The migration over the Mediterranean has developed into one of the deadliest sea voyages of our age. Cynical people-smugglers are sending migrants into a predictable maritime distress situation on a daily basis.
100 – 200 migrants were rescued from this vessel by MS Siem Pilot (in the background). Both photos: Kripos/the Royal Norwegian Navy
In summer 2015 I served as a ship’s doctor on the vessel MS Siem Pilot, assisting in the search and rescue of migrants left helpless in the southern Mediterranean. I have previously shared my experiences of medical work in Afghanistan (1, 2) and Syria (3) in the Journal of the Norwegian Medical Association. The tragedy now unfolding in the Mediterranean has left an even deeper impression on me than my previous experiences.
The route to Europe
At the start of 2015, around 60 million people worldwide had been driven from their homes (4). These figures, which represent the highest ever estimates for the UN High Commissioner for Refugees, bear witness to a desperate situation for people in countries all over the world. The majority of migrants who are attempting the sea crossing to Europe are thought to be fleeing from war, conflict or persecution in their home countries (5).
There are two routes into Europe for migrants. One takes them by road through Turkey and onwards by boat to the Greek islands in the Turkish archipelago. The other route goes through Africa and ends with a sea voyage across the Mediterranean.
In order to address the migrant crisis in the Mediterranean, brought on by people-smuggling through Africa, the Norwegian National Criminal Investigation Service (Kripos) chartered a civilian vessel, the Siem Pilot, in spring 2015. The vessel was equipped for search and rescue and placed under police command before being sent to its area of operation in the Libyan Sea in the southern Mediterranean. It became part of Operation Triton and provided support for Frontex, the European border control agency. The Norwegian Navy provided maritime capacity, including medical services at sea and coastguard competence.
The Siem Pilot is the largest vessel of its kind in the Mediterranean with capacity for rescue, care and transport of almost 1 000 migrants at a time. The transit time for the Siem Pilot between its operating area in the Libyan Sea and the port in Italy is between one and two days. The medical service on board was therefore planned with a view to providing immediate medical assistance to a large number of people as well as catering for the migrants on the journey. Handling and storage of corpses and assessment of causes of death also formed key parts of the medical field of work.
The sea voyage
People are daily pushed out into the Mediterranean in small inflatable dinghies, wooden boats and other flimsy vessels from ports in North Africa. Maritime distress lies at the core of the people-smugglers’ business concept: it triggers other seafarers’ obligation to assist (6, 7) and allows access to Europe. All the vessels that I came across in my work were inadequately equipped for a Mediterranean crossing. They lacked the necessary supplies of food, water and fuel. The migrants’ only hope at sea is for someone to come to their rescue before their boat sinks. Despite this risky migration strategy, almost none that we saved were equipped with life vests.
In the overcrowded boats, the migrants bring with them all the diseases and injuries they have suffered earlier on their journey. Infection on board is therefore rife, and hygiene measures are non-existent. Drinking water is a scarce commodity and is usually mixed with salt. Sunburn at sea rapidly leads to dehydration, and seasickness and vomiting exacerbate this fluid loss. Moreover, poor-quality air mixed with exhaust can kill people who are huddled below deck if the ventilation is inadequate. The difficult living conditions on board can soon give rise to friction between the travellers. Several migrants told of conflicts that had been resolved through violence, others of conflicts that had been resolved by throwing people overboard. So-called sea corpses, dead people drifting in the sea who cannot be linked to a migrant vessel or a known shipwreck, are not uncommon in this part of the Mediterranean.
The holding area for migrants on the quarterdeck. To the fore (bottom left of the picture) is shown the treatment area for the migrants with the most serious conditions, and the infection control sluice in towards the rest of the vessel. Astern is a glimpse of the refrigerated container for the storage of corpses
Since summer 2015 the Siem Pilot has saved more than 6 000 people and dealt with more than 50 corpses as part of Operation Triton. My onboard medical team included nurse Adrian Christiansen and nurse Janne Backus. Our work in the Mediterranean helped to save around 1 500 migrants in maritime distress and escort them to the reception facility in Italy.
The boarding process onto the Siem Pilot was organised in such a way that all the migrants were assessed/triaged by either a doctor or a nurse as soon as they arrived on the vessel. They were then given water and blankets and shown to the vessel’s quarterdeck. All had their temperature measured to detect any illness involving fever. At an early stage, we explained to migrants with less serious conditions what we could help them with and what they would have to wait for until they reached Italy, in an attempt to control the run on the medical services during the voyage. Attempts were made to quarantine the migrants with diarrhoea on deck to limit the spread of infection. Implementing the quarantine was challenging due to the large number of migrants on board, and was only partially achieved.
Toilets and water stations were set up astern, and camouflage nets were hung up to provide shelter from the sun in the holding areas for migrants. Energy bars were distributed to provide sustenance.
Communicable disease control for our own crew was undertaken with the aid of surgical masks, goggles and protective clothing. Dedicated procedures for dressing and undressing were drawn up, as well as for the cleaning of equipment. An infection control sluice was also installed between the quarterdeck and the remainder of the vessel to prevent infection of the ship’s personnel.
Apart from drowning, the disease panorama among the migrants whom we rescued particularly included skin infections, abscesses, upper respiratory tract infections and gastroenteritis. Several had fractures and wounds that bore witness to traffic accidents and in some cases severe violence prior to the sea voyage. Some were dehydrated due to the hot weather and lack of access to fresh water. The great majority could be rehydrated orally, but some were so debilitated that intravenous fluid treatment was necessary. Approximately 20 % of those we saved needed medical assistance during the journey to Italy.
We unexpectedly came across a number of chemical skin injuries. Leakage of petroleum products on board migrant vessels proved to be a serious health threat. From one boat we saved more than 20 people with extensive chemical burns. Clothing adhered to the wounds, and the disease picture was characterised by severe pain. The injuries were rinsed with saline and dressed using the cleanest possible procedure.
Massacre among the skerries
I can look back on more than 1 500 human lives saved after a busy summer in the Mediterranean, among whom were many children. They all reminded me of the arbitrariness of being born into war and crisis-ridden regions.
We have a duty to rescue those in maritime distress. We have a duty to provide protection to people who need it. The flood of migrants across the Mediterranean is a manifestation of crisis in our own backyard – a crisis of extraordinary dimensions. It is planned that the Siem Pilot will operate for a total of nine months, and a possible extension to this is a decision for politicians.
We must acknowledge that the southern Mediterranean is the crime scene of a massacre at sea.