At the time the 2005 Boxing Day tsunami struck, a little boy and his sister were playing on a pristine beach in the Maldives. They were engulfed by a huge wave and when the little boy came to his senses his sister had vanished. His parents searched in vain before realising that their daughter had perished. I am unsure if her body was ever found.
I met the little boy, barely six, when I arrived on his island as a Commonwealth volunteer physician. The neighbouring island had been decimated, hence evacuated. I worked amid a swollen population due to the relocation of residents from the other island.
There was the anticipated break of gastroenteritis that required door-to-door visits, skin infections arising from water-logged homes, exacerbations of asthma and hypertension, and blood sugars gone astray because food supply became unpredictable for a while. Two young nurses and I, working out of a basic facility, constituted all the medical expertise but the islanders were largely young and healthy so our care mostly didn’t seem onerous.
Except in the case of the little boy. Some days after I had settled in, the parents brought him in.
“Our son doesn’t talk since the day of the tsunami.” It was now many weeks later.
“Can’t talk or won’t talk?” I probed.
“Just doesn’t talk.” Tears clouded their eyes.
“Was he previously well?”
“He was the happiest boy.”
“Did he say anything after the tsunami?”
“Never.”
The other islanders corroborated the history that the child had been developmentally normal until the disaster. But after the tsunami he had never been heard to speak, inside or outside his home. My tentative efforts to engage him were in vain; I possessed neither the knowledge nor the amicability of paediatricians.
He refused to leave his father’s side, sitting quietly in his lap for entire days. His expression was placid, his eyes always lost in thought. What crossed his mind as he stared out at the vast ocean that gleamed like an emerald?
Did he wonder, like I did, how that calm, inviting surface could froth in rage, take lives and then resume being beautiful? Or did he just think of the last game he played with his sister? What did death mean to him? Did he understand that she would now only exist in his memory, or did his eyes stay peeled on the ocean in case she returned? The island elders tried to help, offering him treats, speaking gently and sometimes teasingly but all they got was a resolute silence.
More weeks went by and it was clear that the little boy was severely traumatised and needed the assistance of mental health experts. Mindful of the limited resources, I nonetheless suggested this to the island chief who immediately made enquiries. It turned out that there was such an expert stationed in the capital and the little boy and his father were shipped there with great fanfare. There was a palpable sense of relief among the islanders for whom no suffering was greater than that of a young child.
But much to our surprise, the little boy returned after two days. Apparently he had met a psychologist of international repute but there was no medical handover, no instructions to the parents and no follow up care. Needless to say, he remained mute and his parents remained alarmed.
As long as I was there, I kept pointing out the lack of genuine help and those in power kept nodding but nothing happened. Finally, the truth dawned on me. The boy was no better but the official boxes had been ticked – his handling had been a bureaucratic success.
Ten years since I met him, I have been thinking a lot about that little boy in the context of children in detention and what the Australian government boasts about the provision of medical treatment for refugees. The situations could not be more different – the tsunami gave rise to unprecedented international goodwill and more money than the Red Cross knew what to do with. The refugee situation has done the opposite. But when it comes to healthcare to disadvantaged and vulnerable people, the spin stories bear similarities.
The boy’s ignored plight with lifelong consequences represented a failure of the system but you would never know it. On paper, the island had a specialist doctor stationed on it, never mind that the doctor was a physician whose only paediatric experience had been on the ward of a Melbourne hospital as a medical student. On paper, a patient with unmet needs could be sent to the mainland for management but the process was haphazard and unaccounted for.
How did a scared, illiterate patient even know what had transpired? I saw a few times that while the official line on medical aid sounded good, only someone with inside experience would appreciate the innate deficiencies and the maddening contradictions. The notion of patient confidentiality was a fig leaf – it obscured the lack of process and transparency.
Last week we were shocked by images of babies in detention who risk being sent back to Nauru and then, by the illustrations of young children depicting their traumatic experiences and deepest fears, released as part of a Human Rights Commission report in the wellbeing of children in immigration detention. I saw any number of such illustrations post-tsunami when the island’s school reopened.
We know that living in detention traumatises children. The Human Right Commission report released last week found that 34% of children in detention visited by the report’s authors had severe to moderate mental illness, compared to 2% of children in the Australian community.
Figures released by International Health and Medical Services (IHMS) – the company contracted to run medical services in immigration detention centres in Australia, Nauru and Papua New Guinea – paint an equally grim picture for children in detention. Almost 16% of children under four had been taken to a doctor with a mental health condition in the quarter from April to June 2015. IHMS believes those figures are understated and have concluded that children suffer more serious mental health crises than adults in detention and that those conditions deteriorate the longer they are held in detention.
Here are two things I’ve learnt about trauma in children.
First, children can’t employ the same frame of reference of adults and yet, their emotional struggles can be just as powerful, insidious and silently erosive. The little boy’s father used to glance at the sky and say it was God’s will his daughter died. His mother forced herself to imagine her at peace so she could get on with the cooking and cleaning. But the little boy didn’t have these perspectives to help him reconcile to his loss. His parents thought that he felt responsible for her death but didn’t understand what he had done to deserve such a harsh punishment. Many months later, still mute, he finally drew a picture depicting this.
Second, children are not little adults. Paediatricians say this in half jest to hapless medical students who like to retrofit adult concepts to children but the maxim applies especially to psychologically traumatised children who need expert and sensitive intervention, and crucially, continuity of care, to have any hope of restoration of their former selves.
I have lost touch with the islanders who kept me posted about the little boy. I console myself that surrounded by the community’s patience, understanding and compassion he eventually found his voice and halved the sorrow of his parents. But it’s difficult to imagine the psychological trauma of children in Australian detention being easy to erase even if by some miracle, we came up with the right ingredients.
Children do not belong in detention. Silently appalled and deeply conflicted, doctors are ready to help them. We can do better. Make our job easier, Malcolm Turnbull.
guardian.co.uk © Guardian News & Media Limited 2010
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Children are not little adults. The trauma of living in detention could last forever
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