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Gavin: Hello and welcome to this episode of the Lancet Voice. I'm Gavin Cleaver. It's September 2021 and we're very pleased to have you on board. I just wanted to mention before we got going that we've been doing this podcast for about 18 months now and we're very keen to hear your feedback on it. What would you like to hear?
What have you enjoyed so far? What do you think we could improve? You can email the team on podcastsatlancet. com. That's podcastsatlancet. com with your thoughts, and we'd love to hear from you. On this episode, we're talking about the humanitarian situation in Afghanistan and refugee health. Later on, Professor Mohamed Zaman, a biomedical engineer from Boston University, is going to be chatting to me and Jessamy about how STEM graduates can help revolutionise refugee health and what's changed since the COVID 19 pandemic.
First, though, we're going to talk about the humanitarian needs in Afghanistan following the change of government with two authors of a recent comment in The Lancet. I'm joined for this discussion by Dr. Mohammed Hakmal Dr. Hakmal was a senior Afghan government official and is a former leader of health programs across five provinces in Afghanistan.
He's now a lecturer in public health at the University of London. Dr. Ahmad is a senior lecturer in global health at St. George's University, London, and an honorary lecturer at UCL. Welcome to the podcast, Mohamed and Aisha. Thanks so much for joining us. Thank you. Thank you for inviting us. Obviously, this is a somber topic and difficult to talk about, but it's an important conversation to have.
It can seem in the news over the last few weeks that the scale of the kind of humanitarian crisis in Afghanistan is overwhelming to think about what are the most important factors to bear in mind? And how is the situation now that the last of the foreign forces have left?
Mohammad: I think it's a difficult situation now in the ground for the people, so it's something, but full of fear, people are. And because the, especially, as we are discussing, the humanitarian side. 90 percent of the clinic and hospital funded by foreign aid have not been operating since the donors suspended their funds to Afghanistan on September 25th.
As Afghanistan health system has highly dependent on foreign aid. So the World Bank on 25th of August, they announced that they will be not there will be no any more funding, from the donor side to the health sector. So this is something concerning people. And also it, there was a sudden change, in the government.
So the bank has been not operating properly. So people are also facing, shortage of food, shortage of monies, like no cash also in the ground. And so these are all the concern that people are now suffering. And there was also big, like brain drain in the country. So majority of the people, unfortunately, they were working with international community.
They also left. So this increase, the level of stress among the people.
Gavin: So the increase in poverty is a serious issue.
Mohammad: Increase of 90%. So 90 percent of people, Afghans, are living under poverty line. And 50 percent of the Afghans, unfortunately, they are faced, with the shortage of food.
And I was just reading, the United Nations report. So two days back, the head of the United Nations visited Afghanistan and he found that 50 percent of the Afghans are facing, shortage of food. So they need, urgent, international support. It's the same also for the children, so 35 percent of the children, they are also facing, shortage of foods and nutritious also for them. So pregnant women, and as I mentioned, also the hospitals are closed, and especially in the remote area where 75 percent of the Afghans are living. So these are all, the level of, so these are factors, which created a kind of stress in the communities.
Ayesha: I would add that the humanitarian issues that we're discussing here, these are magnified and from pre existing humanitarian issues as well. So these needs are becoming even more important to try to prevent from worsening. In the current situations with the changes that's going on. And I'd also add about the mental health aspects as well.
All the factors that are associated with the humanitarian needs at present, poverty, hunger, displacement, these also have mental health components attached to them. And without adequate interventions, there will be long term impacts which will further increase the vulnerability of the population.
Gavin: Yeah, really important to bear in mind that the health system in Afghanistan is quite heavily foreign aid dependent and there's been obviously large health gains in the last 20 years, which have been highlighted in the media, but in terms of kind of capacity building and infrastructure.
Has enough been done to secure these gains or are they a risk?
Mohammad: In terms of last two decades gain, so they, as you mentioned, so there was enough support in terms of capacity building, so infrastructure has been also started something from scratch. And in terms of maternal mortality and child mortality, like maternal mortality around 70%, there was a reduction in the maternal mortality.
Afghanistan in 2001 2 had, the highest maternal mortality rate in the world. Child mortality rate in the world. So now what happened? Maternal mortality rate, as I mentioned, reduced almost, by, sorry, by 65 percent. Child mortality under five by 30 percent. So it's the same, number of clinic, during 2002 and three's, only 10 percent of the Afghan had access to the health services.
While now it's almost like 85 percent of the Afghan, they have access to the basic health care services in their remote area. number of health facility also increased in 2002 and three, we had a 400 health facility in Afghanistan. So now so like last month, the number of functional health facility was 3, 600, so unbelievable, increasing the number of.
clinics. It was the same also for the midwife, and 2002 or three, we had very limited number of midwife. So during this last two decades, at least we had one midwifery schools, community midwifery school in each province. So this increase, the number of skilled trained staff as well. So it was also, we got enough support in international support for the capacity building in long term.
So we have. Now, hundred and hundred, like most of public health, we have PhD holders in public health. In the clinical part, the number of transclination have been significantly increased. Several things have been increased, in different aspects, but unfortunately now. The sudden announcement of the World Bank that they suspended their foreign aid.
So this put all of us, under confusions and we are not very sure what will happen in the future. So that's why we published on this article and we request, for the urgent humanitarian assistance.
Ayesha: Yeah. And even though the country has been dependent on foreign aid the delivery has been significantly improved because of the efforts of non governmental organizations.
And these NGOs are essential to responding to the health needs of the Afghan civilian population. because they understand the social cultural context. And so it's very important and essential for continued health delivery to continue to support these national and international NGOs as well.
Gavin: What role do you both see the neighboring countries around Afghanistan playing in the months to come and how can they best be supported?
Mohammad: In terms of, if we talk about the health sector. Afghanistan was also highly dependent on medical tourism because many Afghans, they were either going to India, Iran or Pakistan or Central Asia country.
And the annual expenditures on the medical tourism was between 300 million up to 400 million US dollars. Now these days when we have, like a problem also in provision of health services inside the country, unfortunately, despite the fact that The level of poverty has been suddenly increased.
Still many people will be also traveling when we have, like open flight or open roads, to the neighboring countries to receive the services. So this service will be increased. And unfortunately the, We were not able, to have, to have a proper development in terms of the, in the private sector to reduce this medical tourism in our levels, to have a very good hope also for the future.
So we try our best during the last two decades, but unfortunately in medical tourism, still we were depending on these foreign neighboring countries. And I think that will still continue. And I hope, the neighboring country can also provide, a level of support to the Afghan. When they are traveling and going there, to give them a kind of exemptions or maybe not exemption, a kind of discount and provision and receiving the health services.
And and if there is also a possibility to donate, some of medicine and other medical related stuff to the health system in Afghanistan. Because during these changes, there was conflict in different countries, different provinces inside Afghanistan. And we, some of our hospitals was totally destroyed because of the conflict.
So now people may go a lot, as Aisha mentioned, mental health is also one of the area. Unfortunately, in Afghanistan, we don't have qualified health staff for that one. And with the sudden changes sudden change also in the country, there's confusion and also this. Some sort of, crisis in the country, this will also increase the level of mental health disease in the country.
So if people are traveling to our neighbor countries, our expectations on the humanitarian grounds from our neighboring countries also to provide, as much support to the Afghan patients when they are going there.
Ayesha: An essential part of the mental health response is safety and security as well.
So that's an essential component of humanitarian passages for populations that are traveling or who are displaced.
Gavin: When we talk about humanitarian crises around the world, these, obviously, most strongly affect the most vulnerable groups. So what would the health prospects for these most vulnerable
Mohammad: groups be currently in Afghanistan?
As you mentioned worldwide in Afghanistan, also during the last four decades, conflict in the countries in different, through different, way. So children and women are the more optimized population. And so they, they were, how been, like victims most of the time. And so now when the international community also suspended their foreign aids and up in the health system and women and children, they need, basic services.
If they have been deprived from the health services in the country. So this will also increase, the level of. Stress or the level of tensions on women and children and then this deprived population or high vulnerable population will be more vulnerable. So that's why we are just lobbying, for this humanitarian supports to increase, the level of crisis in the country with international humanitarian support.
And we don't want to see, our children and also women to suffer a lot because they have suffered a lot during the last two decades. And these are the high vulnerable population so far.
Ayesha: I would say that in the context of humanitarian crisis and conflict, that every member of the population is vulnerable, but there are certain groups within the population that are exceptionally vulnerable.
And those structural factors are social cultural as well. and need to be understood and we can draw on existing experiences to understand who will be the most vulnerable but also what will happen if there are health needs and I'm talking health in a very broad way so prevention of domestic violence is included in that as well.
Gavin: So we've been talking very broadly about humanitarian aid efforts and obviously the the problems that Afghanistan now faces in terms of getting funding and aid into the country. How can these humanitarian aid efforts remain effective going forward? What has to happen?
Mohammad: As Aisha mentioned in Afghanistan, 90 percent of the health service delivery has been implementing by the non governmental organization, either national or international.
And also there was also a kind of international organization, they were also overseeing, the health services. So we would call it, third parties. So independent organization was even doing, the monitoring and evaluations to see that the international, communities fund.
through those NGOs and government is also properly spent. So we have that structure fortunately in place, already in place. And so our expectation is now on the, from the humanitarian, from the international community is to resume, their international, their fund. and spend it through these already existing, structure of the non governmental organizations and also provide, fund also for this third parties where that they are also doing, monitoring in evaluations or they are overseeing, the expenses of the health services, quality of the health services.
So that will also help us. to make sure that people also have access to these services rather than waiting for this long extended dialogues, between politicians. So we, today we are here just to talk about the humanitarians and that the mechanism is already in place. So we have, these two organizations, so two side of organizations, humanitarian organizations with international experience.
So they were also working 25 years back, during the previous Taliban government, and they are also working in. different other countries under conflict like in Syria, in Iraq and Sudan, in different African countries. So our expectation is also to have, that experience and also to use the available opportunities in the ground.
So this will also help us to reduce, the level of crisis in the country. So it will increase, job opportunity for the people. Many people will also have job in the country. And they will also have access in their own area. For your information in Afghanistan, 75 percent of the population, they are living in remote area.
So we are not very concerned about the people inside the main city because in the main city, they also be have also a private sector. So in some way, one way or another way, they will have access to the services. Our main concern is to, in the remotest area, where private sector is not existed at all there.
And where people are living are suffering a lot, from, and they suffer a lot during this conflict as well, during the last four decades. And the only option, best option for us is, to support, to provide funds to those humanitarian organizations that they have experienced, they are in place and they already have, local staff.
So this, I hope, the international community will take this action quicker rather than later because if we don't have, services in the ground for some time, we will be also losing these health workers and they will be either, flying, to moving to Pakistan to other neighboring country or coming to these capital of the city, then it will be difficult for them, to send them back, to reorganize every step.
Ayesha: So health must be the focus of the international community and there can no, there cannot be any form of recovery of the country unless there's a healthy population.
Gavin: Yeah, that brings us on actually really nicely to my next question, which is asking about the kind of responsibilities of the international community going forward.
How should the international community currently be acting towards Afghanistan?
Mohammad: What I think, what we are hearing about women's rights, child rights, all those rights in the world, I think the Afghan, the expectation of the Afghan is to see those, support that they are providing to different other countries during the conflict also inside Afghanistan, because now we have.
We economically, we are also very poor these day and 90 percent of the people are living under poverty lines and our health system was already shocked, stuck also through these COVID 19. And then we lost also some of the health workers to with the COVID 19 during the fighting with COVID 19.
And so now. Our expectation is also to resume those things, and bring, whatever they have in their principle and put it in practice in Afghanistan and ensure that these communities not only making, noises to provide the services or to support, children, women in different aspects from the humanitarian side, also in the ground.
Ayesha: When we're talking about health needs, it can be quite easy to slip into thinking about data and how many deaths are cured because of polio, how many people are the transmission of COVID 19, how many people need to require surgery, etc. But we also need to understand. As well about the lived experiences.
Internationally it can be quite difficult sometimes to understand the local experiences. The individual lived experiences of living with health burdens in a context that is already weighted by humanitarian health needs. And various other factors as well, such as previous decades of conflict. But these additional health burdens that then place further burdens on the post conflict health system when the population are already suffering from poor health.
Gavin: How do you both see the next few months and years playing out?
Mohammad: What do you hope will happen? There is two scenarios for us. One is, the best scenario that the international community will resume, their fund, and we will be having, back, these health systems operating, and this is the achievement, let me give you a few examples. Every day in Afghanistan, only with this international fund, we, we have, 180, Caesarean section. per day. We have around 520, surgery, major surgery cases, and we have around 50, 000, children are treated daily, visiting, the health facility.
We have around 3, 000, institutional delivery. So these are the figures. So if international community resume back, their fund, and then we will be having, all those things in place. If not, as I mentioned in the beginning, maternal mortality was the highest in the world.
Child mortality was the highest in the world. So now if you stop something, we will be going back to that worst scenario that we had, in 2001 or 2. So now the international community also has two options, either to invest on their previous investment because they invested a lot. We have been already grateful, for their support because they started something from the scratch.
As I mentioned, 65 percent reduction in mortality, maternal mortality. It's a huge number. It's a huge, and then 30 percent in child mortality, an increasing number of clinics, everything in place. So if. They started these, like the foreign aid, and the situation in Afghanistan economically, the government will not be able, to support that one.
So it will be suddenly collapsed. And this will also create challenges for the world in terms of COVID 19, because COVID 19 cases will be increasing in Afghanistan. Unfortunately, so far, I think it's between one or 2 percent people already got, the vaccine. So if 98 percent of the Afghans, they don't have, vaccine.
They have not received the vaccine and it's also for the polio last year. Unfortunately, we have around 300 polio positive cases. Although before that we were just moving forward, to eliminate the polio cases from Afghanistan. So now if the international community don't, start, back, their support.
So a number of polio cases will be risk for the world's number of TB cases will also. Especially for those people that they are immigrating to different countries, they will be bringing, those TB cases, to different countries, it's measles as well, these child mortality, as I mentioned, and also the major surgery like daily around 800 people will be losing their life because they will be not having access, to this cesarean sections, especially, the pregnant women that they really needed and also the other major surgery.
So it's big, big lose, if they, if we don't get, the support.
Ayesha: If there's sufficient humanitarian intervention, then there could be potential for stability and opportunity, but that needs to ensure both the availability and also the accessibility of healthcare services.
Mohammad: Maybe if we want to talk about the COVID 19 a little bit, so like in terms of capacity building, capacities.
So we have diagnostic facility in all those major cities in Afghanistan, especially these five regional cities in terms of treatment, we also have. system in place in term of surveillance, case detection was also very good also just before this recent change. And now if the international community stopped their support, we will not, we will have a kind of disruption, sudden disruption in supply of medicines, medical supply.
So everything will be somehow, in term of diagnostic facility, because the, it's not only machine also needs, a kind of regent, also to operate. So if we don't have regent, for those already existing lab, if we don't have trained staff in place, if we don't have, others, surveillance system in the ground.
So it will be again, big challenge for the neighboring country, as I mentioned here, but now with a very small support, we will be able to provide, to, to control, COVID 19 because Afghanistan response, if we compare it with the neighboring country was much better. in other country.
So now it depends on the available resources because the health personnel staff, they have, they were successful. They were very good. If they don't receive, we will be much worse than other country in a, even the country in the region will also suffer a lot from our side.
Ayesha: Yeah, and we mentioned about mental health aspects previously, but I would also add that in addition to the availability and accessibility of the treatment of general mental disorders, that the country is also experiencing and has experienced collective trauma.
And there needs to be sufficient culturally appropriate interventions to be able to understand these aspects and on a long term basis.
Gavin: I'd like to thank you both for talking with me today. It's a very difficult subject, but it's important we have these conversations and talk about the problems and their solutions.
So thank you both very much. And I wish you both the best for the future.
Mohammad: Thank you very much. Thank you very much.
Gavin: Thanks again to Mohammed and Aisha for sharing their thoughts with us there. There's so much to bear in mind. We covered there, of course, health in humanitarian crises. And an important aspect of that is protecting the health. of people forced to flee their homes. Professor Mohamed Zaman of Boston University is a professor of bioengineering at the University of Boston and he spoke to us about the changing health needs of refugees during the COVID 19 pandemic and how STEM graduates can help to revolutionize refugee health.
So Mohammed, thanks so much for joining us today. I wanted to start off by talking really about the kind of changing health needs of refugees over the last 18 months. We've talked a lot on this podcast about the physical and social aspects of the COVID pandemic and, the COVID pandemic has affected the most vulnerable people.
And refugees are the most vulnerable people. So this, these effects have been multiplied on them. What are your thoughts over the last 18 months on how Covid has affected refugees and and how do you think the kind of status of being a refugee has been affected by the pandemic?
Muhammad: So first of all let's try to separate a few technical terms.
So they're refugees who are across the border in another country where they have no political social. financial agency and they may be in camps, they may be in cities and in urban areas. Then there are people like in Yemen who are citizens who are not necessarily crossing the border, but themselves are displaced, right?
So they are forcibly displaced people there as well. And then there are people who have not moved, but the borders move or stateless. So for example, the Bengali community in Pakistan is an example of that. They've always been living there. but are essentially stateless because they are considered to be sympathizers of Bangladesh, even though they were part of Pakistan.
And so there are different sort of groups of these forcibly displaced people who are in many countries, as many as perhaps 70 or 75 million people all over the world. The pandemic has really hit them on several levels. So one is, of course, the fact that there is a sort of infection and people who are vulnerable are more exposed to infectious diseases.
There's certainly an element of mental health stress and tremendous anxiety, worrying about the fact that whether they would get vaccination or not whether they would get their jobs back or not. But then there's the other element of the collapse of the informal economy on which many of the refugees belong.
So in some of our work in Uganda and South Sudan, When the lockdowns happened, basically the informal economy in some of the camps completely collapsed, which meant that people had nothing to eat, literally nothing to eat. And they were forced to go back in case of Uganda and South Sudan, that people ended up coming back, many people from Uganda back to South Sudan, only to find the country that they left to be in a much worse state than when they left off initially, right?
So there's that element. of being moving again to a place that might be even worse than a refugee camp, if you can imagine that. And then remember that there is the vulnerability and there's a political agency. And one of the things that I find very disturbing is that you have this vaccine nationalism and vaccine inequity, but in countries you also have inequity, right?
So you may have a vaccine rollout. Everybody gets it except the refugees. Everybody gets it except the stateless. So that element also further increases both the risk of infection, but also this tremendous sense of exclusion, of marginalization, of othering the groups that are already struggling. So I think all of these things work synergistically.
They work hand in hand, and it's very hard to separate the mental from the social from the socio political and economic and the health, and they all reinforce each other. Unfortunately, even though there is data, or there's not a lot of data demonstrating the total impact on refugee health.
Part of it is we haven't collected it, part of it is some things have worked well, but I think the long term impact, both psychosocial and also the societal engagement is really is really tremendous.
Gavin: It's really important to bear in mind, isn't it, that when we talk about distributing vaccines to low and middle income countries, and obviously there has been a massive disparity in vaccination distribution around the world.
Even when those vaccination doses get distributed to these lower middle income countries, they might not necessarily reach refugees.
Muhammad: Not at
Gavin: all. Not at all.
Muhammad: As a matter of fact, it's more a case of that not happening than happening, right? So until very recently in Pakistan, for example, as I mentioned, the Bengalis were not eligible to get vaccination.
In many cases, it was Jordan that sort of initiated this vaccine equity system for anybody, but that was the exception and not the norm for vaccination. We all saw in early summer this whole issue of the conflict in Israel and Palestine and the vaccine associations with that, whether they were sending it, whether they were closer to expiry dates or not, and all of those kinds of things, and whether there was some kind of issues there.
So it unfortunately has become very local. So there's a global disparity, but then there's a local challenge as well that is often at the whim and the political sort of decision making, which is extremely problematic and increases both marginalization and vulnerability.
Gavin: Apart from this broad kind of wider distribution of vaccines around the world, what do you think has to happen for refugees to be prioritised for vaccination?
Is it a case of messaging? Is it a case of NGO action? What do you think?
Muhammad: So I think it's, there's several things. First of all, I think trying to think in a very pragmatic way is important, but you have to combine the humanity and pragmatism together, right? So the humanity and the decent thing to do is that everybody should have equal right.
But then you also have the public health messaging that look, you can't have a group of people who are already very vulnerable. not having some of the most essential tools we have because that puts everybody at risk, right? So even if you were to look at it from a purely pragmatic standpoint, it's a good decision.
It's a good policy. And I think that has to go hand in hand with that. The other thing that has to happen is that the countries have to feel because they are basically controlling that they are by giving vaccines to refugees doesn't mean deprioritizing anybody else, right? So you have to create an equitable system because there's often this kind of hysteria, often this kind of feeling that if they get it, Other people who are bona fide citizens, whatever that may mean, will not get it.
I think that sense of comfort, that sense of reassuring its group of citizens is absolutely important to say that this is actually for everybody, and it's not taking anybody's rightful share away. So I think if you have those kinds of things, it is possible. But there's the other things as well, Gavin, that are often not appreciated, and those are investing in systems that are allowing sort of efficiency.
So Even in the United States here, we have lots of vaccine losses, right? So you, they get wasted, they get not stored properly, the states that don't need as many get it. I think part of it also happens, we don't hear about it as much, but also happens at the in country level. in, in low and middle income countries as well.
And really trying to make sure that you minimize the losses can really stretch whatever little resources they have in vaccines a little longer as well. We've seen for the longest time, for example, this issue that Pfizer and Moderna vaccines can go to low and middle income countries because we're you don't have the infrastructure in place, the cold chains and things like that.
And that's, I think, an important lesson for science and technology to really contribute in this area to create. And allow for the infrastructure that allows for the absorption of new technologies and increase equity there.
Gavin: Moving on from COVID 19, as much as we can, of course, it seems to be the spectre that hangs over all of our conversations.
You gave a fascinating lecture to Boston University, talking about the kind of absence of STEM graduates, of STEM disciplines, of scientific engineering, of medical thinking from refugee health over the last few decades. Tell us a little bit about that. Has refugee health not moved on in the last few years, and how could these extra disciplines help?
Muhammad: Refugee studies or displacement studies has been taught in political science and international relations, perhaps in anthropology, sociology in history as well. And then you have the public health side of it, but in this entire sort of I would say spectrum, what is missing is basic science, what is missing is technology engineering.
And there's several reasons for that. One is, of course, the fact that people think that these problems are, there's nothing new to be discovered. These are. Sort of implementation problems. And there's some truth to that, but not quite as some of our work and others have shown that there are actually unique scientific questions that need to be solved.
Antimicrobial resistance and refugee camps is as an example of that. We often talk about the sort of aspect of one health where environmental human and animal health really interface and leads to new sort of discoveries, new genetic changes in pathogens. So
Gavin: why are refugees more at risk from antimicrobial resistance?
Muhammad: Yeah so you have several factors. So you have really this perfect storm, if I could use that overused analogy. You already have people who have underlying vulnerability. They are exposed to diseases because they're living in a very concentrated area. Diseases spread fast. You also have no primary healthcare system that really takes care of this.
Then you have the exposure to environmental degradation, right? So it could be because of conflict, it could be because of sewage, it could be because of lack of wastewater. And the fact is that there is lack of sort of awareness of what are the appropriate antibiotics you take. So you have a lot of over the counter prescriptions.
You also have people who are not taking it adequately long enough. And on top of this, you have the presence of poor quality and substandard medicines that really contribute to the problem even further, right? So you have all of these factors. There's not one factor, but all of these factors that contribute together.
and create this problem. I was talking to a colleague from WHO yesterday who put it very well, said that antimicrobial resistance is not a disease. It's a systems problem, right? It's not like polio. It's not like hepatitis. It's not like cancer. It is a systems issue. You could have a disease driven by a bacterial pathogen that may be resistant, that may not be resistant, all of those kinds of things.
Systems problems require a systems level understanding. And that takes me to my other point is that in some ways, That's why science, technology, engineering, mathematics and medicine really have to think of these as systems problems. So one issue was, as I mentioned earlier, the fact that people think that there are no new science problems here.
So that's one. The second reason is that for the longest time we have done science in the lab or engineering in a very, I would say, clean controlled experiment kind of a way, which doesn't quite work in these kind of complex situations. So we really have to do a rethinking of the public health challenges in a different way.
And that's why I personally, and many of my colleagues love to work with ethicists and sociologists and humanists, because these are complex social problems. And then final reason, which is important to, to recognize is that. Research is driven by funding. We haven't had really those kind of incentives that are needed to do that.
When I was an undergraduate about 20 years ago, global health was not flavor du jour as it is now. And that is because the funding nature in sciences has changed. There are new players, Gates Foundation, Wellcome Trust, they were already there. Gates wasn't there. But welcome was there but their movement towards science and technology and engineering has created a new generation of people that hasn't happened in refugee health.
Gavin: Yeah, that's really interesting. I guess one of the things as well I wanted to talk to you about is that it seems there's been a kind of Not attitude change, but attitudes seem to be slowly hardening towards refugees in high income countries. And it's been a kind of situation that's developed over the last few decades, but as you've pointed out, the number of refugees is not falling. It's growing. The need to house people around the world is growing. How do you think high income countries can address this? this attitude, this this disparity between their actions and what needs to happen.
Muhammad: Absolutely. So let's put that in context. So in 1980 and for several years after that, the United States couldn't fill its refugee quota. It was well over 250, 000 a year, somebody in between 200 and 250, 000. The number came down to almost four or five or 10, 000 in 2020, right? So you, So you had going from almost 250, 000 to just a few thousand in a matter of a generation and a half.
Part of it has to do with the political climate, which I think we are all seeing in Europe, in the United States, in Australia and elsewhere. I think part of it also has to do with the frustrations of many low income countries to use this rhetoric and say, look, just because we happen to be next to a place that has refugees, it shouldn't just be our responsibility.
When we weren't the ones who were starting that war, when we weren't the ones who were driving that and the refugees, unfortunately become this kind of a group that is tossed around. for political bargaining, and we see that in Turkey, we see that in Pakistan, we see elsewhere. And that sort of really frustrates people like myself and others of losing that humanity.
Now, how do we change that? We change that first of all through awareness and a genuine understanding. I think we are living in a moment where there is reckoning about racial justice, about sort of inclusion. And I think that is important to recognize that problem cannot just be. in America as well, that racial injustice extends well beyond the borders of America or borders of Europe.
So I think there's an opportunity to really say that, look, we would be doing this service to the justice movement if we only focus it on a single city. I think that's absolutely important to focus in every city but there's a global sense of injustice that comes from racial discrimination, from colonialism and from xenophobia.
So I think that's the opportunity. The other side of the equation I think is just as important is arguing historically, and even though data may or may not help, is the fact that refugees, refugee movement in any country that you look at, has not led to the realization of the fears that are associated with it.
Loss of jobs, increase in crime, all of those, that just hasn't happened, right? So I think, That's important. And third thing I tell people, and I try to practice it myself as well, I think a hostile or an aggressive attitude towards those who politically disagree with you is not going to win them over.
I think one has to engage that just by saying that, oh, these people are, use your favorite sort of word to, to dismiss their views is not going to really solve the problem. I think people have to hear. each other and create that sense of decency, even when you strongly disagree, to be able to try to work with them.
I think if we are trying to really solve these issues, an increase in separation between this worldview and that worldview, this sort of political angle and that one is not going to solve the problem. It's only going to drive a bigger and bigger wedge and then people are not going to come to the table.
As much as I like science and engineering and technology, I don't think there's a technological problem. I think it's a problem of our fundamental humanity and knowing what we are and who we want to really be as a group of people.
Gavin: Thanks so much to all of our guests today. I hope you found the podcast interesting and as I said at the beginning, you can send all of your feedback to podcasts at lancet. com and we'd love to hear from you. Thank you so much for listening to this episode of the Lancet Voice and we'll see you again next time.