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Time for global health to zoom in on migration

Migration is on the rise globally, not only  between low/middle income and high income countries, but also within countries (rural-urban migration). Lately there has even been some migration from developed countries in crisis to former colonies in better shape economically. Currently, a lot of attention is being paid to migrants trying to reach Europe due to a series of humanitarian disasters. Other dangerous routes and reasons for migration across the world are abundant with similar stories of struggle and tragedy, but due to recent events, this post will focus on migration through the Red Sea and the Mediterranean. In total, more than 22,000 people have died trying to cross the Mediterranean Sea to get to Europe since 2000. However, the number of migrants and deaths has increased in the past few years. For instance, in 2014 more than 3,000 deaths were recorded whereas in 2015 (shortly after wishing each other a prosperous life on New Year’s eve), more than 1,500 people have already perished in less than 4 months, the worst record in history so far. In April 2015, more than 900 migrants from one boat alone died while crossing the Mediterranean. If policies don’t change, the  death toll is predicted to reach as high as 30,000 this year, with few promising solutions on the ground.  Many vulnerable people also attempt this risky crossing, including children and the elderly. So far, many of the migrants are from the Middle East and Africa, including Syria, Eritrea, Somalia, and more.

The Mediterranean is not the only one claiming lives, particularly of Africans. The Red Sea is another major migration route, where human traffickers often use unseaworthy boats to smuggle African migrants to Yemen, seen as a gateway to wealthier parts of the Middle East, like Saudi Arabia and Oman, and Europe, as reported by Aljazeera. Tens of thousands attempt to cross the Red Sea into Yemen every year, and hundreds have died during this journey. Even now, with Yemen in war, many people still attempt the journey. A BBC documentary  estimated that about 80,000 Ethiopian migrants undertake this dangerous journey every year. In December 2014, BBC reported that a boat carrying Ethiopians sunk, killing 70. And those are just the figures we are aware of, many people drown (or are even thrown overboard by human smugglers) in the Mediterranean and Red Sea without us knowing.


Migrants vs. Refugees

Before lumping together everybody trying to get to Europe under the term “migrant”, as is currently being done, we need to differentiate between migrants and refugees. The 1951 Convention Relating to the Status of Refugees and its 1967 Protocol defines a refugee as a person who leaves his/her country due to oppression and insecurity, while a migrant leaves for other reasons like economic, study, or family opportunities. Therefore, genuine refugees are often fleeing conflicts and discrimination, while migrants are seeking employment or reunion with families. Our current focus is on both refugees and migrants (although we shall refer to them as migrants), even if we agree with Nick Clegg that they are first and foremost people. Unfortunately, a major driver of migration at the moment is human trafficking, as many legal ways to enter Europe (and other developed regions in the world) have been closed in recent years. Traffickers are paid by people to help them cross over to Europe, and yet they know that the chances of success are slim. Additionally, the growth of media and expansion of social media networks have made the world a ‘global village’ now, leading many people to seek what they believe to be better lives in more affluent parts of the world.


The Plight of Migrants

The causes of death during these journeys are plenty, including drowning, poor conditions on the ships, and overcrowding. Migrants are often in the hands of unscrupulous traffickers, suffering torture, abuse, and rape. They risk being exploited by criminal gangs and the Yemeni military in the 500 km trek across Yemen to the Saudi border, as well as by criminals in lawless Libya, which has become a major trafficking hub after the death of Gadaffi. The journeys undertaken by migrants across places like the Mediterranean and the Red sea are full of hardships, and many suffer from desperate deaths. Some survivors of these perilous journeys have narrated that when they tried to refuse to board the boats at the last minute, they were forced to do so by traffickers.

Migrants are viewed and welcomed differently, depending on the receiving countries. Some African countries like Uganda and Kenya have hosted refugees for many years, in camps and within the communities. Uganda, despite its status as a developing country, has been noted for its hospitality and asylum policies. For example it is currently hosting an estimated 139,000 refugees from South Sudan, most of whom can access lifesaving protection and assistance services, in addition to others from the DRC, Somalia, and other countries. It works with the UNHCR and other partners to provide safety, services, and above all to save lives during humanitarian crises. Kenya also hosts many refugees and asylum seekers, for example in 2015 it is expected to be hosting more than 650,000 in total, 70% of whom are from Somalia. This has also been done without much hostility, until the recent Al-Shabaab attack on Garissa University where 147 lives were lost, causing the Kenyan Government to demand for the relocation of the Dadaab refugee camp that is suspected to house some of the terrorists.

The African examples are in almost total contrast to the current lack of hospitality shown by European countries. The deaths among migrants crossing the Mediterranean have highlighted the low level of real concern for migrants’ lives, in spite of lamenting statements by European leaders in the wake of human tragedies in the Mediterranean. As a European observer noted this week, if there a few tens of people drowning in the Mediterranean, European leaders pretend not to know. If a few hundred die, European leaders get emotional. If 800 people die, there will be teary and grim looking European leaders, a crisis summit and one minute of silence for all the victims, but still, not much will change. What we need are functional policies, backed by strong leaders and regulated by the appropriate authorities with sufficient resources to address the scale of the challenge.  The average citizen too can play a role by demanding appropriate responses to such tragedies. Cynically, to stay in public favour, quite a few European leaders use public opinion to determine how to respond to tragedies, whether under ‘human right’ or ‘migration’ law.


The Politics of Migration

The Mediterranean tragedy has complex origins, one of them being the war led by the West in Libya. If we were to put to the same extent of resources put into the Libyan war into preventing deaths in  the Mediterranean, it is safe to say we would get the humanitarian situation under control. However, the world is acting as though creating unsafe routes for migration  is a deterrent tool. The migrants seem to be viewed as economic migrants who are taking a calculated risk; however, many of them are from Syria and have limited options for security and peace. It was not until the absurd rise in deaths recently that this caused an outrage. This led to the EU leaders crisis meeting on migration. But already, organisations like MSF say the summit fell short of expectations for meaningful change.

The negative reactions towards migrants in many destination countries in the West stem from a number of causes:

* Lack of acknowledgement of migrants’ contribution to destination countries. For instance, in UK politics, the election debate on migration is overwhelmed by talks on the costs (but rarely benefits-e.g. brain drain) of migration.

* The economic state of some destination countries with huge areas of poverty, like South Africa (an outlier in Africa), where unemployed nationals blamed migrants for their situation, resulting in xenophobic violence against African migrant workers. This might be the case particularly when immigrants are likely to be better educated and more resourceful than locals – and the local response may be to turn to violence to stamp out the competition. In Europe, as some (increasing?) groups in society don’t benefit from globalization, or even suffer austerity policies (like in Greece), the ground for xenophobia has become more fertile (and this puts mainstream politicians under pressure as well).

* When democratic institutions are also perceived to be failing, people increasingly seek answers in populist, tribalist, ethnic and fundamentalist “solutions”. They look for scapegoats, whether they are labelled as “capitalists”, “settlers”, or “foreigners”. Thus people might respond violently.

* Government officials and respected traditional leaders may also mislead people of a given country regarding foreign migrants’ roles as recently happened in South Africa

* Governments may want to better guarantee the security of their population, as in the case of Kenya, especially when terrorists exploit the rotten system to carry out their mission.


The West has, until recently, mainly seen globalization to its advantage, as a primarily economic phenomenon marked by the influence of a few giant firms, the dominance of economic activities by the omnipotence of a single market in global scale and financial strategies which now regulate the course of the world. The West, or at least the corridors of power in the West, also had a rather benign view of globalization, as “a rising tide lifting all boats” eventually. It is perhaps time to realize that true globalization is also the freedom for individuals to settle where they wish. In an increasingly liberalized and interconnected world, one should realize that there is no only commercial properties, goods and commodities, capital, … that can travel from the North to the South, and back, but also accept that more and more people migrate from south northward in search of greener pastures, just like northern products flock to southern markets in search of profits, or resources are extracted from the South and then go to stronger economic regions in the world. In the last fifteen years or so, the migration picture has become more complex, with not just South-North migration of people, but also migration to the Middle East, China (and vice versa), and other booming economic regions. Add to this a more volatile world with more hotspots than ever, and it’s clear that the system has to change. We’ve reached a tipping point.


The role of the Health Sector in Migration

As young health systems researchers in Africa, we would like to point out that an aspect of migration that has been somewhat ignored by the global health community is the health of these migrants and their impact on local health systems. When the global health community discusses migration, it is mainly with respect to brain drain of health workers.  Other migrant-related health (and also health system) issues get some attention, but not that much, comparatively. Could this be because migration is too “political”, that powerful global health stakeholders are well aware of the controversial nature of this issue among Western leaders, and that quick and relatively ‘innocent’ techno-fixes are thus not possible to address this issue?  Or is it due to the fact that most of us are far away from migrants, who are just nameless faces somewhere across the globe that have brought their fate upon themselves? Or is it because many in the global health community are doctors themselves, and thus naturally tend to focus on an issue like brain drain of health staff? Or because good evidence is lacking, in many parts of the world, on the predicament of migrants? There are probably many reasons for this relative neglect of migration-related health (system) issues, but it seems clear that this has to change.

Clearly, migration does have far reaching effects on health and health systems of the migrants, in both the countries of origin and host countries. Often, migrants arrive very sick, suffering from petrol burns, dehydration, scabies and lice, or even gunshot wounds. Many have suffered sexual violence, as well as psychological and emotional trauma as in the case of torture camps in Yemen.  Therefore, as soon as they arrive in the host country or are rescued, they require urgent medical attention in order to avoid further mortality and morbidity.

It is no doubt true that the rise in migrants may stress the health systems in the receiving countries, but all human beings have the right to health as enshrined in the International Covenant on Economic, Social and Cultural Rights (1966). Besides, certain diseases spread easily, so if the migrants do not receive good quality healthcare, then an epidemic can easily erupt (case in point, if a migrant arrived with ebola or tuberculosis). Nevertheless, in many cases migrants who live in a country illegally (having “made” it into Europe)  have challenges accessing health services.


Ways Forward

At the third Global symposium held in Cape Town in 2014, although the theme was “Science and practice of people-centered health systems”, there was no session on migration. As we prepare for Vancouver 2015, so far there is still no – direct – discussion of migration and its effects on health and health systems scheduled among the themes, although there are related topics like mobility of health workers, health systems in conflict, global political economy, and possible causes of migration (like climate change) might be briefly touched upon in other sessions. The current migration crisis fits right into the fourth symposium, we feel, because many of the migrants are escaping problems like non-existent health services. Additionally, migration is a complex issue that affects health globally. Therefore, this can be a platform on which to highlight existing problems and advocate for better services in the countries of origin. Studying this issue may also result in innovative ways in which to provide medical care to the migrants on arrival, and reducing stress on host countries health systems.

What then do we as young Africans (living in Africa) believe would have an impact?

* Provision of quality healthcare for migrants is of utmost importance on their arrival, regardless of whether they qualify as refugees or not (before being sent back to their homes, they should also be checked to make sure they have not picked up any diseases). The rescue boats should have medical staff and be able to provide basic care, while the transit services should provide a wider range of services.

* Migration needs to become a priority in the Sustainable Development Goals agenda – for the moment, it’s not an SDG goal (it is politically very contentious). Many goals are indirectly linked to migration, though (by taking away the incentive for people to move in the first place). But is this enough? Would migration not require more high-level political attention, by being included as a goal? Why is it that Europeans, Australians and Americans don’t have trouble to go anywhere, and get a visa easily if needed, but the same is anything but true for Africans? If capital can move freely, why not people? Is money more important than human beings then in this world? It’s clear that, if people could move freely, the incentive to set up a global social protection floor would suddenly become much bigger.

* The global health systems research community should pay more attention to this gap, and carry out studies focusing on the effects of migration on health systems. They could analyze migration in light of global social protection, human security, and complexity.

* It is important for grant makers and donors to dedicate some funds to health systems strengthening in the host countries as well, particularly areas like Italy, Greece and Malta where many of the migrants arrive first. The health systems of some of these host countries are in trouble themselves, currently (with Greece as a case in point), or sometimes not organized very well.

* We hope that, just like the recent Ebola crisis in the West Africa has led to some promising progress in the area of global health security (such as the establishment of an African CDC, and reorganization of WHO’s house), perhaps the migrant tragedies that have occurred this year might have the same impact for global migration? (MSF, for one, is certainly trying to get the issue higher on the political agenda, and the global health community should fully support them)


At a more general level, migrants are well aware of the risks they could face on the journey, but that is not stopping them. They see the boat as the only chance that they are left with. One could say that nothing will stop them from taking the risk by attempting the dangerous journey across the Mediterranean so long as conflict, violence, abuse and poverty are rampant back home. Therefore, making their home countries stable should be included in agendas on migration, even if that’s easier said than done. This requires more diplomacy than external intervention this time round, so that African democracies and economies can be boosted and managed by Africans themselves. If implemented, such tangible efforts might help in solving the humanitarian crisis rooted in migration.  We do not deny that our own governments in Africa and the Middle East have a huge responsibility themselves for the current predicament, but it would certainly help if European and American countries had coherent policies in place to help development in North-Africa & Middle East, rather than prop up dictators and authoritarian regimes, and occasionally come up with the ‘responsibility to protect’ to remove them (and then start all over again with a new strongman). Or as Michela Wrong rightly put it in Foreign Policy, UN checklists are not enough.

Migration is a priority for development, and can be an effective way of reducing global poverty, as well as a powerful tool to achieve a better, more equitable world.  Furthermore, sustainable efforts to build stable governments and thriving economies across Africa is probably a promising way forward to tackle the crisis.  The western countries should uphold their moral duty to humanity (like the poorer African countries do) and not use such crises for political propaganda that will not help to devise real solutions.

The current crisis demonstrates that Europe will never be the same again. Europeans will no longer remain like goldfish in their fortress Schengen because they will never be in peace as long as deficiencies and hungry will remain at just a few miles from their shores. Between the West and the developing countries, we need a win-win partnership, with mutual benefits for both sides.

Some wonder whether Europe should accommodate all the misery of the world. Perhaps the question that should be asked, though, is whether it is not the migrants who take all the misery of the West: their declining population, their dirty production, their aging population, ….; in this sense, Europe should be seen as welcoming the wealth of the world. As the global North and South engage in pointing fingers of blame, it’s worth re-focusing the philosophy of our global village to include shared responsibility and mutual accountability across borders. It has taken all of us to contribute to creating these complex problems and it will take all of us to find solutions.

Let’s not forget it’s our brothers and sisters making the difficult and often horrendous journey to Europe and other more “developed” parts of the world, with many of them losing their lives on the way. We owe it to them to change the system for the better.





Acknowledgement: some inputs & editing assistance were provided by Dena Javadi & Kristof Decoster

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