Migrants’ and Refugees’ Health
Member of the Board of Trustees
While the number refugees worldwide has greatly increased in recent years, their health needs are often poorly met and sometimes completely ignored. An ‘agenda of solutions’ identifies ways in which migrants’ and refugees’ right to health can be addressed.
Overall numbers of international migrants rose from below 100 million in 1975 to more than 240 million in 2015. The issue of migration has become increasingly politicised in many countries during this period, with divergent views as to whether it is ‘good’ (e.g. providing humanitarian help and contributing to economic development, productive workforces, entrepreneurship, cultural diversity) or ‘bad’ (e.g. incoming migrants taking advantage of state benefits, competing for jobs, distorting cultural identity).
Alongside this general picture, there has been a greatly increased number of refugees in the last few years, with one major cause being conflicts in many parts of the world. The number of people displaced by conflicts rose from 37.5 million in 2005 to 45.2 million in 2013 and then jumped rapidly to 65.3 million in 2015. This was the largest and most rapid escalation ever in the number of people being forced from their homes. Millions fled conflict in Syria, Iraq, Afghanistan and Ukraine, as well as persecution in areas of Southeast Asia and Sub-Saharan Africa, creating the highest level of displacement since World War II – a situation that has been widely described as a refugee ‘crisis’.
Most refugees remain in countries close to their origins, which in practice are usually low- and middle-income countries. In 2015, 54% of refugees worldwide came from just three countries (Syria, Afghanistan and Somalia) and the top six hosting countries were Turkey, Pakistan, Lebanon, Iran, Ethiopia and Jordan. However, in 2014 Europe began to see a big jump in arrivals of people forcibly displaced, which totalled 6.7 million at the end of 2014, compared to 4.4 million at the end of 2013.
In 2016, UN Secretary General Bang Ki-moon emphasised that “this is not a crisis of numbers; it is a crisis of solidarity. Almost 90% of the world’s refugees are hosted in developing countries. Eight countries host more than half the world’s refugees. Just ten countries provide 75% of the UN’s budget to ease and resolve their plight.” In his State of the Union address, the President of the European Commission, Jean-Claude Juncker, said, “It is impossible to talk about health issues in the past year in Europe without reflecting on the refugee crisis, and the challenges and opportunities that it has presented for Europe. Over one million children, women and men arrived at our shores and borders last year. The EU had a common responsibility to ensure that these persons, many of them physically and mentally exhausted, were offered care and support, including through the provision of healthcare when required.”
Faced with the rapidly worsening situation, on 19 September 2016 the UN General Assembly held its first-ever High-Level Summit to address large movements of refugees and migrants. All 193 Member States signed up to the New York Declaration. Health appears at several points in the Declaration, encouraging States to address vulnerabilities to HIV and the specific health-care needs experienced by migrant and mobile populations, as well as by refugees and crisis-affected populations and to support their access to a range of health services.
The onus of responsibility rests with States to respond to the health needs of migrants and refugees arriving in their own countries and to support those trying to meet the health needs of migrants and refugees in camps or transit locations on the way to their destinations. To date, it appears that solidarity from the international community is lagging far behind the commitments made in New York. There are notable exceptions – for example, Sweden, Norway and Germany have been very generous in taking in large numbers of migrants and refugees. But this can come at a high political cost, as Germany has been experiencing during 2017.
Against a background where the general approach to migrants and refugees can range from welcoming sympathy to rejection and hostility, responses to the health rights and health needs of these people is extremely variable, both at official levels and within society.
A 2008 World Health Assembly resolution on the health of migrants identified many areas where there were problems, calling on Member States to:
- promote migrant-sensitive health policies
- promote equitable access to health promotion, disease prevention and care for migrants, without discrimination
- establish health information systems to assess and analyse trends in migrants’ health, disaggregating health
- devise mechanisms for improving the health of all populations, including migrants, in particular through identifying and filling gaps in health service delivery
- gather, document and share information and best practices for meeting migrants’ health needs in countries of origin or return, transit and destination
- raise health service providers’ and professionals’ cultural and gender sensitivity to migrants’ health issues
- train health professionals to deal with the health issues associated with population movements
- promote bilateral and multilateral cooperation on migrants’ health among countries involved in the whole migratory process
However, in 2016 the World Health Organization noted continuing problems, with refugees’ access to health services being affected by poverty, stigma, discrimination, social exclusion, language and cultural differences, separation from family and socio-cultural norms, financial and administrative hurdles, and lack of legal status.
Risks to health of migrants and refugees can occur at every stage before, during and after the migration process:
- Before migration, factors that can affect the health status of the individual migrating include socio-economic status, education level, genetic make-up, local disease profile, poor personal & food hygiene, specific health conditions, environmental push factors, conflict, disasters and other traumatic events, and weak health care systems.
- During travel, factors include modes of travel, legal or illegal border crossing, environmental elements, sexual and other violence, detention and other traumatic events, sexually transmitted diseases, injuries, exposure to physical dangers and extreme environmental conditions, unsanitary conditions and overcrowding, inadequate nutrition and poor personal and food hygiene.
- At transit and destination locations, migrants and refugees can experience problems with adaptation to new life, surroundings and culture, collective accommodation, uncertain legal status, access to basic survival needs, entitlement and access to health services, susceptibility to new diseases, environmental conditions, social exclusion, cultural, linguistic and legal barriers to access health services, discrimination and lack of access to healthy food.
Nevertheless, a ‘healthy migrant effect’ has often been observed, with migrants arriving in the host country being healthier than comparable native populations. This may result from positive self-selection of migrants (the youngest and fittest being sent abroad with the best hope of establishing themselves and remitting money home or bringing family members to join them later) and positive selection, screening and discrimination applied by the host countries. However, the effect may be absent in refugees whose pathways to a destination country have included prolonged residence in refugee camps or arduous journeys. Moreover, the health status of migrants may deteriorate with additional years in the country: in the longer term, the health of migrants reflects changes in lifestyle, diet and environment in the host country, for example leading to increases in cardiovascular disorders.
A ‘productive migrant effect’ is also often seen. Migration has a number of positive societal effects, including economic, employment and development benefits. World Bank studies have shown that immigration increases labour and skill supply, innovation and entrepreneurship; and the OECD has also found that immigration provided a net positive fiscal effect. In ageing societies, immigration of young workers could ease the strained pension systems and the burden of caring for the elderly.
There is often a major disconnection between perceptions and reality regarding migrants and refugees. Many citizens and policymakers in destination countries fear that immigration leads to loss of jobs, imposes heavy burdens on public services, erodes social cohesion, and increases crime levels. But in practice, in many countries migrants have net positive effect on government budgets and immigrants are less likely to commit serious crimes or be behind bars than the native-born. Another facet of the issue is that migrants have a more precarious position in the labour market and are more vulnerable to economic downturns than the general population.
Partly, the divergent attitudes are a result of how migrant and refugee issues are framed or represented in the media and political statements. In the UK, for example, newspaper headlines about “migrant hordes” intending to invade “soft-touch Britain” are more common than sympathetic ones recognising the plight of people fleeing conflict, violence or persecution. Pictures of migrants packed in a small boat attempting the dangerous crossings of the seas to Europe can be labelled as ‘people at risk’ or as ‘people who present a risk’.
The UK accepts international conventions on refugees and asylum seekers. There are no official figures for refugees in UK, but the number is estimated at 123,000 in 2015, corresponding to c. 0.2% of population. In 2016 there were c. 39,000 applications for asylum in the UK, including dependant family members of main applicant. These people were among c. 600,000 immigrants in 12 months to September 2016, most of whom come to work or study. Over the past few years, around half of asylum applications have been ultimately successful, while the other half were withdrawn or rejected.
Contrary to popular belief, migrants’ health tends to decline within months of arrival in the UK due to environmental and social stressors. Numerous formal and informal barriers are encountered by migrants and refugees in accessing health services in UK. While resident individuals and many EU citizens are ordinarily entitled to access to NHS care and domestic pricing when moving to UK, for new migrants, asylum seekers and migrants from outside the European Economic Area, health charges can apply. Other barriers to migrants’ access to healthcare include issues with GP registration, uncertainty about healthcare and migrants’ legal status, financial concerns, cultural issues and clashes with staff.
A World Health Summit Expert Group Meeting on migrants’ and refugees’ health was held in Rome on 23-24 June 2017, organized by the M8 Alliance (an international alliance of academic centres). A paper prepared from the meeting, now submitted for publication,1 proposed an ‘agenda of solutions’ to address the health needs of migrants and refugees. Its recommendations include:
- developing a comprehensive framework, which normalises the issue of migration as a constructive, adaptive response to local realities;
- intensified international collaboration and support for the health needs of migrants and refugees;
- developing policies based on principles of the right to health, equity and social justice, with inclusion of the voices of migrants themselves;
- effort at an early stage to address physical and mental health issues
- expanding the education and training of health professionals and ensuring that health professionals, institutions, agencies and interpreters working with migrants and refugees are trained in cultural/transnational competence;
- supporting research agendas that address migrants’ and refugees’ health, across the spectrum of physical and mental health and wellbeing;
- encouraging academics to use their voice to speak out, presenting facts and countering misinformation, in order to promote the health and rights of migrants and refugees; and encouraging national academies and professional associations to play an active role.
- In parallel with dealing with the current problems of the health and welfare of those displaced, addressing the root causes of displacement, including through promoting peace and conflict resolution.
- SA Matlin, A Flahault, A Depoux, S Schütte, L Saso. Migrants’ and refugees’ health: Towards an agenda of solutions. Submitted, 2017.