Recently, Italian Foreign Minister Matteo Salvini went to the docks of Sicily and spoke to 158 refugees disembarking from an MSF rescue ship. He said to them, “The good times for illegals are over” and “get ready to pack your bags.”
One of my former students was working on that ship and wrote me that day. He had spoken to a refugee woman who had been trafficked and raped uncountable times. He had seen signs of torture on many of these people, and was very upset by the behavior of Mr. Salvini.
Between Brexit, the wave of recently elected nationalist governments, and heart-wrenching pictures of refugees in Bangladesh and migrants on rafts, it is hard to feel good about the state of international compassion. UNHCR reports that over 60 million people, perhaps 0.8% of our species, are presently displaced. As a fraction of the global population, this is four times the rate ever seen in the 1950s and 60s, and more than twice the rate ever seen in the 1990s according to a Pew Research Center report.
Making matters worse, the first UN Humanitarian Summit, the news reporting of sexual abuse by aid workers, and high profile experts all seem to be concluding that the humanitarian system is broken. Taken together – our political mood, numbers in crisis, and ability to underperform – it is a wonderment that the humanitarian community has not either given up or entered into a state of collective depression.
But as health professionals, we should be in the business of collecting and evaluating evidence…and the last half century of evidence makes the aid community look pretty good! In 1963, the ICRC defined humanitarian imperative as “No human caught in a life threatening situation should be denied assistance” – a concept very close to the long-standing French notion of “droit d’ingerence.” Thus, in the 1990s the standard definition of a humanitarian crisis was a situation in which the mortality climbed to four times the baseline. And we as a community have gotten spectacularly good at keeping people alive in the most dire of settings.
The figure below shows the worst measured mortality rates for any given period over the last four decades. These data come from a search of the Centre for Research on the Epidemiology of Disasters (CRED) database and Google Scholar.
While some events may be missing, and some acute events (such as the Haitian Earthquake) kill many people but are not ongoing, there is an overwhelming trend that there are fewer and fewer high mortality crises over time, even though more and more mortality measures are undertaken.
There are certain situations where history has come close to repeating itself and the relief community has done far better more recently. For example, over 400,000 Kurds were trapped on the border with Turkey and experienced a peak death rate of 12.6/1,000/month in the camps, 18 times the baseline mortality with most deaths from diarrhea.
The priorities for refugees and people in crises are no longer primarily about staying alive, they are about reducing suffering and improving quality of life.
Similar intensity crises in Mosul and with the Yazidi in Northern Iraq have produced comparatively little excess non-violent mortality. In 1991, more than half a million Rohingya refugees fled into Eastern Bangladesh and experienced a mortality rate (4.8 deaths/1,000/month) six times their baseline for months. No such elevated mortality reportedly arose when a similar number of Rohingya refugees fled to the same area in 2017.
Thus, the priorities for refugees and people in crises are no longer primarily about staying alive, they are about reducing suffering and improving quality of life. Chronic conditions and mental health needs often account for the majority of patient morbidity, and expectations of building health systems are innately more difficult tasks than controlling measles, acute respiratory infections, and diarrhea: the control priorities in the crises described in the figure above.
We have come a long way. We have likely never been better at keeping refugees and displaced people alive, so the priority has moved to averting suffering. It is human nature that our expectations will rise with our competence, leading us to deal with more complex and intractable challenges. Is the humanitarian system overwhelmed? Yes. Is the system broken? Yes. But it is broken primarily by the crush of ever rising expectations, and that is a beautiful thing!
On this World Refugee Day, we should be motivated to do better for the world’s displaced. Better means many things, including more complicated, political, and multi-sectorial roles as humanitarians.
That MSF doctor so outraged by the Italian Minister jesting about “packing your bags” to 158 poor souls without a bag among them admirably responded by writing an editorial in Politico pleading for immigration policy reform in Europe. The editorial has yet to induce any change as Italy has actually started turning away boatloads of those rescued at sea.
As health professionals, that sort of political engagement and corresponding economic and health policy engagement is not within most of our comfort zones or areas of expertise. But, it is what the world’s refugees most need now, and if we don’t make the case, who will?