Oireachtas Joint and Select Committees

Wednesday, 14 January 2015

Joint Oireachtas Committee on Foreign Affairs and Trade

Migration Issues: World Health Organization

2:30 pm

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I welcome Dr. Santino Severoni from the World Health Organization. For years migration has been an issue in Europe. The expansion of the European Union and the increasing numbers of migrants from various parts of Africa and Asia have added to the issues arising from it.

Migrants' health is an inter-sectoral issue which includes a significant foreign affairs involvement. In the past few months the committee has discussed the impact and consequences of the Ebola outbreak in countries in western Africa. In addition, members have concerns about the health issues affecting some members of the Diaspora.

The format of the meeting is that we will hear Dr. Severoni's opening statement. We will hear the responses of members and bank all of the questions raised and then hear a final response. The normal warning about the use of mobile phones applies. I ask members to decommission their mobile phones for the duration of the meeting because they affect the sound and recording systems and create numerous problems.

While members of the committee have absolute privilege, guests, on the other hand, have qualified privilege. Members and guests should always try to ensure they do not mention persons outside the Houses who are not in a position to defend themselves or their interests in a way which might be derogatory or defamatory. I ask them to observe this rule.

I welcome Dr. Severoni. The issue he is about to discuss with the committee is one on which it has engaged previously. Obviously, given current and developing circumstances, the issues of the past six months serve as a useful backdrop to his presentation. The normal presentation lasts ten minutes. I ask members to ask their questions and make their comments in a way which will facilitate the satisfactory and efficient conclusion of the business to be conducted.

Dr. Santino Severoni:

I thank the Vice Chairman and distinguished members of the joint committee for the invitation to appear before the committee today and giving me the opportunity to make a presentation on the work of the World Health Organization for Europe in the area of migrants’ health issues and to discuss the possibilities for further collaboration with Ireland. I am honoured to be accompanied by three Irish colleagues, partners of the WHO, from the mental health services of Cavan and Monaghan which have been collaborating with the WHO since 2001 in implementing major mental health reforms in the Balkans. I thank them for accompanying me.

We all know that the overall health of the population across Europe has improved in recent years, but we also know that these improvements have not been equally shared within and among the different European countries. Migration is a key factor in influencing these avoidable and unfair health inequalities. The main contributing causes of migration are natural and man made disasters and social, economic and political disruptions. An estimated 8% of the total population of the WHO European region, which comprises 53 member states, is composed of migrants, with women accounting for 52% of the overall migrant population. This influx represents an increase of 5 million people since 2005 and accounts for almost 70% of the population growth between 2005 and 2010 in Europe.

In this context, the project - Public Health Aspects of Migration in Europe, PHAME, - was created by the WHO regional office for Europe in 2011 to respond to the public health needs of migrants. It was precisely in 2011 that the crises in north Africa and the Middle East started posing significant challenges to the health systems of European countries in the Mediterranean, as a result of the large influxes of migrants arriving to Europe from across the sea. This WHO project on health and migration was defined with the aim of supporting member states in strengthening health systems to address the public health needs associated with migration, consequently improving the health of the migrant and resident populations. Its objectives are also to contribute to a productive debate on migrants’ health at all levels within and outside the government, sharing knowledge and increasing awareness throughout the European region.

With these same objectives in mind I am appearing today before this committee. The phenomenon of migration and its consequences in the health of the migrant and resident population affect the European region entirely, but manifest in different ways. For example, our region is characterised by three main challenges in dealing with migration, where the southern part of the region must confront undocumented migrants arriving across the sea. The member states of the eastern part of the WHO European region must confront increasing movement of labour migrants, while northern Europe is a major attraction for people requesting asylum and protection and governments face the challenge of integrating these asylum seekers.

In the southern Mediterranean region, WHO-Europe has already established collaboration with the ministries of Portugal, Spain, Italy, Malta, Greece and Cyprus. Health system assessments have been conducted jointly with the ministries of health in these countries and similar exercises are also under preparation with the ministries of health of Bulgaria and Turkey. These missions have the aim of supporting the work of policy makers, health planners, national, regional and local health professionals and all those responsible for providing quality health care to migrants. The final objective is to develop expertise and capacity and to identify and fill potential gaps in health service delivery, including services for the prevention, diagnosis, monitoring and management of disease, and to share best practice among member states. As a result of these exercises, several reports have been published indicating key findings and areas for future collaboration. These activities and publications have initiated a dialogue among southern European countries towards a common understanding of the phenomenon of migration and public health.

In order to address the complexity of migration health, it is important to raise awareness on migrant health and of the need to address the issue in an equal and inclusive way. In this regard, WHO-Europe is producing a number of publications that will contribute to bringing relevant stakeholders within and outside the health sector together and start a cross-sectoral and region-wide dialogue on migrant health. There is also a growing demand by member states to strengthen health information for decision making in the field of migration and health. Responding to this need, the European advisory committee on health research is currently working on the development of three reports to synthesise the best available evidence on the public health responses to migration and identify potential gaps in order to inform policy makers.

At this stage, anyone could ask himself or herself why I am addressing these questions to the Joint Committee on Foreign Affairs and Trade. The answer is that migrants’ health is an intersectoral issue that not only involves professionals working within the health sector, but also the ministries of foreign affairs, interior, employment, education or social affairs.

The diversity of actors involved in the process and the political sensitivities attached to this field of work make of migration a challenging field for public health. At the same time, the intersectoral nature of this area brings an opportunity for the health sector and governments to explore ways to work horizontally and transform migrants' diversity into greater health equality and sustainability in Europe. By promoting an intersectoral and intergovernmental approach to migration, the WHO project supports the implementation of the European policy framework, Health 2020, signed by all 53 European member states, including Ireland, and the implementation of the World Health Assembly resolution 61.17 on the health of migrants adopted in 2008 and also ratified by Ireland.

Migration is an international phenomenon which manifests in different ways but affects all countries regardless of their borders. As a consequence, there is a growing need for a more comprehensive and systematic approach, recognizing countries' specificities while identifying regional priorities and agreeing on a common strategy to address migration and public health. During the last WHO Regional Committee for Europe session, a technical briefing on health and migration was held - and attended by member states - by the standing committee of the WHO Regional Committee for Europe for the preparation of a European action plan on health and migration. This is a remarkable new initiative. While we have already engaged in discussion and consultations with southern and eastern European regions, we are looking now at the northern countries in order to add all voices to this regional dialogue on migrants' health. More specifically, we would like to strengthen our collaboration with Ireland in this area of work, following the example of the national strategy, Healthy Ireland, in which the objectives of the Health 2020 European policy framework have been successfully applied to the national context, aiming at the improvement of everyone's health with a focus on the most vulnerable through whole-of-government and whole-of-society approaches.

Ireland is a country with a huge experience of emigration and immigration which understands the challenges related to this phenomenon. Ireland also has great experience in the area of health inequalities and vulnerability. The WHO is looking for success stories and best practice approaches on migration health. Ireland could be a northern European champion in this regard. I thank the members for their attention.

Photo of Brendan SmithBrendan Smith (Cavan-Monaghan, Fianna Fail)
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I welcome Dr. Severoni and his colleagues. I have some knowledge of the collaboration between Cavan-Monaghan mental health services and the WHO, particularly the work that was carried out in the Balkans, particularly Albania, where a model and a template was established for the provision of mental health services. In his concluding remarks, Dr. Severoni asked if Ireland could be a northern European champion on the exchange of best practices among countries with regard to the health issues affecting migrants. It is a good question to pose to us. Dr. Severoni's presentation was very interesting in highlighting to us an issue that may often not be given the attention it deserved.

In the formation of the new EU college, the Home Affairs Directorate General is now Migration and Home Affairs. I presume the WHO regional office has ongoing contact with the EU Commissioner for Health and Consumers. Dr. Severoni referred to the need for collaboration in northern Europe, noting the collaboration already happening in the Mediterranean area. All of the countries in northern Europe with significant immigration are within the European Union. I presume the Council of Ministers configuration with responsibility for health, whatever the title now with the change of directorates, would be useful in that respect. I assume the WHO has ongoing contact with it.

My understanding is the leading relationship between us and the WHO is through the Department of Health in respect of other ongoing health issues and through Irish Aid in the case of developing countries. The significance that we as a country attach to the WHO lies in the fact that it is one of six UN priority partners. This denotes its significance from an Irish perspective.

As to whether the WHO has ongoing contact with the Department of Foreign Affairs and Trade, Irish Aid, a unit within that Department; and the Department of Health, the delegates have outlined issues that are extremely important. Perhaps the committee might write to Deputy Sean Sherlock, in his capacity as Minister of State with responsibility for Irish Aid, to suggest he be in a position to meet those in the regional office to hear at first hand its particular suggestions in dealing with these health issues because this country has a very proud tradition of providing significant funding in overseas development aid, despite the economic challenges. Before the State began to give assistance, it was provided in many countries going back many decades by Irish people, both missionaries and lay people. Perhaps the committee might suggest as a useful follow up having a meeting with the Minister of State and his colleagues in the Irish Aid division.

I appreciate the presentation from the regional office and can see why it sought a meeting with the committee because the issues raised cross many sectors. As I said, I have some knowledge of the work done in collaboration with the Cavan-Monaghan mental health services. I commend Ms Margaret Fleming, Mr. Brian Clerking and Mr. Damien Murray on the great commitment they have given to these programmes during the years.

Photo of Eric ByrneEric Byrne (Dublin South Central, Labour)
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The delegates are more than welcome. It is suggested in the presentation that the regional office appreciates the role Ireland plays with the WHO, despite being a small country. The regional office has been head hunting countries and Ireland has been mentioned. We are very proud that it has suggested Ireland could act as a champion. It is quite capable of doing so.

I also congratulate the Italians. Dr. Severoni is the second serious Italian we have had here in the past two days. We have also heard from the EU High Representative, the European Union's foreign Minister. She is a very fine woman and was most impressive. I congratulate Dr. Severoni on his role.

On the statistics given, I am surprised that 52% of immigrants are women. It strikes me that we always thought they were predominantly men. I do not know why I thought that, but I certainly did not think 52% were women. Is there an explanation for this?

It is interesting that Ireland has transformed itself in the past 30 years from being a monocultural society. We were white and Roman Catholic and that was it. Now Ireland is extremely diverse. The Government has just made 70,000 people from 120 countries Irish citizens. Citizenship ceremonies are still taking place. We see the impact at hospital level, particularly in maternity services where the health authorities have identified a particular difficulty for the children of African women. I cannot remember its name, but there are rumours or perhaps statements of fact that there is an antibiotic-resistant strain of TB. This could be exploited by those who are nervous about the influence of immigrants, but a particular problem, at least for children of African women, has been identified because of a particular strain of TB.

We are at the forefront in addressing the health issues of immigrants. Notwithstanding all of the criticism of the direct provision system, we provide an excellent medical service for asylum seekers and immigrants.

I record my appreciation of the staff of the Department of Foreign Affairs and Trade in Africa. In particular I highlight the role of our ambassador, who is female and her two female staff members in Sierra Leone, a country at the epicentre of Ebola outbreak and riddled with the disease. We have three very brave women in our embassy. Irish Aid has provided funding of €12 million to fight this deadly disease.

Sierra Leone is coming out of a horrendous war, where young boy soldiers in the army were engaged in terrible deeds during this war. We must applaud the work of the ambassador and her staff. None left during this period. They were offered a break and did not take it but stayed and worked. They are still engaged with the country. It is indicative of the deep engagement of the Irish embassy staff in the fight against disease.

May I ask the witnesses to comment on the situation regarding polio? The World Health Organization in conjunction with the Pakistani Government has been attempting to inoculate the children in Pakistan. Some of their health workers have suffered death as a result of rumours that the polio vaccine is doing something weird to their population. If it is a fact that health care workers who were working in the field of public health have suffered a dastardly death as a result, I would like to extend our condolences to their families.

Photo of Maureen O'SullivanMaureen O'Sullivan (Dublin Central, Independent)
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I thank the witnesses for the presentation. There is no doubt about the challenging and very demanding nature of the work of the WHO. Its staff are facing new challenges in Syria, with the migration of the people from Syria which is adding to the difficulties of the countries that are taking in the Syrian refugees. The Ebola virus is also causing difficulties. No doubt migration has played a role in the spread of the virus. I would like to hear their views on the way the virus is being treated. There are concerns that when people who have the virus and are moved out of their communities to a so-called treatment centre, it is almost like their death warrant has been signed. It is managing the illness as opposed to really getting to treat it with the hope of recovery. We are seeing far more deaths from the Ebola virus than there should be.

I am aware that much of the funding goes to the major NGOs but how much is trickling down to the local community groups who are active on the ground in the community and have direct contact with the people? They are much more effective with people who are in danger of contracting the Ebola virus and could prevent the disease from spreading further.

We must address women's safety before we can talk about women's health. We know from migrant women that their safety is very much at risk at times. HIV-AIDS, the story of the time for so long, has disappeared off the agenda in certain areas. We know it is still a major factor and migration contributes to that. There are a great number of men who have to move from their country to work in mines and who then contract HIV-AIDS and bring it back to their home.

I am involved with a group of polio survivors in Dublin. The WHO talks about eradicating polio, but what level of support is being provided for the survivors of polio? This one of the areas that the WHO deals with.

When we speak about health we tend to concentrate on physical health with mental health having lower priority. However, we should give equal concern to mental health issues.

Photo of Dan NevilleDan Neville (Limerick, Fine Gael)
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I also welcome the group. I do not want to repeat any of what has been said, but I wish to raise two issues.

As Dr. Severoni is aware, we attended refugee camps in both Jordan and Ethiopia in the past two years and, having visited them, one is very conscious of the health issues in them, including sanitary services, the fact that ten people are sleeping in one tent and the general health issues that are present, despite the best efforts of the UN commission for refugees. Will Dr. Severoni comment on this issue and involvement in dealing with it? When we were there, we did not come across the world health authority. We were there as guests of the United Nations.

The other point concerns what we found in some of the refugee camps. There were people within the refugee population with a lot of medical skills. What usage is made of their skills to improve or try to manage the issue in some way? It is almost impossible to talk about an improvement other than trying to maintain a reasonable level of health. One would be absolutely frightened of an outbreak of any contagious disease in some of the places we saw during our visits. The camp in Jordan appeared massive - the camp in Ethiopia was probably a little more manageable - because of the flood of refugees from Syria into Jordan. To me it looked like a very serious health issue or a potential health issue. Will Dr. Severoni comment on this?

Photo of Jim WalshJim Walsh (Fianna Fail)
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I welcome Dr. Severoni and thank him for his presentation. I have three very quick questions. He mentions that the integration of asylum seekers is a challenge facing northern European countries. Given what we have seen in Paris recently, for example, and Britain also, many migrants have become segregated rather than integrated. What is Dr. Severoni's view or does he have a policy on inter-culturalism versus multiculturalism, which is probably at the root of some of the difficulties? There is, obviously, a significant difference in the approaches adopted. The multiculturalism approach which has been embraced during the years seems to have failed and there has perhaps been segregation as a consequence.

Mention has been made of our system, how we handle asylum seekers, in particular, and our system of direct provision. It can take up to nine years in many instances for the process to be completed. This means that people are living in these facilities together in what are probably overcrowded conditions. Is Dr. Severoni familiar with the process? Will he comment on the delay in processing applications? Does he see implications for the mental health of migrants in that scenario?

My third question concerns Ebola. Some medical staff who were very brave and good to volunteer their services are returning from affected areas having been infected. They comprise a very small number, but we have seen this happen in the United States and Britain. Presumably, it has happened elsewhere. There has been a debate in some places, particularly on the neighbouring island, about quarantining those who come back having given their service. Will Dr. Severoni comment on this?

Has that debate in any way inhibited volunteers or is the WHO happy with the number of medical volunteers going to affected areas? One of these cases appeared to arise in this country but it transpired that the individual concerned was not affected. The individual was shunted from one hospital to another, which did not appear to be a good approach. Has the WHO issued clear guidelines on what should take place in such a situation?

Photo of Michael MullinsMichael Mullins (Fine Gael)
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I join my colleagues in welcoming the representatives of WHO and commending the people of Cavan-Monaghan on the good work they are doing. The service is often held up as an example for how good mental health services could be provided in the regions. The witnesses indicated that the number of migrants increased by 5 million people since 2005. What is the total number? Can they outline any best practice in other countries that they would like to implement as part of this project? I hope Ireland can take a lead in helping on this project. Is the funding adequate to makinig a serious impression on the challenge that the team faces?

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Members have raised an interesting range of subjects. As the witnesses can probably ascertain, members are familiar with the subject matter and Mr. Clerking, Mr. Murray and Ms Fleming are well known to us.

Several members raised the issue of health and development workers going abroad in the current environment. They face considerable risks and are making a huge sacrifice but they remain dedicated to their tasks. We should consider the degree to which we can learn from their experiences, and how they can learn from our experiences. I commend those people, including the witnesses, who have made a massive contribution to dealing with ebola and other challenges.

In regard to the health of immigrants and the reason there are more women than men here, this is self-evidently due to health and safety concerns, including traditional practices in certain countries which appear barbaric to us. An issue also arises in regard to the mistreatment of young women and girls. I note the ongoing situation in Nigeria. Even though that country is geographically distant from us, these issues arrive at our doors in various shapes and forms.

A third group of migrants who were not mentioned came here a number of years ago either as visitors or on stamp one or two clearance. During the economic boom they had full access to employment, some legally and others without authorisation. They now present serious problems for themselves and for us as a country in terms of dealing with their situations. It is difficult to deal with them because of their lack of documentation and status in many cases. This is something we have to attend to. Once a girl or a women with a child is in that situation, health is the last issue to be addressed because the more pressing issue is feeding the family.

We have all dealt with direct provision in Monaghan and the other centres all over the country. One of the issues that worries us is the fact that the undocumented people have no status and have very pressing health requirements which are obvious even to a non-medical person. We need to consider this and would be interested in the witnesses' comments on the issues they raised and those the members raised, based on their one-to-one dealings with people who have come here for whatever purpose. Direct provision is not ideal and although it is supposed to be temporary, in some cases it has dragged on for years. In some cases there is a clear explanation while in others it is not so readily explained. We must remember that the health and welfare of a person who is in the country, whether legally or illegally, has implications for our society, the health of our society and our need to be alert to the kind of situation that can emerge very quickly and tragically in some cases.

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.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I thank Dr. Severoni. We are running out of time but Deputy Maureen O'Sullivan had indicated that she wanted to ask a brief question. Deputy Seán Crowe, unfortunately, could not be here at the beginning of the meeting and I will give him some time also. I ask the Deputies to ask brief questions and I will then ask Dr. Severoni's colleagues if they wish to make a quick comment.

Photo of Eric ByrneEric Byrne (Dublin South Central, Labour)
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Can I just say that sickle cell was probably the issue?

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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It is one of the issues, yes.

Photo of Eric ByrneEric Byrne (Dublin South Central, Labour)
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I could not remember the name of it.

Photo of Maureen O'SullivanMaureen O'Sullivan (Dublin Central, Independent)
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I want to return to the Ebola situation. How would Dr. Severoni define success in dealing with Ebola if, as one of the non-governmental organisations tells us, there is a 30% survival rate for people in the management centres? That brings me to another question. What is Dr. Severoni's definition of public health? Is it for everybody or for certain people?

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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We will take a quick question or comment from Deputy Seán Crowe.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Apologies for being late. I had questions for the Minister in the Chamber. Dr. Severoni spoke about the common approach needed to deal with the issue of immigration but I will give him one example of what works and what does not. A boat arrived at the Canary Islands recently from Africa. It was surrounded by police. The boat was set on fire. The immigrants were left on the strand. This is an area where people are on holidays and taking photographs on their cameras. For seven hours people were sitting in the sun surrounded by police, with the boat having been set on fire. That is the panic that occurs with regard to people coming from Africa in terms of the possibility of them being a danger and so on. That is something that does not work yet we have the idea that there is a common approach.

Those of us in Ireland have no sense of the difficulties facing many countries, even in Europe. People visiting the Canary Islands would see clothes on a beach or even a body swept onto a beach, which is an awful situation. That is unknown to us but we still have a sense that we are being swamped or that there is an influx. That is the language being used relating to migration. We do not take huge numbers of immigrants but we try to help out in different ways.

With regard to the common approach, it must be common across Europe in terms of how we deal with people coming into the country. There was mention of the direct provision centres here where there are huge difficulties, but other countries would have a different approach. Some keep people in camps while others integrate them almost immediately into the community. I see the witnesses having a role in that regard in terms of best practice and what is and is not working. Do the witnesses see themselves having a role and making recommendations to countries?

In terms of the direct provision centres here, the witness mentioned mental health and the food the people are eating. Culturally, their backgrounds are very different. Many of them do not recognise the food and find it unpalatable. They are mixing with groups that are alien to their own values. People from a criminal background outside the centres are preying on them. Those are the difficulties, and they are being experienced across Europe. As well as dealing with the issue, would the witnesses accept there is clearly a role for them in that regard?

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I ask Dr. Severoni to give a quick reply. I know it is difficult to do so but we have to try.

Dr. Santino Severoni:

I will try to be quick. Yes, there is a role. We have this role and we have been trying to play it in the best way we could. I agree with the Deputy that we have been seeing all sorts of situations but there is something that is still not properly understood across Europe, and I am telling him this because once a year we meet all member states so we have a chance to see the different positions.

I mentioned during my presentation that southern European countries need to deal with an emergency response. This means they need to be ready to receive and manage a large number of people who, unfortunately, will probably arrive suddenly overnight, which is likely to disrupt the services of the receiving country. The more the country wants to have border controls, registration and police inspection of those people, the heavier their distress will be. Basically, a bottleneck will be created unless properly prepared plans and intersectoral collaboration between police and the ministry of the interior in that sector have been put in place.

We realise that this situation was not present everywhere. The only country with a meaningful preparedness capacity was Cyprus because in 1996, it had to face an influx of people from Lebanon. When we say we have a role, we mean we have been working with ministries of health and ministries of the interior in most of the southern European countries to help them set up capacity, preparedness facilities and procedures in order to manage the migrant process. Police control or registration procedures from the ministries of the interior cannot do everything and we want to help these countries to set up a common plan to manage this situation, which has not arisen before. It seems a very simple, banal issue but it was not being dealt with, although the flow of irregular migration has been happening for at least two decades.

With regard to the other questions, in particular the question of public health, we are deeply concerned about hard-to-reach groups of population which would not be covered or would not have access to services because, for us, this would be a failure. I was the director of the WHO country office in Tajikistan, which had the largest polio outbreak in the world in 2009. It was a very serious situation. Basically, the polio outbreak happened because the country was unable to immunise children in remote areas in the valleys and the mountains. They had been immunising children year by year but the number of unvaccinated children was growing and this exploded like a bomb, not only in Tajikistan but in all of Central Asia and Russia. It was something that could have been managed with a few hundred thousand dollars worth of vaccines but it has cost the community more than $50 million to respond to the tragedy.

With regard to the Ebola virus, I am not involved in the response procedures so I am in a difficult position but I do have some experience of emergency response. During an emergency, there is only the response. The evaluation of what has been functioning or not functioning, and whether there has been a failure or not, comes only when we have finished saving lives. More than rating success or failure, my colleagues should be and are focusing on trying to respond to this question, which is still very complicated. A committee member asked whether we have enough people going there and the answer is that we do not. If anyone opens the vacancies page on the WHO website, they will see that two thirds of vacancies for the West Africa Ebola response have not been filled. We are continuing to recruit and would welcome colleagues going there.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I am anxious to bring the debate to a conclusion as quickly as possible. I think Ms Fleming wishes to make a short comment as well. Mr. Clerking and Mr. Murray may also wish to do so quickly.

Ms Margaret Fleming:

I wish to sincerely thank each and every committee member for their time, interest and questions. Ireland led the way and provided the leadership on mental health in the Balkans. I am confident that Ireland can now lead the way and provide that visionary leadership in public health and migration.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Does Mr. Murray wish to comment?

Mr. Damien Murray:

I would like to comment on polio and the people who were killed in Pakistan and Afghanistan, albeit by a rumour. I am a member of Rotary International which has worked in this sector. For the last 30 years, the WHO has been trying to eradicate polio. On that occasion, some Rotarians were killed because the rumour was that they were poisoning children.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I would like to thank each and every one of the witnesses for addressing the committee. I also thank members of the committee for their attendance and interest. As the witnesses know, members of the committee are conversant with the subject matter and are dealing with it on an ongoing basis. By their own expressions of concern they have indicated likewise.

Deputy Brendan Smith has proposed that the committee should refer this matter to the Minister of State with responsibility for overseas development aid, Deputy Sherlock. We will do so with a recommendation that the Minister of State should attempt to co-ordinate the northern hemisphere efforts in this regard.

It might be no harm to send a copy of the presentation to the Minister of State for him to study. In addition, we should also send copies of the address to the Department of Health which, from a national perspective, can do what is required to deal with such situations, and to the Minister for Foreign Affairs in respect of what applies overseas.

I thank the witnesses for their submissions on this interesting subject at an appropriate time.

Dr. Santino Severoni:

Thank you, Vice Chairman.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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We will now pause for a moment to allow the witnesses to withdraw before the next submission by Deputy Eric Byrne.