White beaches, palm trees, a sparkling turquoise sea under a blue sky speckled with white clouds—Manus Island appears to be the archetype of a tropical paradise when observed from afar. For several hundred people, it is rather the opposite: here, 3700 km north of Canberra, Australia’s capital, on an island which is part of Papua New Guinea, the Australian Government detains refugees and asylum seekers accused of trying to enter Australia “illegally” by boat. For several years, inmates were “processed offshore” and held in a facility called Manus Island Regional Processing Centre (MIRPC). Since the Supreme Court of Papua New Guinea intervened, they may roam about the island but still not leave it. And they have no way of knowing for how much longer their “administrative detention” will last.

Behrouz Boochani, a writer, journalist and political scientist who had to flee Iran, ended up in detention on Manus Island in 2013 after narrowly escaping a disastrous shipwreck off Indonesia. He wrote about his experiences, transmitted his texts (often clandestinely in small snippets by SMS) to Omid Tofighian, a researcher and activist at the University of Sydney who translated Boochani’s work. The resulting book, “No Friend but the Mountains. Writings from Manus Prison”, appeared in 2018 and won Australia’s prestigious Victorian Prize for Literature and the Victorian Premier’s Prize for Nonfiction in January 2019. As of May 2019, Boochani remains on Manus Island.

“Manus prison”, as in the subtitle of Boochani’s book, is a misnomer. Manus lacks the goals of a modern utilitarian prison: it does not promote personal reform, as would be expected from a correctional institution. Its contribution to protecting the public is negligible, given that the “offence” of crossing a border and seeking asylum is not a danger to communities. Most importantly, a prison system entails due judicial process, judicial oversight, and appeal. MIRCP, in this respect, came closer to a concentration camp, defined as a place “beyond the law” (Stone 2016).

Sociologist Erving Goffman (2007 (1961)) speaks of a “total institution” when the three spheres of life—sleep, play and work—are organised for a group of people under one authority which thereby extends social control. Offshore detention falls under Goffman’s description. Structural “elements” that are shared by total institutions comprise the bureaucratic organisation of blocks of people; their constant surveillance; and their exclusion “from knowledge of the decision taken regarding [their] fate”, e.g. the duration of detention. Total institutions develop procedures to disrupt self-determination, autonomy, and freedom of action of inmates, with the intention to stifle resistance. Goffman subsumes such procedures under the heading “mortification”. Mortification is inflicted, e.g. through degrading admission procedures; by issuing of uniforms; by having to beg for daily necessities, including essential medical and dental care and medications; by suppressing work or play, thus instilling boredom; and by reduction of privacy. Boochani’s book teems with examples illustrating mortifying procedures, from ill-fitting uniforms to chaotic food dispensing. In a particularly poignant incident, Manus inmates drew a backgammon board on a table. The camp officers almost immediately crossed out the game, stating that games were prohibited—an action comprising mortification in several regards (Boochani 2018).

The health consequences of indefinite administrative detention can be grave. Detainees report experiencing humiliation, loss of agency and hopelessness due to the symbolic violence of detention, which may lead to re-traumatisation (Cleveland et al. 2018). Suicide, severe mental and physical decline, permanent disability and self-harm are documented as consequences of detention on Manus Island (Amnesty International Australia and Refugee Council of Australia 2018). The focus of well-meaning policymakers and health professionals to this grave symptomatology was for a long time a call for providing appropriate medical treatment, rather than eradicating the underlying structures. Treating the health consequences of politics without addressing their role in aetiology not only runs the risk of pathologising human responses to inhumane detainment. It also misses the opportunity for medicine and public health to be part of the political accountability mechanisms.

Boochani’s experiences are Kafkaesque, given the absence of fair legal recourse. His work is also an archetypal twenty-first-century epic, a contemporary Odyssey. This Odysseus travelled not only literally across oceans, but also metaphorically through the horrors of the (under)world of detention. Such voyages are not restricted to Australia. Andrea Pitzer (2017) observed that “[p]olicy planners will always return to mass detention, because it seems as if it should work, and it feels as if it could be done humanely”. We see this in the EU’s plans to set up extraterritorial refugee reception centres in Libya (Martens et al. 2018). Boochani’s harrowing account reminds us that the conditions imposed by “turn back the boats policies” and “offshore processing” of refugees and asylum seekers in detention camps, which will impact millions given current global politics, are such that health personnel cannot remain neutral (Dawson et al. 2018). The public health community must do more than demand adequate medical care for detained refugees: we should speak out against camps.