Evolving migrant crisis in Europe: implications for health systems

The Lancet Global Health – Manuel Carballo, Sally Hargreaves, Ina Gudumac, Elizabeth Catherine Maclean

The 2016 UN high-level Summit for Refugees and Migrants in New York (NY, USA)1 provided a historic opportunity to engage world leaders in responding to the health dimensions of mass migration. Despite the magnitude of the phenomenon and its potential for changing global as well as national health patterns, the response to date has been, at best, variable.2, 3 At worst, it has been an example of national and international benign neglect. The health sector has been especially passive on this issue.

More than 65 million people are estimated to be displaced worldwide,4 with European countries registering over two million asylum applications since January, 2015. The number of people moving for economic reasons has also grown exponentially, and the UN now estimates that one in 30 people in the world meet the definition of a migrant.5 The pace of both forced and so-called voluntary displacement will probably continue to accelerate in the years to come. More than two billion people are living in places where their health and social development is chronically threatened by a pernicious mix of extreme poverty, political fragility, and febrile violence if not open conflict. Of 33 situations around the world that are already dependent on massive international humanitarian support,6 16 are serious enough to warrant UN peacekeeping forces. Left alone, these countries will inevitably contribute tomorrow’s asylum seekers and economic migrants.

Experience suggests that most migrants and refugees are young and relatively healthy, but this should not eclipse the fact that many are coming from countries whose health-care systems have broken down, and where protracted conflicts and poverty have long limited people’s access to quality health care, including screening and vaccination.7 In Europe, migrants bear the highest burden of infectious diseases, including tuberculosis, HIV, and malaria.8 The risk of outbreaks as a consequence of this burden is, nevertheless, extremely low. Displacement adds a litany of other health challenges, such as intentional and accidental injuries, psychological trauma, sexual abuse, poor nutrition, and exposure to infectious diseases. For many refugees and economic migrants, the journey in search of what UNDP has termed human security is often long and arduous, and their socioeconomic vulnerability during this process makes them easy prey to abuse, exploitation, and further health risks. The fact that many of the countries that migrants and refugees travel through are either unable or unwilling to provide free statutory health care accentuates an already precarious situation long before they reach their final destinations.

Final destinations, moreover, are not always what migrants and refugees expected, and even in Europe, living conditions in the transit camps, where they often spend months and even years, often fall well short of basic humanitarian standards. Poor sanitation, overcrowding, and insecurity are commonplace, and in 2016, Médecins Sans Frontières noted that a large proportion of the health problems being seen in these camps are linked to these conditions and could be prevented.7 Meanwhile, health and social policies in host nations are becoming increasingly restrictive, with the issue of entitlement to health-care services now a political football. Partially as a result of this constraint, the onus for migrant health care has been increasingly devolved or simply left to the non-governmental organisation community. At present, most of the health care being provided to refugees and migrants arriving in Europe is by volunteers and non-governmental organisations that do not necessarily have any special training or formal links with the health-care system, leaving many migrants with variable qualities of health care and making timely referral to secondary or tertiary institutions difficult.9 Finding durable solutions to this problem is urgent.

While the UN Summit on Refugees and Migrants1 went some way to addressing these issues, and expressed a commitment to improving integration and inclusion through access to education and health care, there have been few initiatives by governments to accomplish these goals. If action is to be taken, governments first need to accept that migrants’ and refugees’ rights to health are not only enshrined in universal conventions, but are part of a pragmatic reality. The fact is that most migrants and refugees will stay, are sorely needed, and will become a core part of European society. More active promotion and protection of their health will speed up their integration and contribute to the public health of both migrants and that of the countries hosting them.

An imperative need now exists for new thinking, increased resources, and better training of health-care staff working with these new populations. At a time when there is a danger of religiopolitical extremism in the wake of perceived (and sometimes real) antipathy to newcomers,10 the health sector has a unique role to play in enhancing social integration by demonstrating a proactive willingness and capacity to help, and a resolve to challenge restrictive policies. The health sector is a gateway to other social services, and health-care staff are the people that migrants and refugees look to most for help and advice. Therefore, health-care professionals have a unique role in taking up this challenge. More forward-looking health policies, which involve robust research on how best to deliver health services and screening, and training of health-care professionals in cultural competency, are all essential steps. Without these steps, opportunities to accelerate the social integration of migrants and refugees and avoid health and social problems in the future will be lost.

SH is a freelance Senior Editor for The Lancet Infectious Diseases and The Lancet Global Health. All other authors declare no competing interests.

References

  1. UN General Assembly. New York Declaration for Refugees and Migrants. A/71/L.1 (Sept 13, 2016). http://www.un.org/ga/search/view_doc.asp?symbol=A/71/L.1. ((accessed Jan 17, 2017).)
  2. WHO Regional Office for Europe. Cyprus: assessing health-system capacity to manage sudden large influxes of migrants. Joint report on a mission of the Ministry of Health of Cyprus, the International Centre for Migration, Health and Development and the WHO Regional Office for Europe. World Health Organization, Geneva; 2015
  3. WHO Regional Office for Europe. Malta: assessing health-system capacity to manage sudden, large influxes of migrants. Joint report on a mission of the Ministry for Energy and Health of Malta, the International Centre for Migration, Health and Development and the WHO Regional Office for Europe. World Health Organization, Geneva; 2015
  4. UNHCR. Global trends: forced displacement in 2015. United Nations High Commissioner for Refugees, Geneva; 2015
  5. UN, Department of Economic and Social Affairs, and Population Division. Trends in International migrant stock: the 2015 revision. POP/DB/MIG/Stock/Rev.2015. United Nations, Washington, DC; 2015
  6. The World Bank. Harmonized list of fragile situations FY15. http://siteresources.worldbank.org/EXTLICUS/Resources/511777-1269623894864/FY15FragileSituationList.pdf. ((accessed Jan 17, 2017).)
  7. Médecins Sans Frontières. Obstacle course to Europe: a policy-made humanitarian crisis at EU borders. Médecins Sans Frontières, Geneva; 2016
  8. ECDC. Infectious diseases of specific relevance to newly-arrived migrants in the EU/EEA. European Centre for Disease Prevention and Control, Stockholm; 2015
  9. DeLargy, P and Humanitarian Practice Network. Refugees and vulnerable migrants in Europe. Humanitarian Exchange Magazine (London). September, 2016; : 5–7
  10. Sude, B, Stebbins, D, and Weilant, S. Lessening the risk of refugee radicalization: lessons for the Middle East from past crises. RAND Corporation. 2015; DOI: http://dx.doi.org/10.7249/PE166
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