a pretty safe means of providing valuable anaesthesia in the face of urgent surgical need. And you get to reminisce about cereal ads from previous decades while you marvel at this triumph of pharmacology.

Well, no. Because ketamine also has other effects. It can produce some pretty gnarly visions in that dissociative state. Some of them feel fantastic. Some of them are horrifying. But those formers ones can be popular leading some to pursue the dissociative state or their positive experience of the trip. Some are therefore concerned about its potential for abuse. And some people do abuse it. Probably not in the same numbers as the millions who benefit from it of course.

Here is a green tree frog seen through 'ketamine goggles' (actually it's an entirely different frog from the Congo and the photo is via Nick Hobgood (unaltered) under CC 2.0)

Here is a green tree frog seen through ‘ketamine goggles’ (actually it’s an entirely different frog from the Congo and the photo is via Nick Hobgood (unaltered) under CC 2.0)

Why bring this up?

At a time when one of the priorities of the World Health Organisation is making safe surgical care the norm, China has lodged a proposal before the UN ‘s Commission on Narcotic Drugs that ketamine be placed on a restrictive schedule which has the potential to limit its availability to medical professionals.

China, with the support of Russia amongst others, seems to feel there should be more concern about the potential for abuse. Of course the same question was addressed in 2006, 2012 and 2014. It’s repeat season.

If the proposal was to pass, it would be devastating for surgical care in low resource countries. Decisions like this are well known to cause big issues for access to health care. It’s only recently that international bodies have been prioritising access to opioid medications so that people throughout the developing world don’t die in the sort of pain most of us would never expect to be left with. The reason opioids have traditionally been hard to access? The 1961 decisions of the UN Single Convention on Narcotic Drugs to regulate access because of fears of abuse.

Sounds familiar, right? But hey, the UN only estimates 5.5 billion people don’t have access to adequate pain relief.

The Push Back

Is the persistence of this proposal likely to change the result? It seems unlikely. There’s been coverage of the issue in the general press and lots of groups raising a collective “no thanks very much that would be somewhere beyond the Magellanic Clouds for intergalactic stupidity” (though a fairly shameful silence from Australian groups near as I can tell).

While we’re all on the ramparts though, it’s probably a timely reminder that access to health care is still a major worldwide issue. It might be something worth talking about when it’s not just partygoers under threat.

 

If you’d like an example of a direct thing you can do to aid surgical care in developing countries you might like to check out Lifebox. It’s a program endorsed by the World Federation of Societies of Anaesthesiologists amongst others and delivers monitoring we’d consider a basic standard of care to areas it’s not available, with training to boot. I have no links with the program, beyond having donated myself. 

I also didn’t go into ketamine as a treatment for depression, because that’s still in the early stages of being tested. But you can read more here

 

Edit note: In response to the comment re: hallucinations, I’ve tried to make it even clearer that some people do seek to pursue the dissociative state or their positive experience by inserting the following in the section “Sounds good” – “leading some to pursue the dissociative state or their positive experience of the trip”

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History Will Teach Us …?

3 weeks.

3 weeks of trying to make sense of things I saw on my last day in Rwanda.

This was after the 18 operations. After packing up the theatre. Around the same time as the intensive care was being decommissioned. A few of us went beyond the hospital to visit sites significant in the genocide of 1994. We came to play a small part in improving the lives of kids whose hearts would otherwise fail them before they’d really learnt to run into the world. We came to help with futures. But there were histories to learn.

 

The Million

In 1994 I registered the genocide like the insular teenager I was. Since then I have learnt numbers. 100 days. 1 million dead*. But numbers are both overwhelming and incomplete.

We drove up through the hills of Kigali then into the eastern areas. Our stop was at a local Catholic church that is just one of many sites where the stories of those who died are told in the hope those stories won’t have further chapters. There have been too many already as it turns out violence against the Tutsis started many decades before. At least as far back as the 1950s.

Through many outbreaks of killings where the Tutsi were the victims, Catholic churches offered safety. So Ntarama is just one they came to. 5000 of them. They were all killed.

Today there is a quiet garden gated behind the red dirt of the road. No photos are allowed inside the churches. I do not know that a photo of rows of skulls and other bones would help anyone else absorb the scene. Pictures wouldn’t really catalogue all the piles of clothes left from the victims.

5000 people.

When we leave three kids stop us to play a game in the international language of clapping. Inside there is the room where Sunday school took place. And a wall of dried blood where children were slaughtered.

The gardens at Ntarama

The gardens at Ntarama

*               *                 *

Around the time we were leaving this first church, we were missing a morning with our patients. They went down to the lawn to fly kites. I’m told the kites wouldn’t get up into the air. No one cared.

*              *                  *

After the first church we went to another. Here we could hear kids at the local school playing games as we walked amongst more piles of clothes. 10,000 died in one day here. 50,000 are buried in the graves. Our guide, again, was a survivor of 1994.

We drove back to the genocide museum in the city of Kigali. Here 250,000 are buried. They are still receiving remains.

There is a gallery at the top where photos of kids hang. They have the slight blurring of a small photo blown up to take over the memory. Each one has a story. Something like:

“Matthew

Favourite toy: His football.

Favourite food: Chips and ice cream.

Best friend: His mum.

Age at death: 7.

Killed by machete.”

 

I stand still for a long time before I leave.

 

Decades

Richard Flanagan, the much awarded Australian author, has no doubt spent much time thinking about how people come to view other humans as less than human.  His father was a prisoner of war and his Booker prize winning novel spends much time in the harsh jungles of Burma.

A while back he reflected on how you get to such a point, a point where war crimes are possible:

“… it begins years and decades before when terrible ideas are let loose upon a society that some people are less than human. And once you allow those ideas to take hold, at a certain point crimes like the death railway become inevitable.”

The genocide in Rwanda didn’t start in 1994. It started decades earlier. Is the curse of history that it is so vast that we struggle to take the lights it has left us to see the path in front of us? Or even where we are right now? Could the people who started burning the homes of Tutsi in 1959 see how much the flames would consume? Do we have the imagination to see where that first moment where we value another’s humanity as less than our own might lead?

Home

I live somewhere that swelters in its own advantage. We have a proud narrative of believing in a fair go for all comers. Back in 1994 I do recall thinking that such barbarity defied all experience of the place I grew up.

Last week, a politician in Australia introduced the idea in parliament that he should have the power to decide in secret whether someone seeking an asylum can ever make a claim for protection under a definition of character or national interest known only to the relevant minister. It frees the local government from any pretence of obligation to the Refugees Convention. Anyone can be deported anywhere, without any consideration of whether they might be returned to danger or torture. Or even if it is known that is likely. There is no meaningful means for review or oversight of any of these new powers.

This is apparently to stop boats leaving foreign shores. Except they’re not stopping. At most they’re less visible from our beaches for now. Faced with the possibility that the parliament might not agree to these measures, the involved politician played a new card. He told others in the room that if they said yes, he would release children in detention from one offshore site, Christmas Island. He has had that power any time in the last 15 months. Of course if they said no, the children would stay locked up.

So I now live in a country where uses children, trapped in horrifying conditions described in terrible detail by  experienced paediatricians, are used as hostages. You could not treat someone you viewed as human like this. The ideas are loose.

So the other politicians said yes. And we are told children will leave Christmas Island. But not the other detention centres. There we continue to imprison children. Where will these decades lead us if this carries on?

 

Returning

After the museum we returned to the hospital. King Faisal Hospital wasn’t quite open when the genocide began. Within a short time up to 6,000 sought safety on its grounds. The first operations performed there were undertaken by aid staff treating the wounded.

In the corridor on the ward, an infant is chasing a pink balloon. Unsteady on her feet, when she picks it up and turns, her naked chest wears a broad white shield. It is the dressing over the sutures and wire holding her mended breastbone together. Decades later there are smiles to hold on to.

 

A day later I’m part way through the hop-step-and-jump of a broken journey back to Australia. I have a day in Johannesburg and time to visit the street in Soweto where both Mandela and Tutu have lived. I’m not sure what I expected Soweto to be but it wasn’t this place where I cross between luxury cars and the minimalist concrete of modern restaurants. Why didn’t I expect change from the events of history?

On the way between the school where children marched and Mandela’s house, there are words on a wall:

Words

They are worth believing.

 

 

 

 

The Easy World for Modern Kids

One day I’ll get to that slowly receding retirement age. Hard-etched stereotypes tell me there will be certain expectations when I get there. I will have angry letters to write to council, dinners to start before the evening news kicks off and wistful reflections to cast about that young people have never had it so good.

Actually I hope the last of those will be true. In my short medical career around kids’ hospitals one of the most inspiring features is the resolute focus on improving the recognition of children as unique individuals with distinct rights. There is no better example of this than the recent release of the statement on the Rights of the Dying Child which defines these vital standards with such clarity. Perhaps we examine the value of a life hardest when chance bears a snarl rather than leaving us to easy joys.

The easy conclusion when reading something on the lot of children on a digital device scarcely imagined a generation ago is that progress for the rights of children is assured. Those same devices lead us easily to enough information to check that. It doesn’t stack up.

Whether in conflicts from South Sudan to Syria, or during actions by terrorists in places like Nigeria, children are increasingly not just collateral statistics of grown-up violence. They are the targets. In the conflict in Gaza there are two sides both destroying the next generation. The death toll exceeds 1300 and children are bombed while they sleep.

The Australian Commissioner to the UN recently noted that beyond the horror of militias recruiting child soldiers, eight government armed forces do this. Stories of child sexual abuse continue to emerge to shock. Despite progress millions of children under the age of 5 die every year and UNESCO report that 57 million children do not have a school to attend. Can we say that things will automatically be better for all these children?

So clearly we must start looking further afield to advance the case for the rights of children. Except that the most recent report from the Australian Institute for Health and Welfare points out that there are still significant issues of inequality in children’s health to address in Australia. Indigenous children still have a rate of chronic ear infection 3 times higher than that deemed a massive health problem by the World Health Organisation. Childhood mortality rates in some areas are equivalent to Libya. 7.3% of children in Australia are living below the poverty line. That’s almost 600,000 children. The interim report of the royal commission into institutional responses to child sexual abuse points out that children remain at risk.

Most disturbing are the stories emerging from the Human Rights Commission inquiry into the bipartisan morass created by detention of children seeking asylum. This is a policy which sees children trapped in an environment that fails to provide for their basic needs. Referring to themselves by number, scarred by post-traumatic stress disorder and undertaking self-harm at disturbing rates they are so unable to access adequate health care that it emerged in earlier reports that a child is losing vision in an eye for lack of some glasses.

Then today, amongst the distressing further stories of sexual assault and serious mental health issues being shared by professionals who have either worked in these detention centres or visited as part of the review, more serious allegations emerged. Psychiatrist Peter Young described being asked to remove some of the most damning evidence of mental health problems in children from formal reports. Departmental alarm led them to try and find a big enough carpet to sweep the dirt out of sight.

By a child on Christmas Island, with her identity numbers obscured [via ABC]

By a child on Christmas Island, with her identity numbers obscured [via ABC]

 Any doctor in New South Wales seeing a child in a situation equivalent to these detention centres would be required to notify community services. The legal guardian for these children is the minister. At what point do we stop standing by?

Childhood should be a time of wonder. It should allow the exploration of the miracles of the every day to inspire a future life. Unless all kids can do that there is a need to focus on real progress. Everything we are hearing now says that must start with Australia, but not end there.

The thing about saying that kids have it easy is that it is supposed to be true. It is supposed to be something to say with quiet pride. It is not supposed to be a delusion.

Sideshow Distractions from Bad Injections

Occasionally, a topic flares up amongst the daily news chatter and people suddenly take notice and think more deeply. A bit like the uncomfortable recollection of where eggs for the plate originally came from. Or something more serious like the world’s belated recognition that hundreds of school girls abducted in Nigeria might warrant some form of wider discussion. This event has already drawn plenty of social media activism and hashtaggery. It has now been through the full media cycle, with Michelle Obama’s input being hijacked to point out inconsistencies in the regard for kids in Nigeria and the thoughts for those killed by drones.

Similarly, over the last month lethal injection and the death penalty have been very much in the news thanks to the case of Clayton Lockett. Failing to get the desired response from the injection, after 10 minutes he  “lurched forward against his restraints, writhing and attempting to speak. He strained and struggled violently, his body twisting, and his head reaching up from the gurney.” He finally died, some 43 minutes after proceedings commenced, apparently due to a massive heart attack.

Oklahoma has put a moratorium on further executions.  New variants on the drug cocktails traditionally used have been scrutinised. The quality of staff involved has been derided (Dr Jay Chapman, designer of the three drug technique himself has said  “It never occurred to me when we set this up that we’d have complete idiots administering the drugs.”) All of the analysis, however, seems to miss the reality of what was witnessed – people got to see the turmoil usually hidden by the second part of the drug mix. They had a forbidden glimpse of the torture that is usually masked, and they could no longer skate by.

How did we get here?

In the long history of capital punishment, many variants have been described. Way back in 1977 Dr Chapman, who sees no issues with medical practitioner assisting with executions, was on the lookout for a method as humane as putting down animals. Over three weeks he came up with a suggested cocktail of drugs to be injected. Thiopental, capable of producing general anaesthesia and thereby removing an awareness of what followed, was first. This was followed by the muscle relaxant pancuronium, a drug which stops the small packets of chemicals released by nerves to stimulate muscles from binding to their target, producing paralysis by stopping muscle movement. The final drug is highly concentrated potassium chloride to bring the heart to a standstill.

The recent spate of experimentation in regimes has come about because  manufacturers of the anaesthetic component of this final trip have ceased permitting sale in the US. Various jurisdictions have tried sourcing thiopental or an equivalent and those options have now failed too. So they are left trying out hypothetical combinations at the time of death, secure in the knowledge that feedback will mostly not be an issue. This search for new options is the same one that led to Dennis Maguire being given a combination of midazolam, a sedative, and hydromorphone,  a painkiller, which put Ohio in the firing line for its approach to lethal injection.

In desperation they have started using regimes that are likely to fail. An uncontrolled experiment on death row prisoners. Midazolam is not truly capable of producing general anaesthesia. It produces sedation. Most times, but not always,  it will also produce amnesia for the events after it is given. Of course occasionally it will produce extreme agitation termed akathisia in the recipient. It’s not just the mild jitters either. It’s enough to make them a reasonable option for mixing paint.

Of course, when you have a three drug system and the injection starts going into the tissues instead of a vein while the muscle relaxant is going in, you leave a person aware of what is happening, and just weak enough that the best they can manage is a groan or an uncoordinated effort to lift their head. What is that feeling of weakness like? The best approximation I can come up with is to suggest that as you sit there, you take a breath out. When you go to breathe back in, take only as much air as clears your mouth. This is the amount of air you are left with as you try to breathe in and out.

See how long you last before your greedy lungs demand a deep breath. Now imagine experiencing that for 20 minutes. This is not the choking gurgle of the screen, but a silent or guttural asphyxiation. Imagine how much you’d try to cry out in the stillness of your breath. In other cases where the muscle relaxant works the prisoner would be left as a marble mask, even if their mind was racing. This time witnesses saw the turmoil, and they recoiled.

So unsurprisingly lethal injection has come under serious scrutiny in a response which fundamentally misses the point – we can’t excuse the death penalty because we thought we had a better way of killing.

The issue here is not the colour of the cape they use. [via gomanzanillo.com]

The issue here is not the colour of the cape they use. [via gomanzanillo.com]

The Flawed Case Behind the Death Penalty

Articles had already been appearing suggesting a return to old methods or switching to a single drug lethal injection. Rather than pursuing the line of reasoning that it just needs fixing,  surely the real question for discussion is whether there is any justification in the setting of law enforcement for violating the most basic human right of all – the right to life. To be able to justify such a violation would surely demand that the vast amounts of good flowing from the decision to devalue the significance of that one life overwhelmed any  concerns about capital punishment.

It would have to be obvious that it went beyond extracting ‘an eye for an eye’ and produced genuine changes in crime rates through deterrence. It would be  so efficient that it would save money that would be wasted on long term incarceration. It would not inflict ills on those convicted. Most importantly, you would surely expect that it provided benefits to victims’ families. Perhaps a sense that the grim pain surrounding the events is sealed up..

The thing is that none of these assumptions seem to hold. There is no convincing evidence that the death penalty deters those likely to commit terrible crimes. It costs millions more to navigate an individual through the capital punishment process and the other costs quickly add up. Exercising capital punishment rather than Life Without Parole is a sure fire way to ensure everyone convicted will go through multiple appeals to try and get free. That is more time and money. Of course with a death row population that contains way more non-Caucasian people than seems justifiable, the appeals might hold some water. Particularly given that up to 4% of convictions might be flawed.

More importantly, the assumption that execution automatically brings about peace for those close to the victim may well be flawed. What research has been done hints at the fact that closure is too complex and nuanced to be universally delivered by retribution and that Life Without Parole may provide more certainty for victims’ families to move on. It is not so much that revenge should be served cold, but that as a dish it is just as likely to leave the grieving half-satisfied at best.

A punishment that is more expensive, doesn’t provide deterrence, fails on delivery via any of a number of ways (with lethal injection leading the way) and doesn’t seem to help families all while eroding human rights is worthy only of chapters in history books. This is not just true in the US, but in any of the 22 countries who employed the death penalty in 2013.

There is a lot more discussion required to cover the full range of responses. The challenge for those advocating that any moratorium on execution become permanent is to make the issue broader than the comparative pharmacology of drugs authorities don’t really understand. It is a fundamentally bigger story about human rights. It deserves to outlive a hashtag.

 

If you’re after  a longer examination of Life Without Parole vs Capital Punishment, you’d do well to look here. There’s also a really nice summary piece from the ‘BMJ’ just below. Of course, you could just watch 12 minutes of John Oliver

Lethal injection feature

The Challenges of Speaking Up

I have an early memory. A memory that does me no credit. I’m a kid, maybe 5 or so. I’m in a playground and there’s a slightly older kid who really wants to use the slippery dip. There’s a younger kid in the way. And when he hatches a plan to run the kid away a bit, then push him over so his parents will come to scoop him up, I can see what’s happening and I don’t speak up. It all unfolds and I’m silent.

I don’t even quite know why I’m silent. I can’t quite put my finger on why I don’t speak up to stop the squeeze in my chest somewhere. It’s a memory that’s been reconstructed that replays from time to time. It replays whenever I am reminded of how difficult it is to make some sound.

Giving Voice

I’d like to think that as a doctor I’d speak up now if something was happening in front of me. I’d like to think I’d start making noises like the doctors in this story, covering details of a 92 page letter written by doctors working with a health contractor in the offshore detention centre. Or Dr Caroline de Costa, detailing concerns about obstetric and perinatal care in detention centres here and offshore. I would like to think I’d take steps to address the erosive ulcer at the heart of refugee policy – the denial of humanity endorsed by the civic machinery of successive governments.

In recommencing then continuing offshore detention, federal governments have wasted no opportunity to demonise a voiceless group to suit political ends. It has steadily reached new peaks of absurdity under the current regime, fronted by a minister who seems a little too delighted at being given real navy ships to play with, rather than those usually reserved for bath time.

To ‘take the sugar off the table’ we have to impose ever harsher conditions. Media are not allowed in, but have the opportunity to hear the Foreign Minister refer to conditions as better than mining camps (presumably the sort of mining camps where you can’t leave, have extremely limited access to basic amenities and can’t work). Governments do all of this because they know that once the public truly identifies with asylum seekers as human beings, the game will be over.

The Kids

Nowhere is the horrifying institution of these policies more distressing than when considering the plight of children. If you need an international reference, then perusal of the UNHCR – Refugee Children: Guidelines on Protection and Care has it all. The Convention on the Rights of the Child clearly states that “Every child has the right to the “highest attainable standard of health” amongst other goals that aren’t actually that lofty.

The simple goals stated such as nutrition, opportunities for appropriate stimulation, adequate clean water and hygiene are all too high for the camp conditions to consistently maintain. Transfers out to address issues like defective pacemakers seem too difficult. Children are being held in centres where frustration boils over to violence and abuse. As in so many situations, children bear the scars of the folly of  adults. But this time, it is a government acting in our names inflicting those scars.

Futility in Action

To top it off, it’s hard to see how this approach will succeed in influencing refugee arrival patterns in the long term. For all the hyperbole attached to the numbers of arrivals by governments, placed in context they are a drop in a global current. The numbers from Syria alone are staggering.

Australia has agreed to take 500 of these people.

Australia has agreed to take 500 of these people.

The future is likely to see vastly increased numbers, not decreasing numbers. That growth will surely swamp any deterrents advertised by politicians. If the goal is truly to stop drownings at sea, then it’s time to genuinely engage with regional solutions rather than dazzle the populace with shiny generals’ stars.

See No Evil, Hear No Evil, Speak of Nothing

What is abundantly clear is that there can be no hope that the current political class will alter course through a sudden revelation on the road to whichever illusory Damascus they set out for. That letter from the doctors was received in government circles on December 6. On December 13, the Independent Health Advisory Group providing support on asylum seeker and detention health matters was advised they were no longer required. Less engagement advertised as ‘streamlining’.

A bipartisan touring party visited, with the Foreign Minister lauding conditions, as noted above. Of course, the fact they hadn’t inspected the facilities for the actual asylum seekers was only confirmed after further reporting.

Another farcical briefing from the relevant minister on Friday, replete with the usual refusal to engage with the actual matters at hand ensued. The standard patter, dense with references to investigations and processes seemingly designed to distance himself from a responsibility to act were all that was allowed.

The Doctors’ Response

So we are left with the efforts of the medical professionals on the ground. They have concerns as to whether they are threatening their own medical registration by being part of the system. Thankfully they have not forgotten their duty to the patients in front of them, and are advocating for change from within.

It cannot be easy to be faced with a situation where your care is limited by the structures above. They are seeing the grim effects of an inhumane system seeking to crush the few to send some sort of message to the many. Even with their advocacy, the experience will undoubtedly haunt the rest of their careers and scar them as well. That they are seeking to stay and produce change is something we should all be grateful for.

In Our Name

This treatment of asylum seekers is being conducted in the name of the people of Australia. The most extraordinary element of that original story is the following quote towards the end:

“According to the doctors the same IHMS manager told them in September: ‘There will one day be a royal commission into what is taking place on Christmas Island. He suggested we document well.'”

There is another royal commission proceeding in Australia at the moment. It is exploring the devastation across many lives and generations after institutional child abuse. At the time it may have been that the problem was hidden behind the curtain dropped by trusted bodies.

Those delivering health care, including the company contracted to do so, are telling us that child abuse is happening now, in institutions overseen by the federal government. The Northern Territory branch of the Australian Medical Association says the same. We cannot claim ignorance.

The Minister for Immigration and Border Protection, Scott Morrison, is the guardian for all unaccompanied minors in detention. If you were in the position of being guardian to those children, I’d venture that you would see only one appropriate response – get the children out.

Politicians on both sides are pursuing a policy that seems destined to fail in its aim, and asking us to accept a high price on their way. The doctors involved seem to be trying to find their voice. Now I just have to figure out how to lend mine and convince others to do the same.