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“They have to keep moving because as long as a border is open, it’s their only chance,” says Dr Karl Blanchet Co-founder of the  at the London School of Hygiene & Tropical Medicine.

His words are the thoughts of more than 13.9 million people who were forced to flee their homes in 2014. They are the live-saving thoughts of a refugee.

All you have is your health

The majority of refugees are healthy. “You have to be quite healthy simply to make the journey to a country,” says Martin McKee, Professor of European Public Health at the School. Migrants must be strong to face the horrors encountered when crossing mountains and seas, with the ever-present risk of death from drowning, exposure, or even attacks. They need their health to embark on the journey.

Today, one in four refugees begin their journey in Syria, the main source of refugees globally. Waves of both migrants and refugees are now traversing neighbouring continents in search of a better future and are unable to stop until they reach their destination.

For many, the destination is unknown.

“There’s no time to wait,” says Dr Karl Blanchet; who has seen, first-hand, the continuous and rapid movement of people crossing whichever border is available to them as they flee conflict and persecution. Time is of the essence for Dr Blanchet and all public health teams as they race to treat these mobile populations.

“It’s very hard to save lives while people are walking,” he says.

Where have people been? What risks have they faced? Where are they headed to next? These are key questions health teams need answered to do their job. Often these answers are elusive, in an informational transit, prolonged by the language and cultural barriers of those displaced.

Numbers may be at their highest to date, but this migration of people is nothing new.

“It’s a phenomenon that has been increasing in recent decades,” says Dr Bayard Roberts, fellow Co-founder of the Public Health and Humanitarian Crises Group at the School. According to Roberts, the mass movement of migrants and refugees in Europe in 2015 is emblematic of the situation globally, and a feature of globalisation. People have greater access than ever to greener, safer, pastures.

One man’s journey

Arif Sahar fled to Pakistan from his home country of Afghanistan more than 20 years ago — aged 14 years — as the Taliban began their control of his country. Prior to Syria, the main source of refugees globally was Afghanistan, which held its place at the top for three years running. In 2000, during the height of the Taliban regime’s power, Sahar chose to move further afield and build himself a better future.

His first stop was Iran.

“We stayed for six weeks gathering people and found a broker,” says Sahar looking back at the steps he took to get started. Forty-five days later, he reached Turkey — which now hosts the largest number of refugees globally, standing at 1.59 million in 2014. Here, Sahar was locked up by traffickers for more than one month and his health deteriorated.

“We were kept in a small room and everyone fell ill,” says Sahar. He recalls having no clean water, sanitation or food as he — and many others — were hidden to avoid the authorities. Sahar resorted to drugs others had brought with them to treat their own, chronic, health conditions. “They didn’t work as it took two weeks to feel any better,” he says.

Once freed and able to access healthcare in Turkey, he found that services were too expensive and he couldn’t obtain the medication he needed. All the while, the fear remained of being caught in his tracks.

"We were kept in a small room so everyone fell ill."

Arif Sahar, Afghan Refugee

Over one year, Sahar travelled through Turkey, Greece, Italy, and France to reach the United Kingdom where he now lives. He met many people like himself along the way and formed many friendships and connections, many of which he was forced to leave behind as people grew less able to carry on. “I look back now and feel sad I had to leave my friend in Greece…he grew ill and had developed a form of TB,” says Sahar. His friend had made the sacrifice not to hold the others behind and still remains in Greece today.

The majority of Sahar’s journey was on foot, leaving him with aching legs thereafter. Throughout his expedition he encountered multiple forms of healthcare ranging from private, to humanitarian aid and official United Nations (UN) camps. He reached the UK in 2001 and is now back in the UK studying for his PhD. “I want to go back and help my country,” says Sahar.

An evolving community

This route to a new life has not changed much since Sahar path in 2001, but the nature of the people moving has. The demographic profile of people now finding themselves displaced has evolved and with this comes a new health profile to be dealt with. “We need to understand the affected population,” says Dr Roberts.

When people are displaced an emergency response kicks in and the challenge begins to keep them alive and well. Typically, the response begins with crisis intervention.

“You start with life-saving services, such as preventing disease outbreaks through vaccinations,” says Dr Roberts. The close proximity people find themselves during migration and mass movement puts them at constant risk of new infections. People coming from spacious, rural villages can now find themselves surrounded by hundreds or thousands of people in a form of “moving town” and facing new risks in every location they encounter.

But this is addressed through screening, diagnosis, treatment and immunisation among those displaced.

“One would expect an essential package of services and medicines,” says Dr Roberts. Sanitation, malnutrition and maternal health services are also a priority to ensure the survival and wellbeing of these newly formed — but transient — communities.

Dr Roberts believes provisions today should expand beyond communicable disease and include more chronic, non-communicable disorders. “People living with heart disease or diabetes need to maintain treatment before complications set in,” says Dr Roberts. Failing to help them could prove fatal.

The occurrence of conflict in more middle-income settings, such as Syria, involves treating a new group of conditions found among more affluent populations. In 2014, 7.4% of the Syrian population was diabetic, according to the International Diabetes Federation, and in their prior life, treatment would have been readily available, and accessible.

“With increasing migration from Syria and Iraq, people are coming from countries with reasonably well functioning health systems,” says Prof McKee.

The problem, however, is the additional complexity that comes with this change, such as treating the later stages of diabetes, cancer or cardiovascular disease. A careful selection process is required to identify those with the greatest need. “This is a huge new challenge to the humanitarian sector and it’s generally much more expensive,” says Dr Roberts .

Remembering the past

People classed as refugees are deemed so because they are forced to leave their country due to conflict, persecution or natural disasters. Their last memories will have been tormenting and emotional.

“The kind of populations we work on, such as trafficked persons and asylum seekers, are usually people who have been through traumatic events,” says Dr Cathy Zimmerman, Reader in gender violence and health at the School, who highlights how the main health issues affecting displaced people is their mental health.

There is growing recognition that the psychological stress of exposure to violence, being forced to flee your home or country, and loss of  all social networks, has massive health consequences.

“[People] have often witnessed violence, experienced it themselves, or suffered various forms of deprivation or exploitation. Women and girls, in particular, are vulnerable to sexual abuse and exploitation,” Dr Zimmerman says. Her team researches mental health, including post-traumatic stress disorder, depression, and anxiety.

“If you ask what the most obvious health issue is, it’s mental health,” says Dr Zimmerman.

She works mainly with people trafficked for various forms of exploitation.  Her team’s research includes the health and well-being of trafficked people and the measures needed to prevent unsafe migration, and the subsequent health consequences.

“There’s a migration process,” says Dr Zimmerman who has indicated that the various stages of a migrant’s journey can adversely affect their health – pre-departure, travel and destination. However, each stage offers opportunity for practitioners to intervene to provide care. “Even once they arrive, there are all sorts of risks, including health service access and even harassment and abuse on the streets,” she says, adding it’s a big contrast to the hope of a safe haven.

“Clearly conflict is going to exacerbate poor mental health,” agrees Dr Roberts, who also researches this issue. He investigates the effect on people forced to flee within their own country, known as internal displacement. There were more than 38 million internally displaced persons (IDPs) in 2014, according to the Internal Displacement Monitoring Centre (IDMC).

The mental health response includes ensuring safety and security to those finding themselves in new environments, and the provision of safe spaces for discussion and counselling as needed. “People need to discuss their experience,” says Dr Roberts. This needs a clear understanding of communities and cultures to adapt and suit each population.

The impact of poor mental health goes far beyond the individual.