Archive for Human Rights

La Caravana: retos en salud, desplazamiento forzado y respuestas humanitarias en Centroamérica

Please note: this is a translation of the blog post published on 3rd December.

Desde mediados de octubre de 2018, más de 7.000 centroamericanos han están recorriendo el trayecto a la frontera de EEUU a pie y en vehículos sobrecargados. Han viajado juntos en la denominada caravana de migrantes desde el Triángulo Norte (Honduras, Guatemala, El Salvador). Aquí usamos la palabra migrante una vez y con serias reservas. Las palabras importan y la semántica en torno a la caravana esconde y permite discursos anti-migración discriminatorios (por ejemplo yuxtaponiendo la necesidad de prevenir la migración económica al derecho a protección de solicitantes de asilo ‘legítimos’). Este desplazamiento masivo de personas ha reavivado la atención sobre las vulnerabilidades que empujas a los centroamericanos a un viaje peligroso en busca de una vida más digna y segura. En este blog buscamos reflexionar sobre algunos de los desafíos en materia de salud a los que han afrontado, afrontan y podrían seguir afrontando en el camino.

family travelling with the caravan

Fanny Cortés, de 23 años, lleva a su hija, Escarlett, de dos años, mientras que su compañero, Jonny Ramírez, de 22 años, lleva la única maleta con las pertenencias de la familia. La pareja comenzó su viaje en San Pedro Sula. Crédito de la foto: Simone Dalmasso, Plaza Pública “

 

Breve Contexto en Centroamérica

Centroamérica es una región hermosa y diversa entre México y Colombia. Aunque pequeña en extensión, tiene una gran densidad de población y diversidad etno-lingüística. La región, con una larga historia de conflicto armado, autoritarismo y política excluyente, fue ‘pacificada a finales de los 80 y 90 con la desmovilización de combatientes guerrilleros y un proceso de democratización de sus regímenes militares. Sin embargo, la violencia sigue desenfrenada, constituyendo uno de los muchos desafíos de salud que conducen al desplazamiento y afectan a los que se quedan.

La mayoría de centroamericanos de la caravana viene de El Salvador, Honduras y Guatemala donde los niveles de homicidio llevan décadas a niveles de ‘epidemia’. Estos países son el 2º, 4º y 17º más violentos del mundo, respectivamente. La tasa de muertes violentas en los tres países llega a 99,7 (El Salvador), 67,7 (Honduras) y 32,7 (Guatemala) por 100.000 habitantes. En este blog, nos enfocamos en Guatemala, principalmente porque el país guarda un lugar especial en nuestro corazón, pero sobra decir que las circunstancias son insostenibles en toda la región.

 

Salud (y otros) desafíos en casa

En Guatemala la malnutrición y la violencia son los factores de riesgo de muertes prematuras más importantes. La malnutrición es endémica, 50% de ninos menores de 5 sufren retraso en el crecimiento, mientras el 28% de ninos en edad escolar tienen sobre peso y la obesidad en adultos va al alza con estimaciones de que un tercio de la población tendrá obesidad en 2025.
Infecciones prevenibles agudas de las vías respiratorias bajas son la mayor causa de muerte. Sin embargo, enfermedades no-contagiosas, como las cardiovasculares, cánceres y diabetes son comunes también, causando aproximadamente un 59% de las muertes totales, asociadas con malas condiciones de vida y acceso insuficiente a estilos de vida saludables.

La brecha entre la población rural y urbana tiene un impacto sustancial sobre la salud. Entre lo más preocupante está el hecho de que los el estado de salud o el acceso a la sanidad están muy asociados con la etnicidad. La población indígena sufre tasas desproporcionadas de pobreza, la destrucción del ambiente con macroproyectos desarrollistas (presas hidroeléctricas o minería), la falta de acceso a servicios públicos y barreras lingüísticas añadidas.

El Estado históricamente ha fracasado a la hora de proveer servicios básicos para superar estos desafíos. Guatemala tiene la recaudación fiscal (en % del PIB) más baja de toda América Latina y es el tercer país con menor gasto social (en % del PIB). Es así que los servicios de salud están infra-financiados de manera crónica, lo cual lleva a repetidas y largas huelgas de personal sanitario por su bajo salario (a veces impago), la más reciente desde agosto de 2018.

 

Desafíos de salud en el trayecto

Este no es el primer desplazamiento masivo en Centroamérica y la situación de los miles de refugiados tampoco es única. Con frecuencia, los centroamericanos arriesgan sus pertenencias, integridad física e incluso su vida en el trayecto hacia el norte. Emprender el camino en grupos pequeños, organizados por coyotes (traficantes), permite avanzar sin ser detectados. Sin embargo, expone a los refugiados a ser víctimas de violencia o abuso sexual, a que los estafen los coyotes o que los retengan contra su voluntad como esclavos modernos.

Desplazarse en un grupo grande probablemente ha permitido reducir la vulnerabilidad de los refugiados, que no han tenido que ponerse en manos de coyotes. El tamaño del grupo ha provocado actos de solidaridad emotivos, como la movilización de organizaciones de derechos humanos mexicanas para negociar un tránsito seguro a través de cordones policiales en la ruta. Aun así, la salud de muchos se ha deteriorado dadas las condiciones durante el trayecto: deshidratación, quemaduras severas por la exposición al sol, ampollas afectan a personas de todas las edades. Los niños sufren golpes de calor e infecciones respiratorias agudas y se ha documentado la muerte de dos adultos al caer de vehículos sobrecargados. La dureza de las condiciones ha podido con los miles que han decidido regresar al país de origen.

 

Desafíos de salud en el destino
A finales de noviembre, los refugiados encaminados a EEUU fueron recibidos en la frontera con gas lacrimógeno. La cobertura mediática de la ‘caravana’ se ha enfocado principalmente en la reacción de EEUU. El presidente estadounidense ha securitizado el problema, azuzando el miedo a una frontera insegura, migración masiva sin control y la llegada en masa de criminales peligrosos.

Como cabe esperar, la evidencia contradice la imagen que el presidente de EE. UU. intenta difundir. Mientras el número de solicitantes de asilo (lo que podríamos llamar, con reticencias, migración ‘legal’) va en aumento, la migración ‘irregular’ (medida en el número de detenciones en la frontera EE.UU. – México) está en mínimos históricos. Asimismo, el presidente actual ha solicitado eliminar las partidas presupuestarias de cooperación al desarrollo al Triángulo Norte, afirmando que estos países generan necesidades humanitarias, en vez de satisfacerlas. De nuevo, esta postura da una impresión errónea de que la ayuda humanitaria es malversada o ineficaz. De hecho, Guatemala y  El Salvador encabezan la clasificación de crisis humanitarias ‘olvidadas’ dada la magnitud de las necesidades, la capacidad para afrontarlas, atención mediática sobre la crisis y la cantidad de ayuda disponible per cápita.

La medida en la que los centroamericanos que lleguen a EE. UU. disfrutarán de mejor salud allí dependerá de sus medios financieros y su status legal. La población latina en EE. UU. tiene un mayor riesgo de indicadores de salud negativos y generalmente son una población con menos cobertura sanitaria, aunque esto varía según el estado. Los problemas de salud mental asociados con las dificultades del trayecto, experiencias de abuso antes del desplazamiento y el estrés asociado con empezar una nueva vida en EE.UU también es probable que afecten sustancialmente a su bienestar.

Ya se ha establecido una respuesta humanitaria a la crisis de desplazamiento de Centroamérica. Sin embargo, la falta de intervenciones efectivas y sostenibles en la región viene de largo. La caravana es un conjunto de poblaciones desplazadas forzadas  que afrontan desafíos que ponen en riesgo su salud, sus medios de vida y supervivencia. A corto plazo, deberían establecerse medidas de protección para los que huyen de la miseria. Para los que sigan desplazados, el acceso a servicios humanitarios de transporte, albergues, agua, saneamiento e higiene (WASH) y nutrición es esencial. Se debería garantizar el acceso a protección legal y un debido proceso para los solicitantes de asilo como exige el derecho internacional (que por ahora, al menos en papel, rige en EE.UU). A largo plazo, urge un reconocimiento de que la mejora de los sistemas de salud requiere inversión, lo que esperamos se traduzca en acciones urgentes de los pueblos y gobiernos centroamericanos.

Evelyn Balsells es doctoranda de la Universidad de Edimburgo. Su investigación se centra en la carga global de enfermedades infecciosas y está interesada en temas que afectan a poblaciones vulnerables y contextos humanitarios. Daniel Herrera Kelly es doctorando de la Facultad de Relaciones Internacionales de la Universidad de St Andrews, donde investiga la violencia colectiva en Centroamérica. Las opiniones en este artículo son a título personal y no representan los puntos de vista de las instituciones a las que están afiliados.

The Caravan: health challenges, forced displacement and humanitarian responses in Central America

Since the middle of October 2018, over 7,000 Central Americans have been making their way by foot and overcrowded cars to reach the United States border. They have travelled together in the so-called “migrants’” caravan from the so-called Northern Triangle (Honduras, Guatemala, and El Salvador). We use the word “migrant” once and very reluctantly. Words matter and the semantics of the caravan hide and allow for discriminatory anti-migrant discourses (e.g. juxtaposing the need for prevention of economic migration and the right to protection of ‘legitimate’ asylum seekers). The mass-displacement of people has renewed attention to the needs that push Central Americans on a dangerous journey to seek a safer and dignified life. In this blog, we would like to reflect on some of the health challenges that they have faced, are facing, and may face in their journey.

family travelling with the caravan

“Fanny Cortés, 23, carries her daughter, Escarlett, two years old, while her partner, Jonny Ramírez, 22, carries the only suitcase with the family’s belongings. The couple started their journey in San Pedro Sula. Photo Credit: Simone Dalmasso, Plaza Pública”

Brief background to Central America

Central America is a beautiful and diverse region between Mexico and Colombia. Though small in size, it is densely populated and hosts rich ethnolinguistic diversity. The region, with a long history of internal conflict, authoritarianism and exclusionary politics, was ‘pacified’ between the late 80’s and 90’s with the demobilisation of guerrilla fighters and a process of democratisation of its military regimes. However, violence remains rampant which is only one of the many health challenges that are driving displacement and affecting those who have stayed.

Most Central Americans in the caravan come from El Salvador, Honduras and Guatemala where homicide rates have been at ‘epidemic’ levels for decades. These countries rank as the 2nd, 4th, and 17th most violent in the world. The rate of violent deaths in the three countries stands at 99.7 (El Salvador), 67.7 (Honduras) and 32.7 (Guatemala) per 100,000. In this blog, we focus on examples in Guatemala, mainly because it is a country close to our hearts, but needless to say, circumstances have become unbearable across the region.

Health (and other) challenges at home

In Guatemala, malnutrition and violence are the two most important risk factor for premature deaths. Malnutrition is rife, 50% of children <5 years are stunted, yet 28% of school-age children are overweight and obesity among adults is on the increase with a third of the population expected to be obese by 2025. Preventable lower respiratory infections are the leading cause of deaths. However, non-communicable diseases, such as cardiovascular diseases, cancers, and diabetes, are also common, accounting for approximately 59% of all deaths, which are closely associated with inadequate living conditions and access to healthy lifestyles.

The concerning gap between rural and urban populations has a significant impact on health. Most concerning is the fact that the likelihood of favourable health outcomes or access to healthcare are defined by ethnicity. The indigenous population faces disproportionate rates of poverty, is directly affected by the destruction of the environment through development projects (e.g. hydroelectric or mining), poor access to public services, and the added challenge of language barriers.

The state has historically failed to provide basic services to face such challenges. Guatemala still has the lowest fiscal revenue (as % of GDP) in Latin America, and is the third lowest in social spending (as % of GDP). As a result, health services are chronically under-resourced, pushing medical doctors to go on strike for months due to low or lack of payment, most recently since August 2018.

Health challenges during the journey

This is not the first mass attempt to leave Central America, nor are the thousands of refugees in a unique situation. Most often, people risk their few possessions, their physical integrity and their life to make the perilous journey North. Taking the journey in small groups via the services of coyotes (smugglers) helps travel undetected. However, it makes refugees more vulnerable to violence or sexual abuse, being tricked by coyotes and held against their will as modern slaves.

Travelling in a large group has allowed perhaps to reduce the vulnerability of refugees, who have not had to put themselves at the mercy of coyotes. The size of the group has stirred emotive acts of solidarity, such as the mobilisation of Mexican human rights organisations to negotiate safe passage through police blocks along the route. Yet, the health of many has deteriorated during the rough conditions during the journey: severe dehydration, sunburns, blisters are affecting people of all ages. Children are suffering from heat exhaustion and acute respiratory infections and two adults have reported to have died after falling from overcrowded vehicles. These conditions proved to be too much for the thousands who decided to return to their country of origin.

Health challenges at the destination

At the end of November, at the border, US-bound refugees were faced with tear gas. Much of the coverage of the ‘caravan’ has focused on the US reaction. The US President has securitised the issue and stoked fears of insecure borders, mass uncontrolled migration and waves of dangerous criminals arriving.

Unsurprisingly, evidence contradicts the image the US President is trying to paint. While the number of asylum seekers (what we could reluctantly call ‘legal’ migration) is up, ‘irregular’ migration (measured in the number apprehensions at the US-Mexico border) is at a historic low. In addition, the current US president has called for an end to foreign aid to the Northern Triangle countries, since he claims they generate rather than meet humanitarian needs. This posturing, again, gives a misleading impression of misspent, ineffective aid. In fact, Guatemala and El Salvador are considered the two top ‘forgotten’ humanitarian crises given the scale of need, coping capacity, media attention to the crisis and public aid per capita.

The extent to which Central Americans who make it to the US enjoy a better health there will depend on their financial means and legal status. Latinos in the US are at great risk of negative health outcomes and are generally less likely to have health insurance, though this varies by state of destination. Mental health problems, associated with challenges during the journey and abuse prior to departure and stresses associated with establishing a new life in the US are likely to have a large and detrimental impact on their well-being.

A humanitarian response to the current Central American displacement crisis has now been mounted. Yet, effective and sustainable interventions in the region are long overdue. The caravan is a group of forcibly displaced populations enduring challenging situations that pose risks to their health, livelihoods and mere survival. In the short term, protection measures can and should be offered to those fleeing misery. For those who continue to displace, provision of humanitarian response in transportation, shelter, WASH, and nutrition are essential. Legal protection aid and security warranties should also be provided so that those seeking asylum can do so as provided by international law (which, so far, binds the US government at least on paper). In the long term, an urgently needed recognition that health systems improvement requires investment – we hope – can be translated into equally urgently needed action by Central American governments and peoples.

By Evelyn Balsells and Daniel Herrera Kelly

Evelyn Balsells is a PhD candidate at the University of Edinburgh. Her research focuses on the burden of infectious diseases globally and she is interested in issues affecting vulnerable populations and humanitarian settings. Daniel Herrera Kelly is a PhD candidate at the School of International Relations in the University of St Andrews. His research is on collective violence in Central America. All the views shared in this post are held personally by the authors and do not represent the views of the institutions they are affiliated with.

Reflections from the HIV, Human Rights and Development (HHRD) Network on World AIDS Day, December 1, 2014

The Joint United Nations Programme on HIV/AIDS (UNAIDS) (2014) Report “Fast-Track: Ending the AIDS epidemic by 2030” provides more than a beacon of hope on World AIDS Day 2014.

It states boldly that “The world is embarking on a Fast-Track strategy to end the AIDS epidemic by 2030”.

It envisages that if the world scales up its HIV prevention and treatment programmes and reaches certain fast-track targets or goals, it will manage to prevent almost 28 million new infections and more crucially “end the AIDS epidemic as a global health threat by 2030”.

The report points to a number of “fast-track targets” that need to be achieved in the next five years by 2020. These optimistic targets include: attaining a 90-90-90 target, i.e. 90 percent of people with HIV knowing their status, 90 percent of those who know their status being on treatment, and then 90 percent of those on treatment suppressing the virus. For the year 2030, this goal goes up to 95-95-95. New infections will be reduced by 75 percent to 500,000 by the year 2020, and then to 200,000 by 2030. And, it points to the overarching goal of zero discrimination and zero tolerance for both years—2020 and 2030.

However, to achieve this monumental, yet attainable goal, the report cautions that “countries will need to use the powerful tools available, hold one another accountable for results and make sure that no one is left behind”.

We at the HHRD Network believe that the commitment to human rights will provide the bedrock of the AIDS response, and that human rights will need to remain in the fore front of all efforts. Moreover, that there is a need for a sustained and continued investment to build and promote the capacity of health systems all over the world, but particularly in the context of developing countries and forced migration. We need to consider on how best we can attain the theme of World AIDS Day 2014 to “Focus, Partner, Achieve: An AIDS-free generation – to highlight the need to for governments and health officials, NGOs and individuals to address AIDS prevention and treatment”. And, finally, the “fast-track targets” need to be held closely by all players across the globe if we are to not just bend the epidemic trajectory, but to break it irreversibly”.


 

Dr George Palattiyil and Dr Dina Sidhva

Joint Convenors, HIV, Human Rights and Development Network

The Year of Environment and Health

“A point has been reached in history when we must shape our actions throughout the world with a more prudent care for their environmental consequences. Through ignorance or indifference we can do massive and irreversible harm to the earthly environment on which our life and well being depend. Conversely, through fuller knowledge and wiser action, we can achieve for ourselves and our posterity a better life in an environment more in keeping with human needs and hopes …” Stockholm, 1972

All living things depend on their environment for energy and for the basic requirements that sustain life – air, water, food and habitat. This simple dynamic is not in dispute. However there is a growing body of evidence that suggests the relationship between environment and human health is in fact a reciprocal one, each having complex effects on the other. According to the UN Environment Programme, every human being has the right to a safe, healthy and ecologically-balanced environment…….but what exactly are these complex relationships, and how can we ensure that human rights to a safe and healthy environment are delivered, even under conditions of rapid global environmental change?

Much of our society’s development has depended upon technological advancements in our environment; improvements in agriculture, sanitation, water treatment, and hygiene have had revolutionary effects on health, well being and longevity. While our environment and the natural resources within in it sustain human life, it can also be the limiting factor in improving health, as well as being a primary source of disease and infection. Lack of basic necessities are a significant cause of human mortality. Approximately 1.1 billion people currently lack access to safe drinking water, and 2.6 billion do not have proper sanitation1, so while advancements in managing the productivity of our environment has resulted in access to surplus quantities of food, water and services, for many, this development has not occurred equally across the world.

Our environment can also be a major source of infection. It is estimated that almost one quarter of global disease and 23% of all deaths can be attributed to environmental factors2.  Pollution and other environmental hazards such as food contaminants, over-exposure to sunlight, algal blooms, flooding and drought increase the risk of a myriad of health concerns that include cancer, heart disease, asthma and respiratory diseases, anxiety, stress and depression as well as many other illnesses.   Environmental factors influence 85 out of the 102 categories of diseases and injuries listed in the World Health Report and in 2012, 7 million deaths worldwide were attributed to exposure to air pollution – now the world’s largest single environmental health risk3.   However social and political aspects that affect our environment such as housing conditions, access to education, access to green space and poverty are major influencing factors in the relationship between health, well-being and environment.

On the other hand, policies and processes that are undertaken with the aim of promoting health and well-being can have significantly detrimental effects on ecosystems as well as our human environments. For example, food production requires unsustainably large volumes of fresh water and causes environmental damage from pesticides and fertilizers, soil erosion, animal wastes and carbon emissions from food manufacture and transportation. Disease prevention can also drastically alter environments. For example, malaria was eradicated in many developed nations in the 1950s by draining wetlands and spraying DDT to kill mosquitoes. The destruction of these ecosystems to control malaria, and the addition of persistent and toxic chemicals into the soils and watercourses has had long-term detrimental impacts on these ecosystems at a regional scale. Wide-spread disease prevention on a global scale creates additional consequences for the environment as the subsequent increase in longevity and reduction in human mortality creates further pressures from overpopulation, increased use of fossil fuels, increased land-clearing, water use and agriculture, as well as generating high volumes of pollution and waste. Recently, a socio-economic approach to evaluating the benefits and services provided by ecosystems has provided insight into the threats and challenges that may lie ahead.

The ecosystems services approach provides a framework for decision making, and for valuing the ‘products, functions and services’ ecosystems provide, to ensure that society can maintain a healthy and resilient natural environment, now, and for future generations. For example, The UK National Ecosystem Assessment indicates that the United Kingdom relies on it’s ecosystems for a range of services that include climate regulation, waste removal, pest control, flood protection, food supply, potable water, natural medicine, aesthetics, recreation and tourism, among many others. However, this innovative approach recognises and strives to promote the philosophy that our environment provides much more than material benefits. It states clearly that ecosystems contribute to national security, resilience, social justice, health and well-being, and freedom of choice and action4. Therefore, the degradation of our environment, and the ecosystems it supports can have seriously harmful and far-reaching impacts on society, its governance and the economy.   Primary impacts of ecosystem degradation relate specifically to human well-being: ‘significant and detrimental human health impacts can occur if ecosystem services are no longer adequate to meet social needsWorld Health Organisation Secondary impacts that may result from a decline in ecosystem function can affect jobs, income, local migration and, on occasion, may even cause political unrest and conflict. The Economics of Ecosystems and Biodiversity report estimates that globally, the degradation of our planet’s ecosystems is costing us €50 billion each year.   This figure does not take into account the resultant impacts on national security and social justice, which have wide-ranging impacts on well-being, and the availability and access to food, water and healthcare provisions. Of great concern is the way that the complex relationship between health and environment is evolving due to a culmination of global-scale changes including rapid changes in climate, flooding, drought and fluctuations in temperature, not to mention population growth and urbanisation.

The World Health Organisation Global Forum on Urbanisation and Health in 2010 highlighted that for the first time in history more people live in urban settings than rural, and that conditions in cities will be among the most important health issues of the 21st century5. Greater urbanisation puts ever increasing pressure on services such as housing and health. Understanding the surrounding environment, the impact that an ever increasing population has on it and how we can develop and increase services with the least impact is key. The use of our natural environment has provided human civilisation with many benefits, but the costs to our ecosystems have been severe and extensive.   As our population continues to grow and our demands for food, fresh water, healthcare, fuel and building materials soar, we must ask ourselves what price we are prepared to pay. What legacy do we want to leave for future generations? Both the Convention on Biological Diversity and the World Health Organisation have made clear that unless we come to understand the relationship between environment and health and address they way we use and manage our environment, then we will substantially diminish the benefits and well-being that future generations can acquire from ecosystems, and severely compromise their ability to meet their basic human rights to a safe and healthy environment.

The Year of Environment and Health is a collaboration between the University of Edinburgh’s Global Health Academy and its Global Environment and Society Academy. It endeavors to examine the key issues in the relationship between Environment and Health through the lens of Global Change.

Join us in a series of public lectures exploring some of the themes discussed above:-

  • Urbanisation and Health
  • Pollution and Health
  • Ecosystem Services and Health
  • Extreme Weather and Health

References

  1. UNESCO http://www.unesco.org/bpi/wwap/press/pdf/wwdr2_chapter_2.pdf
  2. WHO http://www.who.int/quantifying_ehimpacts/publications/preventingdisease.pdf
  3. WHO http://www.who.int/features/factfiles/environmental_health/environmental_health_facts/en/index7.html
  4. Convention on Biological Diversity http://www.cbd.int/
  5. WHO Global Forum on Urbanisation & Health 2010

Catherine Morgan (Global Environment & Society Academy); Lisa Wood (Global Health Academy), University of Edinburgh.