Event: Migration in the shadow of a pandemic

Kavita Menon:             

Hi, thanks for joining us for this discussion about migration in the shadow of a pandemic. I'm Kavita Menon, Editorial Director for Doctors Without Borders in the United States. You might know us by our French name, Médecins Sans Frontières, or MSF. You'll hear us talk about MSF throughout the discussion. MSF teams work in more than 70 countries, and many of our projects involve care for migrants and refugees. Today, we're going to focus on our work with people on the move in the Americas and how they're affected by COVID-19.

A few housekeeping notes to start. This discussion will last about an hour, and wherever you're joining us from today, you can submit questions to add to the discussion. We've already had some great questions sent in via Instagram. And if you're watching on Zoom, send questions in using the Q&A option. If you're joining us on Facebook Live, YouTube Live, or Twitch, just post your questions in the comments section. We are very lucky today to be joined by a panel from across the Americas. I'm going to ask each of you to introduce yourselves, and I'm going to start with you, Carol Devine, from MSF in Canada.

Carol Devine:               

Thanks so much Kavita, and hello everyone. I work in MSF Canada's office as humanitarian affairs advisor. I also work on our Climate Smart MSF Incubator Project, and I've worked with refugees and displaced people since beginning my work with MSF in Rwanda, East Timor, and recently I was in Mexico where I met Sergio and where there's a huge migration support project.

Kavita Menon: 

Thanks, Carol. And from Mexico City, we have Sergio Martin. Welcome, Sergio.

Sergio Martín: 

Thank you, Kavita. Good morning, everyone. And well, it's a pleasure to be here with you. I'm Sergio Martín. I'm the Head of Mission of Doctors Without Borders operations in Mexico. We are working with two main axis, violence and migration. And in immigration, we're working in the original countries in Guatemala, Honduras, El Salvador, but also along the road in Mexico, from south to north, and mainly now in the northern border within the pandemic. A pleasure to be here. Thank you, Kavita.

Kavita Menon: 

Thank you, Sergio. And joining us from Manaus, which is the capital of Amazonas state in Brazil, we have Vitória Ramos. Welcome, Vitoria.

Vitória Ramos: 

Thank you, Kavita. Hi, everyone. This is Vitória. I'm talking from Manaus in Brazil. I'm working with MSF since 2017 for MSF Brazil. I'm the Humanitarian Affairs and the Advocacy Office here. I've been dealing with several agendas like neglected diseases, but also migration, especially since MSF opened the project with Venezuela migrants and refugees in 2018. And also, my background is international relations where I use it to study migration a little bit too.

Kavita Menon: 

Great. Thank you, and thank you all. We decided to have this event to mark World Refugee Day, which is this Saturday, June 20th. And the global refugee crisis has been completely knocked off the headlines by COVID-19, but refugees and migrants are actually among those worst affected by the pandemic. At MSF, we've been talking about the humanitarian crisis facing migrants and refugees in the Americas for a long time and now the Americas is also the epicenter of the coronavirus pandemic. I wanted to start from all of you, to hear how is COVID-19 affecting people forced from home in the region? Who wants to go first? Sergio, do you want to start? Because, I think we see it's really obvious in Mexico.

Sergio Martín:

Yeah, well, I can. I want to highlight first that we had a very bad previous situation to the COVID. We have been talking about this in several locations and for the last year, in fact, and maybe the last couple of years, where the situation along the migrant road has been worsening and worsening, mainly due to new factors of the new policies that are coming North to South, in fact, in the region. What we are having now, we see the main roads here. We have some migrants in one of the shelters we are supporting in Tenosique, this is in the South of Mexico where you can see the picture, some migrants that are heading North, and trying to plan the trip, right? What we see before the pandemic was already a very complicated situation where the migrants were facing violence and were facing a very difficult road that they were forced to take in many cases because of violence in the places of origin in the original towns and countries.

And with policies that were happening and hardening this road and with consequences, we should not forget that people are really forced to flee. That people are not leaving because they want to or it's an adventure or something like that. It's a very dangerous road. We have hundreds and hundreds of deaths. Kidnappings, sexual violence is very complicated, so people are forced to flee. And they're finding all these obstacles on the road. And we have seen with these policies a frame that is just putting people more in danger than before. From the United States in concrete in March last year, 2019, it was started this so-called Remain in Mexico policy. The Migrant Protection Protocol is very ironic because to protect migrants from safe places like Texas or San Diego in California, we are sending them to Tijuana, which is one of the towns in the world with a higher killing rate and homicide rate per capita, or to places like Nuevo Laredo as we have a witness and we have testimonies and we have the figures like three out of four people sent by the United States to Nuevo Laredo in September, October in the last months of 2019, just before the pandemic have suffer a kidnapping episode in the previous four weeks.

In Mexico and in the place where the United States is sending them, we're talking about families that were rising in their numbers in the total of migrants last year, mainly. We had this situation already underlying. On top of that, the pandemic is coming, right? Increasing the vulnerability of these people and what is worrying us a lot is that this is increasing also the visibility of these problems. This violence was already quite invisible, and we are one of the few organizations that are meeting these people, listening to them, giving a voice also to these events that is happening and to these violence. On top of that now with the pandemic that is covering everything is much more invisible, but what we are denouncing now is that the US government is using the pandemic, and this is a fact, it's using the pandemic as an excuse to harden even more the immigration policies, so-

Kavita Menon:

I want to actually follow up on that point as well, how is the pandemic being used by governments in the region? And this is something we're seeing both from the US side as well as from Canada. I wonder, Carol, can you expand on that point too? How are governments using the pandemic to shut down borders and to keep this as a security threat?

Carol Devine:

Yeah, for sure. As Sergio said, these are some of the most vulnerable people in the world and COVID has only magnified that greatly. And already before COVID, we were seeing state sanctioned violence, but we were also seeing this retreat from a protection of these very vulnerable people. And what happened recently with COVID, much to our deep concern in the Americas region but also globally, the US first shut the border in March with Mexico.

And on March 19th, Canada said the border stays open to asylum seekers, which is the right thing to do. Public health responses to outbreaks work when they're inclusive. It is counterproductive and it goes against humanity principles, but also public health principles to shut the Canada US border border to asylum seekers. Canada and US governments made that decision on March 20th, and what we say, which we say elsewhere around the world is it's against international law. Canada and the US have signed the Refugee Convention, the Convention Against Torture. We also are... these countries were trying to do the best evidenced public health response and shutting the border to people who are trying to seek asylum, it just doesn't make sense from a public health perspective. We understand countries want to protect their peoples, but we know public health action works when everyone's included.

That means instead of just shutting the border to claimants, it's been opened up slightly for people who have previous claims or unaccompanied minors, at least on the Canada side. But the point is that the public health approach that we're all working, especially those of us who are able to isolate and able to make sacrifices to try to flatten the curve, everybody, migrants should not be victimized or there should not be this government attempt to use the pandemic as a way to crack down on rights, because anyone, we will all benefit when we are able to be tested, have ability to quarantine if we're positive and then the tracing. Again, we're just concerned about this breach of international law and a practice that will make everybody safer and it threatens to prolong the pandemic if we keep excluding migrants and asylum seekers.

Kavita Menon:

That's a really good point. And Vitória, can I bring you in on the perspective from Brazil and how are migrants and refugees at particular risk there as the pandemic is spreading?

Vitória Ramos:

Sure. In Brazil, since March first, there was the first decree closing the border with Venezuela, where we have the biggest influx of migrants coming. Then, they expanded it to any person coming to Brazil, so now only people with residency or families can enter Brazil, which is complicated because it's not clear. For example, if an asylum seeker can come and ask for asylum, because actually the interpretation that we have now is that they can't ask for as asylum. They will be deported, but we haven't had many cases of people trying to get in and not being able to, although there are people trying to return to their homes and they also can't. For example, Colombians in São Paulo, but in Brazil, historically we had an influx of mostly Colombians and Belizeans and people coming from the Democratic Republic of Congo too, but since 2015, 2016 it's mostly the Venezuelans that are coming and a great difference of Venezuelan population that are arriving from the border.

And it's important to remember that Brazil is a very big country with a very big population, so migrants, they are less than 1% of the population here but they are coming in the region that is one of the most neglected regions in Brazil, which is the North region of Brazil. Also, the Amazon region and those are places that already have problems with the health system. The structures are already collapsing. They are the poorest states in the country, so it's already very complicated for the population that were living there. And when you have a great number of people come, it just collapses and explodes. And that's the situation that we're facing in the state of Roraima since at least two to three years.

And now, with the pandemic it's getting even more complicated now. We had this terrible situation here in Manaus, in the Amazonas in the past few months. And now, we are seeing the peak coming to Roraima where we have the biggest concentration of this Venezuelan people now, and people are even trying to go back to their countries because they are afraid of the healthcare they will receive in Brazil right now.

Kavita Menon:

And I think all of this has been complicated because it's so politicized, right? Both in each of these countries, we see different forces at play, and we have a great question that we got from Instagram about MSF. And the question is how do you remain neutral? MSF is famous for its neutrality. And so, the question from Rafael is how do you remain neutral when just supporting migrants and refugees is a political position? I wonder who wants to take that question?

Carol Devine:

I can have a go. Thanks, it's a really good question. And we've valued since the very beginning and today the independence to help people on based on need. And I think that's what gives us our legitimacy. We say, "We have done our needs assessment. They are excluded peoples and we don't care whether they have a passport. We don't care whether they're stateless." And same within the Americas, the definition of the person matters for their state and their next step in trying to have a home. I think in our response, if we say this person is based on need and it's same in another country, I think also the fact that our funding is independent. We're not an arm of foreign policy, and I think sometimes independents, we have in the past, when we speak out it's because we make that decision that it is so important to say that this person's health relies on a bigger picture and that is not being criminalized, not being discriminated. And also, we base our work on international humanitarian law, we base our work on basic rights that the countries we work in are meant to give people within their territory and global system.

Kavita Menon:

That's great, and-

Vitória Ramos:

And the, just to jump in, sorry.

Kavita Menon:

Yes, please.

Vitória Ramos:

I think we also need to remember that being neutral doesn't mean being apolitical also. We have a side, in the side of the people that are most neglected and have the biggest needs and the most vulnerable, so that's where we spend it.

Kavita Menon:

And has that been difficult in the Brazilian context? Has MSF been seen as political for speaking out about the needs of vulnerable communities?

Vitória Ramos:

No, actually MSF is a very respected organization in Brazil. We are perceived as a neutral organization and people tend to see us as neutrals and people only looking for helping those who need the most. But yes, it's a very political scenario and the problem is that since the beginning, there is no clear direction from the government on what people need to do. And now, it's three months that people have no strong policies, they have no stronger coordination or what they should do.

So, you have these States, the governor of the States, they have their own measures. And then the federal government, they have other measures, and people are so confused. And now people just want to get back to their jobs because they have nothing to eat. We have a huge number of informal workers, so they need to work, and then they will follow anyone telling them to go back to work now, because that's what they need.

Kavita Menon:

Mm-hmm. We had a really good update on the work in Brazil. And MSF is really scaling up in a big way in Brazil to meet some of these needs. The number of COVID-19 cases in Brazil is the second highest in the world. So the crisis is really acute, and really calling for more action from the central government. And talking about how important the action at the local level has been in fighting the epidemic. Sergio, do you want to give us your perspective from Mexico, and some of the ways that this has become a political issue? And how does MSF respond? You’re on mute, I think.

Sergio Martín:

I'm on mute.

Kavita Menon:

There you go. I can hear you now.

Sergio Martín:

Great, thank you. It's very political here, in Mexico, and that's clear. And with all these borders we have with the United States and with the North part of the country where a lot of the migration flow is going and it's heading, right? But as Carol was mentioning, we are a base need organization, and we are treating human beings regardless of where they came from, passport or not. Where they are, what are they intended to do later. And this is what we are doing. The fact that this is becoming political. When we see that the policies, as I was mentioning before, is putting in danger these people. And this is happening. And with the COVID, yes, a very clear and concrete example. So we were working one of the shelters in Nuevo Laredo. Nuevo Laredo is one of the most dangerous border towns in Mexico, even for Mexicans. Our team has a curfew there, regularly, it's complicated security-wise. But the United States is continuing, or has not discontinued deportation there before or during the COVID. Without the proper public health measures, that's clear.

So we had a Mexican deportee that was arriving to one of the few shelters that continued to work in the North in Nuevo Laredo. And after a couple of days resulted confirm for coronavirus, for the COVID-19. And infecting also 15 people in the shelter, including staff in the shelter. So these made the shelter dysfunctional, so they couldn't continue work. So this is still reduction and this is something we have seen along the road, the response and the capacity to shelter migrants. Well, and to protect them from violence and from the organized crime. But this is a very clear example where a policy from the North that has not been put on hold or something with the pandemic. As Carol was mentioning, measures, public health measure, and including everyone use it, and this is the case.

So this is not only spreading the virus among the migrant population, but also in Mexico, and within the Mexican population. And there's something very clear. There are other examples of that in Guatemala, deportations that lead to Central America without proper quarantine measures. We have seen a lot of that. And this is touching the policies, or when we say that the United States is using the pandemic to harden and to build more on the bureaucratic wall. This is happening when they are expelling within hours people from Guatemala, Honduras, or Brazil, to Mexico without any kind of paperwork or tests or medical care whatsoever.

So we are just sending people from a third country to Mexico, in this case. What was not happening before at the border, using the excuse of public health for the US, obviously. And this is normal. And we understand perfectly they want to protect... I mean, we want to protect the people, but we are just posing more the risk, and it's spreading the virus in fact. And this is really happening. So these centering politic there, but it's always based in what we see and in the consequences, and the consequences of this policy. From our point of view, that clear. It's not a political position, it's a human position, I will say. Yeah.

Kavita Menon:

Yeah. I mean, it's horrible to hear you say the impact of that. I remember MSF really early on sounded the alarm about the potential impact of these continued deportations. So not only had the US shut its border, but was continuing deportations at a time when the US is still one of the epicenters of the global pandemic, and has the largest number of cases, confirmed cases of COVID-19. And there weren't as many cases in Latin America and the region. And so the US is deporting people across the region to Latin America and the Caribbean, and MSF joined several other organizations in speaking out about the dangers of this policy compounding what is already a massive public health crisis. Jeopardizing the health of individuals as well as of entire communities, societies, countries.

And then you talk about how you're seeing the impact in Mexico. And there weren't enough shelters to begin with. I mean, I remember last year we were talking about how the shelter system is already completely overwhelmed. So to say that then if one infected person comes and then other people are infected in that shelter, and then that shelter shuts down. The domino effect of that is just unimaginable. And how many shelters are operating right now? How have shelters been effected by the coronavirus?

Sergio Martín:

It's difficult to say, but we calculated 60, between 60 and 70% of the shelters in Mexico have shut down. Some because they are working on voluntary basis, so they cannot continue to work because now the pandemic is affecting Mexico. But some of them, because they had a confirmed case and they couldn't continue working, as happened in Nuevo Laredo. In a given moment where you saw the map and the border, and you saw all the cases in Texas, California was one of the first places in the Americas confirming the presence of the virus. While in Mexico was still quite okay. But all of these contribute to expand the pandemic in fact. Yeah.

Kavita Menon:

And what about in Brazil, Vitória? What's the shelter system like? What are the facilities available for migrants and refugees?

Vitória Ramos:

So you have shelters all over the country. In the beginning, in April, we started, for example, MSF, training the staff of some of those shelters. Because they have no clue on how to prevent and control infections. So we were working with them in Roraima where we have a lot of official big shelters for the Venezuelans. We were since the beginning, also working with the operation there, the humanitarian operation there, to support with some knowledge on infection prevention control. And here also in Manaus, you have the shelter, we have shelters for Venezuelans, and you have shelters for the Warao population, one of the indigenous populations in Venezuela. Which is the second biggest population, indigenous population of Venezuela. It's over 50,000 Waraos.

And they are migrating to Brazil since at least 2015. And they were first arriving in Boa Vista, but now they are more and more coming to other states and to other cities in Brazil on their own. Now they have their own family networks, which they do spontaneous movement. And here in Manaus, the city of Manaus has some shelters for these populations. And it was a big challenge in the beginning because when you had a suspected case, MSF was doing triage in all of the Waraos shelters, and the shelters for Venezuelans too. And when we had suspected case, what we do in a situation like that, they were all in the same place. They were all together. So we started setting up some places inside the shelters to isolate the family, but it was obviously not working because you didn't have a toilet in that space.

So, we were pushing for an isolation observation center for the people, the symptomatic people in the shelters to be transferred to since they didn't need to go to a hostel because they were mild cases or asymptomatic cases, but they were in contact with someone who are symptomatic. And then we finally used this observation center to send the people identified as symptomatic on contact. And that's what you guys saw in the pictures was the isolation center that we set up. And those are indigenous populations. So they have their own culture, they speak their own language. Some of them speak Spanish, and Portuguese is even harder. So you'd need to do a lot of health promotion action, and you need to be very culturally sensitive, obviously, because we're talking about in a specific population.

And even the Waraos, there's such a big population. You have different cultures within them, so it's very important to understand, and to work closely with them, with their leaders to see what's the best way. And to build from bottom up the best ways to deal with this population. For example, the isolation center, we set up these hammocks. In Portuguese, we call it redário, like several hammocks. But we put it in a way that they had the proper space between the hammocks. But even so, we needed to call the indigenous leaders, Warao leaders, to approve the center. And they had to do this whole ritual of protecting the place before the families could come inside. So this kind of sensitivities of bottom-up approach, they are very important. And sometimes during emergency in a humanitarian world we can forget that very easily because we're just running around and want to get things done. And then sometimes we forget that we will have to stop and do it the right way anyway.

So we might as well just start doing it the right way with working with indigenous population is, well, they are very vulnerable right now as other vulnerable populations in Brazil. We are also working with Brazilian indigenous here. And it's amazing the solidarity between the indigenous communities. It's amazing how the Brazilian indigenous leaders and communities, they have a strong solidarity if they are Warao population, for example. They, since the beginning, when they were calling for help for them and for the Warao, they don't make this distinction. So I think we have lot to learn from them.

Kavita Menon:

Interesting. Carol, can you also give us a little bit more international perspective on how MSF works with communities? It's community based approach and also the importance of health promotion and outreach in our work?

Carol Devine:

Yes. Around COVID, we're working on our ongoing, already, very serious humanitarian issues and health issues globally. And now on top of that, we have COVID. So we're responding in many countries in those 70, but plus. And something that has really concerned us from the very beginning, but it's really coming true. What Vitória is seeing, and Sergio is seeing in Brazil and Mexico, is the further discrimination and further exclusion of migrants and asylum seekers. And so what we're doing too, is trying to help with basic prevention and control measures. And that is from Bangladesh, for example, where the largest refugee population in the world, the largest refugee camp in the world is with the Rohingya refugees.

They're already in a compromised location. They are already 10 people per household. Violence is going up in families. And so what MSF is doing in camps, whether it's in Bangladesh or in slum areas in Kenya, is on top of our regular programming, really trying to help with those prevention measures for people who have less access to water, less space. And I think that's been really, really important. And then, as we know, in Canada and in Europe and in the US, COVID is so disruptive. And so exposing vulnerable peoples and health systems that we've also opened to help with homeless people, elderly care, migrants. As you know in the US for the first time ever it's unprecedented. But also we responded in Italy. So whether we did a direct operational response or whether we supported healthcare systems, MSF has experience from Ebola, from other pandemics.

So I think that's where we jumped in and we're going to continue to support ongoing COVID efforts. And at the same time, use our goal to also speak out and amplify voices of people. Because, once again, COVID is not going away. It's a longterm issue, as to is migration. People need mobility. So we want to help those most excluded people suffering from COVID, or in conflict zones. I mean, Yemen has been brought to its knees because of COVID. So to the DRC. You have cascading crises, you have malaria outbreaks. So it's really a moment for us, while there are all of these challenges, it's really a moment for us to come together collectively. And the political bodies retreating from international and global commitments, and national laws, it's not tenable. We have to come together.

Kavita Menon:

Thanks, Carol. I'm going to take some questions from the chat. We have a question from Ashna on Facebook, just asking, are refugees and migrants getting medical care in the shelters that remain? Are the shelters equipped to provide medical support?

Sergio Martín:

I can jump on that. Yeah, it's a very good question. In fact, it's not only that some of the shelters shut down, but also a lot of the actors that were working on the ground, they are not there anymore. So we find ourselves now going to places where we weren't needed because there was medical care or psychological care. And now we are doing that in more and more places, and we are mapping more and more places where our presence will be needed because of that. Because their response is retreating because it's more difficult to work with the COVID, ourselves, MSF. And we should not forget, it's not only the response of the pandemic as we were mentioning, as Carol was mentioning now, but it is also how we run a maternity now in Congo or in Africa.

Malaria, she was mentioning or dengue here, the violence also. There has been still more people, now, I think it's more or less the same. Now COVID is taking advantage but it's still, some weeks ago there were more people killed this year in Mexico than then killed by a gun, an arm fire, than by COVID.

The violence is very present. It's an epidemic and we were talking about that already before, and this is still there. Dengue is still there. We are also working with rural areas in Mexico, where people had a very hard life before. They were already forced to move and forced to flee from Mexico before, and this is increasing their vulnerabilities.

Violence is still ongoing and even increasing because there is a retreat from the government, also. A forced retreat we can say but people are moving, continue to move, continue to flee. And it's incredible now, I was reading yesterday the apprehensions in the US-Mexico border, there is a huge increase of Mexicans that were a minority in the previous months. And now it's increasing very, very, very sharply, and it's because Mexicans are fleeing more. You have all the economic reasons that is provoking the COVID crisis, but also a lot of them and we see the same people in the areas we're working in Michoacán or Guerrero and we see them later in the border because they are fleeing home because of violence.

So it's hard to work. It's very hard for organizations to work, for us too, and some of them, they are not able to work anymore so they stopped providing some medical care in many places. We are providing it. In Mexico in some areas and it depends on the state, people and even migrants, we need to intercept for them and to push a little bit sometimes but they had access or a certain access to health care when was an emergency, but today this is not true even for Mexicans. There is fear, there is this reconversion on COVID restrictors. There is no vaccination in rural areas. All the primary healthcare system is very, very heavily affected, not only Mexican, all Latin America. That's clear everyone in the world has been in the peak, but now in Latin America, we are in the epicenter. So access to health care is compromised for Mexicans, so far more for migrants. Yeah, definitely.

Kavita Menon:

So we've talked a lot about compounding crisis or crisis within a crisis, and the secondary impacts of COVID in some cases being even more deadly than the disease itself. And I wonder, Vitoria, do you see that playing out in Brazil as well?

Vitória Ramos:

Yeah, for sure. Here, for example, we are now getting to the time of the fires in the Amazon so that's already a time where we have a lot of problems with respiratory diseases. And we've been hearing people at the hospital saying that people are not, during the peak of COVID, people are not coming to the hospital. So people are dying at home from other causes like a heart attack, and that we don't even know because they were not searching for healthcare because everything was turned into COVID response. And it was needed also, there's not much you can do, but then you have a lot of people dying inside their homes and you have not a picture of this necessarily.

But here in Brazil we have a universal health system so everybody has access to the health system, even you don't need to be Brazilian. Anyone can access the health system but that doesn't mean it works perfectly. So there is a lot of challenges, especially in those states where we are in the north of the country, you have already collapsed structures or historically neglected structures. And during the peak here, for example, in Manaus, some of the primary healthcare structures were closed. The people in the shelters, for example, they would access these kinds of services but they didn't for a while. And now after the peak passed here, the hospitals are already receiving a lot of patients with more complicated cases because they are coming in late. And here we also have malaria, we have dengue we have everything so it's a big mess. So COVID actually is showing the differentiators that we already had, but of course, much worse. Yeah.

Kavita Menon:

I'm getting a question from Clea, if there are any positive responses that we can take note of. Have governments in particular done anything positive, extended social services or given additional support to migrants and refugees at this time? Are there any good practices to be praised? So whether in the Americas region or elsewhere. Carol, I see your hand up.

Carol Devine:

Canada, Prime Minister Trudeau said, "Canada, welcome refugees." We try to be this country that is a leader in human rights but then we are part of this continuum of refoulement which is that sending home of people, refusing people at the door in Canada, the US sends them back and it just gets worse. But a shining light and I don't know a lot about it, but I was so pleased to hear that Portugal in this time, in this middle of this pandemic, is giving healthcare to asylum seekers.

And it's kind of what a lot of countries are doing, as we've been talking about this afternoon, is using the pandemic as a political tool to crack down on peoples and be xenophobic. But Portugal is showing the right public health way, the right human way and the right law way of giving people healthcare in crises. And it's a lesson for every country because this is not going to go away and walls are not the solutions.

Kavita Menon:

I want to talk a little bit about this problem of xenophobia and really like the response to seeing people who are in need is to kind of shut them out or to ignore them or even to demonize them as we've seen in many cases. And this also has severe mental health impacts and I think that that's been a hallmark of the work in Mexico. So Sergio, I wonder if you can talk a little bit about that, like some of the mental health needs that you've seen and also what's the situation now as the crisis has become even more extreme.

Sergio Martín:

Yeah. We had already, before the crisis, a center here in Mexico City where we are referring the most complicated cases on mental health that we see along the road, and not only our patients but also other organizations are referring to this center. And it's people that in many cases have suffered incredible stories of violence since they were children and very complicated stories. And for me it's very touching when I go there, right?

We have seen some success cases and some of them that were in our center are now in United States or in Canada. And it's a pleasure to see how these people have recovered and have a life today. So these things encourage us to continue in that, but the mental health consequences of people coming from a fragile situation already, living violence and being forced to flee, I mean, what will we do if we need to leave our house today?

I think if we really manage to have these thoughts and to enter in this role, I mean, we will understand a lot of what's going on with these people. And a lot of what is on the other side of this xenophobic trend that at the end is used politically, but that is having consequences on people, right? So basically, and we have been denouncing this even before the COVID already, and in the north the mental health consequences of kidnappings, violence, sexual violence, killings.

We have people that have been witnessing how their travel companions have been killed, raped, familiars, et cetera, some on the road, some before coming and some at the northern borders after being deported from the United States. We need to know that people are not choosing where to cross, and we need to know that the United States is sending them back by the nearest port they are, right?

So people are in the hands of criminal gangs that are just the “coyotes” or “polleros” as they are called, and they don't choose where to go. So they are really a business, they are good for the organized crime that is selling and reselling them, after they are crossing into the United States, after they are caught. And now they are just sent back immediately without any paperwork or even under the MPP program, the Migrant Protection Protocol, so called program.

They are sent back to a town they don't know, they were not intended to go. They don't have the lace in the shoes so they are very easy to identify. They are really a prey for the-

Kavita Menon:

They're targets.

Sergio Martín:

They are targeted, completely targeted. And this is what we need to understand that we're talking about human beings that are targeted as a consequence of these policies, right?

Kavita Menon:

And what kind of care does MSF provide? I mean, from psychological first aid to longer term care, can you just talk a little bit about what that looks like?

Sergio Martín:

Yeah, definitely. We do a lot of psychological and mental health care, also for our staff because it's very hard to be there in the front line and after these more complicated cases, we try to refer them as fast as possible on day one to this center and there have been some patients that have been within this center for nine months, one year. We are empowering people to recover.

And when I say it's wonderful to see people that today they are working in places like Canada and in towns in the United States, you need to understand that there are people that have been raped since they were six, seven years old that have suffered a lot of violence, that were sold to the gangs, that already had never had a real life or what we call a life.

So having a success story with all that background is incredibly rewarding for our teams and it's what is keeping us going on with the work we are going. So we have everything, we have sometimes one short mental health consultations that are just boosting people and empowering them to continue and to build a life. And sometimes we need to work a much, much longer time, right?

In the north and in the northern border of Mexico with the US, it's very particular what we see in mental health. Everybody coming from the road, they have suffered a lot, they are suffering a lot. They know the road is very complicated and difficult, but they have a target. They want to find a place to be. They want to go north, they have an objective. When they arrive to the north and they are in front of the wall or the river or they are crossing and sent back, then everything is collapsing and everything is, yeah. They understand that will be very complicated for them to have a life and there is no way out, really. They are trapped in Mexico and a lot of them are trapped in Mexico. They are willing, they do want to work, they want to do things, but they are trapped.

Kavita Menon:

The situation is really bleak on a lot of levels and we have a question that this must be tough on aid workers and you alluded to that a bit on how hard it is for staff. And I wonder if Vitória, can you pick up on that and relate it not just for MSF staff, but for health workers in general in Brazil. I know the toll of COVID-19 in particular has been really tough and there is work being done in terms of psychological support, psychosocial support.

Vitória Ramos:

The hospital, for example, one of the hospitals here in Manaus, the one that we are working at, they lost 18 staff during the peak. And they can't even recover or rest because they are still working a full time job so when MSF came, I think it was, we have some doctors and nurses working there and it was, I think one of the best things is that it was good for the current staff to just breathe a little bit, because it has been too, too hard on them. We have one, I think, of the highest number of deaths between nurses in the world.

And I remember in April, in the beginning, where we were all discussing the lack of PPEs and so on that there were a lot of denounces in human rights courts, nurses not having access to PPE and-

Kavita Menon:

That's personal protective equipment, just so everybody-

Vitória Ramos:

I'm sorry, yes.

Kavita Menon:

We love acronyms at MSF.

Vitória Ramos:

So they were privileging doctors and not nurses or cleaning staff, for example, and that was very, very serious. We as MSF try to put very high standards on using the protective equipment and control for infection. Actually, one of the things we did in a lot of places in Brazil in different states were training on infection prevention and control, and the use of PPE. How to put it, how to take it off it, even for non-health professionals, but frontline workers, like working with migrants, for example. Our lawyers that are going to the prisons to visit the detainees, we had no clue on how they could protect themselves so we are offering some virtual trainings too, but it is still a massive problem.

And also we have a big problem here is the lack of health professionals in the poorest regions. So here, for example, it's already difficult in São Paolo which is a big city, we have a lot of doctors. But here is impossible. In Roraima the humanitarian operation there, they are trying to build a big field hospital there, but there are not enough health workers to put there.

So the one good thing is that they are now trying to hire, for example, Venezuelan doctors, Cuban doctors. They don't have the validation of their diplomas here so they can cannot practice as doctors in the country, but some states are already flexibilizing that, at least during the emergency, so we can have more people working and we can train these people to respond to COVID, but there is a lot of resistance also on this topic, so that is the strong advocacy work from civil society that works with migrants in Brazil now, to push for the opportunity for the migrant doctors to be able to work even without the validation of their department, but it's not also an easy agenda, but that's also how migrants can support in these scenarios as well.

Kavita Menon:

Yeah no, that's really a good point also to think about who are migrants and refugees. Many of them were professionals in their own country before being forced to flee and can be a resource to responding to the pandemic.

Vitória Ramos:

We had a Venezuelan surgeon working for MSF as a health promotion agent because he couldn't perform as a surgeon here. We have several doctors that are working in administrative jobs because they can't practice, but now we need everyone, and it's not even enough.

Kavita Menon:

Yeah. I think picking up on that point about how people can also protect themselves, we have a question from Instagram, from Sue Haas, basically, how do you teach migrants and refugees to protect themselves in the camp? How do you practice social distancing, hand-washing, any other infection prevention control measures, what are some of the ways that you are teaching people how to protect themselves?

Vitória Ramos:

Can I go?

Kavita Menon:

Yeah.

Vitória Ramos:

So we have in MSF, what we call the health promoters. So they are the ones that develop strategies on these kinds of things. They work with the local leaders. So for example, in a shelter, it's important to identify who is the leader, the chief if it's an indigenous shelter or the people that have more influence in the shelter.

So you pick some people and you train them, and they are the ones who will be talking with the community to train and to tell them the importance of those practices because it's a long way explaining the disease, explaining why we need to change, why we need to wear masks. It's hard for everyone.

So we identify also what are the means to do that. For example, we did a lot of videos here with people from the different ethnicities and speaking in their own language. And we made it a strategy to share those videos for WhatsApp, for example, which people are using the most, and you have a lot of sessions with the communities, but it's a lot of work.

I remember one house shelter here, I went there one week in the beginning when we started working in the shelter. So we put some water points like these big buckets with water and the small sink, how you call it, to wash their hands, for example, with soap.

And I remember in the first few days, it was a mess. The kids were playing with the water and it didn't make much sense. But then when I went one week after, I saw people washing their hands, wearing masks, and then I was washing my hands and this little girl, she was four or something, she came and she opened the sink, and she showed me, she didn't say anything to me, but she started washing her hands, the right way by the five steps, very properly to show me that she knew.

For me, that was amazing because it hard to change these kinds of things, especially for such a small child, but it was so cute. The kids were all doing that and it became like a game for them. They understood.

Kavita Menon:

Wow. Thank you. Sergio, can you talk a little bit about that, about the work in the camps and what do you tell people about practicing social distancing when they're living in these really cramped...

Sergio Martín:

Yeah. That's the difficult part, social distancing and also when everybody in the world and United States I understand was the same, or in Europe, we work with all these messages. The huge message was stay home. We are talking about people that have no home. So by definition, how are they going to do? And this is helping us also to understand the difficulties they're going through now with the situation, right?

So we have our health promotion workers, also like we have in Brazil that Vitória was talking about, and we try to spread the messages. It's also hard with the local population and with domestic population, and the social distance in particular, we were saying, "Okay, stay home," to people that have no home. We are saying, "Okay, stay home. Don't go work," in a country like Mexico, where you have 59 million people living under the poverty line.

So this is not manageable and is not feasible. People need to eat. So you can close your tacos kiosk one week, but after that, you need to work and you need to feed your children. So this is the difficult part when you have already a difficult situation. And it's because of that, we were also denouncing. And this was happening when we were sending people from the United States, when in Mexico, we didn't have still a lot of cases. They didn't have a lot of cases yet. This is the difficult part, right?

Instead of trying to help and try to become together and to stay together in this situation and helping areas and people that are in far disadvantage, comparatively, we are doing the opposite. We are in Europe or in North America, we're closing the borders. We are sending them far to be sure we are protecting ourselves and forgetting them.

And this part of the game, and this is what we are putting on the table. Somebody was asking about the positive things on this pandemic. And I was hoping that we will see more solidarity between people, but instead of that, it's again, you use politically to gain votes and to spell and to use as a xenophobic argument, and to send people home and people far away.

There are some positive things, besides that. We have also a lot of migrants working as doctors here. So the Mexican government, and this is happening in Mexico, this is very good. The detention centers are almost empty in Mexico, in Spain and in other countries also. And that's great. Not everywhere, but there are some positive things, despite all that in this situation.

But definitely we need to understand that we are working with populations that are in a very, very difficult situation. Not only those on the move, but also the people that have already a very difficult day to day, day by day. Right?

Kavita Menon:

Yeah. I want to pick up on that. I mean, we only have about five minutes left, but I do want to pick up on this idea about how interconnected we are. And I think that's really obvious with the pandemic. It's also the story of global migration, and I think it would be really interesting to hear from you all.

Is there anything that we can learn in terms of the response to the pandemic, the response to the migration crisis to do better going forward? What do we recommend both for governments as well as for ourselves, for other organizations, if any of you have recommendations for the way forward, I think everybody's hungry to hear them. Carol?

Carol Devine:

Yeah. I'd love to jump in, and both Vitória and Sergio talked about solidarity, and that is the silver lining. I mean, COVID has been unbelievably destructive. We know that. But also as a revealer of what's already fragile, as been said, it's also showed us what we can do, those of us with means, right?

And so some big takeaways for me are that within our own sphere of influence, we have to push back against this criminalization of people and even of helping people and discrimination. So in our own countries, in our own towns, in our own small community, just saying no to leaders who used politicized people.

And then I think too, we need to push for safe and legal pathways. And what we're seeing is the opposite of that. And it's going to get us nowhere. We're going to have other pandemics and we can't not talk about the climate crisis.

There's no direct link, but what the two together reveal are, vulnerable people who will become more vulnerable, excluding them, makes us all more vulnerable, and that we need to strengthen health systems, but also the roots behind COVID also have roots in how we treat each other, how we treat animals, and that's something we need to work on.

We need to have asylum policies within pandemic policies, and we need to really get serious about climate action. And that will bring health benefits, that will bring humanity benefits because when it's 50 degrees somewhere, we know that Mexico and Brazil and El Salvador are climate hotspots and it's not going to get better.

So this is an opportunity for us to see how nature can heal and how we can also be resilient and help those who are not as resilient.

Kavita Menon:

Thank you. Vitória, do you want to jump in?

Vitória Ramos:

I've been discussing with some friends at MSF lately, and I think this is showing also the importance of a strong public universal health system. I think countries that are most successful facing it, are the ones that have this strong public health system and people can access it. It's not the case of, if in my country that we have one, it's very poor. It's still the structures.

And it has been facing a lot of threats and dismantling lately. So I think what we miss the most here with a strong scientific technical approach and the focus on the problem of the disease and not something else, and the politicization of hey, this is something that we are facing all over the world for such a long time, and we as a humanitarian actors, we have been discussing that.

I think this has shown that we reached the unimaginable levels of politicization of aid and the response, and people are dying immediate, so that's very frustrating. And also, I think we can't forget about the neglected diseases, the diseases that are killing a lot of people, these vulnerable people, because COVID reaches the upper classes, at least in Latin America, for example.

And it became a big issue because it is of course as a pandemic, it's a big issue. But yes, it exposes mostly the vulnerable people. There are a lot of things that they have been suffering so much. So maybe it's an opportunity for us to look into them, to look at their access to health, to look up the situation of ICU care in those places that's not sustainable, and that needs to be addressed.

Kavita Menon:

Okay, well, I'm going to give you the last word because we're about out of time, but I'm hearing from all of you that we basically have to use our head and our heart and take better care of each other to get out of this crisis and the related crises.

So I want to thank you, Carol Devine, Sergio Martín, Vitória Ramos. This has been a really interesting discussion. There were many questions that we didn't get to take, but it's really good to see so much interest and curiosity about this topic. So keep talking about it in your circles. I think that's really good advice in terms of what you can do.

Check out our website, doctorswithoutborders.org for more information about upcoming events. And if you're in Canada, that's doctorswithoutborders.ca. The website's a great resource to stay informed about MSF's work, including our response to COVID-19, and also learn more about how you can support us by becoming a donor.

You can also find links there to follow us on Facebook, Twitter, Instagram, and YouTube, and for any other specific information or questions we didn't get to, you can contact us at [email protected]. So thanks again. Stay safe, stay home if you can, and be well.