Adequate responses to migration flows have been increasingly hampered in Europe by policies that limit freedom of movement and foster stigmatisation of humanitarian assistance. [1,2] These policies are based on a restrictive interpretation of refugee laws, overuse of detention centres, limitation of access to health services, and criminalisation of migrants. [3-5] Even if most legal instruments recognise the right to health for all, including people on the move, the health needs of migrants remain neglected.  Furthermore, organisations conducting lifesaving search and rescue operations often face accusations of colluding with human traffickers. 
This scenario has become even more complex after the onset of the covid-19 pandemic. Firstly, border controls and measures for restricting mobility have been tightened as part of the pandemic response, with a severe impact on refugees’ and migrants’ access to adequate healthcare services and information. [7-9] Secondly, inadequate living conditions, such as overcrowded and informal housing in the countries of transit or arrival, increase the risk of contracting covid-19 as well as other infections.  Thirdly, pandemic-related logistical constraints caused a slowdown of search and rescue operations in the central Mediterranean Sea and formed an obstacle to provide humanitarian help for asylum seekers. Based on our experience at Médecins Sans Frontières (MSF), search and rescue operations and health assistance during the migration journey are essential for an adequate response to migrant flows and for adequately tackling migrants’ health needs, including those related to the pandemic, as part of a coordinated public health approach.
Health and human rights along during migration journeys
From 3 May 2015 up to 31 December 2019, 339,476 migrants had been rescued in the central Mediterranean Sea by different stakeholders such as institutional organisations, NGOs, commercial actors including fishermen, coordinated by the Italian Coast Guard.  Of these, 81,186were either rescued or transferred by MSF vessels.  Between 1 January and the 30 September 2018, MSF rescued 3,184 people and conducted 1,385 on-board consultations.  The most common problems were benzene, chemical burns (86/1,385; 6.2%), wounds (70/1,385, 5.1%), hypothermia (62/1,385, 4.5%), and violence related injuries (39/1,385, 2.8%). Out of 3,184 individuals, 464 (14.6%) belonged to pre-specified categories of vulnerability: 81/464 (17.5%) were unaccompanied minors, 216/464 (46.6%) were victims of torture/ill treatment, 121/464 (26.1%) were survivors of sexual violence and 27/464 (5.8%) were possible victims of sexual trafficking. Most of them had transited via Libya, a key country for migration routes.
The EU and some member states have adopted policies that delegate the control of migrant flows, by making neighbouring countries such as Libya act as Europe’s de facto border guards.  These policies have prompted cruel detention systems and created unprecedented human suffering, with people subject to long-term detention in centres run by the Libyan interior ministry or local militias, often in inhuman conditions. [15-18] For example, it is reported that between 1 September 2018 and 31 of May 2019, at least 22 people died in Zintan and Gharyan detention centres.  Nutritional screening undertaken by MSF at the Sabaa detention centre (Tripoli) among 205 individuals in February 2019, found that one in four people were malnourished or underweight.  In 2018, MSF helped 1,783 migrants who had reached Italy after having been exposed to torture during their journey.  It is very likely that those forcibly returned to Libya will re-enter the same cycle of violence.
More recent data suggest that fewer search and rescue operations were conducted in 2020 than in previous years, both before and after the adoption of pandemic containment measures. The 2,300 people held in detention centres across Libya up to July 2020 were reportedly kept in overcrowded and unhygienic conditions, with poor access to food and water and no possibility to adopt covid-19 containment measures, such as physical distancing. Furthermore, visits by humanitarian organisations to detention centres have been reduced because of pandemic related movement restrictions and insecurity. 
Living conditions also tend to be inadequate in the European countries of transit or arrival. A survey carried out in 2015 among an estimated 10,000 migrants living in 27 informal settlements in Italy indicated that 11 settlements lacked running water, 13 electricity, two drinking water and six even toilets. The public health consequences of such situations will only be magnified during a pandemic, as essential public health measures – such as social distancing, hand hygiene and self-isolation – can hardly be implemented under such circumstances.
Figures from the UN High Commissioner for Refugees (UNHCR, now known as UN Refugee Agency) suggest that fewer people died or went missing in the central Mediterranean Sea in 2020 (473) vs 2019 (750), with a decrease of reported death rates from 3.7% (750/20,506 departures) in 2019 to 1.4% (473/33,953 departures) in 2020. [23,24] However, this may be subject to serious underreporting because of difficulties in collecting data on migrant deaths in 2020. 
The decrease in humanitarian search and rescue operations, combined with the lack of any EU led activities, results in an increasingly dangerous void in the central Mediterranean, where the numbers of individuals attempting to make the journey from Libya to Europe dramatically increased in 2020 according to the UNHCR. [26,27] Furthermore, inadequate health assistance during and after the journey, either in reception centres or in informal settlements, makes it impossible to prevent, diagnose, and cure various treatable conditions and it even prevents the adoption of adequate measures to contain the pandemic. The pandemic is providing further evidence that a migrant inclusive health access approach is urgently needed in Europe. Everybody should have access to essential medical services; and during epidemics and pandemics, nobody should be left out of the outbreak response plans. Furthermore, the moral imperative of saving lives should be acknowledged by all stakeholders and policy makers and they should support efforts to rescue those attempting to reach Europe.
As European medical staff and public health specialists serving patients and communities within our own borders and beyond, we should take an ethical stand by speaking out against policies that threaten health, lives and public health, and by combating misinformation. Today more than ever, in the middle of an unprecedented pandemic, solidarity needs to reach beyond national borders. The systematic collection, analysis, sharing, and dissemination of robust and ethical data will be essential for shaping public health and human rights oriented policies, and for contributing to building an inclusive society, able to adequately respond to medical needs including in global emergencies. 
Claudia Lodesani, president of MSF Italy. She is an infectious disease specialist and has been working with MSF since 2002. She has coordinated the MSF’s intervention for covid-19 in Italy. Twitter: @claudialode
Silvia Mancini, has been working with MSF in many developing countries carrying out epidemiological and public health evaluations. She holds a masters in public health from the London School of Hygiene and Tropical Medicine.
Raffaella Ravinetto, is a senior researcher and policy adviser at the Antwerp Institute of Tropical Medicine (Belgium), and a former president of MSF Italy. Twitter: @RRavinetto
Favila Escobio, family and community medicine specialist. He has been working with MSF since 2013.
Zeno Bisoffi, PhD on Medical Sciences at the University of Antwerp. Since 1 December 2017 he has been associate professor of infectious and tropical diseases, under an agreement with IRCCS Sacro Cuore – Don Calabria Hospital, Negrar (Verona).
Competing interests: none declared.
Thank you to Gianfranco De Maio (1960-2020) for supporting and inspiring us in our work related to humanitarian medicine.
The authors thank Marco Bertotto and the team of Médecins Sans Frontières/Doctors Without Borders (operational centre Amsterdam) for providing data on search and rescue activity and medical consultations on board.
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