Borders and migration: an issue of global health importance

Comment Borders and migration: an issue of global health importance The movement of people has featured throughout human history; so substantial is the legacy of migration that the freedom of movement within and across borders was enshrined in article 13 of the UN Universal Declaration of Human Rights in 1948. The UN estimates that 232 million people migrate between countries annually.1 In recent years, political unrest and conflict in parts of the Middle East and north Africa have redefined regional patterns of migration. In response, high-income countries, principally member states of the European Union (EU), have taken increasingly violent measures to police their borders, and to regulate the entry of individuals considered neither economically valuable nor deserving of state protection as prescribed by the often narrow and complex interpretation of refugee and asylum legislation. For the EU, the enforcement of the external border of 28 member states continues to manifest in different ways: in 2009 the Italian Government and specialist surveillance and policing agency Frontex forcibly returned people found at sea to Libya, a practice later deemed illegal by the European Court of Human Rights; on Morocco’s northern coastline, the Spanish authorities have constructed 6 m high razor wire fences around the enclaves of Melilla and Ceuta; in May, 2015, the British Government appealed for approval from the UN to launch a military response in Libya, with the intention of destroying boats and staging points implicated in attempted ocean crossings. As Grove and Zwi2 observe, increasingly complex measures used to deter refugees and other individuals fleeing conflict, socioeconomic inequality, and other manifestations of structural violence have placed an emphasis on protection from the refugee above protection of the refugee. As a result, both the humanitarian and welfare aspects of migration are superseded by the desire to restrict the movement of people.3 Such skewed priorities have a catastrophic effect on health; UNITED for Intercultural Action has attributed a conservative 22 394 deaths between January, 1993, and June, 2015, to the policing and border control measures in place across Europe.4 These tragic statistics draw attention to a migratory process that is fraught with danger.5 Conflict, internal displacement, poverty, and chronic health inequities are often responsible www.thelancet.com/lancetgh Vol 4 February 2016 for substantial predeparture morbidity. During the transitory phase, tighter border controls and associated programmes of involuntary detention have forced people to attempt extraordinarily dangerous border crossings.2 In desperation, an increasing number of people have attempted to enter Europe by sea, despite frequent reports of suffocation and physical injury in crowded vessels, dehydration and hypothermia secondary to prolonged exposure to extreme temperatures, and drowning.2 Irrespective of the chosen route, or of an individual’s migratory status, violence perpetrated by border officials, and the stress and psychological trauma associated with the experience of migration, is often compounded by an inability to access basic medical care and other essential services.6 The repeated exposure to institutionalised mechanisms of marginalisation and discrimination in turn generates what has been described as a cumulative vulnerability.6 The negative health effect of Europe’s protectionist policies is so dramatic that humanitarian organisations have launched their own emergency programmes across the continent, from Calais in northern France to the Greek islands of Kos and Lesbos in the southern Mediterranean. In Calais, Doctors of the World’s medical teams have treated patients with complex psychological issues; a multitude of minor injuries, fractures, skin problems and scabies; diarrhoeal diseases; acute and chronic respiratory infections; complications secondary to exposure to tear gas; and more. In southern Europe, the organisation has also documented a growing number of displaced women and children, many of whom will inevitably require specialist paediatric and obstetric care if present conditions persist. The adverse effect on health of both the violent policing of borders, and the exclusion of vulnerable groups once they have crossed such borders, is a matter of grave global health significance. Increasingly broad theoretical interpretations of global health, and the recent introduction of a framework for planetary health, have largely skirted more meaningful engagement with the relation between borders, sovereignty, policing, and health. Notable exceptions include the 2014 Lancet– University of Oslo Commission on Global Governance for Health, which emphasised that an “increase in irregular e85 Comment migration reflects policy choices and legal definitions poorly adapted to present realities”,5 and a provocative commentary authored by Frenk and other prominent global health advocates7 earlier in the same year, which drew on globalisation and our resultant interdependence to call for a “global society”, which in turn would transcend the inherently reductive nation state. Europe’s ongoing refugee crisis and the underreported injustices endured by other crisis-affected communities worldwide, are indicative of a system of global governance that does not place equal value on human life. In a world in which capital and commodities flow more freely than compassion and humanity, a fundamental friction exists between the expression of solidarity and the protection and promotion of sovereign interests. Only with a radical reimagination of the practice and study of global health, and of the systems and ideologies that remain a threat to health, can we ensure that the needs of the most vulnerable are prioritised above all else. LD is the Executive Director of Doctors of the World UK, an organisation that provides essential medical care to excluded people at home and abroad, while fighting for equal access to health care worldwide. We declare no other potential competing interests. Copyright © Smith et al. Open Access article distributed under the terms of CC BY. 1 2 3 4 5 6 7 UN Department of Economic and Social Affairs. International migration report 2013. New York: United Nations, Department of Economic and Social Affairs, Population Division, 2013. Grove NJ, Zwi AB. Our health and theirs: forced migration, othering, and public health. Soc Sci Med 2006; 62: 1931–42. Karmi G. Migration and xenophobia in the Mediterranean. EuroMeSCo conference; May 16, 1998; London. In: Pugh M. Europe’s boat people: maritime cooperation in the Mediterranean. Paris: Institute for Security Studies, 2000: 24. UNITED for Intercultural Action. List of 22 394 documented deaths of asylum seekers, refugees and migrants due to the restrictive policies of Fortress Europe. 2015. http://unitedagainstrefugeedeaths.eu/aboutthe-campaign/about-the-united-list-of-deaths/ (accessed Aug 28, 2015). Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Médecins Sans Frontières. The illness of migration. Ten years of medical humanitarian assistance to migrants in Europe and in transit countries. London: Médecins Sans Frontières, 2013. Frenk J, Gomez-Dantes O, Moon S. From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence. Lancet 2014; 383: 4–10. *James Smith, Leigh Daynes Homerton University Hospital NHS Foundation Trust, London, UK (JS); Junior Humanitarian Network, London, UK (JS); and Doctors of the World UK, London, UK (LD) [email protected] e86 www.thelancet.com/lancetgh Vol 4 February 2016