Dr. Manuel Carballo On The Physical and Psychosocial Challenges Refugees Face

Children, new mothers, the elderly, and the disabled have special challenges

I am pleased to bring you this interview with Dr. Manuel Carballo, who is an epidemiologist and Executive Director of the International Centre for Migration, Health and Development (ICMHD), a Swiss-based research, training and policy organization. As the World Health Organization's Public Health Advisor in Sarajevo during the Balkan war, and at ICMHD, he has worked extensively with refugees around the world in contexts of war and natural disaster. Dr. Carballo has directed major studies on the impact of migration on HIV, viral hepatitis, and other diseases. He is a technical adviser to ECDC, the Council of Europe, WHO and UNAIDS. Our conversation took place on March 8, 2022, and has been edited for clarity and flow.

Ruth Ben-Ghiat (RBG): I want to speak to you about the Ukrainian refugee crisis and get your sense of this first stage where people are in shock, having to abandon everything they've built in their lives, and maybe feeling guilt about the people they have had to leave behind.

Dr. Manuel Carballo (MC): Thank you for the invitation to join you. I think it's important that we recognize that this is one of the largest humanitarian crises that Europe has seen since the Second World War. There are crises that are what we might call slow onset and others that are sudden onset. In slow onset situations, the notion that a crisis is going to occur, that there is going to be a massive incident, is something that people gradually prepare for. This does not in any way lessen the impact, but there is a sense of preparation.

The Ukrainian crisis has been far more sudden. People understood that Russia was antagonistic, but the extent to which the Russians are invading Ukraine and what they're doing is catching people by surprise. When we think about humanitarian crises, we traditionally think about physical injuries. I would like to remind people that the psychosocial aspect of these crises is just as important as the physical and in many ways is longer lasting and more debilitating.

When you have people who are injured but are not receiving care, people who cannot be reached by medical staff and others, the interaction of the psychosocial and the physical is truly devastating. You have mentioned guilt, and this is something that the literature on the Shoah teaches. Survivors live with the feeling that they left people behind and that they survived when others didn't. And that is very debilitating and in the long term, such guilt can influence all aspects of life.

The issue of prime importance with refugees is loss of place. When I say loss of place, I do not mean simply losing house or your apartment, but rather losing everything that constituted your life, all the investments that were made in your future, the memories, the family experiences that went with those physical situations.

There is also of course the loss of social links and social networks that are very important for us in our daily lives. Sometimes we don't realize it until we actually lose them, but we build on and we contribute to networks that provide continuity and support to us and are vital for our wellbeing. Forced uprooting and forced migration immediately breaks that network and those links.

Some would argue that uprooting and forced migration are designed to do that. We should never forget that perpetrators know what they're doing. They know the importance of culture. They know the importance of social relationships.

Some think that the term genocide has been loosely used with regard to the Ukrainian situation because it is not genocide in the classic sense of the word. But there can be no doubt whatsoever that in the minds of the perpetrators there is a desire to destroy the culture and society of Ukraine.

RBG: I've been struck by accounts of younger Ukrainians who are fleeing and trying to get their extended families to safety. And a lot of them said that their parents and grandparents had trouble believing that the Russians would bomb them. Those generations were less prepared.

MC: Yes. This is, of course, a fratricidal war. I think this is part of what caught Ukrainians by surprise, particularly the people in the Donbas region who are Russian speaking and who identified in many ways with Russia and suddenly realized that they were not exempt from the terror either. So, the war has eroded that notion of society and involves emotions about those relationships and ways of thinking.

When we see people on television moving with a bag, people moving with a dog in their arms, children with one single doll in their arms, we see people who are forced to make some terrible decisions of not only what to leave behind, but who to leave behind.

These pictures of Ukrainian fathers taking their children and wives to railway stations, and then leaving them to go back and fight, show us one of the most frightening experiences of all in a war situation, because all parties concerned know that this may be the last time they see each other. And for children that is devastating. Children need continuity. They need structure. And the crisis in Ukraine, like all crises of this kind, eliminates continuity. It also breaks childrens' belief in the ability of their parents to protect them.

RBG: That has long-term psychological effects.

MC: Yes. And this brings us to another issue, which is the perceived loss of power. The feeling of not being able to control what is going on around them, not being able to protect themselves, their children, their parents, their pets, their households. People who feel this sensation of having lost power will have difficulty making decisions.

In Bosnia, where I worked extensively, people would say, we feel like grass in the wind. The wind blows one way or the other, and we just bend with it.

There is also the issue of chaos, which is particularly difficult for children and the elderly. Children depend on parents, relatives, schools, and others to provide an environment of security for them in the same way that the elderly do. The elderly have limited mobility. They don't see well, they don't eat well. The elderly and children are particularly vulnerable.

Another population that we must never forget are pregnant women, and women with babies. For pregnant women, there is the feeling that they're on the verge of bringing a new life into the world, but not knowing whether it will survive or whether they will survive. Some women abort in these situations because they do not think it is feasible to bring children into the world at this particular time.

For women with young babies, there is the issue of breastfeeding, which is interrupted by trauma. What can mothers provide for them, are breast milk substitutes available? Can they be used safely in these situations? Probably not.

Overall, we are also dealing with the disorganization of families, which has far-reaching implications. To what extent spouses, children, and elderly parents will be able to remain in contact with each other remains to be seen.

It's estimated that as many as four million people will be forced to move. 4 million people who will be totally disorganized, in a chaotic environment, who don't know what is going to happen to them and whether they’re going to go back.

That is extremely important in the initial period for refugees. People always have the feeling somewhere in the back of their minds that it's going to be over quickly and they are going back. That rarely happens. And if they do go back, they go back to a very different  setting and environment.

RBG: Among exile populations that I have studied, such as Chileans who fled the military dictatorship, or Turks escaping Erdogan's state today, it is the normalization of the waiting to go home, the extended period of limbo, that is so difficult.

MC: The limbo that you refer to is so emblematic of this process of disruption and is at the heart of the psychosocial issues around forced migration. What is going to happen? Where are they going? How are they going? Are they going to be accosted or assaulted on the way? Who else are they going to lose on the way?

I want to mention one other group that we rarely talk about, and that is people with disabilities, both physical disabilities and psychological disabilities. People who are in treatment for different illnesses and then that treatment is interrupted. Mothers are moving children with life-threatening conditions. They're moving children with autism, they're moving children with disabilities that make it impossible for them to walk.

We should never forget just how complex this process is. No matter how much the television covers this, it will never be able to describe the profundity of what is happening to these people.