Migrants crossing the Mediterranean Sea: an opportunity or a duty?
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“For over twenty-five centuries we’ve been bearing the weight of superb and heterogeneous civilizations, all from outside, none made by ourselves, none that we could call our own”
Giuseppe Tomasi di Lampedusa, The Leopard.
Between January 2015 and December 2016, more than 1 million people crossed the Mediterranean Sea to Europe, exposing themselves and their relatives, including infants, to extremely dangerous, life-threatening conditions. The International Organization for Migration, and the UN Refugee Agency Web sites have published troubling statistics on this tragedy: 4913 deaths were recorded in 2016, and 5740 in 2015. Beyond the reasons prompting migration, often an attempt to flee violence, there is the not negligible psychological trauma inherent in migration, further exacerbated by the journey itself. Survivors can be affected with a variety of conditions and diseases, such as polytrauma, hypothermia, burns, pregnancy- and delivery-related complications, carbon monoxide poisoning, and gastrointestinal illnesses, all potentially requiring hospitalization upon arrival on the mainland. This scenario is accompanied by social instability, poverty, and a lack of food and water, delineating a very fragile, and often desperate, population that may have a relevant impact on our health care systems in the first weeks after migration, but also in the subsequent months because of diseases that in their countries of origin were not screened for or treated. There are a number of challenges in intensive care for migrants, beginning with language and culture barriers. In addition, it may be difficult to obtain a clear medical history, and even more so to obtain medical records. From a clinical perspective, while most of the conditions or diseases that migrants present with are well known to Western clinicians, they are most often present in otherwise physically and psychologically healthy patients. In the case of sick migrants, this cannot be assumed.
This situation poses an increasing challenge, and is surrounded by divided public opinion. Often, the health risks that migrants are believed to pose (e.g., the spreading of tuberculosis), in the absence of an adequate knowledge of the clinical processes, are cited to limit interventions.
Sicily (and its small surrounding islands) is the first mainland to be reached by migrants leaving North Africa and, in collaboration with the WHO/Europe project Public Health Aspects of Migration in Europe, has become a pioneer region, developing an operational strategy to respond to the public health implications of sudden and large arrivals of people. A standard medical triage is performed for crisis management to direct migrants to the appropriate health care routes. An extracorporeal life support (ECLS) program, in the immediate future, would add a new piece to the mosaic of integrated health intervention for newly arrived migrants.
It is difficult to know how the Italian national health system is responding to the need to provide care for migrants, mainly because of a lack of documentation in the literature. Local, regional, and national networks of hospitals and centers, and attendant registries, would go a long way in helping health care organizations who find themselves facing the new challenges posed by the increasing influx of migrants. From 2011 to 2016, our regional health care system supported 624 migrants transferred by helicopter from Lampedusa, and hospitalized in Palermo. Intensive care medicine was required for life-threatening conditions, notably burns, dehydration, suicide attempts, hypernatremia and rhabdomyolysis, pulmonary embolism and, recently, chemical pneumonia in people locked in the holds of boats. These patients presented with a variety of conditions, clinical pictures and, perhaps most important, unique stories of personal tragedy and endurance.
At our research institute, in 2015, 22 migrants were admitted, and seven required assistance in the intensive care unit (ICU). Given Sicily’s central position in the Mediterranean Basin, IRCCS-ISMETT is a point of reference for European and non-European Mediterranean countries, and it ensures the most advanced treatment, including an ECLS program for acute cardio-respiratory failure unresponsive to conventional medical and surgical therapies (up to 2015, 132 patients were treated with veno-venous ECLS and 124 with veno-arterial ECLS and two patients were migrants).
Migrants’ health and access to the health system may be a blessing in disguise for the Sicilian, and Italian, community. Independent of questions of ethics, an efficient and timely management of migrants, with their peculiar clinical conditions, would reduce the burden of prolonged hospitalization and costs of patients with unresolved problems. By treating diseases uncommonly experienced by our population, we might advance our knowledge and gain new expertise in, and insights into, the management of conditions previously considered unamenable. Centers with highly specialized technology for the treatment of cardio-respiratory failure could help promote greater awareness of the indications for, and benefits of, ECLS among health care providers. The Italian Ministry of Health has an ongoing procedure to develop guidelines for the treatment of migrants, starting with those who have suffered violence and arriving at patients admitted to the ICU.
The European Union now has an important opportunity to disseminate a basic foundational social concept: solidarity with, and assistance for, people in difficulty. Building integrated networks to answer an emerging health need will also help mitigate the expensive rescue operations that are employed only in emergencies.
Health care providers have a duty to provide the best possible care with a reasonable use of resources, assigning patients to the adequate level of care in light of their clinical condition, and not simply because of their status as “outsiders”.
We imagine a relevant duty for the European Society of Intensive Care Medicine (ESICM), the only organization that could promote a network of intensive care units able to better describe this phenomenon and guide a rationale use of resources, which by definition are limited.
We are sick at heart to hear international news reporting people dying in the Mediterranean Sea and to see pictures of children lying dead or dying on the shores of Europe, images that have become a symbol of human and social failure.
With no end in sight to wars and conflicts in the Middle East, North Africa, and Africa, the flow of migrants will likely increase; so, an advanced health care plan in the acute care of migrants, including ECLS, must truly move from the conceptual stage to reality.
The first author would like to thank Dr. Angelo Luca, Director, and Ugo Palazzo, Director of Health Care Activities of IRCCS-ISMETT. Dr. Michele Pilato, Chief of the Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, and Dr. Antonio Arcadipane, Chief of the Department of Anesthesia and Intensive Care and all physicians involved in the ECLS program at IRCCS-ISMETT are also gratefully acknowledged.
For their assistance, collection of clinical and epidemiologic data, and intellectual support, the authors would like to thank Dr. Linda Pasta, Domenico Serravalle, and Leonardo Antonio Suero; Dr. Antonio Romano and Dr. Francesco Clemenza; Flavio Di Giacomo and Rossella Celmi, from the International Organization for Migration; Dr. Virgilio Costanzo, from the Italian Ministry of Health.
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Conflicts of interest