JSUR Journal

Introduction

Trinidad and Tobago, a small twin island Republic is the southernmost of the Caribbean Islands located just seven miles off the coast of Venezuela. Due to this proximity, for decades areas like Carenage in the north of the island and Icacos in the south have traditionally seen the movement of people and commodities between them and the Venezuelan mainland (Figure 1).

Figure1:  Proximity of Trinidad to Venezuela.

Venezuelan Sanctions

Sanctions against former President Hugo Chavez and Petróleos de Venezuela, S.A (PDVSA) dates back to 2011 and has intensified under current President Nicholas Maduro. In 2014, [1] The US Congress passed the Venezuela Defense of Human Rights and Civil Society Act which imposes asset blocking and exclusion sanctions against any person or entities acting on behalf of the Maduro government. These sanctions coupled with decreasing global oil prices, economic mismanagement, hyperinflation, severe shortages of food and medicine and social unrest due to political instability have triggered a humanitarian crisis which has resulted in the mass exodus of persons. United Nations (UN) agencies have estimated that 5.6 million Venezuelans have fled the country as of April 2021 [2-4].

Migrants at our T&T Shores

According to the UNHCR ‘migrants are people who move by choice rather than to escape conflict or persecution, usually across international borders to join family members already abroad, to search for a livelihood or for a range of other purposes.’ The New York Declaration (2016), to which Trinidad and Tobago is a signatory, recognizes that migrants may find themselves in vulnerable situations and calls on member states to:

1. Consider developing principles and guidelines on the treatment of migrants in vulnerable situations, which would complement national efforts to protect and assist migrants.
2. Consider effective protection of the human rights and fundamental freedoms of migrants including women and children, regardless of their migratory status, and the specific needs of migrants in vulnerable situations.

In terms of Trinidad and Tobago law, the Immigration Act Chapter 18:01 of 1969 [5] does not address the issue of refugees and asylum seekers; hence the Government of Trinidad and Tobago classifies these individuals as undocumented migrants. As a result due to this policy position, unlike refugees, migrants are subjected to a country’s immigration laws and procedures and can therefore be turned away or deported back to their homeland. Due to the issues outlined above, we have seen an exponential increase in migrants arriving on our shores. These migrants brave the treacherous seas in pirogues (small boats), which are usually designed to hold six to eight persons, crammed in numbers of twenty to thirty persons (men, women and children) without lifejackets or emergency supplies. Anecdotal evidence suggests that there may be in excess of sixty thousand Venezuelan migrants presently in Trinidad and Tobago.

While Trinidad and Tobago require Venezuelan Nationals to hold a valid passport and visa to enter the country, in 2019 it offered an amnesty to Venezuelans already in the country. The government’s Migration Registration Framework (MRF) was implemented between 31^st May to 14^th June 2019 (2 week period), and resulted in 16,535 migrants registering with the authorities. Those registered were now legible to receive work permits for an initial period of six months and with their families’ access basic medical care at our hospitals and a registration identification card.

Pandemic Dilemma

The WHO declared the SARS Covid 2 virus (Covid19) a global pandemic on 11^th March 2020 and Trinidad and Tobago identified its first case on 12^th March 2020. At inception, little was known of this Novel CORONA VIRUS but as data emerged and our knowledge of the virus improved, the true magnitude of this highly transmissible virus and its ability to stress the health care system became evident. In preparation, the Ministry of Health developed a network of hospitals referred to as the Parallel Health Care System where patients with Covid19 could be managed independent to our public hospitals. Additionally, national quarantine and “step down’ facilities were developed and operationalized within the Parallel Health Care System. In response to the COVID 19 pandemic, the government of Trinidad and Tobago like many countries around the globe took several measures to prevent community spread of COVID 19 inclusive of officially closing the air and sea boarders in March of 2020. International travel of nationals and non-nationals to Trinidad and Tobago was restricted and rigidly monitored by the state. All repatriated individuals required state permission to enter Trinidad and Tobago and were required to undergo mandatory quarantining at a national quarantine centre. COVID 19 however only worsened the economic and social conditions in Venezuela and though our official boarders were closed, the illegal entry of the now increasing number of immigrants continued. Further compounding matters, the first official case of P1 variant (Brazilian Variant) in Trinidad and Tobago which is more transmissible than the Wuhan variant (original variant) was identified in a Venezuelan Migrant.

Role of The Trinidad and Tobago Defence Force (TTDF)

The Defence Act Chapter 14:01 6 (1) states

An officer, petty officer or man in command of any unit of the Coast Guard, in any case where he has reasonable cause to suspect that any vessel is engage in any unlawful operation whatever within the territorial archipelagic or internal waters of Trinidad and Tobago, may stop and board and search, with any assistance, any and every part of such vessel and if he thinks it necessary may direct such vessel to proceed to such place as he may specify. Enforcement of this mandate by the TTDF, has resulted in the interception of several vessels containing illegal migrant, however with limited capacity at the Immigration Detention Centre in Aripo and no mechanism for COVID 19 testing, quarantining and managing COVID 19 positive migrants at their immigration facility, the TTDF was given the task to develop a strategic plan for the management of the migrants entering the country illegally during the pandemic.

The Development of the COVID 19 Response Coordinating Centre (RCC)

The TTDF COVID 19 Response Coordination Centre (RCC) was established in April 2020. It staff structure included senior officers of the Defence Force such as  the Assistant Chief Staff Officer Medical (ACSO Medical), Director Operation and Director

Logistics; and its core function was assisting the Ministry of Health in preparing the quarantine sites and the repartition of individuals to the Trinidad and Tobago. In terms of illegal immigrants, the RCC was earmarked as the focal point and coordination centre between several agencies including the Ministry of Health, Trinidad and Tobago Police Service, Immigration, Customs and Exercise and Trinidad and Tobago Defence Force (Figure 2).

Figure 2: Algorithm outlining the coordination role of the RCC.

Additionally, the RCC was tasked to work with the Ministry of Health (MOH) in the development of a National Quarantine and Immigration Detention Centre at Heliport facility, Chaguaramas.

Infrastructural Development at Heliport

After appropriate space identification, two separate areas were envisaged; a holding area, where migrants who are brought to the centre and awaiting COVID 19 test would be kept for appropriately 24-48 hours until COVID 19 test results are obtained and a general area where migrants who are COVID negative are kept. The General Area has a capacity for 100 individuals while the Holding area, a capacity for 50 persons A complete overhaul of the Heliport Wellness Area (infirmary) was also performed for the management and treatment of sick, injured and COVID 19 positive migrants.

Human Resource Allocation

The identification and placement of specialized medical professionals to the Heliport facility was a major challenge given our limited human capital and the fact that our medical teams were already overwhelmed in their respective Formations and at the national level dealing with various aspects of the Covid 19 pandemic. Key health support areas initially identified included the general medical and physical health screening of migrants on arrival, the Covid 19 testing and management of Covid 19 positive patients, mental health and psychosocial support provided to migrants and the management of Non-Communicable Diseases as diabetes and hypertension. However, as the centre opened its doors to migrants several areas of deficiencies were identified including sexual and reproductive health paediatrics and the provision of minor surgical procedures. Additionally, in terms of staffing, doctors, nurses and medics from Coast Guard and the Defence Force Headquarters were asked to assist when possible with the migrants at Heliport.

Policy and Standard Operating Procedures (SOP’S) Development

Unlike military SOP’s, several operating procedures with respect to the care and support of migrants had to be developed. These policies included the medical management of migrants, the documentation and confidentiality of their COVID results, the admission and discharge of ill or sick migrants from the Coast Guard Wellness Area, the access to visitors and legal representative of the migrants and the access and interaction of service personnel with migrants.

Methodology

The participants of this paper were detained immigrant at the Heliport Detention Centre, Chaguaramas from its inception in 2019 to present. As this was a targeted population with a language barrier between participants and the authors, all initial interviews were conducted in the presence of an interpreter and all participants were required to provide informed voluntary consent (consent forms were in Spanish). A mixed-methods approach was employed to gather information for this paper as several strategies were utilized to obtain information for this paper including the initial mandatory screening medical process on arrival at the Heliport, medical reporting and medication requirements for medical conditions and unstructured interviews by the authors of this paper. . Quantitative data was collected through a comprehensive review of medical records at the Heliport Facility and the procurement practices of the medical department. . This allowed for the identification and coding of medical conditions, the frequency of procurement of medical consumables and the specific services provided. Qualitative data was collected through in-depth interviews with detainees who had received healthcare services at the facility.

Data Extraction and Analysis

Although the vast majority of immigrants received at the Heliport are Venezuelan, we have also received migrants from other South American countries as Colombia and neighbouring Caribbean islands as Grenada, Cuba and the Dominican Republic. According to the UN High Commission on refugees, most migrants are usually young adults but increasing numbers of elderly, pregnant, disabled as well as minors (many of whom are unaccompanied children) are being noticed globally (Oxford Law Faculty 2021) [6]. From inception to October, 2023 a total of two thousand, eight hundred and forty two (2842) immigrants have been processed through the centre. As seen in the Figure 3 below, thirty seven (37%) percent of the immigrants processed at the Heliport thus far were men while fifty six (56%) percent were women and seven (7%) percent were children. In terms of the children, we have managed babies as young as two weeks at our facility but the vast majority of children are between two (2) to twelve (12) years of age (Figure 3).

Figure 3: Age and Sex distribution of the migrants.

It was initially thought that the vast majority of migrants would be male as it was believed that these individuals were coming to Trinidad to seek employment and as a result, the Heliport facility was initially configured to accommodate sixty males and forty females. This premise was partly correct as from April 2020 to November 2020; the majority of individuals processed at the Heliport facility were male between the ages of eighteen (18) to thirty five (35). However, from November 2020 to October 2023, we have seen a steady increase in women and children being processed and managed at the Heliport facility and as a result, we have had to increase the accommodation for women and also provide bassinets and cribs for babies and infants.

Cooke (2003) [7] highlighted that there are non-economic factors associated with a women’ decision to migrate such as family reunion and marriage. The increase in women with children at the Heliport centre can partly be attributed with family reunion as husbands or partners are already established in country, employed for several months with suitable housing and thus ‘sending’ for the family. An increasing trend at the Heliport in terms of Female Demographics is the young single female between the ages of sixteen (16) to thirty (30) of which there has been eight hundred and sixty four (864), which equates to fifty four percent (54%) of the total detained females. Factors associated with the increase in young single women include domestic and recreational (bars, clubs) work opportunities, marriage to Trinidadian men and thus citizenship, prostitution, human trafficking and the illegal sex trade.

The United Nations Convention against Transnational Organized Crime (Palermo Protocol 2000) is a key instrument in the fight against transnational organized crime and targets specific areas including protocols to prevent, suppress and punish trafficking in persons especially women and children and protocols against the smuggling of migrants by land, sea and air. It is also therefore quite possible that many of the single young females especially those between the ages of fourteen (14) to twenty (20) have been trafficked into country Another trend we are monitoring is the number of pregnant females at the Heliport. To date, we have managed sixty four (64) pregnant individuals inclusive of providing medication, midwifery services, fetal doppler ultrasounds to expectant mothers and assisting with the registration and vaccination of infants.

The Economic Side Of Medical Migrant Management

As one may expect, the establishment and maintenance of such a centre is significant and in our case the associated cost is strictly absorbed by the TTDF and by extension, the Government of Trinidad and Tobago. An often overlooked expenditure is the medical aspect of care and management of these migrants as it costs the TTDF, two thousand, six hundred and fifty ($2,650) dollars for the initial medical screening on the arrival to the centre and eight thousand, eight hundred and fifty ($8,850) dollars per week thereafter to medically care for a migrant. The figures below further itemize these costs (Figure 4);

Figure 4: Cost of medical care per immigrant.

From the figures shown above one can decipher that medic services and Protective Personnel Equipment (PPE) are associated with significant cost. In terms of the medic services, two (2) medics are stationed at the migrant centre on a twenty four (24) hour basis with their sole task being migrant care which therefore results in the associated cost. PPE for our purposes refers to gloves, face mask and isolation gowns which are typically single use and must be discarded thereafter. On a weekly basis, the doctor may at minimum review each migrant twice while the nurses at a minimum will review each migrant three times. Of course, depending on a migrant’ health status, medical reviews, medication and monitoring by our nurses will increase and therefore the associated cost will also increase. Typical examples whereby the frequency of medical reviews may increase include the management of COVID 19 positive patients, patients with infections, chronic non communicable diseases or the pregnant migrant. The management of these patients are more labour intensive resulting in increased health visits by medical staff, reviews by medics ‘on duty’, medication and specialized procedures which can all increase cost.

Medical care not factored into the figures above but also associated with significant cost includes:

1. Ambulance services – an ambulance from the Defence Force Headquarters has been assigned to the Heliport facility on a twenty four basis to assist with migrants who have hospital clinical appointments or require emergency treatment at hospital. The cost of ambulance services privately varies from two thousand to three thousand dollars ($2000-3000) per day.
2. Repeat COVID 19 testing- migrants who are COVID positive or primary contacts are re-swabbed at least twice (on day 7 and 14) to confirm status. As mentioned prior, each COVID 19 test cost one thousand dollars ($1000).
3. Infirmary Care- immigrants who are ill, injured or pregnant are usually admitted to the infirmary for closer monitoring by the medical staff. The typical cost of bed occupancy in a private hospital per night varies from eight hundred to fifteen hundred ($800-1500) dollars. Thus far one hundred and twenty four (124) immigrants have spent at least one night in the infirmary at a cost of ninety nine thousand, two hundred dollars ($99,200). This figure utilizes a cost for eight hundred dollars (lower limit) per night and assumes that a sick patient spends only one night at the infirmary (which is highly unlikely).
4. COVID 19 Testing- One thousand, eight hundred and sixty four (1,864) COVID 19 test have been performed at the Heliport thus far at a cost of one million, eight hundred and sixty four thousand ($1,864,000) dollars. Routine Covid 19 testing on all detained immigrants was discontinued in May 2023 and testing is presently focused on symptomatic individuals.

Health Assistance To Immigrants

The journey of an illegal immigrant from the Venezuelan mainland to our shores is quite hazardous and may take several days. As they try to evade capture, many immigrants may stay in less than ideal situations (Ibanez 2021 often times in the forest, cramped boats and dilapidated houses where the risk of disease, infection, dehydration and even death are high) [8]. According to the International Organisation of Migration (IOM 2018) [9], the process of migration and the conditions surrounding migration may increase inequalities and expose migrants to greater risks and poorer health outcomes. In 2008, World Health Assembly resolution WHA61.17 called WHO Member States to strengthen their efforts at addressing the rapidly growing need for appropriate health assistance for migrant and refugee populations.

Disease Burden

At the Heliport facility, we have seen a myriad of medical concerns ranging from dehydration, chronic medical conditions as diabetes and hypertension, infected cuts and wounds, musculoskeletal injuries, Covid 19 and pregnancy as can be seen from the chart below (Figure 5).

Figure 5: Medical Condition of Immigrants seen at Heliport.

Communicable/ Infectious Diseases

According to Greenaway (2019) [10] Declich (2021) [11] and several factors are associated with the risks of communicable diseases including the nature of infectious disease burden in the country of origin, conditions endured in transit or prior to capture such as overcrowding and poor sanitation facilities and barriers to accessing healthcare post arrival. Infections seen at the Heliport facility have ranged from gastroenteritis, viral type illness, tonsillitis in children and abscesses which have required incision and drainage.Although migrants may pose an increased risk to a country’ population with regards to vaccine preventable diseases as chickenpox and sexually transmitted diseases as syphilis but not vector borne diseases (Ibanez 2021) [8], the COVID 19 global pandemic and the high transmissibility rate of the COVID 19 virus has placed particular spotlight on immigrants not only in Trinidad and Tobago but across the globe (Clark 2020, Guadagno 2020) [12,13]. With regards to the COVID 19 virus, our data has shown that seven (7%) percent of immigrants tested at the Heliport were COVID 19 positive. However, as mentioned earlier, due to their compact living conditions and the fact that they work and interact with the local population on a daily basis, this can lead to a significant number of cases in a relatively short timeframe.

Non Communicable Diseases

The medical management of existing and previously well managed chronic medical conditions can deteriorate due to the effects of migration and detention (Hampton 2022, Venters 2009) [14,15] and factors contributing to this may include mode of travel, poor conditions endured during transit or detention, interruptions in management plans and loss of medication or equipment. It has been our experience that few (<2%) of the immigrants brought to the Heliport with NCD’ presented with medication for their condition(s). Medication was either lost in transit, confiscated or exhausted and they had no money to purchase. As a result procurement and administration of all medication was thrust onto the Defence Force.

Maternal and Child Health

Zeitlin (2009) [16] reported that migrant women face poorer pregnancy and birth outcomes with a higher incidence of induced abortions, caesarean sections and pregnancy related complications. We noted that of the sixty four pregnant females managed at the Heliport, only one woman sort antenatal care prior to coming to Trinidad. The majority of women were either in the 1^st or 2^nd trimester of pregnancy. Through our midwifery service, we were able to arrange medication, ultrasounds, counselling and hospital clinical appointments for these individuals. Thomas (2017) [17] and Baauw (2019) [18] both highlighted that immigrant children constitute a particularly vulnerable group and require basic and preventive health care. Health concerns of immigrant children at the Heliport facility included initial dehydration, uncared and infected cuts and bruises, parasitic infestations (head lice), dental issues and problems associated with diet as the meals provided were not only different but not tailored to the needs of children. Unaccompanied minors were a significant concern as they are at particular risk for trauma, exploitation, abuse and trafficking. At the Heliport thus far we had had thirty one (31) unaccompanied minors (3 children whose parents were already in Trinidad, 19 teenage girls and 9 teenage boys).

Mental Health

Given the language barrier and our limited expertise, capturing data on mental health disorders was a significant challenge. We did however note that many of the immigrants exhibited symptoms of anxiety, stress and depression but given the circumstances of their detention coupled with the uncertainty of their situation and as noted by Priebe (2016) [19] immigrants are already a vulnerable group due to trauma pre and peri- migration, detention may act as a new stressor thereby increasing the likelihood of mental health difficulties.

Limitations

1. Deportation- from April 2020 to present, there has been twenty one (21) deportation exercises which is an average of one (1) every two (2) months. There needs to be a more structured approach to the repatriation efforts as the longer immigrants remain at the Heliport, not only is there is significant depletion of resources but also the mental and medical conditions of immigrants may deteriorate (Saadi, 2021; Von Werthern 2018) [20,21].
2. Language and Cultural barriers- A significant challenge to both staff and immigrants at the Heliport Facility was that of language and cultural barriers. Language barriers can impede the ability to obtain accurate medical histories, explain procedures or complications, and establish a trusting patient-provider relationship. Inadequate communication due to language barriers can lead to misunderstandings, inadequate care, or medical errors, potentially jeopardizing the health and safety of detained immigrants (Diamond 2019) [22]. Cultural barriers to healthcare included varying perceptions on mode of disease transmission, disease prevention and treatment strategies and health seeking behaviour (Castelli 2018) [23]. Interventions utilized at the Heliport facility to conquer these barriers included using appropriate trained interpreters, encouraging staff to utilize appropriate health promotion techniques and training staff in the provision of culturally competent care.
3. Staff shortage and burnout- as mentioned prior, the medical staff at Heliport though specialized is also finite and has been involved in immigrant care from inception. Coupled to this are the additional strains of the global pandemic, Covid 19 protocols, diminishing resources and the volume of immigrants which typically averages at fifty four (54) per month. These factors have contributed to staff burnout in a high dependency area where due diligence is required.
4. Supply Chain- immigrants arriving at the Heliport are provided with basic amenities as toiletries, clothes, baby formula and diapers as most would have either lost all their belongings in transit or while evading capture. The procurement and supply of these items is relatively new to the TTDF and thus far has been intermittent. The majority of these items have been obtained from relatives of immigrants in country, the ministry of health (MoH) and non-governmental organizations (NGO’s) [24].

Conclusion

As the political, economic, health and social conditions in Venezuela continue to deteriorate, neighbouring countries like Trinidad and Tobago must prepare for increasing numbers of immigrants arriving at their shores. This will require a ‘whole of government’ approach as multiple ministries will be required to assist in the formulation of a comprehensive plan with appropriate budgetary allocations which must cater for the social, health, education, housing and integration concerns of immigrants in our society. Our experience at Heliport thus far has also shown that purpose built facilities are required to manage illegal immigrants as these facilities must be able to manage children and migrants with health concerns as NCD’s and pregnancy. The role of the Ministry of National Security and more specifically, the Trinidad and Tobago Defence Force should not be confined to maritime and border security as we have demonstrated our ability to be an important coordinating unit for all Divisions of the Ministry of National Security. Additionally, our medical staff given the limited resources has risen to the challenge of providing quality health care for the immigrants at the Heliport facility.

References

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