Category Archives: Humanitarian Spotlight

Tackling the Complexity of the Yemeni Crisis

Learn more at our upcoming event at Fordham University.

New York City, April 10, 2017 – Two years after the onset of conflict in Yemen, the country is facing one of the worst humanitarian crises of our time. Despite the two million Yemenis internally displaced, seven million at risk of famine and 18.8 million in need of humanitarian aid, less than 10 percent of the United Nations two billion dollar humanitarian appeal has been met by donor nations and nations party to the conflict have done little to cease hostilities.

Giulio Coppi, Institute of International Humanitarian Affairs Innovation Fellow, recently embarked on a fact-finding mission to Oman and Djibouti to study the impact of the crisis and subsequent forced migration in the region. He sat down with the IIHA Communications Officer, Angela Wells, to recount his findings.

What was the goal of your recent research trip on the Yemeni crisis?

This recent research trip led me to study the regional impact of the Yemeni crisis, with a special focus on migration and health. I traveled through Oman and Djibouti, meeting local actors and visiting refugee and migrant communities. I also tried – unsuccessfully – to enter Yemen to meet people and local organizations. I really focused on understanding what lies beneath the surface of the most banal crises in the current media landscape.

 

How would you explain the Yemeni crisis to someone unfamiliar with what lies beneath the surface of the crisis?

To an outsider with little background, Yemen could look like just another case of civil war due to bad governance and political instability, or maybe another country engulfed in sectarian and religious violence. The truth is much more complicated than that: Yemen is being intentionally strangled economically, militarily and politically by internal and international actors involved in a conflict with profound historical and geopolitical roots.

Yemen was recently listed as one of four of the most serious humanitarian crises of our time. Can you explain the situation provoking people to flee the country and the complexities humanitarian workers are dealing with within Yemen?

The inclusion of Yemen as one of four of the most serious humanitarian crises of our time comes right after its definition as a forgotten crisis. The country passed from oblivion to full spotlight in a matter of days. This is mostly due to the adoption by some organizations and UN agencies of the keyword “famine”, that immediately made it to the headlines.

Unfortunately, this leads to yet another oversimplification. It generates the false impression that all is needed is to fund agencies that deliver food. This action alone would be shortsighted and ineffective, as the situation requires a much bolder response. Humanitarians are faced with a daunting task: replacing the whole public and private sector that has been wiped away by sanctions, embargoes, violence, and corruption. Overstretched and exposed, humanitarians increase their risk of being perceived as non-neutral, or partial, and becoming a target for further violence.

We know that mixed migration flows to and from Yemen are very complex with migrants from the Horn of Africa fleeing to Yemen and Yemenis fleeing to the Horn. Can you explain this in more detail?

Due to its strategic position, Yemen has always been a crossroad of nations and people. The escalation of the conflict in 2015 resulted in a temporary suspension of the migratory movements of people from the Horn of Africa, most notably Ethiopia and Somalia, towards the Arab Gulf countries.

It is counterintuitive, but with the conflict, these figures have actually increased. Some migrants do not know about the conflict, but others actually hope the collapse of internal governance could facilitate their journey. Unfortunately, this is far from the truth. Saudi Arabia and Oman have sealed and militarized their borders, and militias control most areas of Yemen, who kidnap for ransom and often abuse migrants.

On the other side, Yemenis fleeing to the Horn of Africa has actually dwindled. I found that Yemenis prefer to seek asylum in countries more culturally similar and with more economic opportunities. Most of the refugees who sought safe haven in Djibouti tried to move on as quickly as possible, once they realized the hardship of living as a migrant in the country.

What is the reality for Yemenis fleeing to nearby countries like Djibouti and Oman?

 For most Yemenis arriving in Djibouti, one of the poorest countries in the world, they are really shocked at the conditions in the camps. Markazi camp, where they are hosted, is a camp in the middle of a desolate desert. The closest city, Obock, is a provincial town without markets or livelihood opportunities. Food and other goods arrive from the capital city from time to time, while many items are still being brought in from Yemen. In summer, the camp is swept by the khamsin (dust storms with wind speeds as high as forty miles an hour), and temperatures can reach 120 degrees Fahrenheit. Refugees endure these conditions in tents, huts or in containers with no electricity and really meager food provisions.

In Oman and Saudi Arabia, conditions are much better for those who manage to enter and stay. In contrast to Djibouti, which grants all Yemenis prima facie refugee status, Arab Gulf States are not parties to refugee treaties and only grant standard visas. While initially they made a display of generosity towards their neighbors, that attitude quickly changed as it became clear the conflict would not be a short one. Today, those under official visas – like medical or study visas – are granted the same services as local nationals. Those who are not so lucky face exclusion from any assistance, and a constant risk of deportation.

Where else are Yemenis seeking refuge and what are they experiencing in these reception countries?

Today, the majority of Yemenis are not hosted by their next door neighbors, but have rather continued on their journey to seek asylum in Egypt, Jordan, and Lebanon, while some have been able to make their way to Europe or the United States. Yemen has a vast diaspora, and very often families have at least one member with a foreign citizenship allowing some refugees a chance of reunification with their community abroad, be it in Djibouti, Oman, Lebanon or Germany. Those who are able to join their communities abroad have a better chance for smooth integration and acceptance by local populations. However, coexistence isn’t always easy, especially when their expanded presence puts a strain on limited land and resources, which can destabilize local demographics and add further strain to existing public services.

Recently, a boat of Somali migrants was bombed 30 miles off the coast of Yemen by Saudi-backed forces. Do you see this as a worrying trend for the future or an isolated incident and why?

Unfortunately, this is not an isolated incident and I do not think it will be the last. The Bab-el-Mandeb strait, a vital commercial route, was already heavily militarized before the conflict and even more so today. Furthermore, this attack is representative of a worrying trend on the access of safe routes for forced migrants globally. We see around the world how increasingly innocent civilians trying to escape the perils of war are being directly and purposefully attacked in systemic and horrifying ways. This is not only in violation of international laws, but is a deeply worrying indication that humanitarian channels and national values for unfettered humanitarian access is more compromised than every before.

 Is there anything else you’d like to add?

In these times when all the attention is focused on Syria and the horrible tragedy in Syria, it is also important to remind everyone of the words of Peter Maurer, President of the International Committee of the Red Cross (ICRC): “Yemen after five months looked like Syria after five years.”

The level and extent of the destruction in Yemen is unparalleled for intensity and impact. What is worse, very little efforts have been made by the UN Security Council to call for safe humanitarian access, cross-border protection, or cessation of hostilities in Yemen. It is about time the UN Security Council, and involved parties to the conflict, adopt a more proactive role to end this conflict, before Yemen and its population reach the point of no return.

Non-Fordham guests must register in advance for the upcoming event Tackling the Complexity of the Yemeni Crisis.

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Syrian Voices: Customs and Traditions in Humanitarian Crises

Monday, March 6, 2017 – As conflict wages on in Syria, nearby countries have opened their doors to millions of new people seeking refuge. In Lebanon, one in four people is a Syrian refugee. While Lebanon is the biggest host of the five million Syrian refugees globally, truly integrating their neighbors into society has proved challenging for the small country where economic strains and competition for scarce resources is ever increasing.

House of Peace (HOPe) in Syria is striving to understand and address the evolving relationships of displaced persons within refugee populations, amongst their host communities and with non-governmental organizations.

Their new report, Syrian Voices, aims to raise voices, analyze opinions and propose positive recommendations for advancing integration and social peacebuilding. HOPe conducted workshops with around 300 participants, most of whom were Syrian refugees living in Lebanon but also Palestinians and Lebanese host community members.

“The main impetus behind this paper is helping people concerned with the Syrian crisis to see things from the eyes of those who are suffering the most; to contribute in bringing people from different points of views closer by helping them overcoming their prejudices and self-evident beliefs,” said Elias Sadkni, Director of HOPe and International Diploma in Humanitarian Assistance 39 alumnus.

Restrictions to integration. A major finding of the report was the ways in which government policy and NGO modus-operandi surrounding refugee response in Lebanon have changed the ways in which Syrian communities relate each other and their hosts.

Strict residency and labor laws for Syrians in Lebanon have made securing employment particularly difficult for men. Women, however, are more easily able to find work opportunities in the informal labor market and through the support of vocational trainings and services provided by organizations.

Perhaps even more disconcerting was the effect that strict work restrictions had on fueling forced marriage or labor on children in the country. In 2016, some NGOs estimated between 60 and 70 percent of refugee children are working and Human Rights Watch reported that more than 250,000 Syrian children were out of school in Lebanon.

“Harsh regulations that prevent most refugees from maintaining legal residency or working are undermining Lebanon’s generous school enrollment policies…With 70 percent of Syrian families living below the poverty line in 2015, many cannot afford school-related costs like transportation and school supplies, or rely on their children to work,” said Human Rights Watch.

The Syrian Voices report reiterated this point adding that “participants felt Humanitarian and UN efforts are not prioritizing educational establishments for Syrian refugees; in addition to this issue, the majority of educational establishments in Lebanon refuse to accept Syrians.”

Blurring cultures. Despite the challenges that come with displacement, Syrian participants also expressed that social solidarity amongst their communities remained strong in exile. This solidarity at times extended into their relationships with their host communities, and in turn caused the lines between Syrian and Lebanese cultures to blur.

“Many participants felt that adapting to Lebanese culture is causing changes in the customs and traditions of Syrian refugees. Some expressed dismay at these changes, fear their permanency, and believe they have been a source of intra-communal tension, whilst others embrace them,” said the report.

Improved humanitarian intervention. Other focus groups with NGO representatives examined the complex role NGOs play in the Syrian crisis.

Representatives voiced concerns that “their presence at times has contributed to existing tensions or created new ones”, because they failed to partake in adequate contextual and cultural analyses before implementing projects. Others noted a lack of transparency between donors and the community.

Syria Voices ultimately concludes in a list of recommendations for the humanitarian community to improve their continuing intervention, suggesting that humanitarian organizations begin to truly address the root causes of suffering amongst Syrians in Lebanon by:

  • Ensuring and advocating for equal access to adult education, vocational training and employment opportunities for Syrian adults of both genders;
  • Developing mechanisms for effective child protection from exploitation;
  • Enhancing educational opportunities for children;
  • Truly engaging with Syrian and Lebanese communities to better understand conflict
  • Improving communication methods between agencies in order to learn from each other’s experiences and best practices; and
  • Promoting more positive and less stereotypically harmful narratives about Syrian refugees in Lebanese media.

Ultimately, HOPe believes this report can be a guiding resource for the humanitarian sector, one that encourages agencies to question and improve their increasingly important response to the Syrian crisis.

Syrian Voices is a research-initiated project aimed at spreading Syrian perspectives on issues of social peace. The goal of the paper is to inform the humanitarian community, allowing stakeholders to implement recommendations and best practices to help resolve conflict in Syria and surrounding areas.

Andrew Seger, IIHA Communications Intern

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Fighting Ebola with Information

What can be learned from the use of data, information, and digital technologies, such as mobile-based systems and internet connectivity, during the Ebola outbreak response in West Africa? What worked, what didn’t, and how can we apply these lessons to improve data and information flows in the future?

When the Ebola outbreak hit West Africa in late 2013, the world was caught unprepared. The consequence: over 30,000 Ebola cases, including more than 11,000 dead, and billions of dollars lost across the global system.
In response to the outbreak, USAID joined with communities, governments, and organizations to help affected countries control and, ultimately, contain the disease. As part of celebrating this hard won achievement, the international community must reflect, learn, and act based on this experience to help ensure such a tragedy is not repeated.

This report is a contribution to that end. It focuses on one aspect of the multi-faceted response: the role of data and digital technologies. Grounded in over 130 interviews and peer review, the report surfaces a breadth of experiences and perspectives, and concludes with practical recommendations that health, humanitarian, and development actors should take to be better prepared for the next crisis.

Information was critical to the fight against Ebola. Both for responders, who needed detailed and timely data about the disease’s spread, and for communities, who needed access to trusted and truthful information with which they could protect themselves and their loved ones. Yet, as we now know all too clearly, the technical, institutional, and human systems required to rapidly gather, transmit, analyze, use, and share Ebola-related data frequently were not sophisticated or robust enough to support the response in a timely manner.

We must strengthen these systems. This is essential both to keep pace with diseases that spread with the ferocity and velocity of Ebola, and to be more resilient in the face of future threats.

Although the focus of this report is the need for strengthened capacity, systems, and use of data, we recognize that this alone is not sufficient. Our hope is that these recommendations are incorporated alongside new knowledge of effective public health interventions, preparedness, and priorities for health system strengthening. Ultimately, our willingness to engage these challenges–on a daily basis and within public health systems–will be the best predicator of our success in stopping similar events.

Let us learn from and act upon these lessons to do justice both to those directly affected by Ebola, and to the efforts that ultimately brought to heel one of the most significant health and humanitarian crises of the early 21st century.

This is the Foreword from the new USAID report, Fighting Ebola with Information: Lessons from the Use of Data, Information, and Digital Technologies in the West African Ebola Outbreak Response. The report details key findings and recommendations about the collection, management, analysis, and use of data and information in countering the Ebola outbreak in West Africa in 2014 and 2015. It reveals common sources of the confusing data picture, particularly in the early days of the response and examines the use of digital technologies to support data and information flows, considering both common barriers and insights from what worked. 

The report was co-authored by Institute of International Humanitarian Affairs Research Fellow Larissa Fast. Dr. Fast is a Fulbright-Schuman Research Scholar at Uppsala University’s Department of Peace and Conflict Research. Her current research compares the practices of data collection and use on the part of scholars and practitioners, focusing specifically on data collected by and about peacekeepers and aid workers. She is also the author of Aid in Danger: The Promise and Perils of Humanitarian Action.

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Featured Resources (WBG): Cash Transfers in Humanitarian Contexts

Upon request of the Inter-Agency Standing Committee (IASC) Principals, the World Bank agreed to coordinate a process of reviewing key issues and options for significantly scaling up the use of multipurpose cash transfers (MPCTs; including digital cash and vouchers) in the humanitarian space. The Strategic Note document, “Cash Transfers in Humanitarian Contexts,” lays out the main findings and options emerging from the process. The main text is complemented by a set of seven appendixes, detailing the process and feedback received, as well as presenting a thorough review of the evidence and evidence gaps in the comparative effectiveness of cash and in-kind programs across humanitarian objectives. This note synthesizes main issues and findings from the process, including defining overarching issues (section 2), setting out the overall context in which a wider use of cash should be considered (section 3), and identifying the specific areas to help unleash a wider use of cash transfers when and where appropriate (section 4).  

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Ecuador Earthquake Response: IDHA Alumni Working Together in the Field

IDHA 40 Graduates Wilson Gomez Vascones (left) and Rahul Singh (right) stand with Colónel Rueda

IDHA 40 Graduates Wilson Gomez Vascones (left) and Rahul Singh (right) stand with Colónel Rueda

Guayaquil, Ecuador (Wilson Gomez Vascones) – On Saturday April 16th at 6:58 PM, a 7.8 magnitude earthquake struck Ecuador; many local efforts started immediately, and in the days to follow, many governments and international organizations began arriving with different types of assistance. The organization that I coordinate here in Guayaquil, Red de Voluntariado Juvenil (“Youth Volunteering Network”), started planning how to best assist with food, shelter management, and also medical assistance in the sectors.

unnamed4Within the first few days of the Earthquake response, Rahul Singh, Executive Director of GlobalMedic and the International Rapid Response Team from Canada, contacted me to offer support and assistance right away. Rahul and I had met during the Institute of International Humanitarian Affairs (IIHA) International Diploma in Humanitarian Assistance (IDHA) Training Course in June 2013, and have since collaborated on building local capacity here in Ecuador. Rahul and I agreed that his team would arrive by Monday night while I worked on securing the necessary permission to operate on ground zero.

The experience that Rahul brought with him – experience gained through his assistance and support of various agencies in disasters and humanitarian emergencies – was invaluable. 13170044_10156821476380307_502367304_oWe visited every coordination table to assist with different relief operations and in addition to experience and knowledge, GlobalMedic assisted Ecuador in its Earthquake relief efforts by providing: the R4 incorporated finders team who, in coordination of Durán Fire Department, worked the whole week on Search and Rescue tasks confirming there were no longer victims under the rubble; AR10 units that produce 2400 liters/hour of potable water, AR3 units which are several trekkers that purify water by 240 liters/hour, and1,000 buckets of fresh rain that produce 3 liters/hour and work best for families; and several thousands of aquatabs.  GlobalMedic also provided a specialty group of drone pilots that flew over the affected areas mapping the areas and allowing for real time information and data to ensure the best resources for decision makers. This effort was done in coordination with the Secretariat of Disaster Risk Reduction (SGR) who requested the areas be mapped, and with the Ecuadorian Air Force that cleared the requested areas so the drones could fly without risks.

The Red de Voluntariado Juvenil continued the programs that were running while providing essential unnamed3logistics and coordination support to GlobalMedic. Now we have around 300 volunteers in the affected areas obtaining information for the next part of the interventions which will be to build houses with partner organizations such as Techo and Hogar de Cristo. The partner organizations also invited Fronteras, a Jesuit spirituality community that looks to serve the people in need where needed the most, to share their knowledge on accompaniment in order to serve better.

unnamedIt has being a great experience to work together with Rahul as IDHA alumni, and all the knowledge gained and shared during the IDHA back in 2013 has assisted us greatly in our work. We look forward to more opportunities to collaborate and we continue to build more great relationships with every course we take through the IIHA.

unspecifiedWilson Gomez Vascones is Coordinator of the youth volunteering network, Red de Voluntariado Juvenil, based in Guayaquil, Ecuador. He is also part of the volunteers at Guayaquil fire department (which has been run by volunteers for 181 years). He is a graduate of IDHA 40.

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Headlining: Helen Hamlyn Senior Fellow

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In February 2016, we featured IIHA Helen Hamlyn Senior Fellow Dr. Alexander Van Tulleken’s article about the European Migration Crisis, which was written shortly after his return from filming the BBC One documentary, Frontline Doctors: Winter Migrant Crisis. Alex, along with his twin brother Chris, spent two weeks observing and visiting camps and clinics throughout Europe to better understand the medical problems that migrants face. Earlier this March, the IIHA held a screening of the film, and Fordham News recently posted an article about the documentary and Alex’s experience in the camps. Alex was also featured in articles in the Evening Standard, Telegraph, and The Guardian.

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IIHA Alumni Reflection: Caitlin Cockcroft-McKay

MHCE 11 - Ethiopia 2015

MHCE 11 – Ethiopia 2015

In September 2015, I attended the Mental Health in Complex Emergencies (MHCE) training in Debre Zeit, an hour’s drive from Addis Ababa, the capital of Ethiopia. The training was organized by the Institute of International Humanitarian Affairs (IIHA) at Fordham University in collaboration with HealthNet TPO, UNHCR, and International Medical Corps (IMC).

I arrived to Ethiopia with my colleague Boniface Duku from South Sudan. He is the Mental Health Advisor for South Sudan’s programmes and at the time, I was the Coordinator for a Psychosocial Project we ran across four counties.

I had been to Addis Ababa before very briefly during a period of leave from South Sudan. However, this was my first time outside of the capital, and my first time to see the wonderfully serene surroundings of Lake Bishoftu where we were staying for the duration. Prior to the training, I had very few expectations due to the fact that I was so immersed in and consumed by my work in South Sudan that I hadn’t given myself the space to fully read up about the content of the course. All I knew is that it would be a prime opportunity to delve into challenges and opportunities of implementing mental health programmes in complex humanitarian emergencies worldwide. In all honesty, I hadn’t even researched the facilitators, who it turns out were renowned and highly experienced members of the mental health and humanitarian professional communities. Once I arrived and took some time to read the articles, look over the agenda and do a quick google of the facilitators I felt pretty sure that I’d lucked out on a potentially life-changing experience from which I would take away a vast amount of knowledge, experience and opportunities. I wasn’t wrong.

While working in South Sudan, I was also undertaking a distance MSc in International Humanitarian Psychosocial Intervention through the University of East London in the UK. Previously, I studied BSc Psychology, with a Professional Placement in a Psychiatric Hospital where I worked with people with severe mental health issues and those who needed additional support in the community. In my role as Psychosocial Project Coordinator in South Sudan, I was able to use some of these academic and practical skills to support people who have experienced trauma and high stress during the period of conflict, as well as during the displacement that ensued. I had never had comprehensive training or academic studies combining the two areas – the support of people with mental health issues within the context of humanitarian emergencies. The MHCE training was the perfect fit for me, and it provided me with information from a variety of sources, contexts and experts to supplement my academic background and work experience. Previously, I mentioned feeling privileged that I was put forward for this training by my organisation, HealthNet TPO. I stand by that and reiterate the fact, because the training did not only enhance my understanding in the short-term or specific context of South Sudan, it also provided me with lasting lessons and friendships with like-minded people.

During the training, the focus was primarily on clinical mental health service provision such as diagnosis and treatment of severe mental health disorders in fragile states, or disaster or conflict settings. This was extremely interesting for me as I hadn’t actually seen this up-close in South Sudan. There are limited clinical mental health services available in South Sudan as it is one of the most underdeveloped countries in the world. It has extremely limited infrastructure, very few resources and the personnel are few and far between, and when they are there they are barely trained, and when they are trained they are whipped up by better paying non-governmental organisations (NGOs) because they are often underpaid in government positions. This is extremely common, and desperately sad for the country, because it means the sustainability of any programming that requires government backing, continued resource supply or long-term supervision and follow-up from training is unlikely to withstand the restrictions mentioned. I also run a Psychosocial project, which although psychosocial issues and mental health issues are on a sliding scale, we aren’t able (given the context) to do very much in the way of clinical support. It was inspiring to hear the variety of challenging circumstances and experiences faced by the facilitators, in humanitarian emergencies across the world, spanning decades, and the innovative and varied ways they overcame and learnt from these situations. It gave me hope that even in the most dire of circumstances, in the least established countries, there are still opportunities where professional communities such as ours can at least initiate the conversation, create an evidence-base and forge the beginnings of quality and impactful work in relation to mental health service provision. Although, in terms of the situation in South Sudan, I fear these goals are still a long way off.

Since the MHCE training, I have been able to integrate some of the elements into my daily work, and I was able to facilitate conversations regarding coordination of mental health and psychosocial support mechanisms within South Sudan. I have referred information to other interested partners, and referred back to it on many occasions as I continued my project through December 2015. I also earmarked many of the readings and research articles in relation to my Masters. There was a wealth of information and knowledge imparted that was invaluable to me and my career development. I can’t fault the content or the delivery of the training as it was varied and engaging throughout. Upon my return to South Sudan, I felt I didn’t fully have time to absorb the content and the lessons learnt because I jumped straight back into work as soon as the training had finished. I am now taking the time to immerse myself in the training again and go through it with fresh eyes to really take on some of the wisdom I may have missed first time around.

At the beginning of December I was fortunate enough to be able to attend another IMC event, this time a workshop in Juba, South Sudan. It was a presentation of the current delivery of mental health services in the country, drawing on experiences from other countries, and the disparity between them. It became very clear from the presentations that the current level of the health systems within the country would be an unfertile ground for consistent, quality mental health service delivery. This, combined with the previous ten-day training in Ethiopia were starting to bring together a formation of ideas for me to present to the coordination mechanisms in country, as well as discussions about how we can document this. From the MHCE training it was abundantly clear that we need to step up our game as an international community in terms of creating and sustaining an evidence base to support our work. It’s not good enough to share ideas once a year at trainings such as this; we need to have a systematic way of recording our experiences, both positive and negative, to inform future project implementation.

Stepping back from the technical side: the lack of systems, infrastructure, resources, funding and personnel, the poor attitudes and awareness of mental health in the communities, is really devastating. It is truly heart-breaking to hear about individual cases of people who are systematically uncared for because there is just no support available, or lack of knowledge or understanding. People with severe disorders are often chained to trees in order to ‘limit their aggressive behaviour’. A common misconception, or an immediate knee-jerk reaction to people expressing symptoms of mental health issues, is that violence will ensue. Sometimes, it does, but is usually related to the negative response from the community and the lack of effective treatment.

Much of the mental health and psychosocial work carried out in South Sudan currently is focused on internally displaced people (IDP) settlements or camps, because the needs are extremely high. Many of these people have experienced extreme levels of trauma. Some of these people are just children, infants, who have lost members of their families or even seen them killed in front of them whilst fleeing violence consuming their homes and communities. The needs are usually imminent and acute, and require some follow-up but can ultimately, often, be dealt with by mobilising community support systems and resources that the person or family already has. Often whole communities flee together, so their social structures are still around them, it’s just a case of reiterating this and encouraging them to utilise them. The issue for the rest of the country is that it’s in a state of chronic emergency. It’s no longer a humanitarian emergency because the threat or risk of violence is lower in some areas. It’s not, however, in a development stage because as I’ve mentioned, the infrastructure is not there to build upon. Therefore, there is a vast majority of the country that doesn’t fall in this ‘emergency’ phase, requiring only the immediate psychosocial support. People living with mental health issues are at the back of the queue as they don’t fall in the ‘emergency relief’ beneficiary category, nor are they provided for by the services already in place.

The needs are clear. The solutions, however, are not. However, the kinds of trainings provided by the IIHA at Fordham University and IMC bring the mental health and psychosocial support (MHPSS) community within the NGO sector a step closer to understanding what it is that can be done. It helps us to direct the conversation at the ground level, at the national and international level and then to express the needs (and potential solutions) to the donors. The training in Ethiopia has really given me the direction I need both within my work in psychosocial programming, and also at the country level. I am able to feed into the coordination mechanisms and reference the training and experiences of experts in the field, in order to guide the discussion and suggest options for improving the provision of services. This is something that will take time. South Sudan and its mental health services is like a metaphorical Rome; it won’t be built in a day, but with experiences such as the one I had in Ethiopia, I do think with time and passion and imparting of knowledge, we can edge closer to supporting countries such as South Sudan to provide basic mental health services to their people.

Read the recap of the MHCE 11 course and read more about Caitlin’s experience on MHCE participant Sujen Man Maharjan’s blog. The next MHCE course will take place in October 2016 in Geneva, Switzerland. Learn more on the IIHA website.

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IIHA Helen Hamlyn Senior Fellow Reports on the European Refugee Crisis

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What Should We Do?

Contradictions and Complicity in the European Refugee Crisis

I spent 14 days in January filming a documentary about the medical aspects of the European migration crisis for the BBC. The premise was straightforward: to learn more about the health problems affecting migrants on different stages of their journeys. I have worked as a physician in humanitarian crises and for the last five years, I have taught and written about humanitarian responses in my job as the Helen Hamlyn Senior Fellow at the Institute of International Humanitarian Affairs (IIHA) at Fordham University. I didn’t think I was naive about the contradictions and complexities of humanitarian crises but those two weeks of filming presented me with the most appalling, astounding and complex set of circumstances I have ever seen.

I was co-presenting the documentary with my twin brother, Christoffer. We followed some of the migrants’ possible journeys from their arrival on the shores of Lesbos in Greece, to Athens, to the Macedonian border and, for some, into Serbia and then Germany. We finished our journey in the camps in France at Calais and Dunkirk. Migrants are not a monolith: their origins, aims and ambitions vary so widely as to make the label almost meaningless and as a result, there is no typical route through Europe. We chose these particular locations for filming because they are all places where people are forced to pause at a border and where, therefore, various organizations are attempting to meet humanitarian needs. We hoped we might be able to meet people as they paused and investigate their health problems and the organizations working to assist them.

Each of these locations revealed extreme need and vulnerability: trench foot, hypothermia and exhaustion in Greece; frost-bite in Macedonia and Serbia; psychological trauma and depression in Germany; the extreme public health threats of the camps in France. And each site provoked the question: “what should be done?”

In order to answer this question, let me describe the public health conditions I found in The Jungle Camp in Calais. I arrived at dusk (it is possible to simply drive off the main road and into the camp) and there was a dense pall of black smoke hanging over the crude, uninsulated wood-frame shelters that housed around 6,000 people at the time of filming. It was well below freezing and the black smoke was from fires that were burning a combination of plastic and wood – whatever fuel people could find – to keep warm and cook. The health hazards of burning plastic and air pollution are well documented: they are responsible for increased rates of respiratory tract infections, and other respiratory illnesses which significantly increased mortality in vulnerable populations like children and the elderly.

To this respiratory hazard was added, very shortly after I arrived, CS Gas (tear gas), fired into the camp by the French police. CS gas is interesting as a public health problem. Despite its widespread use in the U.S., there has never been a legal action against the police in the United States where anyone has successfully proved damage on health grounds from the gas. The medical literature is rather vague on its potential long term harms because it is very rarely used for routine, day-to-day law enforcement. But studies do suggest that exposure to CS Gas can cause heart and liver damage, severe respiratory damage and increased rates of miscarriage. It was clear to me after being CS-gassed once that this is an extreme hazard for the elderly, people with pre-existing respiratory problems, pregnant women and children. I asked about why the gas was being fired and was told (by NGO workers, camp residents and volunteers) that it was done simply to torture the camps residents. This was borne out by my experience: beyond simply being present in a group of people around a fire trying to keep warm, we had done nothing particularly to provoke the police. The ground around the periphery of the Jungle is completely littered with thousands of spent CS gas shells.

By the end of four days filming in the Jungle, the crew and I had hacking, productive coughs and our clothes and skin reeked of smoke. I spent an evening observing a clinic run by a camp resident, Shakir, a Pakistani nurse, who diagnosed us with “Jungle Lung.” His most common request from people seeking his care was for cough syrup: I saw over fifty people in one evening attend his caravan simply for this remedy. I’ve never put cough syrup very high on my list of essential drugs but for his patients it performed three roles: helped them, and the people crowded around them to sleep; it suppressed their coughs so they had a better change of silently hiding on a truck to get to the UK (the destination of choice for everyone in the camp); and perhaps most importantly, it provided a caring interaction more of the kind your mum might give than a medical professional.

The smoke and CS gas – and the respiratory and psychological problems they caused for the majority of residents – were most immediately apparent health threats on arrival in the Jungle. But these problems paled in comparison to other public health hazards.


 

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Over the four days I spent in the camp there was no running water available anywhere before 1pm (including the MSF/MDM clinic) because the pipes froze overnight. It is almost impossible to overstate the seriousness of this. It means that diarrheal illness can spread extremely rapidly. It means that people are unable to wash themselves or their clothes leading to a proliferation of skin infections and rashes as well as an epidemic of scabies (a kind of body louse) that seemed to be all but unstoppable. It makes staying hydrated extremely difficult. Even on warmer days, when the water points would be working constantly, there were far too few of them, and they were all located so far from the latrines that I – and I have a degree in Public Health – could hardly be bothered to wash my hands.

The latrines themselves were appalling. The provision of adequate toilet facilities is the most basic part of humanitarian public health and widely available guidelines describe the minimum standards: segregated by sex, no more than 20 people per latrine, they must be well maintained and hygienic, and so on. The latrines in the Jungle were unlit, so sparsely distributed, and frequently so disgusting, that, especially at night, many camp residents preferred to relieve themselves in the sand by their tents.

These water and sanitation problems were exacerbated by vast quantities of garbage. At any location in the camp it was possible to find discarded rotting food in large quantities. This led to rat problems which presented further ways of transmitting infections as well as novel health hazards.

The Jungle compounded these problems with overcrowding and weakened or vulnerable immune systems. A typical shelter of around seven by seven feet would hold five people sleeping next to one another. The children sandwiched into these sleeping arrangements had rarely had their vaccinations of early childhood as they had come from Syria, Iraq, Afghanistan and other places where vaccinations rates are far below optimal. The camp had six cases of measles during the time I was there – a statistic that should be terrifying to everyone: young children are extremely vulnerable to infectious disease and this disease can be fatal. And yet no mass-vaccination campaign had yet been undertaken. As well as the lack of vaccinations, the camp’s residents’ immune systems were weakened in other ways: the constant cold and damp, lack of sleep (due to cough, itch, over-crowding and fear), and anxiety and depression provoked by the appalling conditions. I visited many families whose shelter floors were thick with mold from the constant damp.

The nature of these threats to health is that they all add up: poor water and sanitation combines with over-crowding and weak immune systems to create a perfect storm of infectious health hazards. And there are further problems beyond the risk of infectious disease: the vast psychological trauma of a prolonged stay in this environment; the physical risks of the attempts to get onto trucks and cross the border to the UK; and the lack of physical security for women and other vulnerable populations due to lack of lighting in most of the camp.

The only sector of humanitarian need that was fairly adequately provided for was food and nutrition: many of the migrants can afford to eat at the many restaurants in the camps and the food distributions seemed to cover everyone that needed it. There has been no formal survey of nutrition status but this was my impression.

So the medical needs in Calais were straightforward to understand and (in theory) to fix: these are all issues that are addressed in any manual on camp management. It is possible to address every single one of these problems with technology that exists, is widely understood and used on a regular basis by NGOs and humanitarian agencies. The simple answer to “what should be done” is to improve every aspect of these camps. So why then, in northern Europe, in one of the richest countries in the world, do these conditions continue to exist if the solutions are so simple?

The answer to this question could be found, at least in part, in the French Government’s attempt to address the conditions in the Jungle at a cost of approximately $20million. On the eastern edge of the camp there is an area that has improved on every one of the severe needs I have described: shipping containers in orderly rows have been converted to accommodation with insulation, electric lighting and beds. There are well lit, numerous, secure latrines and the containers are on a well-drained gravel bed, free of trash or sources of disease. The compound is expanding but at the time of filming could accommodate over a thousand people with an area that was secured by wire fence. To apply for accommodation here (priority is given to the more vulnerable) all you need to give is a name (any name, you need not present identification) and a hand-print which would electronically open the gate so that you could come and go at any time. I interviewed the manager of the site who insisted that the hand-print information would not, and indeed could not be distributed to any immigration authorities.

But when I toured this facility it was almost empty, despite being surrounded by the appalling conditions I have described. I asked many residents why they didn’t move into these far more comfortable accommodations and I always got the same five answers. First, people feared that their hand-prints would be handed to the authorities. Second, they feared that the open-access system would change so that they would be trapped in a prison. Third, people said that that they need to be able to leave the camp for increasingly long periods to attempt to climb onto trucks and they knew that if they were absent for more than 48 hours they would lose their places and end up with nowhere to sleep. Finally, people mentioned that in the shipping containers they were not able to cook their own food, one of the last remaining rituals of family and social life.


 

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These are compelling reasons and they represent the limits of humanitarian thinking. As long as the answer to “what should be done?” is framed in terms of public health needs and humanitarian norms (latrines per person?), rather than in terms of the ambitions and aims of the crisis affected people, it will fail to address the real, lived experience of the crisis. But these two considerations are to some extent mutually exclusive. The French state’s attempt to address needs necessarily severely constrained people, but how could it do otherwise? Public health is their foremost consideration (as it is a foremost consideration of all modern, western states) and this is discipline and set of practices that fundamentally seeks to govern a population and shape their behavior to optimize health. In order to make a population healthy it is essential to “measure” them: to know their demographics, to understand them in terms of epidemiology and biostatistics. But this is precisely what many of the people in the Jungle do not want: the vast majority of them seek to leave to the UK by means they know are illegal and they are unwilling to be registered and counted and constrained. And so the choice they are forced to make is to live outside the fence and risk their health in order to have what they believe is a chance at a better life in the UK. There is a possibility for formal, organized humanitarianism to make a significant impact and Médecins Sans Frontières and Médecins du Monde are cooperating on health, water and sanitation provision and many other projects which mitigate against the worst effects of the environment in the Jungle. But it is hard to conceive of a solution that would truly address the public health and humanitarian needs that would not involve some severe constraints on the lives of the residents of the Jungle. This is collection of problems that can really only be legitimately addressed by the state, and the state has few shared interests with the migrants.

The camp in Calais was the starkest example of the choices that many refugees face between immediate physical security and comfort and their long-term ambitions. For many of the people migrating in this crisis the choice is simply between one kind of danger and another: risking drowning in the Aegean to avoid the risk of death at the hands of Isis or Assad. In trying to make a film about health we were forced to confront the fact that, for many people, immediate health is a secondary priority to freedom and opportunity.

The sense I had, at every stage of the journey, was that the question of “what should we do?” felt in someway irrelevant. That question suggests a western “we” that doesn’t really exist in the divided world that is modern Europe, and it implies that there might be a “solution” to a problem that is understood and experienced differently by almost everyone involved. Witnessed up-close, this massive movement of people felt less like a crisis and more like a reckoning: a demand from the citizens of many countries that the North service the longstanding debts of empire and post-empire wars. The roads around Calais that lead to the ferries and the channel tunnel are almost entirely enclosed with brilliant white high barned wire fences and there are vast numbers of armed and armored policemen patrolling for miles around the ports. It looked like every dystopian-future movie I’ve ever seen. But these efforts look absurd when considered in the light of the thousands of people arriving everyday in Greece. I had a sense of the unsustainability of the vast North-South inequality that exists and the irrepressible human desire to redress that balance that exists in so many minds around the world. There seem to me to be two ways to react to this manifestation of people’s desire for opportunity and freedom. First, it is possible to react in fear, and build barriers along borders. There are many policy proposals that detail the ways in which migrants can be excluded and returned that seem feasible. But the sense I had was that these plans are unlikely to stop the million migrants that Europe is expecting in 2016. The second way of reacting is to treat this movement as inevitable: and to lean towards more open borders. The global order that the North relies upon is creating a pressure to move that is irresistible: open borders might compel us to address this.


Alexander van Tulleken, M.D. (IDHA 16) is the Helen Hamlyn Senior Fellow at the Institute of International Humanitarian Affairs (IIHA). As such, he is directly responsible for teaching all undergraduate courses that comprise the International Humanitarian Affairs Minor, and serves as the Academic Director for the Masters in International Humanitarian Action. Dr. Alexander van Tulleken has worked for Médecins du Monde (MDM), Merlin and the World Health Organization (WHO) in humanitarian crises around the world. His most recent mission was in 2010 in Darfur running health clinics in the embattled Jebel Marra Region. He has a diploma in Tropical Medicine and a Master’s in Public Health from Harvard. He is an Honorary Lecturer in Conflict and Migration at University College London and is currently editing the first edition of the Oxford Handbook of Humanitarian Medicine.

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Healing Ebola

What happens when a global health crisis leaves the Western media spotlight?

Fordham University recently published the article, “Healing Ebola,” which features the insight and experience of Alexander van Tulleken, M.D. (IIHA Helen Hamlyn Senior Fellow, IDHA 16), Melissa Labonte, Ph.D. (Fordham University Political Science Associate Professor, IDHA Lecturer)Ellie Frazier (IIHA Adjunct Faculty), Laura Sida (IDHA 36, MIHA), and Elin Gursky (IDHA 40).

Read it now!

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Humanitarian Spotlight: Crisis in Calais

The world now faces the largest displacement crisis ever to be recorded, with almost 60 million people forcibly displaced at the end of 2014. For Europe and the United Kingdom, the migration crisis has confronted the region at its shores, and nowhere is this more evident in mainland Europe than in the migrant and refugee encampments of Calais, better known as “the Jungle”. Calais, a port city in northern France, has become a transitory home for migrants, refugees, and asylum seekers trying to enter the United Kingdom. The site has been the locus of ongoing tensions between French authorities and migrant and refugee populations since 2002 when the official Red Cross reception center for migrants was closed due to overcrowding. The collection of informal settlements known as the Jungle developed soon after as a staging post for those attempting entry into the UK, but the camps have now become semi-permanent dwelling places due to the dangers of border crossing and lack of other viable options for settlement. The camps are marked by makeshift tents, overcrowding, and a lack of basic needs and services – squalid conditions that will only deteriorate further if nothing is done to address the situation, especially as the number of inhabitants continues to grow. The population of displaced who inhabit Calais has more than quadrupled since September 2014, now numbering between 6,000 – 7,000 individuals.

Dr. Lynne Jones, Co-Director of the IIHA Mental Health in Complex Emergencies (MHCE) course, recently volunteered in Calais with Help Calais, a crowd funding platform that has already raised more than £60,000 to help various projects in the camps, and shared her experiences in a diary on Calaid-ipedia.

Reflecting on her decision to volunteer, Lynne commented, “I disliked the stereotype of ‘marauding swarms’. I wanted to find out for myself why people were risking their lives on a daily basis to come to Britain. Calais is only 6 hours away. So often, Europeans will go to remote places, while there are people on our doorstep who need help. It seemed only logical to find out how I could be useful.” Lynne found a sizeable network of people who offer their help and services in the absence of much structured humanitarian response. The internet has also contributed greatly to galvanizing volunteers.

As can be expected, the volunteers and refugees in Calais face similar issues to those plaguing the larger humanitarian system including problems of coordination, logistics, how to reach the most vulnerable, funding, and navigating the tensions between the arriving populations and the host community, local authorities, and national government. The broader concerns of host government responsibility and the lack of durable solutions for displaced populations also echo those that hinder humanitarian efforts around the world. Yet despite these challenges and the uncertainty of the future, a community continues to form in the Jungle

Read Lynne’s Jungle Diary!

Lynne Jones, O.B.E. FRCPsych., Ph.D., is a Visiting scientist, FXB Center for Health & Human Rights, Harvard University and Consultant child and adolescent psychiatrist, Cornwall Partnership Foundation NHS Trust. She is also the Co-Director of the IIHA Mental Health in Complex Emergencies (MHCE) Training Course, which is organized in cooperation with UNHCR, HealthNet TPO, and International Medical Corps (IMC). View our recent blog post about this year’s MHCE course in Addis. The next course is scheduled for Fall 2016.

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