Comment

Borders and migration: an issue of global health importance

The movement of people has featured throughout
human history; so substantial is the legacy of migration
that the freedom of movement within and across
borders was enshrined in article 13 of the UN Universal
Declaration of Human Rights in 1948.
The UN estimates that 232 million people migrate
between countries annually.1 In recent years, political
unrest and conict in parts of the Middle East and north
Africa have redened regional patterns of migration.
In response, high-income countries, principally
member states of the European Union (EU), have taken
increasingly violent measures to police their borders, and
to regulate the entry of individuals considered neither
economically valuable nor deserving of state protection
as prescribed by the often narrow and complex
interpretation of refugee and asylum legislation.
For the EU, the enforcement of the external border of
28 member states continues to manifest in dierent ways:
in 2009 the Italian Government and specialist surveillance
and policing agency Frontex forcibly returned people
found at sea to Libya, a practice later deemed illegal by the
European Court of Human Rights; on Moroccos northern
coastline, the Spanish authorities have constructed 6 m
high razor wire fences around the enclaves of Melilla and
Ceuta; in May, 2015, the British Government appealed
for approval from the UN to launch a military response in
Libya, with the intention of destroying boats and staging
points implicated in attempted ocean crossings.
As Grove and Zwi2 observe, increasingly complex
measures used to deter refugees and other individuals
eeing conict, socioeconomic inequality, and other
manifestations of structural violence have placed
an emphasis on protection from the refugee above
protection of the refugee. As a result, both the
humanitarian and welfare aspects of migration are
superseded by the desire to restrict the movement
of people.3
Such skewed priorities have a catastrophic eect on
health; UNITED for Intercultural Action has attributed
a conservative 22 394 deaths between January, 1993,
and June, 2015, to the policing and border control
measures in place across Europe.4 These tragic statistics
draw attention to a migratory process that is fraught
with danger.5 Conict, internal displacement, poverty,
and chronic health inequities are often responsible
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for substantial predeparture morbidity. During the

transitory phase, tighter border controls and associated
programmes of involuntary detention have forced
people to attempt extraordinarily dangerous border
crossings.2 In desperation, an increasing number of
people have attempted to enter Europe by sea, despite
frequent reports of suocation and physical injury
in crowded vessels, dehydration and hypothermia
secondary to prolonged exposure to extreme
temperatures, and drowning.2
Irrespective of the chosen route, or of an individuals
migratory status, violence perpetrated by border
ocials, and the stress and psychological trauma
associated with the experience of migration, is often
compounded by an inability to access basic medical care
and other essential services.6 The repeated exposure
to institutionalised mechanisms of marginalisation
and discrimination in turn generates what has been
described as a cumulative vulnerability.6
The negative health eect of Europes protectionist
policies is so dramatic that humanitarian organisations
have launched their own emergency programmes
across the continent, from Calais in northern France
to the Greek islands of Kos and Lesbos in the southern
Mediterranean. In Calais, Doctors of the Worlds medical
teams have treated patients with complex psychological
issues; a multitude of minor injuries, fractures, skin
problems and scabies; diarrhoeal diseases; acute and
chronic respiratory infections; complications secondary
to exposure to tear gas; and more. In southern Europe,
the organisation has also documented a growing
number of displaced women and children, many of
whom will inevitably require specialist paediatric and
obstetric care if present conditions persist.
The adverse eect on health of both the violent
policing of borders, and the exclusion of vulnerable
groups once they have crossed such borders, is a matter
of grave global health signicance. Increasingly broad
theoretical interpretations of global health, and the
recent introduction of a framework for planetary health,
have largely skirted more meaningful engagement with
the relation between borders, sovereignty, policing, and
health. Notable exceptions include the 2014 Lancet
University of Oslo Commission on Global Governance for
Health, which emphasised that an increase in irregular
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Comment

migration reects policy choices and legal denitions

poorly adapted to present realities,5 and a provocative
commentary authored by Frenk and other prominent
global health advocates7 earlier in the same year, which
drew on globalisation and our resultant interdependence
to call for a global society, which in turn would
transcend the inherently reductive nation state.
Europes ongoing refugee crisis and the underreported injustices endured by other crisis-aected
communities worldwide, are indicative of a system of
global governance that does not place equal value on
human life. In a world in which capital and commodities
ow more freely than compassion and humanity, a
fundamental friction exists between the expression
of solidarity and the protection and promotion of
sovereign interests. Only with a radical reimagination
of the practice and study of global health, and of the
systems and ideologies that remain a threat to health,
can we ensure that the needs of the most vulnerable are
prioritised above all else.

LD is the Executive Director of Doctors of the World UK, an organisation that

provides essential medical care to excluded people at home and abroad, while
ghting for equal access to health care worldwide. We declare no other potential
competing interests.
Copyright Smith et al. Open Access article distributed under the terms of
CC BY.
1

2
3

5
6

UN Department of Economic and Social Aairs. International migration

report 2013. New York: United Nations, Department of Economic and
Social Aairs, Population Division, 2013.
Grove NJ, Zwi AB. Our health and theirs: forced migration, othering, and
public health. Soc Sci Med 2006; 62: 193142.
Karmi G. Migration and xenophobia in the Mediterranean. EuroMeSCo
conference; May 16, 1998; London. In: Pugh M. Europes boat people:
maritime cooperation in the Mediterranean. Paris: Institute for Security
Studies, 2000: 24.
UNITED for Intercultural Action. List of 22 394 documented deaths of
asylum seekers, refugees and migrants due to the restrictive policies of
Fortress Europe. 2015. http://unitedagainstrefugeedeaths.eu/aboutthe-campaign/about-the-united-list-of-deaths/ (accessed Aug 28, 2015).
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health
inequity: prospects for change. Lancet 2014; 383: 63067.
Mdecins Sans Frontires. The illness of migration. Ten years of medical
humanitarian assistance to migrants in Europe and in transit countries.
London: Mdecins Sans Frontires, 2013.
Frenk J, Gomez-Dantes O, Moon S. From sovereignty to solidarity:
a renewed concept of global health for an era of complex interdependence.
Lancet 2014; 383: 410.

*James Smith, Leigh Daynes

Homerton University Hospital NHS Foundation Trust, London, UK
(JS); Junior Humanitarian Network, London, UK (JS); and Doctors
of the World UK, London, UK (LD)
james.dominic.smith@gmail.com

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