Here we describe socio-demographic and clinical conditions on board the rescue boats of the NGO Open Arms.
Because of the inner characteristics of the rescue operations, which are usually massive rescues that include hundreds of people, in which the action must be quick in order not to create a delay that impairs the attention of further people, data are scarce and in some cases not collected in depth. This was particularly notorious during the first missions carried out in 2016. At that time the rescue boat was Astral; its small size did not allow the transfer of the rescued people to ports located many miles away, so they were transferred to other ships present in the area soon after the rescue.
Some clinical conditions, such as mild dehydration or hypothermia, and some symptoms such as unidentified pain or discomfort, as well as anxiety attacks and other mild mental disorders were not recorded, although they are probably very frequent in this context [12, 13]; in many cases the communication was severely hampered due to language barrier, in need of an interpreter, usually another refugee with knowledge of several languages, in some cases only non-verbal communication could be carried out.
Also, the initial diagnoses are mostly clinical, since the only diagnostic tests on board are glucose determination, rapid malaria test and a portable ultrasound; therefore many diagnoses should be interpreted as “provisional” data, meaning that the diagnoses are suspected and with a focus on those needing urgent treatment. A multivariate analysis could not be performed to identify factors, as age or country of origin, associated with the development of some diseases, due to the difficulty of linking the epidemiological and clinical data in some of the most extreme rescues.
Despite these limitations, we believe that these are very valuable data, since there are very few reports on the characteristics of refugees during their migration [6, 14, 15]; as in every context, epidemiological data are essential to plan appropriate interventions and to optimize resources . It is also an issue of exceptional gravity and topicality due to the number of people involved, the very harsh living conditions and the high number of deaths during the migration ; according to the United Nations High Commissioner for Refugees (UNHCR), this is the biggest migratory and humanitarian crisis in Europe since World War II . This study has a number of policy and practice implications, as it shows the failure of organizing alternatives for people to migrate and seek asylum in an organized manner, pushing people to a most dangerous migration and into the hands of smugglers . Since the study was completed, the situation of civil society organizations working in the Central Mediterranean has worsened in a very significant way; the obstacles and difficulties imposed by European governments have prevented the departure of rescue ships since January 2019, making this route the most deadly migratory route nowadays .
The average age of the rescued persons is approximately 20 and almost 23% were minors, the majority of them unaccompanied. These data are similar to data reported by the European Union on the demographic characteristics of asylum seekers . This population is extremely vulnerable both to violence, abuse and traumatic stress reactions [21, 22]. Other major concerns about children’s health in this context are no or incomplete immunization, undiagnosed congenital disorders or poor nutrition that could lead to hampered development .
Another particularly vulnerable population are women, who represented 15% of all rescued people in our study; this figure is lower than the general percentage of women seeking asylum in the European Union, which corresponds to approximately one third of the total . This difference may be due to the fact that this route is particularly tough, including crossing several countries before reaching the detention centers in Libya. In our study, 100% of interviewed women reported to have suffered sexual violence during migration, particularly during their stay in Libya. Almost 12% of women were pregnant, most of them travelling alone; it is estimated than in a disaster situation, 4% of population is made up of pregnant women, of which 20–30% will experience an unpredictable obstetric complication or surgical intervention . The absence of timely antenatal care puts mothers and babies on a higher risk of complications [25, 26]. In this case, none of the women had access to antenatal care during pregnancy; an obstetric ultrasound was performed on board when possible, and pregnancy was reported to the authorities at disembark, with the aim of continuing care.
The majority of rescued people came from Sub-Saharan Africa (74.3%), being the most frequent countries of origin Eritrea (12.3%), Nigeria (13.1%), Ivory Coast (8.4%) and Guinea Conakry (7.2%). Though the three major countries of asylum seekers in last years in the European Union are Syria, Afghanistan and Iraq, Nigeria, Ivory Coast and Guinea Conakry are among the ones with largest relative increases compared to previous years (18). Syria, what was the origin of the vast majority of refugees rescued in the previous mission of the NGO in Lesbos Island, was in this case the country of origin of 462 (2.1%) people; there were refugees from as far afield as Sri Lanka, Bangladesh, Nepal and Comoros Islands.
Seventy-four corpses were recovered during the rescue operations, most of them in rubber boats, also known as dinghies. Both thus kind of boats and the wooden ones, which are also used, are very fragile boats, which sink quickly in case of any crack in their structure. Gasoline burns are more frequent in rubber boats, since the bottom of the boat is easily filled with water and gasoline, while asphyxia from motor smoke is more frequent in wooden boats, due to the agglomeration of people at various height levels. The total number of deaths is unknown and probably much higher, since in several occasions half-sunken rafts were found with only a few corpses and in others the refugees refer people dead during the crossing, and thrown into the sea.
Main diagnoses on board were directly related to the precarious living conditions through migratory route, violence and complications of chronic diseases due to lack of care. The most frequent diagnoses were scabies, fever, respiratory and digestive tract infections, mostly as a direct result of poor living conditions in transit. This is similar to other reports by other NGOs that have worked in the area and summarized by WHO [12,13,14, 21].
On the whole, 42% of diagnoses were communicable diseases. Emphasis is often placed on these ; nevertheless we must not forget that they are primarily diseases of poverty and their predominant role indicates that basic health needs are not covered. Disease prevention and control efforts should be taken in front of these diseases; this is particularly difficult in overcrowded situations. In the case of particularly serious diseases such as tuberculosis, the effort must be greater; in our case the suspected patients remained in a separate and well-ventilated area. No contagion was reported among the personnel on board.
Violent trauma, injuries and burns were present in almost 3% of all attended patients, with a wide variety of causes: accidental trauma due to lesions during journey, wounds due to deliberate violence and burns; a special type of chemical burns found in this situation was gasoline wounds, due to the mixture of salt water with fuel that is often spilled inside the boats and stays attached to the clothing and body, causing deep burns due to prolonged skin contact. Recognition and rapid management of this situation is fundamental and the first action must be to withdraw the contact with the toxic, removing the clothes, then the wound should be cleaned and covered with a universal chelator .
Non-communicable diseases, including complications of chronic diseases were found in a low percentage in this population, in contrast to other reports, which account up to 40% of all diagnoses [12, 21]. This may be due to the low mean age of our group; there is also the possibility that in a transit population, in which people prioritize basic needs, those with mild symptoms on board may not recount. In addition, the hardness of the migratory process in general, an particularly of this route, makes that the people who carry it out are generally healthy . Management of these conditions in a mobile context is highly challenging, as discontinuation of chronic controls and medications may cause exacerbations of previously well controlled non communicable diseases , which globally account for 63% of deaths, including 14 million people of premature deaths . Other conditions related specifically to the maritime route and meteorological conditions, as drowning, hypothermia or heat stroke, were also reported.
The proportion of mental health disorders reported was very low in our series compared with other studies . This is probably due to underreporting previously commented, as well as the inner characteristics of the rescues, in which the refugees are still in a very vulnerable transit situation, and the staff is mainly dedicated to the emergency situations. In addition, the overcrowding on board generally did not permit the needed privacy to attend these issues. Depression, anxiety, sleep disturbance and post-traumatic stress disorder are as common as 20% in situations of forced migrations and abuse according to WHO . One study performed in Greece found that 50% of refugees presenting for mental health screening were diagnosed with mental health conditions and, of these, 60% had experienced potentially traumatic events in their country of origin and 89% during migration . In our study, 100% of interviewed people reported that kind of event, including sexual abuse, violence against themselves or others, or having been witnesses of murders.
In relation to the data presented in this article, the NGO Open Arms continues its work in the Central Mediterranean, prioritizing the rescue and treatment of migrants. Greater emphasis should be placed on mental health management; trauma-focused therapies have been shown to be effective within refugee populations , including in acute rescue situations. In addition, efforts have been made to denounce current migration policies, which make it difficult to rescue people in extremely vulnerable situations and in imminent danger of death. Regarding to it, better coordination between the rescue boats and the authorities would make it possible to ensure that patients are followed up. As this is a particularly fragile situation changing constantly, an integrated information system with the possibility of monitoring the state of health of migrants upon their arrival in the Mediterranean, and sharing information among the different stakeholders regarding the burden of illness and the profile of migrants is essential to elaborate a coordinated response. Studies done in the field that objectively analyze the reality of the current situation are much needed.