Nationality and Borders Bill

Written evidence submitted by Médecins Sans  Frontières /Doctors Without Borders to the Nationality and Borders Bill Committee (NBB42)


About Médecins Sans  Frontières /Doctors Without Borders  

Médecins Sans  Frontières /Doctors Without Borders (MSF) is an international, independent medical humanitarian organisation. We provide medical and humanitarian assistance to people affected by conflict, violence, epidemics, disasters, or excluded from healthcare.  Our actions are guided by medical ethics and the principles of impartiality, independence and neutrality.  At times, MSF speak s out publicly to bring a forgotten crisis into view, or to denounce abuses, or to call out policies that cause harm, restrict access to medical care or essential medicines. Our teams are made up of tens of thousands of health professionals, logistic and administrative staff - bound together by our Charter. We are a non-profit, self-governed, member-based organisation.    

MSF has been providing medical and humanitarian care to refugees, asylum seekers and other migrants around the world for decades. Many of the people we assist have been forced to undertake dangerous journeys, or are trapped in precarious conditions as they attempt to find safety. They have often suffered the consequences of inhumane migration policies focused on deterrence, externalisation and containment. 



Between November 2017 and October 2018 , under an official agreement with the Ministry of Health of Nauru, MSF provided free psychological and psychiatric treatment to Nauruan nationals as well as refugees and asylum seekers sent to Nauru island under the Australian policy of ‘offshore processing’.  Under this policy, asylum seekers who attempted to reach Australia by boat were sent to remote Pacific islands for an indefinite time pe riod to have their asylum claims processed.

In October 2018, we were forced to cease all activities and leave within 24 hours.  As a result, we had to leave behind hundreds of patients in urgent need of continued mental healthcare.   

When MSF began its mental health project in November 2017, 1,099 refugees and asylum seekers, including 115 children – 30 of whom had been born in Nauru – had been on the island for around four years.  Some lived in the community, and others were held in the ‘regional processing centres’.

During  MSF’s  11-month presence on the island,  our  medical and mental health teams on Nauru   provided psychological and/or psychiatric interventions  to 208  refugees and asylum seekers . Among these men, women and children, 39 were children under the age of 18, with the youngest less than one-year-old and the o ldest patient was 68 years old.

This submission mainly focuses on the experience of MSF as an independent health care provider on the Island of Nauru in 2017 and 2018  for those refugees and asylum seekers held there indefinitely under the Australian policy of ‘offshore processing’ . This has been comprehensively detailed in a report released in October 2018, Indefinite Despair [1] . Based on this experience, MSF wants to raise profound concerns over the UK Government’s plans to pursue offshore processing policies , as enabled by Clause 26 of the Nationality and Borders Bill . Having seen first-hand the results of offshoring policies in Nauru, we would strongly urge that the se provisions be removed from the Bill.

Submission Exec utive Summary

1. Between 2017-18, MSF witnessed an alarming level of severe mental illness among refugees and asylum seekers on Nauru Island, linked to Australia’s border protection policy of offshore processing. Data from the project demonstrates some of the worst mental health suffering we have ever encountered in our 50 years of existence, including in projects that provide care for torture survivors.

2. MSF believes that the offshore processing policy was the most significant contributory factor in the mental health problems experienced by MSF’s refugee and asylum seeker patients.

3. Despite horrendous and traumatising migration journeys experienced by MSF’s refugee and asylum seeker patients, which included violence, threats of harm and death and detention, it was the indefinite nature of the Australian government’s offshoring policy that was among the main stressors in their lives . The profound sense of hopelessness the men, women and children held captive felt - which often led to self-harm and thoughts of suicide, even in children as young as nine years old - was associated with their fear that they may be kept on Nauru indefinitely, with no time limit or hope of escape.

4. More than one quarter of MSF’s patients ( 55 people in total) were medically evacuated out of Nauru to Australia , the majority for psychiatric reasons after years of distress on the island.

5. In light of the mental health epidemic on Nauru , including the alarmingly high rate of suicidal ideation and suicide attempts ( 65% of MSF’s asylum seeking and refugee patients had thought about or attempted to kill themselves , and children as young as nine were found to have self-harmed, have suicidal ideation, or attempted suicide ) it is utterly irresponsible for the UK G overnment to plan to introduce offshore processing policies .

6. The Chief Prosecutor of the International Criminal Court said Australia’s offshore detention system amounts to ‘cruel, inhuman or degrading treatment’ [2] , and offshore processing has been found to contravene international human rights standards [3] . It is worth noting that Australia remains responsible for upholding the human rights of asylum seekers and refugees it sends offshore, according to international law [4] .

7. The cost of offshore processing to the UK taxpayer is likely to be prohibitive. Australia’s offshoring policy has been astronomically expensive – with a total budget allocation of (AUS) $8.3 billion between 2014-2020, and from May 2021 costing almost (AUS) $3.4 million a year to hold one person in offshore detention.

8. MSF is resolutely opposed to the inhumane and unsustainable policy and practice of indefinite offshore processing and as such, recommends that Clause 26 should be removed from the Nationality and Borders Bill before this Committee.

9. MSF is seeking reassurances from the UK Government that no element of this policy will be replicated by the UK.

Mental health consequences of ‘O ffshore P rocessing

10. MSF is profoundly concerned that the G overnment intends to grant itself the power, through Clause 26 and Schedule 3 of the Nationality and Borders Bill , to enable asylum seekers to be sent to another country whilst their asylum claims are processed, a practic e commonly known as ‘offshoring’. M SF witnessed the severe harm and destruction the Australian policy of offshoring and indefinite detention on Nauru Island has had on asylum seekers and refugees physical and mental health and dignity , and data from our project demonstrat es some of the most acute mental health suffering MSF has seen in our 50 years of existence, including working with survivors of torture.

11. The severity of mental conditions amongst asylum seeker s and refugee s MSF treated on Nauru was alarming. Our mental health teams determined the severity of mental illness among our patients using the Global Assessment of Functioning (GAF) scale, which measures the extent to which a patient’s symptoms affect his/her daily life on a scale of 1 to 100, with 1 for lowest functioning and 100 for highest. GAF scores of above 70 are considered ‘healthy’. A score of 40 generally represents a major impairment in several areas of one’s life simultaneously (e.g. mood, family relations, work, school, judgement etc. [5] ). MSF’s asylum seeker and refugee patients had very low scores, with the median GAF score in initial assessments being 40 and the most common GAF score was in the category of 31-40, with 31 asylum seeker and refugee patients scoring in this range.

12. There was a high prevalence of severe mental health morbidities (illnesses) amongst our asylum seeker and refugee patients. Of the 208 refugee and asylum seeker s MSF treated on Nauru almost two thirds (129 (62%)) were diagnosed with moderate to severe depression. The second most common morbidity was anxiety disorder (25%) followed by post-traumatic stress disorder (PTSD) (18%). These morbidities are serious mental health conditions that require long-term and specialised care , which was extremely limited during our 11-month project on Nauru.

13. Sadly, ten child and two adult MSF patients were diagnosed with Resignation Syndrome. This is a rare and life-threatening psychiatric condition where patients enter a comatose state, which according to Professor Louise Newman of Melbourne University, ‘appears to be a state of ‘hibernation’ in response to an intolerable reality’ [6] , and that requires medical care to keep them alive.

14. In total, 92% of refu gee and asylum seeker patients reported facing difficulties in Nauru, which we believed were likely exacerbating their mental health problems and feelings of vulnerability. MSF teams observed that the high rate of depression amongst our patient cohort was likely due to the traumatising conditions experienced on Nauru. Experiencing fear for the future was associated with moderate and severe depression, and experiencing a lack of control over events that affect one’s life was associated with all major diagnoses (PTSD and complex trauma, moderate to severe depression and anxiety disorder). A total of 65% of refugee and asylum seeker patients felt that they had no control over the events in their lives. These patients were significantly more likely to be suicidal or diagnosed with major psychiatric conditions. A former MSF patient held on Nauru Island told us: "If I was in my home country, the government wants to kill me straight away. I tried to come to Australia and the government kills me a little by little, step by step. They tormented me a lot over five years on Nauru because I have no future in my life."

15. Almost two thirds (135) of MSF’s 208 refugee and asylum seeker patients had suicidal ideation and/or engaged in self-harm or suicidal acts. Among these, 124 people (60%) had suicidal ideation, 63 (30%)   had attempted suicide, and 34 (16%) had engaged in   acts of self-harm. In our patient cohort, children as young   as nine were found to have self-harmed, have suicidal ideation, or attempted suicide.

16. As time progressed, the number of   suicide attempts increased among the refugees and   asylum seekers on Nauru, for both MSF patients   and those not seen by MSF. This was an expected and   sadly  predictable consequence of  long-term, indefinite processing, when people’s sense of   hopelessness increases and their mental health state declines , as   Dr Patricia Schmid, an MSF psychiatrist who worked in Nauru observed: " The issue of ‘indefiniteness’ – that there is no timeframe for the detention process – has a strong impact on my patients’ mental health. They tell me that even prisoners have a sentence – they know when they will be released, they can plan their lives. My patients don’t have that. So they fear for the future, they are completely hopeless."

Child mental health crisis on Nauru

17. Our teams also witnessed a disturbing collapse of children’s mental health. Of the 39 refugee and asylum seeker children treated by MSF, 17 (44%) were diagnosed with moderate to severe depression. They also suffered from other serious mental health conditions including Resignation Syndrome (26%), complex trauma (18%) and PTSD (15%).  Based on staff observations, the deteriorating mental health conditions among children also led to a worsening of their other family members’ mental health, because their ability to come together and care for and support one another had been depleted by almost 5 years of indefinite containment.

18. Dr Beth O’Connor, an MSF psychiatrist working on Nauru explained: "In a small community that has spent five years together, events have a wide impact. In June, there was the suspected suicide of a young asylum seeker. He was a talented soccer player, well known and respected, so his death was felt deeply by many. This event contributed to further despair, and the community struggled to find the resources to support each other. There was a similar effect in family units: when one person was sick, we would see the whole family collapse."

Compounding trauma

19. The refugee and asylum seekers MSF treated were very vulnerable and the scale of traumatic events they had encountered prior to their indefinite detention on Nauru was extremely high. 155 of the 208 patients ( 75%) reported experiencing traumatic events in their country of origin and/or during their migration journey, including combat situations, threats of harm or death and detention. Yet, despite their horrific experiences during their journey, it was the indefinite nature of the Australian government policy that was among the main stressors in their lives. Kazem [7] , an Iranian refugee who had been held on Nauru for more than five years said: " After a while we found out that there is no difference between the tent and the community, because you’re just transferred from a small prison to the big prison that’s surrounded by ocean."

20. Alarmingly, 23 (11%) of MSF’s refugee and asylum seeker patients reported experiencing psychological and/ or physical violence carried out by local authorities including the immigration authorities and Australian Border Force.

21. MSF believes that the offshore processing policy is the most significant contributory factor in the mental health problems experienced by MSF patients from the refugee and asylum seeker community. This link was reflected both in clinical interviews with patients, and in th e association between factors related to their detention (for instance, family separation and a lack of control over the   future) and adverse mental health outcomes.  

Medical Evacuations to Australia

22. Throughout the time MSF was working in Nauru an official process for medical evacuations (Medevac) was in place for Nauruans , asylum seekers and refugees who could not find adequate medical treatment on the island. During this 11-month period, 55 of MSF’s patients were medically evacuated from Nauru , the majority for psychiatric reasons after years of distress on the island . Despite the medical evacuation me chanism in place, all our patients were evacuated to Australia by Court order so they could receive care they desperately required , or were resettled to the USA. The damage to their mental and physical health was absolutely unnecessary .

23. In 2019 (after MSF had stopped working on Nauru) the Australian Parliament passed a new medical evacuation legislation (known as Medevac legislation) that enabled a further 192 asylum seekers and refugees to be transferred to Australia before the law was repealed in December 2019. Between the repeal of the Medevac legislation and 31 January 2021 another 90 people were transferred to Australia (81 people from Nauru island and 9 people from Papua New Guinea (where Australia funds an offshore processing centre ) . [8]

Impact on international obligations

24. [9] UN experts found Australia’s offshore processing to be in breach of international human rights standards [10] . Furthermore, under international law, Australia is still responsible for upholding the human rights of asylum seekers it sends offshore. [11]


25. The cost of offshore processing to the UK taxpayer is likely to be prohibitive. Australia’s offshoring policy has been astronomically expensiv e: an analysis by the Australian Refugee Council found that the Australian Government allocated (AUS) $811.8 million to offshore management in 2021, which brings the total budget allocation to (AUS) $8.3 billion for offshore processing between 2014 and 2020 [12] . This means that from May 2021 the Australian Government will pay contractors almost (AUS) $3.4 million a year for each person held in offshore detention [13] .

The UK’s responsibility

26. The UK Government has a responsibility to process asylum claims of those arriving on our shores and must not transfer this to another country, where the human suffering can be hidden away from public view.  Offshoring will negatively impact the UK’s international standing.

27. This cruel, dangerous and expensive policy causes severe mental and physical suffering and is completely unsustainable. N o element of this policy should be replicated in the UK.     MSF calls for Clause 26 to be immediately removed from the Nationality and Borders Bill.


  October, 2021




[3] ;


[5] Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, p. 34

[6] Newman, L.K. 2018, ‘Explainer: what is resignation syndrome and why is it affecting refugee children?’, The Conversation, 22 August, explainer-what-is-resignation-syndrome-and-why-is-it-affecting-refugee-children-101670

[7] This is not his real name








Prepared 27th October 2021