Forced to flee: the humanitarian crisis on America’s doorstep

Over the past decade, some 150,000 people have been killed in the Northern Triangle of Central America (NTCA), making the region the most violent in the world outside a war zone. According to the United Nations Office on Drugs and Crime (UNODC), 6,650 intentional homicides were reported in El Salvador in 2015 (a staggering 103 per 100,000 inhabitants). In Honduras there were 8,035 intentional homicides (57 per 100,000) and in Guatemala 4,778 (30 per 100,000). Alongside high homicide rates, forced disappearances, kidnappings, threats, forced recruitment into armed groups, extortion and sexual violence are a daily burden for thousands living in areas controlled by criminal gangs. Poverty, violence or a combination of the two have seen more than 300,000 people from the NTCA flee north to Mexico. In a survey by Médecins Sans Frontières (MSF) carried out in Mexico in September 2015, The Victimization Assessment Tool (VAT) Survey was conducted with 467 migrants and refugees during September 2015 in the albergues in Tonosique, Ixtepec, Huehuetoca, Bojay and San Luis Potosi where MSF was providing health and mental care at the time. Of the sample, 88% of people interviewed were male and 12% female; 4.7% were minors, 59% of them unaccompanied. Regarding country of origin, 67.6% were from Honduras, 15.7% from El Salvador, 10.5% from Guatemala and 6.2% from other nationalities. nearly 40% of respondents from the NTCA cited direct attacks, threats, extortion or attempted forced recruitment as reasons for fleeing their countries. A third gave more than one violence-related reason for fleeing.

Other findings of the survey regarding the situation in their countries of origin illustrate what it means to live under permanent threat:

• One-third (32.5%) of the population from the NTCA entering Mexico have been exposed to physical violence perpetrated by a non-family member (mainly members of organised crime groups) in the two years prior to their flight.
• Half of the people (48.4%) from the NTCA entering Mexico received a direct threat from a non-family member. Almost 80% of victims said that the threat had seriously affected their social and professional activities.
• Some 45% of Hondurans and 56% of Salvadorans entering Mexico lost a family member to violence in the two years before they left. Just under a third knows someone who has been kidnapped, and 17% someone who has disappeared.
• Almost three-quarters of Hondurans and 70% of Salvadorians regularly heard gunshots in their neighbourhood, and 75% and 79% respectively had seen a murder or a corpse in the previous two years.
• In one in ten migrant families, someone had committed suicide in the two years before the family had left, and in one in 20 someone had attempted suicide.

The MSF survey also revealed that almost 70% of refugees and migrants from the NTCA had been subjected to violence in Mexico while in transit to the United States. Almost half of our sample reported having been hit, 40% had been pushed, grabbed or throttled and 7% shot at. One in ten respondents reported being kidnapped and repeatedly beaten, in some cases over a protracted period. Sex in exchange for shelter, protection or for money was mentioned by a significant number of both men and women: of the 429 migrants and refugees who answered questions related to sexual violence, 31% of women and 17% of men said that they had been sexually abused during their transit through Mexico.

MSF’s response

MSF has been running projects in Mexico treating people from the NTCA fleeing violence since 2012. Between 2012 and the end of December 2016, MSF teams carried out 28,020 medical consultations and 5,573 mental health consultations. Another 46,491 individuals attended psychosocial activities organised by our teams. Our objective is to provide assistance to a mobile population in a constantly evolving context, based on the following principles of action:

1. Wide geographical coverage. Several locations along the migration route have been covered by our teams since the programme began: Ixtepec and Arriaga (Oaxaca); Tenosique (Tabasco); Bojay (Hidalgo); Tierra Blanca (Veracruz); Lecheria/Tultitlan, Apaxco and Huehuetoca (Mexico State); Mexico City; San Luis Potosi and Celaya (Guanajuato). Locations have been adapted based on the changing dynamics of refugee flows and the presence of other humanitarian actors.
2. A customised response based on people’s needs. The medical, social and psychological services provided by MSF allow for a comprehensive response that caters to the basic health needs of migrants and refugees. MSF teams comprise a doctor, a psychologist and a social worker. Including a social worker in these teams is a new approach for MSF, but is very much needed in order to ensure the right to medical assistance for those who need a referral to the health system and to refer cases for protection to other NGOs or Mexican institutions.
3. Flexible services in adapted locations. MSF has provided services in hostels (albergues) along the migration route, and mobile clinics have been set up near railways and train stations.
4. Specific solutions for acute cases. A rehabilitation centre in Mexico City, run by MSF in collaboration with the Scalabrinianas Mission for migrants and refugees (SMR), a faith-based NGO, provides comprehensive care for victims of torture and ill-treatment identified and referred from the different locations where MSF is providing assistance.
5. Strengthening local capacity. MSF teams have run training programmes in psychological first aid to 888 volunteers and staff in 71 shelters and hostels. Training on protocols to ensure comprehensive care for victims of sexual violence has been provided to 1,743 volunteers and health staff in 41 shelters and 166 health facilities along the transit route.
6. Partnerships and coordination with local NGOs and faith-based organisations running hostels have been crucial in ensuring humanitarian assistance to refugees and migrants who have been victims of violence. In a context of intensified controls, repression and exposure to violence, the albergues run by faith-based and civil society organisations constitute one of the only safe and dignified options for shelter and rest for the majority of refugees and migrants crossing Mexico.
7. Advocacy at local, state and national level to ensure that state institutions act to fill gaps in healthcare and care for victims of sexual violence. At regional level, recognition of the existence of a humanitarian crisis and the negative effects of the deterrence and detention policy currently being applied by the US and Mexican governments is a necessary first step to avoid loss of life and suffering among NTCA refugees. MSF promoted partnership/coordination models with
   local, state and national governmental institutions, bringing in our experience in the field and providing a reality check for policy-makers and those responsible for implementing migration and refugee policies.
8. Active monitoring of the situation in origin and reception countries, with a focus on border areas.

A quarter of the medical consultations conducted in MSF’s migrant/refugee programme are related to physical injuries and trauma. General pain, contusions, bruises and fractures are the most common conditions diagnosed by our doctors as a consequence of the attacks, robberies, abuse and intimidation that migrants and refugees suffer en route, or while waiting for asylum claims to be processed. But the consequences of violence are not only physical: more than half of the migrants and refugees attended to by MSF in Mexico have symptoms associated with depression, nearly a third suffer from anxiety and 12% have post-traumatic stress (PTSD). The percentage of people affected by PTSD is well above the proportion within the general population (0.3%–6.1%) and very close to rates in populations directly affected by conflict (15.4%). Although post-traumatic stress is not the only or the most common mental health consequence of violence, it can seriously impair a person’s ability to function and face the multiple challenges and risks inherent in the migration experience.

Final remarks and open challenges

The impact of forced migration on the physical and mental wellbeing of refugees and migrants, including women, minors and LGBTI individuals, calls for the allocation of resources to ensure access to healthcare and humanitarian assistance regardless of the legal status of the patient. Addressing gaps in mental health care and emergency medical care and strengthening medical and psychological care for victims of sexual violence, including access to kit PEP/HIV Post-exposure prophylaxis, is fundamental if patients are to be treated with dignity and humanity.

For years, Mexican civil society and individual solidarity, alongside a few international NGOs including MSF, has succeeded in managing an extended network of over 100 albergues along the migration route through Mexico, as well as providing basic humanitarian assistance and protection. However, this positive emergency response does not mean that governments can shirk their own responsibilities. Seeking asylum and protection and securing refugee status in Mexico or the United States is extremely difficult for people fleeing violence in the NTCA. In 2015, Mexico deported 98.4% of the 177,949 migrants and potential refugees from the NTCA. Only 3,423 migrants and refugees from the NTCA started the asylum recognition process in Mexico during 2015, and only 14% of asylum requests were granted. For its part, in 2015 the United States deported 21,920 Salvadorans, 33,249 Guatemalans and 20,309 Hondurans. Of the 69,920 arrivals into the US granted refugee status, none came from NTCA countries. Initial steps by the new US administration may well consolidate the tendency of states in the region to renege on their responsibilities towards refugees and migrants exposed to extreme levels of violence.

Long-standing pressure from the US authorities on Mexico to contain population inflows from Central America should not translate into massive deportations in contravention of refugees’ rights. Instead, what we need is increased capacity to offer asylum at regional level, including the possibility of making a request for asylum in countries of origin and transit, and the effective implementation of regional resettlement policies for refugees fleeing violence in the NTCA. There is a hidden humanitarian crisis on America’s doorstep that calls for urgent action in terms of protection and humanitarian assistance. This must be a priority for governments and societies across the region, and is definitively a priority for MSF teams on the ground.

Marc Bosch Bonacasa is MSF Program Manager for Latin America. Elena Estrada Cocina is MSF Mexico’s Humanitarian Affairs Officer.