EP20 Migrant Health in the Mediterranean with Dr. Nathan Bertelsen

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I AM GPH EP20 Migrant Health in the Mediterranean with Dr. Nathan Bertelsen

EP20 Migrant Health in the Mediterranean with Dr. Nathan Bertelsen

Deborah Onakomaiya: Hey guys, and welcome to another episode of I AM GPH. I am your host, Deborah Onakomaiya. On today's special episode, we have Dr. Nathan Bertelsen, who's a physician in internal medicine and public health. He has joined academic appointment at Koç University in Istanbul, Turkey as well as at NYU School of Medicine here in the city. Currently he teaches for the College of Global Public Health at NYU Florence in Italy. His teaching focuses on migrant health, communication skills, health and culture. In addition to this, his research focuses on resilience factors of Syrian refugee families in Istanbul, Turkey. Finally, he represents NYU on the Board of Directors for the Central American Healthcare Initiative at INCAE Business School in Costa Rica. Let's go to our awesome conversation with him. Thank you so much Dr. Bertelsen for coming on our show today. It's awesome to have you.

Nathan Bertelsen: Glad to be here. Thank you, Deborah.

Deborah Onakomaiya: All right. So, you're well versed in migrant health and the refugee crisis. Our audience will definitely want to know, how did you get into this work, being a medical doctor? What sparked that interest in migrant health?

Nathan Bertelsen: Well, that's a good question, Deborah and I guess there's many different points in my life that started moving me towards this. Thinking like a student, I can say that I got started in global health by the fact that my father is an architect and he's done development as an architect his whole life. He was a young architect in Denmark. He's from Denmark, my mother's American and as a young doctor in Denmark, he left Denmark at about age 28 for Africa for one year. So, thinking about the students here, I like to start there. He went away to Africa for one year and then he never came back. He ended up doing a lot of architecture for medical work with clinics and hospitals and also schools. Then growing up in my life, there were always doctors coming through the house. That sparked my interest in global health early on. Then I would say fast forward through residency and when I took my first job at Bellevue Hospital straight out of residency, there was a need for an Associate Medical Director at the Program for Survivors of Torture. So, I was always interested in global health and doing many different kinds of opportunities similar to the many variety of opportunities that global public health students get. But when I landed at Bellevue, the first year, there was an immediate opportunity for what I like to call the boring details of the medical clinic at the Program for Survivors of Torture. Everybody thinks that global health can be these compelling, and these fascinating and these interesting passionate topics, and they are, but I got involved because they needed somebody to do the boring details at the primary care clinic for these victims of torture. Who was going to track the hypertension? Who was going to keep track of the vaccinations? Who was going to keep track of the PPDs that were sent? Then I signed up for that, and then the rest was history. I've been working with refugees ever since. That was about eight years ago.

Deborah Onakomaiya: Wow, that's quite fascinating. What drives you personally to continue to do this work?

Nathan Bertelsen: That's also a good question. What comes to mind is as an undergrad when I was a pre med, I studied political science at Georgetown in the Government Department and we all tend to be very again, passionate and committed to human rights in the work that we do, as we should be. But what brought me to medicine is, I certainly believe that when we can distill a problem down to life and death, to sickness and health, I do believe complicated problems do become black and white. Now granted, I understand that medicine can be extremely political and the right to health is extremely political. But when we really bring it down to sickness and health, I think it's black and white, and I'll tell you the evidence about what my patients need. So, to answer your question about what drives me to continue to do this work, I try to bring good quality healthcare to people who are not getting it.

Deborah Onakomaiya: And you know, more recently at the GPH Dialogue on Health and Human Rights, you led a panel discussion on grassroots community efforts and the migration experience, and you emphasized unique migration experiences. For example, the African experience versus the Middle Eastern experience. How do these experiences differ from your expertise? 

Nathan Bertelsen: That's a good question. As you know, we have unprecedented migration crisis in the Mediterranean. We're very familiar now that we have not seen this kind of population movements since World War Two. We have a number of routes in the Mediterranean. There's the western route, which has slowed down quite a bit from Morocco into Spain, we have the central route from Libya into Italy, and we have the eastern route from Turkey into Greece. So to answer your question, you typically have Syrians and other refugees fleeing overt war in the eastern route, including also in addition to Syrians, including Afghans and Iraqis and others. And, you have this middle eastern migration from the east into Turkey and to Greece. Then in the central route as you know from our class in Florence, that's predominantly 90%- 95% Sub-Saharan African, and mostly West African. So, there are many ways that they differ but the first thing that comes to mind is how the eastern route, the Syrians and others fleeing overt war, they're considered refugees in the true sense. Bombs are going off, homes are being destroyed, family members are being killed right in front of their eyes and they're fleeing, and they get quite obviously the rights of a refugee. Now, by contrast, the majority of the Sub-Saharan Africans who are leaving West Africa going into Niger, entering Libya and then getting on boats to sail into Italy, those migrants are commonly described as economic migrants. Now again, to keep this short, I would say they can be considered a difference there would be an economic versus a true refugee, but they have similar effects of trauma, they have similar experience of trauma between the two. And, even if you can say that some migrant had left his home in West Africa, there's plenty of conflict to flee from in West Africa, but even those originally economic migrants from Africa, they get traumatized in similar ways as they migrate. As they go through Niger where they're crossing the Sahara Desert in trucks, as dangerously as crossing the Mediterranean Sea in a rubber boat. They get into Libya, they crush through all of these layers of organized crime, and bribery, and danger, and they get into these boats and they go into Italy. So, again, it's not accurate to be looking at these migrants as simply economic migrants, which some people will say don't afford them the same benefits as true refugees, because they're as traumatized as anybody when they get here. So, that's a major difference. Another way that they differ is, I would just say some different themes of health problems that these migrants are facing. In Turkey, let's start with Turkey. Turkey now has 3 million Syrians. They have for some time. More refugees than any other country in the world since 2015 are in Turkey and almost half, you can easily estimate, almost half of those migrants are children. So, first you have major issues of child labor, and also forced marriage. You also have a more balanced male-female divide in Turkey, among Syrians and Iraqis and Afghans. By contrast, in the central route from West Africa into Libya and to Italy, those are predominantly male. Five out of six are males, so that's one difference. You go to Turkey, you're going to have younger migrants, unaccompanied minors, forced marriage, child labor and sexual violence and sexual assault to these young girls. Now, into Greece when you go from Turkey into Greece, you enter the European Union in the eastern route and again, it's a similar population, similar problems. So by contrast in Africa, five out of six of these migrants are men. They're also young but they're young adults, so their health issues are different. You're not dealing with unaccompanied minors, you're not dealing with the same sexual assault in these numbers. You're dealing with men who are leaving their families, men who are on their own, men who have to make new lives for themselves, et cetera, et cetera. Now, an important caveat Deborah as you know very well, I remember your excellent presentation that you gave in Florence. Of the one-sixth women, the majority of them are Nigerian women who are being sex trafficked. There is plenty of violence against women in Turkey don't get me wrong, but sex trafficking from Nigeria through Niger and Libya into Italy is astronomically terrible. These women to summarize as you know, they will be living their lives in Nigeria and some other West African countries but mainly it's Nigeria. They may choose to go into sex work not understanding the risks and the horrors that they're entering, but also very commonly they're being tricked or led to believe that they're going into a different life like working in a nail salon, working in a beauty salon, so they decided, "We're going to go to Italy." They sign up and they go through a juju ritual also. As you know very well, juju can be a very powerful, a driver of behavior, juju is a sense of spirituality and curse. Women will be forced to take on an astronomical debt. They have to sign up literally to indentured servitude and then when they get to Italy, when they get to their destination, they're going to have to pay off this debt and in sex trafficking, that's through sex work. So, they then have their juju ceremony, they have to commit to this debt, and then they go through the incredibly traumatizing route which takes weeks if you're lucky. Easily takes months and easily takes years as they cross. And again, they get into these Toyota trucks, they drive through the desert, they stop in these reception houses along the way, like organized crime type houses. They get into Libya, there's bribery along the way, the women are subjected to more sex work along the way. Then they get in their boats and they go to Italy and in Italy, they get put into this network of madams and other sex workers and they have to pay off their debt, and these ridiculously impossibly high debts. That's also a major, major health problem and tragedy that's more unique to the central route.

Deborah Onakomaiya: Very tough to hear and it's definitely something that we see on the news these days, especially with the crisis in Syria. You mentioned Turkey and you have lived and worked in Turkey for an extended period of time. From a personal perspective, how have you seen migration change as a result of the ongoing refugee crisis?

Nathan Bertelsen: That's a good question. I got to Turkey in 2014, just a year before things really took off. When I got there, anecdotally we were working on tobacco control and smoke-free campuses. Now a year later, interestingly, we hosted a smoke free campus symposium at Koç University in 2015. We hosted Dean Cheryl Healton and Dean Julia Cartwright for the symposium and while we were driving from the hotel the first day to the campus in Turkey at Koç University, Dean Healton turned to me and said, "What can we do from migration?" That gave us an up close and personal view of the fact that 2015 was the year that Turkey had more refugees than any other country in the world and NYU GPH was right up there at the beginning of that. So, what changed? Turkey got put immediately in the center of the global health stage in the sense of hosting all these refugees. And when we think global health traditionally, Turkey is not the country that comes to mind, but Turkey has been the global crossroads where you have east and west coming together, Europe and Asia coming together. You have north and south coming together from the developed north and the lower and middle income south. And now again, at the center of the refugee crisis. So, what changed? We saw a lot of attention on Turkey and interestingly, we saw the tension with the Middle East as an interesting piece that we can come back to, but particularly Turkey's rolling Europe. This was a major change and this is worth pausing on for a second. Now for 15 years or longer, people have been talking about, I would say the lip service of Turkey joining the European Union. Now in 2018, you may have forgotten when we were talking about already. We've forgotten about how we've been talking about Turkey joining the European Union. But just a few years ago, this was reality that at least some people entertained. Now, things that were in favor of Turkey joining is that the Republic of Turkey is a very secular country. It has a very secular government going back to the founding of the republic in 1923. It has been the, I would say the model in the Muslim world for secular Islamic countries. But now, three years after Turkey became the largest refugee hosting country, I'm not saying it's directly related, but it's all happening at the same time, we would never even think about Turkey joining the European Union, would we? Because, I think now these pressures, and these problems, and these burdens, let's say on the country, have really defined the differences that live between Turkey and the European Union. We can come back to this if you're interested. But in a nutshell, then we had a million crossings in 2016 through the Mediterranean and 85% of those million migrants, those million migrants that got into boats and cross the Mediterranean Sea, mostly in the eastern route, then the central route and a few in the western route. 85% of those crossings in 2016 were from Turkey into Greece with 15% going into Italy. Then what happened? Europe was faced with the million dollar question, or let's say the billion euro question when they ask themselves politically, what can we do to stop this migration flow from Turkey into Greece? The European Union gave the famous EU Turkey deal where the EU gave €3 billion to the Turkish government in order to stop the migration. And if you look at the numbers from the International Organization of Migration, IOM, we do see now that in 2017 and now into 2018, those numbers have dramatically fallen for migration from Turkey into Greece. That's been a major change as well. So to summarize, we saw the cultural compatibility, let's say, for lack of a better word has been redefined between Turkey and Europe. Europe basically paid Turkey in order to close its borders from Turkey into EU, and now Italy is the hotspot. So, I'd close on this point. Now in this year where we have the Cross-Continental MPH Program, it's very interesting that these students are studying in the fall, these NYU MPH students are studying in the fall in Ghana, which is a regional leader in West Africa as we know very well, and then they're coming to Italy where now Italy hosts the majority of migration into Europe through Libya, of Sub-Saharan and West Africans. That's been an interesting shift as well, and now we're dealing with the same kind of struggles that Europe is facing with its global neighbors and social integration issues that we'll get back to. We're dealing with that, with Italy at the very center of it. That's been a major shift as well from Turkey into Italy.

Deborah Onakomaiya: And within country, within Turkey has changed daily life after that €3 billion was received, has the crisis changed the country itself? Has that changed Turkey itself?

Nathan Bertelsen: That's a good question. I would say a number of things. I mean, the first thing that comes to mind Deborah is how I've been living in Turkey now for four years and the more I live there the more I realize, nobody understands Turkey. So, I've learned two things. First, we don't understand it and second, we certainly won't understand it if we don't speak Turkish. If we're not hearing the conversations in the cafes, if we're not reading the newspapers and I think that's a mistake I think often made by northern Europeans and North Americans. But, I do understand quite a bit about Turkey living there for years now and I think some positive things have happened. So, whereas we see some terrible xenophobia and violence against foreigners in Europe, we're still seeing more bombs in Europe and explicit violence between hosts and migrants, we haven't been seeing that in Turkey as much now. On the positive side, we have a lot of similarities between Syrians and Turks of the religious, the shared religion has helped and most importantly, Turkey is not kicking out its migrants the way Europe is trying to kick out its migrants. But rest assured, there are still major stressors. Now, we talk a lot about healthcare access with migrants in Turkey. We have to remind ourselves that the universal healthcare coverage which in theory sounds great in Turkey, is strapped thin for Turks. If you go to an average public health clinic or a family medicine clinic in Turkey, you're going to see 100 patients lined up to see a Turkish doctor in a day. So, if you show up as a Syrian migrant, an Afghan migrant, an Iraqi migrant what have you, you're going to have to get in line behind 100 Turks. That's been a problem and rest assured, there still is plenty of racial tension between these two groups. The Arabic language and the Turkish language are very, very, very different languages. The Turks as we know come from Central Asia and over the centuries came down the Central Asian plateaus into the Mediterranean and just 100 years ago, the Turks ruled Syria through the Ottoman Empire of leading up to World War One. So, they're also very, very different groups. So, in short I'd answer your question that there's plenty of strife and conflict between Turks and Syrians. I've walked down the street and I've heard Turks saying to Syrians who are begging in Arabic, they'll say, "You're in Turkey now, beg in Turkish." There's plenty of discrimination, there's plenty of problems that I could go on and on about, but there have been some pleasant strengths that I've seen in Turkey that the European Union hasn't caught up yet. For example, you go to Athens, you go to Rome, you're going to see plenty of migrants completely forgotten, living in tents, living under bridges, living in complete horrible, derelict conditions. Whereas in Turkey, the Turkish Government is housing hundreds of thousands of Syrian migrants at the Turkish border in what we could say are really good camps, so they're doing something well. Syrian migrants in Turkey also have a special protective status that at least gives them more than many of the migrants living under bridges and in tents in Europe, and it's a complicated situation. I'm not sure I've answered that very well, but it's something we can discuss. So Deborah, when you ask about what has changed in Turkey, another major, major issue has been the bombing. Quite recently, 2016 was a terrible, terrible year in Turkey. We mentioned in 2015, Turkey suddenly housed more refugees than any other in the world, and that's due to the enormous war going on in Syria, and that war started spilling over. To preface, Turkey has always had a civil war for the last three decades between the Turkish Government and the PKK, which is a militant Kurdish group in the southeast. And every Turk that I know, they know somebody who's been affected, or injured, or knows somebody who's been killed in that conflict over three decades. There's always been this Kurdish conflict, this Kurdish civil war with the Turkish Government. And, Kurds, as we know are right in the middle of the conflict in Syria. In many ways when we think about American policy, we have to ask ourselves, what side are the "Kurds on" if they're in the Turkish borders or if they're in the Syrian borders? We can come back to that. That's a conflict that was stirred up in 2016. And then ISIS, ISIS entered Turkey with its bombing in 2016 as well. So throughout 2016, especially in the first half, there were bombs almost every month going off in two fronts. One, tourists were getting attacked, tourists were getting blown up. Those were ISIS bombings, those were ISIS attacks in order to strike at the nerve of the psyche of the community. And then on the other hand, police were getting targeted. And in the civil war, the Kurdish militant group PKK was going after Turkish police targets. So every other month in the news, there's tourists being attacked and there are police buses being attacked. This is just literally firing things up in Turkey. Then the airport gets bombed in June, and living in Istanbul, working at Koç University as an academic as you can imagine, we have hundreds if not thousands of international visitors to universities alone. It's a very international, very cosmopolitan place. Very much to make a New Yorker feel at home, yet we have people coming for international events to our campus who are passing through the airport when in June of 2016, the airport gets bumped and there's a shooting there. Similar to what was happening in Brussels and elsewhere. Then leading up to July 15th, the infamous attempted coup in Turkey. This was kind of the pinnacle of the violence in Turkey that has been happening when Turkey got engulfed in the violence that's stirring all the migration from the Middle East. So, we were hosting an event on campus where we had an NIH Research Training Institute, where every year we have researchers like yourselves coming to Istanbul for a research training course. We were having a gala dinner in Istanbul that Friday night, and then suddenly you see a wave of concerned pass over people's faces. We were sitting there having our dinner on Friday night and the first way we learned that something was wrong during this night of the attempted coup was, people were getting texted by friends who were driving home that night. Text messages saying, "My God, there are soldiers on the bridge." That night of the coup, everybody realized, all the Turks look at each other and they say, "This is a coup," as soon as they hear there are soldiers on the bridge. There's no other explanation. So, they all go home and we wait it out. That night was crazy, nobody knew what was going on. I go home, my wife is with her mother outside of the city. We live right in the center of Istanbul, let's say right next to Turkish Time Square. I'm sitting there all alone, I'm hearing jets flying overhead, I'm hearing gunfire in the streets, I'm hearing explosions and interestingly, there were actually no bombs going off in my neighborhood that night. Those explosions were the afterburners from the jets flying overhead. But in short, everyone is trying to figure out, what's going on? This is a coup and we don't know who's in charge. So the chain of events, we go home, there are all sorts of reports on the news and on social media. We hear rumors that there was a bomb that went off at Erdoğan's Hotel, then we hear rumors that Erdoğan had fled to Germany to seek asylum. But at some point that evening, Erdoğan gets on his iPhone on CNN Türk, and a woman at CNN Türk is holding her iPhone in front of the camera and the President of Turkey is sitting there on his phone, urging the Turkish public to get to the streets and fight these soldiers. At this point to paint the picture, there are soldiers on the bridge connecting Europe and Asia, there are soldiers who had taken over CNN Türk, there are soldiers who have taken over the airport, a few strategic locations in Istanbul. And then, there was more I think, active fighting going on in Ankara around government buildings as well. Then he says, "Let's take to the streets," and until this point, the streets had been empty. At that point, the streets filled with people in an outrage, took on these soldiers, engaged these soldiers, fought these soldiers and then the rest was history. So, the night goes on and on and I'm up till 5:00 or 6:00 am. I finally catch a couple hours of sleep and I wake up, and everything is over. We can see the photos in the New York Times where that night we see soldiers on the bridge almost like a Hollywood set, and that morning we see soldiers in camouflage handcuffed by military police being taken into custody. That was the night of an attempted coup and there's all sorts of various explanations for what happened that night. We say that it was an estranged cleric in the United States, an exile in the United States. Erdoğan blames this cleric for being behind the coup. They actually used to be very close as I understand it. This is a Islamic cleric who was very powerful in Turkey, owned a lot of schools and other areas of influence. He apparently had helped Erdoğan come to power in the early days, they had a falling out, this guy moved to the United States. That's the party line of who was behind the coup but to this day, the United States has not agreed to Erdoğan's extradition request because they say there's been no proof to give him up. But to make a very long story short, the coup was kind of the pinnacle of the conflict that was going on in Turkey. And again, this was two fronts of a crazy and ridiculously complicated war of ISIS going after tourists to hit them, kind of the 21st century public psyche of the battlefield that I think they're fighting on. Then the Kurdish-Turkish conflict got involved as well. The rest of 2016 was pretty quiet. However, in December of 2016, there was a bomb at the soccer stadium. Then famously New Year's Eve, there was a gunman entered a high end nightclub on the Bosphorus, shot a couple dozen people to death, changed out of his Santa Claus suit and then left. Tragically, that was also the last terrible attack in Turkey but since then, it's now been a year and a half, knock on wood, that we've had conflict in Turkey. So, what migration has done very quickly, migration has put Turkey in the global stage for global health and the work that we do, it put Turkey on the global stage of this enormously complicated conflict. It has also driven in a huge wedge between the West and Turkey, which is this NATO country, but now is really fighting in between the American versus the Russian forces in the Syrian conflict, and they're really carving their own way here. That's a lot to say about how migration has changed things the last three years.

Deborah Onakomaiya: Wow, that is so amazing and that can be definitely tough to be in that type of situation, not knowing what's going on in Turkey. Switching gears a little bit, you recently relocated to NYU Florence to teach at La Pietra where you're building a specialization for NYU students focusing on health and human rights. Can you please describe what that might look like for a prospective student who is interested in that?

Nathan Bertelsen: That's a good question Deborah. I very much enjoyed working with you in the class that I offered last year. This program to summarize, it started a couple years ago, more than that now with the Health and Human Rights Dialogue about migration in the Mediterranean and in Europe held at the La Pietra Campus. Then two years ago, in fact, there was a second meeting on health and human rights of the migrant family. That was the first meeting I attended and of the many great ideas that came up in that meeting, one outcome that came from that, one deliverable was a J-Term that we offered last year on migrant health. There's many different directions we can go when we talk about migrant health. Migrant health can be as broad as health in and of itself, but a major need when we talk about health and human rights issues in Europe, like much of the world is human rights. And human rights when we talk about migrants trying to live side by side with their neighbors, I would argue is a question of social integration. So, my first question, my first answer to your question is, this is very much a focus on social integration and, what does it take to build communities of people who are now living together who haven't lived together before? That's a major theme here. This was a very successful J-Term last year. We had 19 J-Term students from the MPH program at NYU, yourself included. Then we followed that this year with a site for the Cross-Continental Program. As you know, the Cross-Continental Program is a very exciting way to get your MPH at NYU where you sign up for 12 months, and you get your MPH from NYU in three different continents. This year, our group of students started the year in Washington DC and to immerse in that level of health policy and human rights, they moved to Ghana as a group and studied global health in Ghana at our NYU campus there. Then they got the choice to go between Florence or Abu Dhabi for the spring. Now getting back to the health and human rights focus here, I would argue this is completely a health and human rights program because as we were describing before, Italy is now right at the crossroads, right at the center of the migrant crisis in the Mediterranean and therefore the world. Once the eastern route was relatively shut down between Greece and Turkey, now the bottleneck is coming right from Libya, through the Mediterranean Sea and into Italy. That's very interesting. So, when I first, before I came here, when I thought Florence I thought Renaissance, I thought artists and I thought beautiful buildings. All of that is very important and in our course, when we talk about social integration we also talk a lot about what it takes to heal. We talk a lot about the art of medicine in healing from our wounds, healing from suffering. And as a position, we embrace the science and the technical aspects of what we do, but we often say we have no medicine without science, we have no healing without the creative arts. So, it's very nice to be in a very beautiful, artistic place, a positive place when we're trying to discuss how collectively we can heal from these problems. But also geographically, this is not a program for NYU students in Florence or in Tuscany, or maybe even in Italy for that matter. This is very much so an opportunity for NYU students to study in Europe and in the Mediterranean itself. I would say that the United States and North America, we're very good in our universities at getting out into the world, into Latin-America, into Africa, into Asia. We're very good at global health and getting out there, except I would say, Europe. We have relatively much fewer opportunities for American students to go to Europe and this program, this Cross-Continental site in Florence lets you study health and human rights in two dynamics. You get to see this West African-European dynamic like we've been describing, and you also get to compare the North American-European dynamic as well where there are so many lessons learned in the field of health, such as universal healthcare and human rights. How we look at things, how we deal with racism in the United States versus how do we deal with racism in Italy and the rest of Europe. So, it gives you those two very interesting dynamics here.

Deborah Onakomaiya: That is quite interesting. I myself would love to return to Italy, and you mentioned you get to pick between Italy versus Abu Dhabi. Why should students at NYU pick Italy?

Nathan Bertelsen: That's a good question. I would say again, if you're interested in migrant health, refugee health and all the health disparities that comes with that, and if you're interested in health and human rights, again, the fact that Italy is now at the center stage of migration from Africa and elsewhere coming into Europe through Italy, this is a very exciting time to be right here on the ground in this country. I think it's a fascinating place to be and a fascinating time to be here.

Deborah Onakomaiya: You talked a little bit about how people react to migrants and refugees. More specifically, Dr. Salim Murad presented at the dialogue in Florence. He talked of the mindset of host countries and how that has changed over times towards migrants. The mindset towards migrants in the past were more welcoming and hospitable. This has now changed to more hostile, and sometimes we could say xenophobic. From your perspective, how have you seen that play out in your global health work, in your migrant work? How have you seen that play out?

Nathan Bertelsen: That's a great question. This I think is a perfect example of how we can compare our collective experiences in North America and in Europe. For example, I'm a Danish citizen so I can pick on Danes for a minute. I think Denmark is a leader in human rights. I think Denmark is a leader in so many of the ideal ways we try to construct our health and human rights area. But, Denmark in many ways is I would say, generations behind the United States when it comes to race relations. I'll bring this back to Europe and to Czech Republic and Italy in a minute, and the professor you mentioned is from Czech Republic. We clearly have plenty of work to do in the United States with racism and race relations. Black lives matter more than ever, police violence is as tragic as ever, and we have a lot of work to do. But back to my own personal experience in Denmark, I have a large Danish family. In the 1980s, we could argue Denmark was relatively unchallenged with these issues. Denmark was a very homogeneous country and through the good intentions and the goodwill of Denmark and countries like it- small European countries now were much more diverse. In short, we're now seeing a lot of racist issues in Denmark and Europe that they had not experienced before. Now that they're being challenged, we are now seeing that New York and the United States is ahead of Europe in many ways with that and I think there's lessons that can be learned in that direction. Now, this professor in Czech Republic, now he adds an Eastern European dimension, very central and Central Northern European, but also he adds a Eastern European dimension to this where you still have very much a strong man culture in Czech Republic. So, to switch gears and answer your question, similar to Turkey, which is also an Eastern European country culturally in many ways. Eastern European countries tend to have strong man cultures, strong man societies where you have male chauvinism, gender inequality, strong police. Tragically, where in the sense that police may not be your friend, and very homogeneous, and I would say racist tendencies in our society. Is everybody racist? No, but I think the political discourse in these countries where they have their own versions of the Czech version of Donald Trump in Czech Republic, the Hungarian version of Donald Trump in Hungary, we're seeing these politicians tap into these racist tendencies. In short, the divide of the oil and water let's say, of migrants not living, not mixing with their hosts is a major issue in Czech Republic and they get away with horrible billboards which would never find in the United States even in the Trump era. So, that's one thing. Then the second piece brought up by Dr. Murad's presentation was he pointed out that Czech Republic hosts very, very few migrants. This is fascinating and tragic, tragically fascinating because there are just a few migrants in the country, but also the migration frenzy that has swept up Europe is playing on these underlying racial tensions, racist tensions in the country, so that's interesting. So, keeping a positive, where can we go from here? I think we always bring it back to humanism. When we talk about crossing borders, we talk about humans living next to other humans and anytime you can have that human connection, that human touch, then I think you can get somewhere. And concretely, Dr. Murad gave examples of his young students, his passionate students who wanted to make a difference in the world and advocate for more social inclusion for their neighbors. They would be using campaigns of social media in order to combat these racist tensions. That's an example of what he was talking about. Now finally bringing it back to Italy, Italy is an interesting case study. On the other side of my family, my mother is a second generation Italian-American. My mother's grandparents were born and raised in Tuscany, and they left as migrants from Italy, sailing west to the American Dream, entering the United States through Ellis Island and as we know, Italians received a very unwelcome welcome when they first came. My grandparents who are the first generation to be born in the United States, they don't speak much Italian, and why is it? You can't blame them. When they were kids going to school in the 1920s America, they were punished in school if they were being found to speak Italian, and shame on us in the 1920s. But, would we dare, even the most racist Trump supporters wouldn't punish, physically punish a student in school today if they're speaking a foreign language. But anyway, these Italians had moved away in hordes, and now Italy ironically is now the major country of influx, of entry of migrants into Europe. I would say that the Italians I know are good people with good intentions but if anything, they're not also getting to know each other and they're not having that human touch. For example, the average place I would argue that Italians see migrants from Africa is when they're sitting on a sidewalk café and an African migrant walks up to them trying to sell chewing gum, or tissue paper or something like that. Then they try to say no politely at first, and then they find themselves feeling rude about it and that is not a way for neighbors to get to know other neighbors. This is a very, very, very long conversation, but I bring it back to that dynamic between Europe and the United States and I'll give New York as an example. I affectionately like to call New York my home. Next to the United States, not part of the United States and that's something I think should bring students to NYU, because you get to be in this true global crossroads in New York City. But, New York is a place where you can go from Syria, or from Nigeria, or from anywhere in the world and you can become a New Yorker in Queens, and remain Syrian or remain Nigerian. That's second nature for New Yorkers. You can truly integrate, and by integration I mean, you can take on the host identity but you don't lose your own home identity. Now by comparison, you have assimilation forces in Europe and to be clear about these terms, if integration is a two-way street, where you can, for example, move to Queens and become a New Yorker but remain Syrian at the same time, that's a two-way process and your neighbor, your neighborhood now has your contribution to that collective social identity. In Europe, it's much more of a either/or. In Europe, it's much more you remain Nigerian, or you become Italian, or you remain Ghanaian, or you become Danish, for example. That would be a one-way either/or that you don't have in New York City. So, I can ask my students, why is that and if anything, I would say New York is a better example than anywhere. They got to know each other because they truly live together. By living together, their kids were going to school together, they were literally living side by side together, they literally started eating each other's food. We have the Frankfurter from Germany, and the spaghetti from Italy, and the bangers and mash from Ireland, and all of this is becoming a new social collective identity. That's I think, an example of what Europe can learn from, and we see this melting pot in London with migrants from the former British Empire. We see this melting pot in Paris, there's still tension there. But, it's easier I would say to be a migrant in Paris and London than in most of the European Union. I think those are some lessons that, directions that Europe can take from the United States. All of this comes back to this either/or genetic identity that still drives a lot of the social identity of European citizens.

Deborah Onakomaiya: I would ask as a follow up, is there a light at the end of this tunnel for the migration crisis, or what are possible solutions to this if any?

Nathan Bertelsen: Deborah, that's a great question. Let me go back to being a doctor. When I'm a doctor, I went to medical school and we want to make people healthy, right? So, what do we learn in medical school? We learn about diagnosing heart attacks and how to send patients to the cath lab. We learn about screening for cancer and delivering chemotherapy. We learn about health-centric health interventions. Now to answer your question, the answer to this case is that as health workers ourselves, we want to deal with health problems and improve the health of our migrant neighbors through non-health interventions. For example, it's very familiar to us. It's easy to understand that the young African men living in tents in Rome, while they do have serious health problems as a community, their issues are legal status, not having a visa or any kind of legal identity there, social issues of having a roof over your head, being able to have a job and access to work and employment and all of that, and cultural problems, first and foremost language. We cannot heal until we solve these non-health related issues. So, going back to health indicators, we know from Epidemiology 101 and from Medicine 101, we're very familiar with what health indicators are and as sparing young health students, we know about applying for grants. We need to apply for grants in order to fund health effects of hypertension interventions, health effects of cancer screening. This is familiar and this is good work. Now to answer your question, one thing I have learned in four years in Turkey and Italy, is that we need to fund things like protecting families, activities that protect families on the personal level. We need to fund activities that build community at the level of society. When you think about it, these are very abstract concepts when it comes to life and death and infectious diseases and NCDs. But, what I have learned is protecting the family has become the litmus test or the rate limiting step for healing at a personal level, and I've found that building community in and of itself is exactly how we can have my Italian and Nigerian neighbors getting to know each other. So, how can we do this in a concrete way? One of my students this year in taking Chris Dickey’s class, Rory Kurtan, and Diana Klatt and Kui Wangui, they were asked to make a proposal about what kind of intervention would they give to the migration crisis? What kind of innovative solution would they propose? They proposed a cooking class and I said, "Amen, hallelujah guys." This is exactly the kind of concrete activity that frankly we would laugh away as any kind of NIH grant let's say, to drive the contrast home. But, cooking classes I think is exactly the kind of way that we can get host Italians with migrant neighbors together. And I'm telling you, they come together and they eat the same food and they laugh together, they will build community together. That is what happened to century ago when my Italian great grandparents came to New York City, so I think that's an example with building community. Then the family, we know across the board. We see families getting torn apart in Syria where often the male head of household is lost or killed. We see elder teenage sons being lost or killed. We see unaccompanied minors coming from Syria into Turkey. That clearly breaks up the family, and any way we can protect the family is something fundable, something concrete, something that we can invest in. For example, things that, these are activities that NGOs on the ground working with communities can define and deliver. And in Europe when we still have five out of six of the migrants being young men leaving their families behind, protecting their family. Finding ways first for family unification if they do settle down and build a new life here. Or more importantly, allow them to go back to West Africa, rejoin their family there and live the life in West Africa that they want to live. Because I'm telling you, when you talk to these guys under an overpass of a Roman highway, they're not telling you that that was their dream for leaving Africa. So again, a long story short, protecting families and building communities have been essential outcomes that we need to invest in, and our health in our funding.

Deborah Onakomaiya: Yes. I think my final question to you would be, how do we stay human healthy during a crisis?

Nathan Bertelsen: That's a good question, Deborah. I would say, we can think about a lesson from the Aegean Sea. Let's think for a moment about any Greek music we've heard before, or any Turkish music we've heard before and interestingly, Greece and Turkey are no strangers to conflict. They have their own centuries of conflict and wars and blood being spilled. But, Greece and Turkey have a shared food, they've had their shared communities and they have shared music. To answer your question, they find beauty in suffering and they find meaning in suffering. For example, you can listen to a sad song in Turkey, you can listen to a sad singer in Greece and you start to cry. And we can ask ourselves, why are we listening to this if it makes us cry? It helps us remember, it helps us find meaning. And I'm telling you, I'm a better doctor because of the pain and suffering that I went through in medical school. We learn from the problems that we go through in the past. Another way to answer your question is, we heal by restoring our humanity. What I mean to say is, when we deal with trauma and recovery, when we deal with victims of torture or sexual violence, or any other horrible, horrible thing that people do to each other, the common denominator is often dehumanization. We say that it is dehumanizing to be stripped naked in a juju ceremony in Nigeria. Clearly, it is dehumanizing not to give healthcare to a four-year-old boy. It is dehumanizing to be treated like a stray dog under an overpass of a highway in Athens. So, dehumanization is really I think the characterization of the trauma. So then logically, we need to restore that humanity. So, how do we restore that humanity? I'm telling you, of all the torture treatment programs I've worked with in the world, they come to the same abstract things. They come to things like hope, safety, and dignity, and I can give an example of each. We had a four-year-old boy flee Syria with his mother into Turkey, and they got there safe. She got an apartment, they rented it, they're rebuilding their life. Then he fell from the second floor of the apartment building, onto the concrete. Shattered the left side of his skull. He was taken to the emergency room, he's unconscious. They operated on him in the hospital. They removed the shattered pieces of his skull, they sewed him up and they discharged him with a prescription for physical therapy. Bringing back these resilience factors I mentioned hope, safety and dignity, what comes to mind here? This is clearly not safe, and it goes without saying that this little boy, he's never going to heal and his mother's never going to heal if he doesn't have the safety of healthcare access, that's pretty obvious. Also, if we are fleeing for our lives, we're never going to heal, recover from our physical or psychological wounds if we're not safe. If there are still bombs going off over our heads, we're not going to heal. A second story. I went to Greece with a colleague, a dear colleague from Doctors Without Borders and we toured some of the refugee camps in Athens. Now, these 850,000 migrants who cross the Aegean Sea in 2016 alone. They left Turkey looking for a better life in the European Union and what did they find? They found in Athens for example, empty Olympic stadiums waiting to be filled with refugees. I went to these Olympic stadiums. MSF is hosting missions to deliver healthcare, and it's terrible. You see a baseball stadium with empty stands filled with UNHCR refugee tents. When you think about it, the last place you would ever expect this to be would be the European Union, except for something like World War II when we say that this is the worst type of population movement since World War II. Now, back to resilience and we're talking about resilience factors here. We met a 16-year-old boy who had lost his family, separated from his family. He was an Afghan boy. He met these two Western doctors and he's all excited to talk to us in English, and that's great and we had a good time with him. Then he welcomes us over to the tent where he's living with his adopted family. Then the woman he's staying with, what does she offer us? She offers us tea, obviously. If you're from Turkey, Syria, Afghanistan, that part of the world, she offers us tea. And what did my doctor friends say? "No!" The students in the room at this point, they gasp in shock and they say, "How dare he say no?" I adore him for saying no, and he said, "Ma'am, we are in Greece and I am Greek. Shame on me for not offering you tea. I should be the one offering you tea, therefore I want to be the first one serving us this tea." So, back to resilience factors of hope, safety and dignity. What comes to play here? Hope, it is a stretch of the imagination to think about, what kind of hope can we define for ourselves if we'd been living in a tent in a baseball stadium in Greece for two years? We met a woman who was five months pregnant who had been there for a year. You can do the math about where she was impregnated, and the violence that surrounded that impregnation certainly for this single woman. So, it's easy to imagine how easy it is to lose hope there and these people will never restore their humanity. They'll never find that resilience that they need in order to heal without that hope. Then finally, I spoke earlier about sex trafficking from Nigeria into Italy in particular, and we think about a woman tragically who was stripped naked in front of her peers at home, forced to undergo a juju ceremony where she is led to believe that she's cursed if she does not pay back her captors. This woman is literally dehumanized to the point of being a piece of meat respectfully, and in the most obvious way, she will never heal until she restores her humanity and this comes back to dignity. She needs to restore her dignity as a strong woman standing on her own two feet, in order therefore, to put together the pieces of her shattered humanity. Those are three stories in three different countries very quickly that show these resilience factors of hope, safety and dignity. And as a doctor working with torture victims, you learn very quickly that we can't heal for someone else. We learn very quickly that people need to find their own light out at the end of the tunnel. We can facilitate, we can encourage and we can empathize. We can do everything that we do very well as clinicians, but people need to find that strength inside themselves, and we call that resilience. We need to facilitate our patients', and our clients', and our neighbors' own ways for them to find meaningful help, and meaningful safety, and meaningful dignity in their lives in order to find that resilience in order to restore their humanity. And back to your original question, are we human in spite of our humanity, or are we human because of our humanity? We all become stronger people I think, and more resilient people because of overcoming the problems that we've suffered. So bringing it full circle, when we put together the perfect storm of healthcare, rebuilding lives and rebuilding communities, then we become a collection of humans living together and learning from each other.

Deborah Onakomaiya: Wow. Thank you so much, Dr. Bertelsen for coming on our show today. It was awesome to hear about your work and hopefully we have you back on soon.

Nathan Bertelsen: Great, thank you very much Deborah.