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.
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.
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.