Guest post by Sara Dehm. Sara is a lecturer in international law and refugee law at the University of Technology Sydney. Her research examines the history and theory of the global administration of human mobility, with a particular focus on practices of border control, knowledge-production and technical assistance to states in the Global South. This post is part of our themed series on border control and Covid-19.

The COVID-19 pandemic has starkly intensified the deeply-entrenched intersections between the multi-sited regulation of public health and the nation-centric control of state borders. While the World Health Organisation (WHO) initially advised against imposing travel restrictions on people in states with COVID-19 outbreaks (opting instead to recommend health entry screenings and quarantine), by April the WHO’s updated Global Strategy named “appropriate and proportional” restrictions on international travel as a key means for suppressing COVID-19 infections and transmissions. Many states, with some notable exceptions including the UK, nonetheless already resorted to strict border controls on the basis of ‘public health’ grounds, with over 140 states implementing complete or partial border closures by 31 March 2020.

The Concept of the Medical Border

These drastic measures make visible the global and local articulations of what John Mckiernan-González and others have termed the ‘medical border’. The concept of the ‘medical border’ helps us to attend to the specific ways that medical personnel, practices, knowledges and logics become enmeshed in the performance, function and ends of state border regimes. It allows for tracing, for example, how border regimes further the medicalisation of individual migrants’ bodies and of specific body politics in general, including through racialised notions of illness, contagion and collective well-being. Here, medicine is central to enacting a politics of inclusion/exclusion as well as to state authorisation of particular forms and subjects of human mobility at border sites. In this way, the concept of the medical border is connected to the rich bodies of scholarship theorising ideas of the humanitarian or biopolitical or immunitary border that more broadly attend to how the management of human life becomes the object of governmental care and control within border assemblages.

Such medical border assemblages are, of course, not new. Alison Bashford, for instance, has powerfully shown how public health controls at state and/or colonial borders from the late 19th century onwards – including infectious disease regulations, ship inspections and quarantine stations – have shaped racialised ideas of the ‘undesirable’ migrant. Such practices render the constructed and porous boundaries of nation-states, in Bashford’s words, meaningful as ‘sites of medico-legal border control’ where the nation and its others are imagined and crafted. To take the example of Australia’s history of immigration quarantine, this has shaped and in turn been shaped by, as Suvendrini Perera argues, the racialized geopolitical imagining of Australia as an island-continent capable of being created as an ‘island of whiteness’ through intertwined technologies of Indigenous dispossession and migrant exclusion.

Elsewhere, scholars have traced how medical tourism has more recently given rise to particular mobile subjects and border infrastructures, such as medical border towns that are set against the backdrop of drastically unequal access of decent healthcare, soaring pharmaceutical profits and widening global inequality. And they have shown how hospitals as social institutions have become enmeshed in immigration enforcement and deportation regimes such that undocumented migrants are unable or too fearful to access medical treatment.

The Ambivalent Place of Healthcare and Medical Expertise in Border Control Regimes

In my own research, I trace how healthcare has become a form of border control in Australia’s contemporary border regime, including in recent iterations of offshore detention. Australia’s offshore detention regime has existed as a matter of domestic law since 2001, and has been marked by two distinct periods of operation in which successive Australian governments have sought to justify its brutality as a necessary deterrence measure to stop unauthorised migration. In both periods, Australia built and maintained closed detention centres on two Pacific Island states, Nauru and PNG, which both share a history of Australian colonial administration. Presently, around 400 people remain subject to Australia’s offshore detention regime, many of whom have been officially recognised as refugees.

Within this border regime, the place of medical expertise, actors and knowledge has been ambivalent and contested: both implicated in maintaining the infrastructure of offshore detention, and used to delegitimise, transform and contest its particular configuration and ends. Indeed, the provision – or denial – of healthcare to refugees and asylum seekers in Nauru and PNG is a lucrative business for generating private profits. Between 2012 and 2018/19, Australia contracted the private company International Health and Medical Services (IHMS) to provide ‘health services’ to people incarcerated in offshore detention. IHMS is a wholly-owned subsidiary of International SOS, in turn a subsidiary of the Singaporean conglomerate, AEA International Holdings, that was initially set up to provide emergency evacuations to rich expatriate communities in Southeast Asia. These companies now specialise in so-called ‘medical and security services’ in ‘high risk’ environments, with the US military reportedly being International SOS’s single largest client. Last month, IHMS’s detention health service contractual arrangement was revalued as worth over AU$406 million (UK£225 million), only a fraction of the overall estimated AU$9 billion cost of offshore detention to date.

IHMS’s provision of healthcare under such contracts has been characterised by evidence of poor medical standards, ‘aggressive’ profit-maximisation, alleged breaches of privacy, and fiscal mismanagement. Rather than isolated aberrations, such practices demonstrate a systemic failure to properly care for refugee lives. This can be seen, most vividly, in the death of 24-year old Iranian Hamid Khazaei in September 2014, who died after receiving inadequate healthcare for a minor leg infection after presenting to the IHMS-run clinic in the Manus Island detention centre. The Queensland coroner relied extensively on medical evidence to find that Hamid Khazaei’s death would have been entirely ‘preventable’ had he received a more timely and accurate diagnosis and prompt medical evacuation to Australia. But the coroner’s reasoning demands further consideration, particularly in terms of how it constructs the topography of the medical border. Recognising that Hamid Khazaei’s death occurred within the ‘broader context’ of Australia’s offshore detention policy, the coroner held that Hamid Khazaei was legally entitled to a medical standard of care ‘commensurate with the care he would have received in a remote clinic in Cape York’, a seemingly equivalent ‘remote’ location in Australia, and one where the majority of the permanent population are Aboriginal and Torres Strait Islander people. This particular standard thus equates the care that the Australian government owes to refugees in offshore detention to that of Indigenous people in Australia, people who have been the overt target of racialised practices of state violence, incarceration and dispossession and who consequently have lower health outcomes and life expectancies than non-Indigenous people in Australia.

The place of medical personnel and expertise in Australia’s border regime was further transformed and consolidated through de-incarceration advocacy efforts, including litigation, that sought to compel the Australian government to evacuate people from offshore detention. These have, in part, taken the form of a series of court orders that rest upon asserting Australia’s legal duty of care towards people in offshore detention; and more recently, the short-lived Medevac Law that instituted a process for transferring sick refugees from offshore detention to Australia for medical care provided two Australian-registered doctors deemed it necessary and that the healthcare was unavailable on PNG or Nauru. While the Medevac laws were repealed in February this year following sustained government opposition, nonetheless, around 140 people were transferred to Australia under the process. Many of these people are now held in indefinite closed detention in suburban hotels in Australian cities that act as so-called ‘alternate places of detention’ (or APODs in the bureaucratic lingo), where both social integration and recovery after the horrors of offshore detention are just as impossible as enacting COVID-19 social distancing precautions.

COVID-19 and Contestation in/of Medical Borders

In recent months, the rapid reorganisation of life on a global scale in response to COVID-19 has seen the overt medicalisation of both state borders and refugee lives. Australia’s response, like elsewhere, has mobilised and intensified the logic of the medical border in order to ‘protect’ its population from the perceived threat posed by infected ‘outsiders’. Within Australia, this has been accompanied by closing internal borders between federated states and territories; extending police powers and lock-down measures in a way that disproportionately targets racialised migrant communities; and providing state economic relief that largely excludes non-citizens and people who are not legally-recognised permanent residents. Yet, like other states with large immigration detention populations, the pandemic has also given rise to renewed refugee rights campaigns, led by refugees themselves alongside doctors, academics and advocates, that insist on urgently releasing people from immigration detention on public health grounds, including transferring people from offshore detention to Australia. But, unlike in, for example, the US and UK where such actions resulted in limited releases from immigration prisons, to date, in Australia they remain unsuccessful, ironically in part due to Australia’s comparatively low community transmission rates. Yet the resurgence of COVID-19 infections in Victoria last week, including the confirmed case of a APOD staff member, mean, in the word of one detainee in Villawood immigration detention centre, refugees in Australian immigration detention remain “sitting ducks for COVID-19”, actively protesting their incarceration during a global pandemic and drawing attention to the multifaceted practices of border control that expose them to a heightened risk of infection.

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How to cite this blog post (Harvard style) 

Dehm, S. (2020). The Entrenchment of the Medical Border in Pandemic Times. Available at: https://www.law.ox.ac.uk/research-subject-groups/centre-criminology/centreborder-criminologies/blog/2020/07/entrenchment [date]