Climate migrants and health promotion

‘Burn me / hang me / as much as you wish / as much as history repeats / I will return a hundredfold’ (1). It is rare to begin an editorial in a scientific journal with a quote from a poem, but art is an essential dimension of health promotion. After all, didn’t Winslow daringly assert that public health is ‘an art and a science’ (2) to explain that we must also take our emotions and our experiential knowledge into consideration to act on the social determinants of health, as we celebrate the 10th anniversary of the famous WHO Commission dedicated to said determinants (3)? I read this excerpt by Natasha Kanapé Fontaine, a poet from the Innu First Nation, in a heartbreaking book that shows how European migrants (a term of our times!) who had come to conquer and settle Canada sought to destroy the ‘Laughing People’ (1), themselves migrants. But the people demonstrated their resilience, a word that has come back into fashion (4) even if it is still not used often enough in public health. Despite the twin humiliations of colonization and the unjust governmental policies of assimilation that followed, the people of the Côte-Nord region of Quebec persisted, and still exist today. They, along with the people in central Sahel and at the heart of the Caribbean, are living in an alarming situation today that all too few of us know about.

As the Secretary General of the United Nations reminded us on 16 January 2018, ‘Climate change is moving faster than we are… Inequalities are growing. Nationalism, racism, and xenophobia are on the rise’ (5). Whereas climate change and the associated migrant crisis are without precedent (6), perhaps the reaction of human beings is history repeating, as Natasha Kanapé Fontaine suggests. Current attitudes to the magnitude of human displacement in the world the past few years are indeed surprising. This nationalism, racism or xenophobia is not the sole province of one country’s people. We have only to look at reactions in France, where some wonder if the right to asylum might be called into question; or in Myanmar, where the crisis of the Rohingya was not considered dramatic enough for the Pope to dare mention it during his visit. In North America this past summer, thousands of people crossed the border between the U.S. and Canada on foot to seek asylum following the Trump administration’s decision to lift the moratorium on deporting Haitian migrants that had been in place since the devastating 2010 earthquake. This environmental disaster caused not only thousands of deaths; it also displaced two million people internally and out of the country, leading to a powerful, if not universal, wave of solidarity. Some remember Senegal hosting dozens of young Haitians in the midst of a difficult political period, so that they could have a new life and receive professional training. It wasn’t always accepted by Senegalese students, who didn’t understand why these migrants were being helped while they themselves did not even have the bare minimum to study.

Furthermore, small insular states (7), but also many other countries, are experiencing increasing impacts of extreme meteorological events. These events, beyond their major population health impacts (8), are a major source of migration. The question of equity must be at the heart of what we do in health promotion (2), and it is broached again here since we know that the countries that are most affected are also often the most vulnerable. Between 1996 and 2015, the most affected countries were Honduras, Myanmar, Haiti, Nicaragua, the Philippines and Bangladesh (9). By the end of this century, if nothing is done to address climate change and adapt to its impacts, the number of people at risk of migrating could well reach a billion (10). These climate events also have the potential to increase the number of asylum seekers worldwide (11).

Climate change is obviously not the sole cause of all human migration. Not only are the determinants of migration multifactorial and complex (fragile states, economic factors, conflicts, etc.), but, and above all, there has been practically no research done to understand the myriad causes or their consequences on population health, nor to try to discern which factors lead to displacement. Thus, the concept of the ‘climate migrant’ is by and large still being debated. Is the migration trajectory of these victims of environmental disturbances more violent and traumatizing than that of others? Are its consequences more important?

Beyond words, where are we in health promotion? The consequences of climate change on health are very clear and those of migration are increasingly so. It has thus become urgent both to prevent and to cure (12). However, health promotion practitioners are still struggling to include the ecological dimension of intervention. The Canadian Public Health Association mentioned the link between public health and climate change in 2015 through Trevor Hancock, a health promotion expert (13). But the issue of climate migrants was not brought up. Most of the large ‘without borders’ health NGOs have yet to take stock of the role of climate change in their strategic plans or humanitarian interventions. The interconnections between climate, ecology, migration and health have not yet reached our minds and our actions. The fields of health promotion, One Health and planetary health have not yet spoken enough to each other.

In the face of the immense humanitarian priorities and needs of migrant populations, as well as state responses that sometimes fall short, it is clear that these organizations cannot do everything. Going beyond the advocacy needed internationally, the issue of climate migration is truly a challenge for health promotion practitioners. It means we need to have a comprehensive vision of the problems to be addressed, to care for migrants during their journey and upon their arrival, but especially beforehand, all while focusing on their resilience. We need to heal human beings and the devastated lands they are forced to flee, all of which we know quite well how to do. In addition, and in particular, we need to prevent catastrophes and prepare ourselves to respond to them. According to the WHO, health security also comes from preparing health systems and public health interventions to face climate change (14). Health promotion practitioners must now consider climate change as one of the social determinants of health and of health inequities. While public health professionals are not quite there yet, it seems that policy makers haven’t made it much further. One of the most affected regions in terms of climate change is the Sahel, in Africa. An alliance was launched in 2017 during a Franco-German Ministerial Council meeting ‘motivated by the collective situation of worrying urgency […] notably with respect to growing food and climate vulnerability, insecurity and migration’ (15). However, the initial meetings and discussions seem to have overlooked population health issues, issues of access to care and health promotion interventions especially for climate migrants who are widely present in that part of the world. The solutions to the ills currently faced by the inhabitants and the states in this region must not be limited to security and military solutions. France’s 2017 global health strategy is innovative in this respect, for the struggle against climate change is presented as contributing to one of its objectives, namely ‘to act upon the principal determinants of health’, which notably includes environmental determinants (16).

As health promotion practitioners, we must now take better stock of the issues surrounding human migration borne of environmental degradation, especially climate change. We have to improve our mobilization so that our research, our action and our advocacy finally address the triad: migration, climate change, and health. As the Secretary General of the UN reminds us, ‘I’ve said it before and I’ll say it again: migration is a positive phenomenon’ (5). Health promotion must take its place in this debate.