Dr. Santino Severoni:

We have heard a large set of very interesting questions. I was impressed and very pleased by the committee members' interest in and openness to the concept of placing Ireland as a country that could lead or inspire the policy debate on the public health aspect of migration in the European region in the years to come. It is very important to us and is one of the main reasons I have been asking to be here today. We have set up a process for the next two years in the WHO European region aiming to map out with all member states the priorities and problems, identify gaps and strengths, and formulate an action plan and resolution in order to offer all 53 member states of the WHO European region a rational, harmonised, co-ordinated approach on how to deal with many of the issues addressed today. The issues are recurrent in any country I go to because they are concrete issues related to daily life and the challenges associated with public health.

A relationship with the European Commission and the European Union is a must for us. Our region comprises 53 member state, half of which are EU member states. Non-EU states which are our member states include the former Soviet Union states up to Kamchatka. For us it is very important to have a co-ordinated interlocutor. We are working very closely with the European Commission and 2014 was an extraordinary year because we had been organising some of the key activity on migration and health in Greece and Italy during the two Presidencies. We also have a daily relationship with agencies of the Commission such as the Executive Agency for Health and Consumers, EAHC, in Luxembourg and the European Centre for Disease Prevention and Control, ECDC. We are working hand in hand on many public health issues, particularly on the public health aspects of migration, which is a new area of challenges for many countries.

I would be delighted to continue to meet different parts of the Irish Government because the nature of our work is inter-sectoral. We cannot succeed if the other sectors do not understand our concerns and priorities and if we do not understand theirs.

The most successful stories we have collected across Europe and the countries with which we are working were driven by situations in which we had very close collaboration with the ministry of the interior or of public order that had the mandate to manage the migration system and flow into the country. This interaction and understanding of the public health concern, both with the ministry of health and with us, has allowed the setting up services which are fair, equal and respectful of human rights, as well as the setting up of conditions that are meaningful from the public health point of view because we must not forget about protecting the resident population. Ultimately, I am a technical person and a public health specialist. When one talks about public health, one is talking overall about people in front of one and one does not differentiate because if we have a reservoir of unprotected people within our population, we have a problem.

I thank Deputy Byrne for his nice words. We would be delighted to have Ireland really take the initiative because what we still observe across our region today is that countries tend to be concerned about migration only from their own national perspective. We realise, with communicable diseases, for example, that there are no borders to stop certain diseases. Migration is a structural, global phenomenon that probably cannot be stopped because it is connected with demographic changes, economic trends, globalisation and information. With global issues - which probably are major triggers for migration - although countries are concerned from their national point of view, they tend to only co-operate when they recognise the similarity. In reality, innovation in the future will help in the process by which northern Europe and other parts of Europe understand the challenge of the south and for south and north to understand the east because the reality is that while we read in our media every day about the influx of migrants to European countries, we must recognise that today, Russia bears the largest share of migrants in our region. We are talking about close to 15 million migrants with which it must deal, as well as all the related consequences and issues. We must deal with this issue as a whole region and for this we thought the time was right to bring member states around the table. While our entry point is the ministries of health, we also wish to talk with other sectors because this is the time to have a common approach and an action plan to assist and support our member states.

I hear it every day, and it is normal, but an important emphasis has been given to migration and to this kind of mathematical equation between migration and communicable disease. The Deputy is right in that migration is a bridging phenomenon that is bridging people and populations with different health profiles. However, if he is asking me whether it is true that migration increases the incidence of communicable diseases in the country of arrival, my response is "No" and we have evidence to prove that. Moreover, it is not true that migration is responsible for or is contributing to the spreading of the Ebola virus. Ebola has reached this disastrous condition because the health systems of the countries affected basically were destroyed by ten to 15 years of civil war and consequently, no capacity was in place. I challenge the members present, were they living in a region or place in which the nearest doctor is 250 km distant and is the only doctor available for between 50,000 and 200,000 people, as to how they could get support. There is no system and therefore, there is no parachute and no protection for public health measures.

It is true there has been an arrival of certain diseases, which either were considered to be disappeared diseases or arise from a phenomenon of tropicalisation due to climate changes in Europe. Consequently, one sees the appearance of malaria, dengue fever, chikungunya and so on. Moreover, I like to stress that the movement of people and not migration is usually the most risky position in this regard.

Why is this the case with the movement of people? One instance involves those who travel by plane, which allows a person infected with a disease to travel infected within the contagious period.

The migration phenomenon is characterised by journey and in certain cases it can take years. Unfortunately, it is sad to say that there is a kind of natural selection where only the strongest and the healthiest make it and reach the other country. It is true that in certain cases, people infected have come in. We have data, which I would be happy to share with the committee in future and to provide some numbers. We have started to look at what happened in the past, especially in south Europe where people arrived directly from Africa, the Middle East or Central Asia. They brought with them certain issues, but the statistical incidence in that respect is not concerning. It does not change the routine business we implement or are supposed to put in place every day. The focus or the important aspect here is that we need to have health care workers and a health system that are informed, trained and capable of dealing with this situation.

When I discuss this issue with ministry of education colleagues or non-health care people, I like to provoke discussion by saying that 8% of the European population are migrants. If I would were to tell a doctor of a health Minister that 8% of the European population is suffering from diabetes, we would start tomorrow in the medical universities to focus on training doctors to treat diabetes. Why are we still licensing training and offering job positions to general practitioners who have not been trained to deal with issues related to multiculturalism or migration in terms of public health issues? The future lies there. We need to invest resources in the training and education of that profession to ensure its members are ready to deal with those issues.

However, that is not enough. I have been here before and have spoken about preparedness. A specific request was made inquiring if guidelines had been offered to countries to ensure that they would be to deal with arrival of a person who had contracted Ebola. We have not excluded that sporadic cases of Ebola could be brought in by migrants. The short answer to that question is "Yes". Guidance has been provided to ministries of health. We have been co-ordinating with the Commission and instructions and information have been provided. All WHO EU member states are committed and, I would say, obliged as per their own commitments, to implement international health regulations. This involves building up a certain level of capacity at country level to activate a mechanism of alert and having a response to deal with possible outbreaks. It also involves having a national focal point, the appointment of a national co-ordinator who not only co-ordinates nationally but networks with all the member states. This country's national focal point has the pulse of the situation on a daily basis and knows what is going on in all WHO members states in Europe and in Moldova, Russia, Tajikistan and Kyrgyzstan because those people receive all that information. Guidance has been provided but there are structures in place which, thankfully, were developed prior to that.

TB is another recurrent issue that has being raised at many meetings and it is a big concern, especially antimicrobial resistance to TB, which is a major issue. We have heard complaints from member states that migrants with TB who arrive in a country will require treatment for six months or longer, which involves a cost and the allocation of resources, and they ask who will pay for that. If a service is offered in a country, there will be an increase in the number of migrants who will go to that country for treatment. We observe this every day and we are working on it.

This links in with an issue we need to address, which is to find a way to deal with this problem in a rational manner.

Certainly, we are thinking about TB. If one decided not to accept migrants due to a fear of contracting TB, and someone else would have to deal with TB, then I do not think we would move too far and too fast to resolve the problem. TB is one case, like Ebola, where we need to work without borders and adopt a co-ordinated global approach as was done for polio and other communicable diseases.

Reference was made to the important work done by health care workers from all over Europe and the rest of the world in West Africa in response to the Ebola outbreak. I was also asked whether the resources that have been put on the table are enough. Members will know better than me because of their involvement with public administration that there are never enough resources to fulfil one's desires or plans. That is an easy question for me to answer.

I would like share a thought with the committee. Each western member state has realised that Ebola could threaten Europe and rich countries and is not a problem that nobody cares about because Ebola has existed in West Africa for a number of years. Unfortunately, now we are starting to suffer the pressure of media and public opinion. Even in Europe, despite having very efficient and capable health systems and having resources and everything in place, an additional injection of resources was made at European level to enhance preparedness. That is fine but the immediate consequence is that resources have been shifted from responding, which was done in the middle of a response process, to being prepared. I hope I have explained myself properly. That is like buying an extinguisher for another vacation apartment when the house is burning. We should remain focused on the problem and I shall leave that as an openended issue.

Senator Mullins asked the pragmatic question of whether we have best practice and I shall talk about best practice. Today, reference was also made to mental health and why mental health patients and their families have always suffered the stigma surrounding mental health. However, in this case we are talking about a political stigma. Migration is also a very difficult subject at all levels and one which is very politically sensitive. More attention is given to problems and negative things rather than to best practice. Yes, we have adopted many best practices and we are collecting them.

One of the main objectives of our work at regional level is to facilitate the bridging, twinning and interaction between member states in order to boost the exchange of knowledge, know-how and best practice. For instance, representatives of the WHO went to Portugal to study the situation there because we could not figure out the driving force behind certain political decisions that were made by governments which were completely different from one another. In Portugal the government realised it was cost effective to have a simplified management of migration. The first benefit for the country was a saving in expenditure. The system also simplified the life of migrants and somehow facilitated an integration process. For example, there is a beautiful story about the establishment of a one-stop-shop type of services. Public services were concentrated in one place in a one-stop-shop structure which is an example of best practice. I always like to mention this important example. However, it is not the only one and there are many examples. We have cases where a ministry of interior or health has approached us seeking help to revise standards and services they must offer, according to the EU norm, in centres for migrants because these countries realised they had created an inequity between the migrant and resident populations.

The operations were initially driven by the ministry of interior and have been listed among the successful stories. Again resources is an issue, it is not rhetoric. This is really a new area of work.

The WHO has been ratifying resolution 61.17 in 2008, thanks to the EU Presidency, the Irish Presidency and the Spanish Presidency but not much happened afterwards for a number of reasons. We have been monitoring the implementation of the resolution but not much was done by a single member state.European member states are suffering huge challenges relating to immigration and we decided to step in a very concrete manner. We are not a bank, we are not a Governmentso we do not have taxation mechanisms. We are receiving funding from our member states. Members say they have pledged some resources and that was the start to the process. Certainly if it is possible to expand and identify resources that could be allocated on a strategic intervention which could support the two-year process that we envisage for the future for our region this would be extremely helpful, not only for us but for all the member states.

We have been appraising a great deal in collaboration with Ireland in regard to mental health. That is an example of best practice, a successful story. Our colleagues from Monaghan and Cavan were in touch with our colleagues in the regional office and we started to change our experience and opinion and involved them in the situation in Albania. Through this Ireland became the leading country. We have succeeded in implementing probably the most successful mental health reform in the Balkans in Albania, thanks to Irish taxpayers, its resourceful co-operation and its wonderful professionals, some of whom we meet today. We are seeking the same with migration. We are looking for a country responding to this challenge to work with us, maybe offering secondment of highly qualified professionals from the Government, because we believe that the exchange of experiences can be fruitful for everybody and also to see whether we can engage in one specific strategic area in the future.

There was a reference to mental health. Mental health is a major issue. This was mentioned in reference to the length of the process of protection and the gender and type of migrants arriving in Europe. Perhaps I did not mention that in 2014, out of 150,000 people who arrived in Sicily, there were 14,000 unaccompanied minors. The issue is not only a gender issue but I feel very uncomfortable about those numbers because I cannot stop thinking what is behind them. I cannot believe it is only a question of family reunion. This is something that is very important. When I am asking for is a leadership commitment on an issue of huge pressing relevance in terms of respect for vulnerable groups of population and human rights violations. That 14,000 unaccompanied migrants were crossing the sea in a sinking a boat, I leave it to the committee to imagine what was behind that.

Mental health is one of problems about which we have been thinking a great deal. Despite the process of releasing the protection to asylum seekers, the management of migrants is not enough to be able to trace mental health problems while the person is moving from a reception centre, then to a centre for request of asylum or even a detention centre because they need to be expelled.

We know that a number of suicides have been attempted and that the statistics are high. Today I discussed the matter with Irish colleagues. We have agreed that we need to start looking at a systematic way to assess and study the situation, as well as to plan strategic interventions to address mental health issues. It is the case that the length of the process is markedly influential in respect of mental health repercussions.

When I was a young student, my professor of mental health explained the explosion of emotions a mental health patient could feel once he or she was admitted to a mental health hospital in terms of being a refugee. The person suddenly loses contact with his or her community, family, environment, habits and lifestyle. He or she is living in a depersonalised environment with other people in a place he or she never wanted to be. He or she is completely contextualised. My professor used the example of a refugee to explain the drama a mental health patient faced once he or she was admitted to hospital.

The region where I was born and grew up is proud of its protection of rights and vulnerable persons. It is certainly the best place in which to be born and live. We are also proud because our mental health services are supposed to involve innovative management, particularly in community mental health services. The reintroduction of patients into community life is the best treatment. It is even more effective than drugs and pills and preferable to keeping them in hospital. However, in the case of migration we are doing the opposite. Our policies are inclined to boost or stimulate the institutionalisation of the management of migrants rather than facilitate the opposite, that is to say, access to society, communities and families, which would bring about proper integration.

I work in the area of public health and like to call myself a country doctor. Therefore, I am unable to say whether the integration process in Europe was a failure or a success. I have observed what the committee members observe every day and read what they read every day in the media. Some consideration could be given to the matter. There is probably space to be brave and try new approaches. I will leave it at that, but I hope I have somehow answered the question.

I will address the remarks and comments of the Vice Chairman on the risks health care workers are facing in getting involved in response operations. This is going to be a challenge for the entire continent of Europe, as it has been in the case of Ebola, because the only cases we have had involve returnees who were infected abroad and imported back to Europe.

Migration presents a risk for the population and, again, it is not a simple question. If we were to do the right thing and apply the correct approach, there would be little risk. The problem is that we are more concerned about border protection. Sometimes the paperwork prevails over public health issues. Sometimes it does not even consider public health issues. Where public health aspects are not considered by the migration management process, there can be big risks for the rest of the population.

Out of respect and professionalism I will not name the places we have visited, but we have observed in places where so much emphasis was put on the management and control of the migration flow that all of the attention was shifted to police activity and that no attention was paid to the fact that immunisation was not provided for in the case of people coming from Syria. The Vice Chairman referred to the polio outbreak in Syria. The solution is not to condemn or declare that a given approach was wrong or right; it lies in what I mentioned at the beginning of my presentation. We need to set up a table to seek collaboration and co-ordination not only at international level but also at country level. We must support initiatives to open dialogue between sectors, particularly the non-health sectors, on these matters.

I am very pleased to be here because Ireland is a champion country on this issue. Healthy Ireland is exactly what we are preaching, promoting and inspiring across Europe where the non-health sectors are able to understand the health issues and the health sector has been able to be understood by the non-health sectors.

I hope I replied to all the questions. I am sorry if I took a long time to do so; passionate issues were mentioned and I could not refrain from touching on them. I thank the committee.