The Health of Refugees: Public Health Perspectives from Crisis to Settlement [2nd ed.] 0198814739, 9780198814733

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The Health of Refugees: Public Health Perspectives from Crisis to Settlement [2nd ed.]
 0198814739, 9780198814733

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The Health of Refugees

The Health of Refugees Public Health Perspectives from Crisis to Settlement SECOND EDITION

Edited by

Pascale Allotey and Daniel D. Reidpath

1

1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2019 The moral rights of the authors have been asserted First Edition published in 2003 Second Edition published in 2019 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2018949671 ISBN 978–​0–​19–​881473–​3 Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-​to-​date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-​pregnant adult who is not breast-​feeding The views expressed herein are those of the author(s) and do not necessarily reflect the views of the United Nations University (UNU) or of the United Nations University International Institute for Global Health (UNU-​IIGH) Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

For our parents, Ate, Betty, Gillian, and Kevin whose love and support was a constant in our lives.

Foreword

The rapid movement of large populations is intrinsic to humanity, usually as a result of climate change, famine, earthquake, political or ideological conflict, religious persecution, and war. Societies receiving such populations—​now called asylum seekers—​may be profoundly affected, sometimes positively through moral, demographic, genetic, economic, and cultural enrichment. Places that lose such populations tend to be diminished. Only some of these groups of people are refugees under international law. Although in official parlance, at least in Europe, a refugee is an asylum seeker who has been granted leave to stay, the word is highly descriptive of the entire group of people who seek asylum. It captures the sense of pursuit, fleeing, and the perils of the journey much better than the idea of seeking peace and calm portrayed by the phrase ‘asylum seeker’. Setting aside the nuances of these phrases, the challenges to migrants and to the societies they come to join are immense. Recipient populations and their services have a complex tasks of caring for them and ensuring a favourable outcome for all. These tasks are to be accomplished in the context of the myriad of international, regional, national, and even sub-​national laws, policies, strategic documents, and service delivery plans. Health and health care are amongst the top priorities in terms of the immediate required actions. Public health is central in ensuring the required actions are taken. Historically, societies muddled through, with the indomitable human spirit of the migrants and the recipient populations usually overcoming adversity, through a partnership of community organizations (including faith groups), non-​governmental organizations, legally required services, and the business/​ employment sector. Muddling through doesn’t, however, always work out in the face of social prejudices, language problems, poverty, isolation, detention, unemployment, poor health, and barriers to services. Over the last 30–​40 years there has been a growing realization that laws and even goodwill are not enough. This realization has accelerated in our era of globalization and conflicts with mass movement of people—​for example in the Middle East, Myanmar, and the Balkans, to name but a few. We must do better on many fronts. This book shows us how to do so in health and health care in and for asylum seekers and refugee across their journey from exodus, arrival, and settlement.

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Foreword

Sadly, this is a book of and for our times. In awaiting, and dreaming about, a better world, we need to be armed with ethics, legal stances, principles, exemplars, knowledge of best practice, case studies, and resolve. Thank you to the authors and especially the editors for providing us with all this, and much more. Raj Bhopal CBE, DSE (hon) Bruce and John Usher Professor of Public Health Honorary Consultant in Public Health Edinburgh Migration, Ethnicity and Health Research Group Centre for Population Health Sciences Usher Institute of Population Health Sciences and Informatics The University of Edinburgh 4 April 2018

Contents

Abbreviations  xi Contributors  xiii

Part 1  Concepts and contexts

1 Forced migration, globalization, and global public health  3



2 Humanitarianism, refugees, human rights, and health  19



3 Social exclusion, othering, and refugee health policy  39



4 Health in humanitarian crises  54

Pascale Allotey and Daniel D. Reidpath Susan Kneebone

Daniel D. Reidpath and Pascale Allotey Mike Toole

Part 2  Health concerns

5 Populations in transition and post-​settlement: an infectious

diseases and travel medicine perspective  87

Kudzai Kanhutu, Karin Leder, and Beverley Ann Biggs



6 Mental health of refugees  106

Peter Ventevogel, Xavier Pereira, Sharuna Verghis, and Derrick Silove

Part 3  Impacts of displacement

7 Urban refugees: the hidden population  131



8 Addressing the rights of women in conflict and humanitarian

Sharuna Verghis and Susheela Balasundram

settings  153

Rajat Khosla, Sandra Krause, and Mihoko Tanabe



9 The health challenges facing children on the move  169

Susan Bissell and Jacqueline Bhabha

10 The health impacts of displacement due to conflict on adolescents  181

Anushka Ataullahjan, Michelle F. Gaffey, Paul B. Spiegel, and Zulfiqar A. Bhutta

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Contents

Part 4  Case studies in research and ethics 11 Methodological and ethical challenges in research with forcibly displaced populations  209 Veena Pillai, Alison Mosier-​Mills, and Kaveh Khoshnood

12 Conducting health research with resettled refugees in Australia: field sites, ethics, and methods  230 Celia McMichael and Caitlin Nunn

13 The politics of immigrant and refugee health in the United States  245 Michael Grodin, Sondra Crosby, and George Annas

14 Dual loyalty, medical ethics, and health care in offshore asylum-​seeker detention  260 Deborah Zion

Part 5 Conclusion 15 Controlling compassion: the media, refugees, and asylum seekers  275 Pascale Allotey, Peter Mares, and Daniel D. Reidpath

Index  295

Abbreviations

ACLU American Civil Liberties Union BCRHHR Boston Center for Refugee Health and Human Rights BMC Boston Medical Center BUSPH Boston University School of Public Health CAR Central African Republic CBT cognitive behavioural therapies CESCR Committee on Economic, Social and Cultural Rights CFR case fatality rates CMR crude mortality rates COMPASS creating opportunities through mentorship, parental involvement, and safe spaces CRC Convention on the Rights of the Child DACA Deferred Action for Childhood Arrivals DRC Democratic Republic of the Congo ECDC European Centre for Disease Prevention and Control ECOSOC Economic and Social Council EU European Union FMEG Forensic Medical Evaluation Group GBV gender-​based violence GLP Global Lawyers and Physicians GNB Gram-​negative bacteria HIA Health Induction Assessment HINAP Health Information Network for Advanced Planning HRW Human Rights Watch IASC Inter-​agency Standing Committee IAWG Inter-​agency Working Group ICCPR International Covenant on Civil and Political Rights

ICE

Immigration and Customs Enforcement ICESCR International Covenant on Economic, Social and Cultural Rights ICMC International Catholic Migration Commission IDP internally displaced person IHMS International Health and Medical Services IRB institutional review board IRHP Immigrant and Refugee Health Program ISP Independent Study Project MDD major depressive disorder MDG Millennium Development Goals MDR TB multi-​drug-​resistant tuberculosis MHPSS mental health and psychosocial support MISP minimum initial service package MMR measles, mumps, and rubella (vaccination) NCD non-​communicable disease NGO non-​governmental organization NHI National Health Insurance NHS National Health Service ODA official development assistance OECD Organisation for Economic Co-​ operation and Development PCTF Polio Control Task Force PoC person of concern POV polio oral vaccine PSSA psychosocial structured activities PTSD post-​traumatic stress disorder

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Abbreviations

RAN RPC RSD RUTF SDG SGBV

Royal Australian Navy Regional Processing Centre refugee status determination ready-​to-​use therapeutic  foods Sustainable Development Goals sexual and gender-​based violence SRH sexual and reproductive health STI sexually transmissible infection TB tuberculosis TST tuberculin skin test

UDHR UHC UNHCR UNRWA VFR WASH WCH WHO

Universal Declaration of Human Rights universal health coverage United Nations High Commission for Refugees United Nations Relief and Works Agency visiting family and relatives water, sanitation, and hygiene women’s and children’s health World Health Organization

Contributors

Pascale Allotey Director, International Institute for Global Health (UNU-​IIGH), United Nations University, Kuala Lumpur, Malaysia George Annas William Fairfield Warren Distinguished Professor; Director of the Center for Health Law, Ethics & Human Rights, Boston University School of Public Health, Boston, MA, USA Anushka Ataullahjan Research Analyst, Centre for Global Child Health, The Hospital for Sick Kids, Toronto, Canada Susheela Balasundram Doctor, United Nations High Commissioner for Refugees, Kuala Lumpur, Malaysia Jacqueline Bhabha FXB Director of Research, Professor of the Practice of Health and Human Rights at the Harvard School of Public Health, Cambridge, MA, USA Zulfiqar A. Bhutta Co-​Director, Director of Research, Centre for Global Child Health, The Hospital for Sick Kids, Toronto, Canada Beverley Ann Biggs Professor, Royal Melbourne Hospital, Melbourne, Australia

Susan Bissell Former Director, Global Partnership to End Violence Against Children, New York, USA Sondra Crosby Associate Professor, Center for Health Law, Ethics & Human Rights, Boston University School of Public Health, Boston, MA, USA Michelle F. Gaffey Senior Research Manager, Centre for Global Child Health, The Hospital for Sick Kids, Toronto, Canada Michael Grodin Professor, Center for Health Law, Ethics & Human Rights, Boston University School of Public Health, Boston, MA, USA Kudzai Kanhutu Refugee Health Fellow, Doherty Institute, The Royal Melbourne Hospital, Melbourne, Australia Kaveh Khoshnood Associate Professor of Epidemiology (Microbial Diseases); Program Director BA-​BS/​MPH Program in Public Health, Yale University, New Haven, CT, USA Rajat Khosla Human Rights Adviser, Department of Reproductive Health, World Health Organisation, Geneva, Switzerland

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Contributors

Susan Kneebone Professorial Fellow and Associate, Asian Law Centre, Melbourne Law School, Melbourne, Australia Sandra Krause Sexual and Reproductive Health Program, Women's Refugee Commission, New York, USA Karin Leder Professor, Head of Infectious Disease Epidemiology Unit, Monash University, Clayton, Australia Peter Mares Adjunct Fellow, Swinburne University, Melbourne, Australia Celia McMichael Lecturer, School of Geography, University of Melbourne, Melbourne, Australia Alison Mosier-​Mills ‎Fulbright Student Researcher in Public Health, Yale University, New Haven, CT, USA Caitlin Nunn Assistant Professor (Research), Department of Sociology; and Fellow of the Wolfson Research Institute for Health and Wellbeing, Durham University, Durham, UK Xavier Pereira Associate Professor of Psychiatry, Taylor School of Medicine, Malaysia Veena Pillai Doctor, Dhi Consulting & Training, Kuala Lumpur, Malaysia

Daniel D. Reidpath Professor of Population Health and Director, South East Asia Community Observatory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Malaysia Derrick Silove Professor, School of Psychiatry, Brain Sciences, University of New South Wales, Sydney, Australia Paul B. Spiegel Director, Center for Humanitarian Health, Johns Hopkins University Mihoko Tanabe Sexual and Reproductive Health Program, Women's Refugee Commission, New York, USA Mike Toole Professor, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia Peter Ventevogel Senior Mental Health Officer, United Nations High Commissioner for Refugees, Geneva, Switzerland Sharuna Verghis Senior Lecturer, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Malaysia; Director, Health Equity Initiatives, Kuala Lumpur, Malaysia Deborah Zion Associate Professor and Chair of the Human Research Ethics Committee, Victoria University, Melbourne, Australia

Part 1

Concepts and contexts

Chapter 1

Forced migration, globalization, and global public health Pascale Allotey and Daniel D. Reidpath

People move. They move within countries and between countries. They move to improve their opportunities for a better life, and they move to escape intolerable hardship or the threat of intolerable hardship (Triandafyllidou, 2017, p. 3). In understanding the impetus to move, the notions of ‘structure’ and ‘agency’ have often been highlighted. Structure is broadly used to describe the macro-​level, sociopolitical, and environmental features that encourage or discourage movement, and agency is used to describe the individual motivations and personal resources that promote or suppress movement. In social and political theory the interplay between structure and agency has remained fertile territory for academic contest: see for example Squire (2017) and Hay (1995). Our purpose here is not to contribute to that debate but to give a sense of that complexity. [Structure] and agency logically entail one another—​a social and political structure only exists by virtue of the constraints on, or opportunities for, agency that it effects. Thus it makes no sense to conceive of structure without at least hypothetically positing some notion of agency which might be affected (constrained or enabled). (Hay, 1995, p. 189)

For those potentially in search of refuge, the interplay between structure and agency affects who moves and the circumstances under which they move, and how they are received and the opportunities they have to establish or re-​ establish their lives. Furthermore, the circumstances of the individual and their country of origin, the circumstances of their movement, the time it takes, the route, and their destination all have individual and population health effects. The trends in forced, global migration since the publication of the first edition in 2003 give some insight into this. It also grounds the remaining chapters of this book in the reality of the early twenty-​first century. It is crucial, however, that we have a shared understanding of the population that is the focus of this book, or at

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least a shared understanding of the potential disagreements in defining that population.

1.1 Who is a refugee? In epidemiology and health measurement there is an assumption that the rules for case definition represent natural, intrinsic classes:  with disease—​without disease. We might therefore expect inclusion or exclusion criteria or a case definition for defining concepts and populations; for separating the refugee from the non-​refugee. However, these ‘natural definitions’ are frequently muddied by blurred edges, hubris, and political and disciplinary bias (Reidpath et al., 2003; Reidpath, 2007). The term ‘refugee’ falls into this imprecise category. It is relevant primarily as a sociolegal definition, but in the context of public health and clinical medicine it is important for providing background about exposures, social determinants of health, access to services, and protections by the state and the international community. In outlining the ‘counting rules’ for refugees, we make it clear that there are arbitrary social dimensions involved, with underlying political agendas (Lomell, 2010). Different authors will use different counting rules, and these rules may not always be explicit. It is incumbent on the reader, therefore, to understand this and understand that any analysis is necessarily embedded in a particular understanding of ‘refugee’. One person’s ‘economic migrant’ is another person’s ‘climate change refugee’, and one person’s ‘refugee’ is another person’s ‘internally displaced person’ (IDP). Even within this volume, authors do not necessarily adopt the same definition of a refugee. An eminent international lawyer who was once asked what defined a refugee responded: ‘a person who satisfies the criteria laid down in Article 1 of the Refugee Convention’ (Grahl-​Madsen, 1966, p. 278). This, of course, is not the definition of a refugee, it is a description of a refugee under international law. In common usage the word refugee is used much more broadly. The English word has its origins in the flight from persecution of the French Calvinists (Huguenots) in Catholic-​dominated seventeenth-​century France, and their search for refuge in other European countries (and later the North American colonies of European countries), as the Oxford dictionary definition indicates: Refugee (/​rɛfjʊˈdʒiː/​) Noun: A person who has been forced to leave their country in order to escape war, persecution, or natural disaster. Origin: Late 17th century: from French réfugié ‘gone in search of refuge’, past participle of réfugier.

That idea of fleeing persecution in one place and seeking protection in another, at least in the European tradition, had been known since medieval times

Who is a refugee?

and even earlier. It became more prominent with the Reformation, the growth of Protestantism, and the need for classes of people to flee religious persecution. The modern European tradition of asylum dates from the year 1685. In that year Louis XIV repealed the Edict of Nantes, while in the same year Friedrich Wilhelm, the Great Elector of Brandenburg, issued his Edict of Potsdam, whereby the French Huguenots were authorised to establish themselves in his territories. (Grahl-​Madsen, 1966, p. 278)

In Judeo-​Christian tradition one of the best-​known refugees was Moses who, according to the second book of the Pentateuch, fled from Egypt to Midian, fearing persecution by the Pharaoh, where he settled, married and had children as ‘a stranger in a strange land’ (Exodus, 2:15–​22). Subsequently, Moses returned to Egypt and led the exodus of the Hebrews out of slavery to a place of refuge and final settlement in Canaan—​the first recorded mass movement of refugees. There is an interesting juxtaposition between the refugee status of the Huguenots or the Hebrews and the dictionary definition. The dictionary definition includes natural disaster as a cause to seek refuge—​which it certainly is. If there is not enough food and water to sustain life where you currently live, move! In contrast, the Huguenots and the Hebrews sought relief from politico-​ religious persecution: owing to well-​founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it. (Article 1)

As Hathaway put it, the difference between a common-​sense refugee who pulls at our heartstrings and a Convention Refugee is the concept of a rights-​bearer under international law (Hathaway, 2014). The legal instruments have been applied to individuals who seek asylum outside their country of nationality for a range of political reasons. Recent examples include Julian Assange who sought protection in the Embassy of Ecuador in London against potential future extradition to the United States where he faces prosecution for publication of leaked documents. Similar asylum regulations have been used by politicians who are in opposition to the prevailing political power in their countries. However, unless they are recognized as refugees under international law, the protection granted is restricted to the countries that grant asylum. From a public health perspective, there is greater concern when the drivers for mobility affect a significant population group. In its totality, this book considers the common-​sense notion of refugees, although some authors may focus more narrowly on ‘Refugees’—​under the legal

5

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definition. For that reason, for the most part, we therefore use the umbrella term ‘forced migration’ to emphasize the health implications for a population group. Formal definitions of the different populations affected by forced migration are discussed in detail by Kneebone in Chapter 2.

1.2 Forced migration The push factors for forced migration can conceptually be divided into precipitating events, and a process of social or environmental change, resulting in a catastrophic failure: a sociopolitical failure, an economic failure, or an environmental failure (Figure 1.1). Against a backdrop of political, economic, or environmental conditions, changes occur. ◆ Government policy is implemented that blames and targets a minority group. ◆ There is an economic depression. ◆ An economic policy encourages unsustainable farming practice. ◆ The rate of population increase (from birth and migration) is beyond the capacity of the country. ◆ There is an earthquake or other large-​scale natural disaster. The sociopolitical failure to protect (sub-​)populations, the economic failure removing food from the table, or some sudden or gradual environmental failure becomes the impetus or force to move. The concept map is not intended to identify all contingencies, nor reflect the full complexity of feedback loops, nor address the confluence of inseparable causes. When there is a drought, do people move because of an environmental failure or an economic failure? In times of conflict, is it persecution or a loss of livelihood that creates the duress precipitating movement? What Figure 1.1 does illustrate is that those who move have gone in search of refuge (réfugié). They have gone away from their homes looking for greater safety and security. The concept map focuses on the structural and is intentionally quieter on agency, although it is implicit. We are not interested in a tally-​column of suffering. Who has suffered enough to be a refugee? Who was truly forced? We do not support the argument that one is not allowed to seek refuge until one’s life has been utterly destroyed. It is also clear, however, that the health sequelae will be different for different people. Some of that difference will relate to the extent to which a person can preserve their agency and act within the world rather than have the world act upon them.

Environmental Change

Social Change

Process

Loss of Livelihood

Economic Failure

Floods Droughts Earthquakes

Conflict War Persecution

Socio-Political Failure

Environmental Failure

Exemplar

Outcome

Reproduced courtesy of the authors.

Figure 1.1  Conceptual map of the events, processes, and outcomes leading to forced migration.

Natural

Economic

Political

Events

Economic Migrants

Asylum Seekers

Internally Displaced

Refugees

Class

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1.3 Definitions The need to categorize and label the types of forced migration is politically expedient to direct public opinion, influence policy, and determine states’ obligation. If health is a public good, the rules for who can access health services and the cost of these services are determined by states. Legal status and citizenship therefore often becomes the primary consideration (regardless of push factors for forced migration) and has fuelled recent debates in the movements of people across borders. A Refugee is a person who meets the eligibility criteria under the applicable refugee definition, as provided for in international or regional refugee instruments, under the mandate of the United Nations High Commissioner for Refugees (UNHCR), and in national legislation. An asylum seeker is an individual who is seeking international protection. In countries with individualized procedures, an asylum seeker is someone whose claim has not yet been finally decided by the country in which he or she has submitted it. Not every asylum seeker will ultimately be recognized as a refugee, but every refugee is initially an asylum seeker. Internally displaced persons (IDPs) are those forced or obliged to flee from their homes, ‘. . . in particular as a result of or in order to avoid the effects of armed conflicts, situations of generalized violence, violations of human rights or natural or human-​made disasters, and who have not crossed an internationally recognized State border’ (UNHCR, 1998, p. 5). Mandate Refugees are persons who are recognized as refugees by UNHCR acting under the authority of its Statute and relevant UN General Assembly resolutions. Mandate status is especially significant in states that are not parties to the 1951 Convention on Refugees or its 1967 Protocol. Under national laws, Stateless Persons do not have the legal bond of nationality with any State. Article 1 of the 1954 Convention relating to the Status of Stateless Persons indicates that a person not considered a national (or citizen) automatically under the laws of any State, is stateless. These persons may differ from undocumented migrants, who lack legal documentation and therefore need to make a case for citizenship and migration status. Persons of Concern to UNHCR is a generic term used to describe all persons whose protection and assistance needs are of interest to UNHCR. These include refugees under the 1951 Convention, persons who have been forced to leave their countries as a result of conflict or events seriously disturbing public order, asylum seekers, returnees, stateless persons, and, in some situations, IDPs. UNHCR’s authority to act on behalf of persons of concern other than refugees is

Trends in global forced migration

based on United Nations General Assembly and Economic and Social Council (ECOSOC) resolutions.

1.4 Trends in global forced migration In the first edition of Health of Refugees, Zwi and Alvarez-​Castillo (2003) identified the major forced migration events since World War II. Rather than look back again, we carry that timeline forward to cover the years since that publication. We have the advantage of better data systems and better tracking. Unfortunately, there are no perfect mechanisms for tracking all formal and informal movements of people. A  quick look at the data from the Population Division of the United Nations Department of Economic and Social Affairs (UNDESA, n.d.) reveals the paucity of aggregated migration data. Data challenges notwithstanding, UNHCR tracks their ‘persons of concern’ (PoC) to a greater degree. Within UNHCR, PoC are categorized under ‘Refugee’, ‘Asylum Seeker’, ‘IDPs, ‘Stateless’, and ‘Other’. Each category has a specific legal definition, and while the UNHCR counting rules may not encompass everyone that one might regard as a (small ‘r’) refugee, or might cover additional people one might not regard as a refugee, it does give a snapshot of the broad trends in forced migration. We reviewed the UNHCR Global Reports from 2004, the year after the first edition was published, to the latest report published in 2016.1 We focused principally on the High Commissioner’s foreword and summary data (Table 1.1). For the majority of those years (2005–​2014), the current Secretary General of the United Nations, António Guterres, was the High Commissioner for Refugees. As a lead into those years, it is worth noting that the foreword to the 2003 Global Report opened with the sentence, ‘2003 was a good year for refugee returns’. Since then, and with the exception of 2004, good news openings have been increasingly rare. The succession of Global Reports characterizes an increasingly fragile global situation. The arc of countries through West Asia, the Middle East, the Horn of Africa, Central Africa, and the Lakes Region have dominated the refugee numbers. Some countries that were host countries for refugees have themselves become destabilized (e.g. Syria and Yemen). Other regions, however, have not been immune, including South and Central America, South East Asia, and Central Asia. Figure 1.2 uses UNHCR data to illustrate the shift in refugee numbers since 1990 through to 2016.

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Table 1.1  Information from UNHCR Global Reports, 2004–​16 Year

Highlights

2004 Acting High Commissioner Wendy Chamberlin

The number of Persons of Concern to UNHCR continued to decline. A three-​year downward trend with fewer asylum seekers arriving in industrialized countries during 2004 than in any year since 1988. Crisis in Darfur region, Sudan: 200,000 refugees shelter in arid eastern Chad.

2005 High Commissioner António Guterres

600,000 people in Indonesia and Sri Lanka were displaced by a tsunami. In late 2005 the South Asia earthquake levelled hundreds of villages throughout Pakistan-​administered Kashmir. Darfur worsened, affecting over 2 million people. Conflicts in Burundi and South Sudan continued, raising prospects for two of Africa’s largest refugee populations.

2006 High Commissioner António Guterres

For the first time since the turn of the century, the number of refugees increased in 2006 by 12% to almost 10 million. This was largely a result of the crisis in Iraq. The overall number of persons of concern to UNHCR rose from 21 million in 2005 to 34.4 million in 2006. 50,000 people a month crossed Iraq’s western border, seeking refuge in Syria and Jordan. By the end of 2006, the cumulative total of displaced Iraqis inside and outside the country had reached 3.8 million. Half-​way through 2006 there was a 34-​day war in Lebanon. Around 1 million Lebanese were displaced. Many sought refuge inside their own country; others fled into Syria.

2007 High Commissioner António Guterres

There were 2 million IDPs in Iraq and 2.2 million Iraqi refugees in neighbouring countries. Insecurity in the Central African Republic (CAR), Chad, and Darfur region brought the overall number of refugees and IDPs in these three places to almost 3  million. In Chad, cross-​border raids destroyed several villages and uprooted thousands of people. More than 20,000 Chadians fled into Darfur in 2007. Violence in the eastern areas of the Democratic Republic of the Congo (DRC) displaced an additional 435,000 people internally. In south and central Somalia fighting brought the total number of IDPs to 1 million. It also added some 30,000 Somali refugees to some 325,000 refugees already in neighbouring countries.

2008 High Commissioner António Guterres

By the end of 2008, the total number of refugees under UNHCR’s mandate exceeded 10 million. The number of conflict-​induced IDPs reached 26 million worldwide. Conflicts in an arc from South and South West Asia, through the Middle East to Sudan and the Horn of Africa generated two-​thirds of the total number of refugees worldwide. In Darfur more than 2 million people remain internally displaced, while nearly a quarter of a million Darfurians remained in exile in Chad. 300,000 people became internally displaced in Pakistan.

Trends in global forced migration

Table 1.1 Continued Year

Highlights

2009 High Commissioner António Guterres

There are 36 million persons of concern to UNHCR including 10 million refugees—​the highest number on record. Two-​thirds of the world’s refugees are in developing countries, many in the arc of conflict from South West Asia, the Middle East, Horn of Africa, and the Great Lakes and Central region. Three-​quarters of IDPs are also to be found in this arc.

2010 High Commissioner António Guterres

An estimated 20 million Pakistanis were displaced by floods. Afghan refugees in 19 camps were among those affected, as were people previously displaced internally. The emergency in Kyrgyzstan broke out in the southern city of Osh. Clashes between ethnic Uzbeks and Kyrgyz left hundreds dead and as many as 400,000 displaced. Approximately 75,000 refugees, mostly women and children, fled to the Andijon area of neighbouring Uzbekistan.

2011 High Commissioner António Guterres

Hundreds of thousands of people were forced to abandon their homes as violence erupted in Côte d’Ivoire and Libya. The Somali conflict, already 20 years old, degenerated further and, combined with the worst drought in decades, drove close to 300,000 refugees into neighbouring Kenya, Ethiopia, Djibouti, and Yemen—​ bringing the total number of Somali refugees in the region to some 950,000 by the end of 2011. An upsurge in fighting in Sudan resulted in an influx of nearly 100,000 new refugees into South Sudan and Ethiopia. Old crises in Afghanistan, DRC, and Iraq have not been resolved. As a result, durable solutions have remained elusive for a large number of refugees under UNHCR’s mandate. Over 7.2 million people are now living in protracted situations of exile.

2012 High Commissioner António Guterres

More than 1 million people fled their countries of origin due to conflict and persecution, mainly from Syria, Mali, Sudan, and the eastern DRC. That is the highest number of newly displaced refugees during any 12-​month period since the beginning of the 21st century.

2013 High Commissioner António Guterres

Nearly 2 million people fled the brutal conflict in Syria and hundreds of thousands escaped war, violence and persecution in the CAR, the eastern DRC, Myanmar, South Sudan, and Sudan. By the end of 2013, almost 43 million people—​the highest number ever—​ relied on UNHCR for protection. In just 5 years, from being the second largest refugee-​hosting country in the world, Syria has become the second largest refugee-​producing country, after Afghanistan. More than 9 million people were in flight inside and outside the country in 2013, and hundreds of thousands were trapped and under siege. Syria’s neighbours shouldered the brunt of the burden, as did other countries in the vicinity of conflict areas. (continued )

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Table 1.1 Continued Year

Highlights

2014 High Commissioner António Guterres

Conflict and persecution forced some 13 million people from their homes in 2014, and thousands died trying to get to safety.

2015 High Commissioner Filippo Grand

The world witnessed record levels of forced displacement in 2015. More than 65 million people were uprooted by war, conflict, persecution, or human rights abuses by year end, including over 10 million displaced during the year. The war in Syria was the single largest driver of displacement. At the end of the year, more than 4 million Syrians were living in exile in neighbouring countries and 6.5 million people were internally displaced. Escalating violence in Afghanistan in the second half of 2015 brought the number of internally displaced people to a new high of 1 million. In South East Asia, large numbers of migrants and refugees, including many Rohingya, put their lives in the hands of smugglers in search for safety and a future. In Central America, shocking levels of gang violence in El Salvador, Guatemala, and Honduras displaced tens of thousands of people and forced many of them along traditional migrant routes, mostly travelling north, in search of safety and protection. This was also the year that the global refugee crisis reached Europe. More than 1 million refugees and migrants arrived on the southern European shores. Tragically, nearly 4,000 died in the attempt.

2016 High Commissioner Filippo Grand

At the end of the year the global number of people of concern to UNHCR exceeded 67 million. It encompasses those who fled conflict and violence in Burundi, Myanmar, the Lake Chad region, the Northern Triangle of Central America, and Yemen. It includes millions of refugees, internally displaced people and returnees affected by the unresolved situations in Afghanistan and Somalia. Violent conflict and persecution, compounded by rising food insecurity, environmental degradation, poor governance, and countless other factors, drove more than three million people to leave their countries as refugees or to seek asylum.

Figure 1.2a shows that the number of refugees, approximately 18 million in 1990, declined to approximately 10 million by 2004, before rising again to approximately 17 million in 2016. A dramatic rise in IDPs can be seen from 2003 when the figure hovered around 5  million, rising sharply in 2005, and then again in 2012 to approximately 37 million people in 2016. The total magnitude of the problem, however, is best illustrated by Figure 1.2b, which shows the accumulated numbers of Refugees, Asylum Seekers, IDPs, and ‘Others’ from 1990 to 2016. Until 2003, there was a relatively steady number of people who moved

The distributive burden

IDP

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Refugee Other

10

People (Millions)

People (Millions)

60 30 40

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Asylum-seeker 15

10

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15

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00

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90

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90

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Year Refugee

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Asylum-seeker

Figure 1.2  The numbers of refugees, asylum seekers, internally displaced persons, and ‘others’ recorded by UNHCR in each year from 1990 to 2016. Reproduced courtesy of the authors.

under duress—​a total of around 20 million. Because of the rise in Refugees, IDPs, and ‘Others’ over the subsequent years, by 2016 the total number of people exceeded 60 million. These dramatic increases have been driven by exactly the kinds of processes described in Figure 1.1—​sociopolitical failures, economic failures, and environmental failures, often feeding into each other. The world is facing unprecedented levels of environmental and sociopolitical failure. Climate change, particularly variations in temperature, has been shown systematically to drive migration (Berlemann and Steinhardt, 2017). Similarly, large-​scale environmental events, such as hurricanes, have also been shown to force migration; and it is middle-​income countries that ‘experience significant push and pull effects on migration from natural hazards’ (Gröschl and Steinwachs, 2017, p. 445). Issues of governance, climate change, water access, food production, and economic security have been highlighted by UNHCR Global Reports during the last decade as structural factors leading to forced migration.

1.5 The distributive burden of forced migration In 2003 we looked at the inequitable distribution of refugees globally. We argued that a country’s capacity to support refugees needed to be taken into

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account in deciding on equitable distribution, where capacity combined considerations of national wealth and population size (Allotey and Reidpath, 2003). Our analysis showed clearly that the countries with the least capacity bore the highest burden, and the burden was essentially log-​linearly distributed across the wealth/​population domains. Currently, it is the proximate states that bear the heaviest responsibility for supporting refugees (Reeves, 2017). That is, the countries that share a border with a country in crisis absorb the largest share of the refugees. Because, globally, regions in crisis tend to be poorer than regions without crisis, poorer countries carry the greater burden. The challenges, however, are compounded, particularly when refugees are generated by conflict. Poorer countries have less capacity to provide appropriate support for the resettlement of refugees. Countries proximate to war are more likely to become destabilized by that war (Phillips, 2015). And the combination of managing a refugee population and maintaining national security creates a synergistic burden. This problem is understood. Reeves (2017, p. 642) in a recent argument on the moral redistribution of refugees noted that European Union (EU) ministers suggested relocating refugees to member states along the lines for which we had argued earlier: by the national wealth, population size, and adding unemployment rate and current refugee numbers. Increasing xenophobia, nationalism, and the rise of the #MeFirst movement has unfortunately not worked in favour of refugees. In Europe for example, EU member states showed they preferred to ‘sacrifice European integration because they are not ready to accept their duties towards refugees’ (Bauböck, 2017, p. 1). The problem is not, however, as the French prime minister, Manual Valls, claimed in 2016, that refugees destabilize the state (Chrisafis, Elliott, and Treanor, 2016). Instead, it is that, [R]‌efugee protection and state stability are strongly connected; undermining one factor weakens the other. Policies to protect refugees, both physically and legally, reduce potential threats from the crisis and bolster state security. Overwhelmed and often impoverished, host states cannot provide this protection without significant international assistance. (Lischer, 2017, p. 95)

1.6 Health and forced migration Publication of this second edition has been driven by the rapid escalation in forced migration over the last 10 years and the ‘global migration crisis’. The numbers of refugees have more than doubled since the first edition was published. There have been significant shifts in the global landscape; in the factors that forcibly drive people from their homes creating asylum seekers, refugees, IDPs, and various categories of economic migrants. The

Health and forced migration

scale and types of conflicts have changed, the effects of extreme weather events, natural and human-​made disasters, economic catastrophes, and pandemics is significantly different. Furthermore, there has been a shift in the national and international mechanisms for responding to mass movements of people and other humanitarian responses, coupled with major epidemiological transitions in health and diseases and the ability of health systems to respond. The response of the international community to forced migration is tempered by the complexity of political interests, immigration policies, and border sovereignty. In spite of broader equity-​related discussions on the Sustainable Development Goals (Global Goals; UN, 2015) to ensure leaving no one behind, many governments still argue against an obligation to protect people who no longer enjoy the protection of their own governments. Often lost in these complexities are the specific health needs of this group whose vulnerabilities are exacerbated by the intersectionality of multiple layers of disadvantage that results from the instability of being on the move. These complexities are the focus of the discussion by Reidpath and Allotey in Chapter 3. Specific health needs are created by the outcomes of conflict, displacement, poverty, natural disasters, violence, and other rights violations, and these are addressed by Toole in Chapter 4 and Leder et al. in Chapter 5. Mental health consequences are addressed by Ventevogel et al. in Chapter 6. Also lost in addressing the needs of forced migrants and refugees is the heterogeneity of the populations; diversity with regard to gender, culture, and socioeconomic status all influence the experience of health and disease in the course of the journey and resettlement. Also, mobility offers no protection from other epidemiological trends, such as non-​communicable and communicable diseases or environmental exposure. The lack of stable and robust health systems and problems with access to health services present major challenges to ensuring prevention, clinical management, and appropriate follow-​up for chronic illness. Refugee health, while clearly under the rubric of public health, has a specific meaning depending on the context in which it is used. In humanitarian settings and other mass movements resulting from natural disasters, there is a focus on the acute management of health issues created by conditions of poor hygiene, overcrowding, and lack of health infrastructure. In the process of resettlement to third countries, refugee health involves rigorous health screening and assessment to identify exotic communicable diseases that might threaten the public health of host nations. Following resettlement, it refers to the management of health and health services to control the potential for the marginalization of minority resettled populations, ranging from the provision of cultural

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competencies for health services staff, to addressing the specific physical and mental health needs of torture and trauma survivors. Human rights discourse and rights-​based approaches in health have expanded the role of public health researchers and practitioners to include a more central role in advocacy. The Global Goals and universal health coverage require a more equitable distribution of the resources that enable health and access to health care, particularly for the marginalized and vulnerable. There is a greater imperative for involvement in the political, economic, and social determinants that shape a rapidly globalizing world with increasing disparities in health and wealth, simmering tensions, and potential for conflict and the events that result in the drivers of forced migration.

1.7 Outline of the book Like the first edition, the aim of this volume is to provide a multidisciplinary perspective on refugee health, tracing the health repercussions on individuals and populations from the drivers of forced mass movements of populations from situations of conflict and other disasters through to the process of resettlement in countries other than their countries of origin. The contributors are drawn from public health, infectious diseases medicine, human rights law, paediatrics, psychiatry, social work, and international relations. They include researchers, policy-​makers, and practitioners. They bring experience and expertise from academia, various United Nations organizations including the United Nations University International Institute for Global Health, the World Health Organization, the UNHCR, and UNICEF as well as community-​based and civil society organizations. In updating the first edition, the intention is to highlight the complexity of factors that influence the health of refugees and asylum seekers, the global and national policy environments, ethical dilemmas, and compromises made by health-​care providers and the lived experiences of individuals, families, and communities displaced from their homes. The book is divided into three broad sections. Part 1 provides background information, establishing the international context and concepts. Kneebone explains the human rights and humanitarian framework on which international protection of refugees is based. Reidpath and Allotey place the refugee health in the framework of the social and ecological determinants of health with a focus on intersectionality. Toole, Leder Kanhutu et al. outline the public health and clinical guidelines, drawing on several years of experience with Medicins sans Frontières, the Centers for Disease Control and Prevention, and travel medicine. Ventevogel et al. outline the mental health considerations in working with forcibly displaced populations.

References

Part  2 addresses specific refugee populations, highlighting again the intersectionality of factors that exacerbate vulnerabilities. Verghis et  al. describe the challenges for refugees in urban settings, noting the paradox of the safety and invisibility of urban environments, particularly for those who are undocumented on the one hand, and the increased vulnerability due to poor access to services and protections offered by the state on the other. Khosla et al. note the specific vulnerabilities and rights violations for women in humanitarian settings, drawing out the gendered nature of conflict and displacement. Bissell and Bhabar, and Bhutta and team focus specifically on the issues for children and adolescents respectively. Part 3 presents a series of case studies in undertaking research with refugees, drawing out the ethical issues and lived experiences of individuals and families displaced for a range of reasons. The case studies situate and draw together the impact on displaced persons of the changing global and national policy environments. While the cases are drawn from diverse settings, ranging from the Middle East (Khoshnood et al.), the United States (Annas et al.), Australia (McMichael et  al.) and its offshore detention centres (Zion), they provide a powerful illustration of the importance of resilient and robust health systems to support vulnerable populations. They also highlight the use (and abuse) of the policy environment and health systems to enable or hinder the prevailing populist political and economic ideologies. We conclude with a chapter by Reidpath and Allotey which updates the insightful chapter led in the first edition by the renowned journalist Peter Mares. Using discourse analysis, the chapter addresses the role of the media in shaping popular opinion and influencing policy on humanitarianism and the health and well-​being of refugees.

Note 1. We do not reference the individual UNHCR Global Reports. They can all be found online at http://​www.unhcr.org/​en-​my/​the-​global-​report.html.

References Allotey, P. A. and Reidpath, D. D. (2003). Refugee intake: reflections on inequality. Aust N Z J Public Health, 27(1), 12–​16. https://​doi.org/​10.1111/​j.1467-​842X.2003.tb00373.x Bauböck, R. (2017). Europe’s commitments and failures in the refugee crisis. Eur Polit Sci, 17(1), 140–​150. https://​doi.org/​10.1057/​s41304-​017-​0120-​0 Berlemann, M. and Steinhardt, M. F. (2017). Climate change, natural disasters, and migration—​a survey of the empirical evidence. CESifo Econ Stud, 63(4), 353–​385. https://​doi.org/​10.1093/​cesifo/​ifx019

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Chrisafis, A., Elliott, L., and Treanor, J. (2016). French PM Manuel Valls says refugee crisis is destabilising Europe. The Guardian, 22 January. Retrieved from http://​www.theguardian.com/​world/​2016/​jan/​22/​ french-​pm-​manuel-​valls-​says-​refugee-​crisis-​is-​destabilising-​europe Grahl-​Madsen, A. (1966). The European tradition of asylum and the development of refugee law. J Peace Res, 3(3), 278–​288. https://​doi.org/​10.1177/​002234336600300305 Gröschl, J. and Steinwachs, T. (2017). Do natural hazards cause international migration? CESifo Econ Stud, 63(4), 445–​480. https://​doi.org/​10.1093/​cesifo/​ifx005. Hathaway, J. C. (2014). Food deprivation: A basis for refugee status? Social Res, 81(2), 327–​ 339. https://​doi.org/​10.1353/​sor.2014.0014 Hay, C. (1995). Structure and agency. In D. Marsh and G. Stoker (eds.), Theory and Methods in Political Science, pp. 189–​206. London: Macmillan. Lischer, S. K. (2017). The global refugee crisis: regional destabilization and humanitarian protection. Daedalus, 146(4), 85–​97. https://​doi.org/​10.1162/​DAED_​a_​00461 Lomell, H. M. (2010). The politics of numbers: crime statistics as a source of knowledge and a tool of governance. In S. G. Shoham, P. Knepper, and M. Kett (es.), International Handbook of Criminology, pp. 117–​152. Boca Raton, FL: CRC Press. Phillips, B. J. (2015). Civil war, spillover and neighbors’ military spending. Conflict Manag Peace Sci, 32(4), 425–​442. https://​doi.org/​10.1177/​0738894214530853 Reeves, A. (2017). Responsibility allocation and human rights. Ethical Theory Moral Pract, 20(3), 627–​642. https://​doi.org/​10.1007/​s10677-​017-​9808-​z Reidpath, D. (2007). Summary measures of population health: controversies and new directions. In I. Kawachi and S. Wamala (eds.), Globalization and Health, pp. 187–​200. New York, NY: Oxford University Press. Reidpath, D. D., Allotey, P. A., Kouame, A., and Cummins, R. A. (2003). Measuring health in a vacuum: examining the disability weight of the DALY. Health Policy Plan, 18(4), 351–​356. Squire, V. (2017). Unauthorised migration beyond structure/​agency? Acts, interventions, effects. Politics, 37(3), 254–​272. Triandafyllidou, A. (2017). Beyond irregular migration governance: zooming in on migrants’ agency. Eur J Migration Law, 19(1), 1–​11. https://​doi.org/​10.1163/​ 15718166-​12342112 UN. (2015). United Nations Sustainable Development Goals. https://​www.un.org/​ sustainabledevelopment/​sustainable-​development-​goals/​ UNDESA. (n.d.). United Nations Department of Economic and Social Affairs. https://​ migrationdataportal.org UNHCR. (1998). Guiding principles on internal displacement E/​CN.4/​1998/​53/​Add.2. http://​documents-​dds-​ny.un.org/​doc/​UNDOC/​GEN/​G98/​104/​93/​PDF/​G9810493.pdf Zwi, A. B. and Alvarez-​Castillo, F. (2003). Forced migration, globalisation, and public health: Getting the big picture into focus. In P. Allotey (ed.), The Health of Refugees: Public Health Perspectives from Crisis to Settlement, pp. 14–​34. Melbourne: Oxford University Press.

Chapter 2

Humanitarianism, refugees, human rights, and health Susan Kneebone

2.1 Introduction Over the past two decades, the number of persons displaced globally has doubled. This increase has brought with it increased focus by states on controlling entry to national territory. The perception is that: ‘We are witnessing in today’s world an unprecedented level of human mobility’ (UN, 2016, para. 3). This perception has a natural flow-​on effect for access to health services. Not only has demand for such services increased, but states are internalizing the concept of ‘border’ by using access to health services to deter the mobility of asylum seekers. Control of access is achieved by creating hierarchies of entitlements to health services based on immigration status rather than medical need or status in international law. In this context, doctors and health workers are often at the ‘front line’ of border control, positioned between the state and the individual. The United Nations High Commissioner for Refugees (UNHCR) as at 31 May 2017 estimated that there were 22.5 million refugees (UNHCR, 2017). In 2007, by contrast, the number of refugees worldwide was 9.9  million (Kneebone, 2009, p. 4, n10). Furthermore, the nature of displacement has changed over the past decade, pointing to particular health consequences and issues for access to health services. The United Nations 2016 New York Declaration for Refugees and Migrants states that ‘armed conflict, persecution, and violence, including terrorism, are among the factors which give rise to large refugee movements’ (UN, 2016, para. 64). The main reasons for flight today are civil wars and violence, as well as denial of social and economic rights (Kneebone, 2010, p. 216). Moreover, a large percentage (84%) of refugees and asylum seekers are in developing rather than industrialized countries (UNHCR, 2017). A new category of ‘urban refugee’ has emerged; in 2012 UNHCR estimated that potentially more than half of the world’s refugees are living in large cities, rather than

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in camps. In the New York Declaration, this figure was stated to be 60% (UN, 2016, para. 73). Several reports also recognize that there are particular vulnerabilities of women and children during the journey from the country of origin to country of arrival  . . .  [including] potential exposure to discrimination and exploitation, as well as to sexual, physical and psychological abuse, [and] violence . . . (UN, 2016, para. 29).

The UNHCR has documented an increase in the number of reported incidents of sexual and gender-​based violence among refugees and asylum seekers, from 18,245 in 2014 to 26,632 in 2015 (Türk, 2016). These causes of displacement and methods of shelter bring with them new challenges for the provision of health services, especially in developing countries. In developed countries which practise deterrent measures against entry, access to health care is also a contested issue. In this context, it is important to understand the human rights of individual refugees and asylum seekers, including their right to health at all stages of displacement. While lack of access or discrimination in access to health may be a source of persecution at the place of origin, at the destination, refugees and asylum seekers are often discriminated in access to health on the basis of their migration status. In such situations, doctors and health workers may be faced by ethical conflicts of interest. In government policy, the right to health becomes conflated with access to public services, under a libertarian, ‘consumer–​provider’ model of service provision (Taylor, 2013, p. 297). The tension between the individual rights of refugees and asylum seekers and their status as non-​citizens plays into the hands of policy-​ makers intent on deterring movement. In this chapter, I explain the legal concepts of refugees and asylum seekers, the term humanitarianism, and the applicable human rights principles. I then focus on issues which reflect this context, in particular the conflicted roles of doctors and other health workers in receiving countries, including when working with urban refugees. An analysis of the human right to health is presented to highlight gaps in the human rights frameworks which states can exploit to limit refugee protection.

2.2 Refugees, asylum seekers, and protection

seekers: some definitions In everyday parlance, a refugee is a person in flight, a person seeking refuge. However, in international law, a Refugee is a person who falls within the definition of the 1951 Convention relating to the Status of Refugees (Refugee Convention, Art. 1A (2)). As the European Union (EU) Qualification Directive

Some definitions

2011 says, the act of ‘recognition of a refugee is a declaratory act’ (preambular clause 21) which confirms the status of an asylum seeker in international law (UNHCR Handbook, 1992, para. 28). Although international treaties and conventions are not generally self-​executing but require good faith transposition and implementation into national legal systems, the status of the refugee in international law is distinct due to this declaratory theory. This status distinguishes the refugee from other international migrants, including the humanitarian entrants considered below. Importantly, the New York Declaration for Refugees and Migrants (UN, 2016) recognizes these separate categories with specific needs. An asylum seeker is a person seeking asylum from persecution who has yet to be formally recognized as a refugee as defined in Art. 1A(2) of the Refugee Convention. It needs to be recognized that many refugees and asylum seekers are undocumented or irregular migrants under national laws, as few if any countries provide a legal means to enter a country to apply for asylum. Further, many refugees are present in host countries as migrant workers and may not necessarily self-​identify as asylum seekers (Pittaway, 2017). Although the two categories—​refugees and migrant workers—​are separate and distinct in law, in reality they are often blurred. The Refugee Convention is an instrument of human rights protection which was intended to implement the basic right to flee persecution and to seek and enjoy asylum (Universal Declaration of Human Rights (UDHR) Art. 14), and to enshrine the basic right against refoulement (Art. 33(2))—​the negative right to not be returned ‘in any manner whatsoever to the frontiers of territories where  . . .  life or freedom would be threatened’ (emphasis added). Although the Convention does not state a specific right to seek asylum, the right is consistent with the right to freedom of movement (International Covenant on Civil and Political Rights (ICCPR), Art. 12), which includes the right to leave one’s country, as well as the fundamental right to life (UDHR Art. 3; ICCPR Art. 6.1). Humanitarianism is a term which in this context has mixed connotations. In everyday use, it means ‘having regard to the interests of humanity or mankind at large’ and thus has ethical and moral connotations (Kneebone, 2010). In the context of refugee protection, it is used to stress complementary protection. That is, for those who may not satisfy the Refugee Convention definition, it means substitute (and sometimes inferior) protection granted on ‘a discretionary basis on compassionate or humanitarian grounds’ (EU Qualification Directive, 2011, preambular clause 15). Within the EU, the Qualification Directive has created a status of ‘subsidiary protection’ for those who do not qualify as refugees but who are identified as in need of international protection, defined in Art. 15 of the Directive, as being under ‘a real risk of suffering

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serious harm’. This test recognizes the prohibitions against torture and cruel, inhumane or degrading treatment, or punishment in the ICCPR, Art. 7 and the UN Convention Against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment (CAT), Art. 3. Whereas both refugees and asylum seekers are entitled to protection in international law because of their status, humanitarian entrants or ‘protection seekers’ rely on states to protect their human rights, in particular the right not to be returned to a place where they would suffer torture or inhumane and degrading treatment, standards which mirror the non-​refoulement obligation in the Refugee Convention (Kneebone, 2009, pp. 11–​14).

2.3 Human rights: access to health for refugees

and protection seekers In this section, I first summarize the human rights which are relevant to access to health and then explain their application to refugees, and to asylum seekers and protection seekers at different stages of displacement. Several human rights instruments, which States Parties are bound to implement in good faith, are relevant to access to health and apply to refugees and asylum seekers, irrespective of their status as refugees (referred to here as generic instruments). This is important because the Refugee Convention does not specifically mention the right to health (see below). Some other instruments apply to refugees, asylum seekers, and protection seekers because they have another specific vulnerability status, such as being a migrant worker, a child, or a woman. In the following sections I describe the human rights which apply to all refugees, and to asylum seekers and protection seekers under the generic and the specific instruments, and consider their application. As we will see, migration status and nationality may be relevant in determining access to health care.

2.3.1 What is the right to health? The 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR), to which 146 states are parties, contains the most recognizable universal statement of a right to health. In Art. 12.1 of the Covenant, States Parties recognize ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. General Comment No. 14 of the Committee on Economic, Social and Cultural Rights (CESCR) which oversees the implementation of the Covenant, begins: Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity.

Human rights and access to health

Clearly, the reference in Art.  12.1 of the Covenant to ‘the highest attainable standard of physical and mental health’ is not confined to the right to health care. As the CESCR points out, the drafting history and the express wording of Art. 12.2 of the Covenant (which sets out steps to be taken by State Parties to achieve the rights specified) acknowledge that the right to health embraces a wide range of socioeconomic factors that promote conditions in which people can lead a healthy life. It extends to the underlying determinants of health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment. Some of these rights are recognized for example in ICESCR, Art. 11, in ‘the right of everyone to an adequate standard of living for himself and his family, including adequate food, clothing, and housing’. The ICESCR builds on the earlier statement of a right to access to health in the 1948 UDHR, Art. 25, which pairs it with ‘the right to a standard of living and livelihood’. It includes medical care and necessary social services and social security in the list of basic rights which support a right of access to health. The link between the right to social security and the right to health care is discussed below. The clearest statement of a right to access to health is in the Convention on the Rights of the Child 1989 (CRC), Art. 24.1 whereby ‘States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.’ It continues: ‘States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.’ Other provisions of the CRC recognize the right of every child ‘to benefit from social security, including social insurance’ (Art. 26), and to ‘a standard of living adequate for the child’s physical, mental, spiritual, moral and social development’ (Art. 27). The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW, 1979) also contains the right of ‘access to health care services, including those related to family planning’ (Art. 12.1), and ‘appropriate services in connection with pregnancy, confinement and the post-​natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation’ (Art. 12.2). CEDAW requires States Parties to take ‘all appropriate measures to eliminate discrimination against women in rural areas’ in relation to access to ‘adequate health care facilities, social security and adequate living conditions’ (Art. 14.2). The pattern which emerges from these instruments is that at the most basic level, access to health is an aspect of the individual ‘right to life, liberty and security of the person’ (UDHR Art. 3; see also ICCPR Art. 6.1). It is dependent on recognition of other socioeconomic rights and the specific circumstances of the

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individual (such as child or woman). Such socioeconomic rights are included in the (non-​binding) Sustainable Development Goals (SDGs), such as SDG 3 (ensure healthy lives and promote well-​being for all at all ages), and SDG 6 (ensure access to water and sanitation for all). The human rights instruments sometimes include both access to health care and the right to social security (see CRC Arts. 24.1, 26). In recent years the World Health Organization (WHO) has promoted universal access to public health-​care schemes and affordable health care for all (Lougarre, 2016), but the human rights instruments are not consistent on this issue. CRC Arts. 24.1, 26 for example, includes both access to health-​care services and social security (see also CEDAW Art. 14.2) but other instruments suggest the migration status of the refugee, asylum seeker, or protection seeker is relevant.

2.3.2 Limitations based on migration status and nationality ICESCR and other human rights instruments (including the Refugee Convention Art. 3) contain prohibitions against discrimination of any kind, relating for instance to race, nationality, or status (ICESCR Art. 2.2). This suggests that non-​discrimination is a universal principle or rule of customary international law or jus cogens. There are, however, countervailing indications that discrimination is permitted against some non-​nationals for certain economic rights, specifically the right to social security. Although ICESCR Art. 2.3 gives developing countries a discretion to determine the extent to which economic rights apply to non-​nationals having regard to their ‘national economy’, the breadth of the qualifications in other instruments suggest that migrant status is a basis for discrimination. ICESCR Art. 9 says unequivocally: The States Parties . . . recognize the right of everyone to social security, including social insurance [emphasis added].

By contrast, UDHR Art. 22 appears to limit the right to social security to nationals and residents when it states: Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co-​operation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indispensable for his dignity and the free development of his personality [emphasis added].

The CESCR in General Comment No. 19 (2008) on ICESCR Art. 9 recognizes the link between access to ‘affordable health care’ and social security (para 2). It lists health care for all as the first of nine normative principles of the right to social security (CESCR No 19, 2008, para. 13). It refers to the non-​discrimination

Human rights and access to health

principle in ICESCR Art. 2.2 (CESCR No. 19, 2008, para. 29), and urges States Parties to particularly consider vulnerable groups such as women, children, refugees, and asylum seekers in that context (CESCR No. 19, 2008, para. 31). But General Comment No.  19 also distinguishes contributory and non-​ contributory social security schemes, echoing distinctions made in both the 1951 Refugee Convention and the 1990 International Convention on the Protection of the Rights of All Migrant Workers (ICRMW). Each of these instruments endorses the notion that rights to access to social security, and thus health, can discriminate based on migration status. The Refugee Convention does not mention the right to health as such, but it does grant to ‘refugees lawfully staying in their territory the same treatment with respect to public relief  . . .  as is accorded to their nationals’ (Art.  23). Article  24, which also applies to those ‘lawfully staying,’ grants the ‘same treatment as is accorded to nationals’ in relation to labour protection and social security—​which includes ‘sickness . . . and any other contingency’, subject to the limitation that where such benefits are contingent on contributions to public funds, ‘special arrangements’ may apply (Art. 24.1(b)(ii)) (Lester, 2011). The Convention generally recognizes that refugees are entitled to social and economic rights as the status of the refugee becomes more settled (Kneebone, 2009, pp. 6–​8). It distinguishes, for example, those who presence is merely ‘lawful’ (such as those who are in the process of applying for refugee status) and those who are ‘lawfully staying in their territory’ (who may have some residency status). In other words, the Refugee Convention grants the right to social security only to those who have some settled status, rather than ‘mere’ asylum seekers. The idea that international migrants can be discriminated based on status is reinforced by the provisions of the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (ICRMW). ICRMW contains a non-​discrimination clause with a comprehensive list of prohibitions; however, it does not include migrant status. Indeed, the whole scheme of ICRMW reinforces discrimination based on status as it distinguishes the rights of regular (documented) and undocumented (irregular) migrant workers. Under Part IV of ICRMW additional rights apply to documented migrant workers and members of their families. This includes, for example, greater rights to social and health services—​regular migrants enjoy equality of treatment with nationals of the State with respect to employment ‘provided that the requirements for participation in the respective schemes are met’ (Arts. 43.1(e) and 45.1(c)). By contrast, Art. 27 in Part III (which applies to both irregular and regular migrant workers) makes such rights dependent on ‘the applicable bilateral and multilateral treaties’. Such treaties are likely to be in place only for

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regular migrant workers (see CESCR No. 19, 2008, para. 56 for recognition of that fact). As mentioned, many refugees, asylum seekers, and protection seekers present in host countries as (irregular) migrant workers to whom Part III of ICRMW applies. Article 28 grants equality of treatment with nationals to access emergency medical care ‘required for the preservation of their life or the avoidance of irreparable harm to their health’. ICRMW thus endorses discrimination against non-​nationals in relation to social and health services based on migration status. General Comment No. 19 para. 37 referring to refugees and asylum seekers states: Non-​nationals should be able to access non-​contributory schemes for income support, affordable access to health care and family support. Any restrictions, including a qualification period, must be proportionate and reasonable. All persons, irrespective of their nationality, residency or immigration status, are entitled to primary and emergency medical care [emphases added].

This is consistent with Part III of ICRMW. General Comment No. 19 continues: Refugees, stateless persons and asylum seekers, and other disadvantaged and marginalized individuals and groups, should enjoy equal treatment in access to non-​ contributory social security schemes, including reasonable access to health care and family support, consistent with international standards (para. 38).

As we will see, states discriminate against non-​nationals in access to health, for deterrence purposes, and in so doing apply standards that are arguably not proportionate and reasonable. This suggests that the ‘right to health’ is conflated with access to public services, that the ‘economic’ aspect of the right overrides the basic human ‘right to life’.

2.3.3 Protection from persecution and health rights The root causes of flight can be interconnected with access to health. The Refugee Convention (Art. 1A(2)) defines a ‘refugee’ as a person who: . . . . owing to [a]‌well-​founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.

The meaning of ‘persecution’ is not defined in the Convention, but generally requires targeted acts which are discriminatory against an individual. Some accepted definitions include ‘severe pain or suffering, physical or mental, intentionally inflicted’ (Goodwin-​Gill and McAdam, 2007, p. 90) and ‘sustained

Human rights and access to health

or systemic violation of basic human rights’ (Hathaway, 1991, pp. 104–​105). It is well established that breach of the right to an ‘adequate standard of living’ and threats to health may amount to ‘persecution’ (Hathaway and Foster, 2014, pp.  228–​238; Foster, 2007, pp.  226–​235). Decision-​makers have relied upon ICESCR Art. 12.1 and the statement in the CESCR General Comment No. 14: States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services; abstaining from enforcing discriminatory practices as a State policy; and abstaining from imposing discriminatory practices relating to women’s health status and needs (para. 34).

Thus, asylum claims from members of minority religions in Iran denied access to medical care on religious grounds have been recognized, as have the claims by persons with HIV denied equal access to medical services. It has also been recognized that severe pollution and/​or environmental degradation may seriously affect health and be linked to a Convention ground (such as religion or nationality). In the decision of the High Court of Australia in 2000, Chen Shi Hai (HCA, 2000) it was decided that denial of access to food, shelter, and medical treatment to a child born outside China’s one-​child policy amounted to persecution.

2.3.4 Rights at destination It follows from the fact of persecution and flight that newly arrived refugees and protection seekers often suffer from serious health issues, including mental health problems (Simich, 2006), connected to their reasons for or experiences during flight. As one writer expresses: refugees and asylum seekers suffer ‘a disproportionate burden of illness’ (Taylor 2013, p. 293). A study of refugees arriving in Australia found that many refugees arrive with complex health needs. It estimated that one in six refugees has a physical health problem with a severe impact on quality of life and that two-​thirds experience mental health problems, signifying the important role of rehabilitation (Khan and Amatya, 2017). Further, refugees often face continued disadvantage, poverty, and dependence, which are determinants of both poor physical and mental health, due to lack of support in the receiving country. This is compounded by language barriers, impoverishment, and lack of familiarity with the local environment and health-​ care systems (Khan and Amatya, 2017). In Canada, it was found that many refugees suffer from lack of understanding of the health-​care system, language and cultural barriers, or discrimination in access to services (Rahman, 2017). The process of making and proving a claim for refugee status, the seeking of asylum, is a challenge for every claimant. Refugee status determination (RSD)

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has been described as ‘one of the most complex adjudication functions in industrialized societies’ (Rousseau et al., 2002); it imposes a substantial burden of proof on the claimant, and the need to overcome a tangible ‘credibility deficit’ (Coffey, 2003; Taylor, 2013, p. 290). Moreover, the risk of re-​traumatization on retelling a story of persecution is well recognized (Herlihy and Turner, 2009). To negotiate the RSD process a refugee needs to be in good health, but, as Khan and Amatya recognize, many newly arrived refugees need first to recover their health. To enable refugees and protection seekers to have a proper opportunity to present their case for asylum or protection, they need to be physically and mentally well. The denial of the right to properly present the case for asylum or protection is tantamount to refoulement. The EU Reception Directive 2013 recognizes the link between material well-​ being (which includes health) and the right to seek asylum. Article 17.1 states: Member States shall ensure that material reception conditions are available to applicants when they make their application for international protection.

The Reception Directive 2013 Art. 17.2 states: Member States shall ensure that material reception conditions provide an adequate standard of living for applicants, which guarantees their subsistence and protects their physical and mental health.

In Fedasil v. Saciri (ECR, 2014) the EU Court of Justice stressed that the purpose of the Directive is linked to ensuring the right to seek asylum. The court’s position was that the reception measures must guarantee asylum seekers dignified living, subsistence, and physical and mental health, and be sufficiently stable to adequately satisfy health and other material needs of those undergoing an (often lengthy) asylum procedure. However, the reality is that the current ‘refugee crisis’ in Europe since 2015 has led to a focus on deterrent measures such as detention, and that many asylum seekers are housed in substandard accommodation (Mousourakis, 2016). There is growing discrimination and lack of consistency in standards between Member States. In light of the current situation, the European Commission is considering a further recast of the (already recast) Reception Directive 2013.

2.3.5 Deterrent measures and the role of doctors In contrast to the objectives of the EU Reception Directive, many developed states around the globe when acting as destination countries have developed deterrent policies which fundamentally undermine the rights of asylum seekers to seek asylum, including measures which discriminate against asylum seekers and ‘undocumented migrants’ in access to health care. These states exploit the ambiguities around the human right to ‘access to health’ explained above, and

Human rights and access to health

in so doing undermine the fundamental right to seek asylum. For example, a study of Denmark, Sweden, and the Netherlands revealed that entitlements at national levels for undocumented migrants are inconsistent and often at odds with the international human rights summarized above (Biswas et al., 2012). Further, states often position doctors in situations of conflict. For example, in the United States, doctors have a direct role in the assessment of claims in the RSD process, which puts them in a potential position of conflict between their medical and ‘judicial’ roles (Asgary and Smith, 2013). One of the leaders in this trend to deny health rights as a deterrent measure is the United Kingdom, beginning with the 1999 Immigration and Asylum Act (Cohen et al., 2002) and subsequently the Nationality, Immigration and Asylum Act 2002 and Asylum and Immigration (Treatment of Claimants) Act 2004 (Ghanea, 2007, pp. 125–​127). The Nationality, Immigration, and Asylum Act 2002 s. 55 required asylum seekers to make their claims ‘as soon as reasonably practicable’ upon arrival in the United Kingdom. Failure to do so could lead to the withdrawal of social welfare benefits. This measure led to hundreds of applications for injunctions (Ghanea, 2007, p.  125). In several cases, successful judicial challenges were brought to decisions to remove benefits, e.g. R (on the application of Q) v Secretary of State for the Home Department (EWHC, 2003) and R (on the application of Limbuela) v Secretary of State for the Home Department (EWCA, 2004), which led to some modification of the legislation. However, the Committee on Economic, Social and Cultural Rights in their Concluding Observations on the Sixth Periodic Report of the United Kingdom of Great Britain and Northern Ireland (CESCR, 2016) expressed concern that refugees and asylum seekers, as well as Roma, Gypsies, and Travellers, continue to face discrimination in accessing health-​care services (para. 55). The Committee noted that the UK Immigration Act 2014 has further restricted access to health services by temporary migrants and undocumented migrants. Moreover, in the United Kingdom, the design of the National Health Service (NHS) positions doctors in a position of conflict. Taylor (2013) explains that under the NHS a doctor has the discretion to register a patient (for primary care only). He says: [The] fundamental issue here is the extent to which an individual doctor practising within the NHS is governed by a moral versus a political obligation. At present, there is an uneasy tension between the NHS as the monopoly provider of health care on the one hand, and on the other, the duty of the medical practitioner as an advocate for the care of the sick irrespective of citizenship (Taylor, 2013, p. 294).

In Canada in April 2012 the former Harper government announced ‘a drastic rollback of health coverage for refugees and refugee claimants’ (Raza, 2012) which was available only for conditions deemed to be of an ‘urgent or

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essential nature’ or those to ‘prevent or treat a disease that is a risk to public health or a condition of public safety concern’. The measures were even harder on refugees who arrive from so-​called safe countries, and were clearly intended to deter refugees. These cuts were restored in 2016 (following a successful challenge under the equality rights guaranteed in the Canadian Charter of Rights).

2.3.6 Offshore and onshore detention under Australian policy Australia’s offshore immigration detention centres, the Regional Processing Centres (RPCs), provide one of the most challenging environments for the provision of health care to refugees and asylum seekers, and is also challenging for the health workers. This policy is part of a suite of deterrent measures practised by the Australian government against asylum seekers following the implementation of the ‘no advantage’ principle in 2012 and the reintroduction of offshore processing. It is well recognized that offshore processing of asylum seekers can have serious consequences for both physical and mental health (de Boer, 2013, p. 1). The delivery of health-​care services for asylum seekers on Nauru and Manus Island is governed by Heads of Agreement between the Commonwealth of Australia (represented by the Department of Immigration and Border Protection) and International Health and Medical Services (IHMS). IHMS is required to provide ‘primary level health care’ to asylum seekers and to establish a network of health providers on Nauru and Manus Island (de Boer, 2013, p. 3). IHMS works with local health-​care providers for emergency and acute care. This is a challenging environment for health workers both physically and professionally (de Boer, 2013, p. 22; Sanggaan, Ferguson, and Haire, 2014). Riots, violence, abuse, self-​harm, and some deaths have been reported in offshore centres (Essex, 2016). A number of reports have raised serious concerns about the quality of care provided and whether health professionals have been able to fulfil their professional and ethical obligations to patients in RPC facilities (Sanggaan, Ferguson, and Haire, 2014; and see Chapter  14 of this volume). The death of Hamid Kehazaei from an untreated skin infection in 2015 illustrated the risk that medical recommendations for treatment may be ignored (Essex, 2016, p. 1042). In the detention environment, dual loyalty issues confront health and welfare professionals both in Australia and offshore (Briskman and Zion, 2014). This is particularly acute when mental health issues are present as carers ‘risk making themselves complicit in the system that by its nature causes mental harm’ (Fazel and Silove, 2006). Others have commented that all public health professionals (psychiatry, nursing, and social work) have a responsibility to protect and promote the right to health among populations, especially vulnerable and

Urban refugees

disenfranchised groups such as people seeking asylum, whose health care is frequently compromised (Durham et al., 2016). The Public Health Association of Australia and the Australian Medical Association have asserted that people seeking asylum in Australia have a right to health in the same way as Australian citizens, and they denounce detention of such people in government facilities for prolonged and indeterminate periods of time (Durham et al., 2016). In 2015 the Australian government sought to silence doctors and health workers from speaking out about conditions in offshore detention centres by inserting ‘secrecy’ provisions in the Australian Border Force Act 2015 (Cth). The legislation which prohibited disclosure of information relating to delivery of medical care to asylum seekers was strongly opposed by practitioners and professional associations such as the Australian Medical Association. In July 2016, a constitutional challenge to the legislation was filed in the High Court on behalf of Doctors for Refugees Inc. In September 2016 the government amended the secrecy provisions to exclude doctors, a move which was perceived as a result of a successful campaign by doctors opposed to the laws (Hall, 2016). But lingering concerns centred on the position of other health workers. More recently the government has quietly scrapped the secrecy provisions in their entirety. This episode suggests that health practitioners’ ethical obligations to vulnerable groups such as asylum seekers and refugees are being increasingly understood in Australia and elsewhere to include a positive duty of advocacy (Taylor, 2013, p. 294).

2.4 Urban refugees As noted earlier, the trend over the last decade has been for asylum seekers and protection seekers to look for shelter in urban areas (cities and towns) rather than in camp settings. The exact number of such persons is unknown. In Thailand, for example, many are in regional border towns away from major cities and not registered by UNHCR (Pittaway 2017). In other settings, such as Jordan, refugees may move back and forth without permission and so forfeit their UNHCR registration (Amnesty International, 2016, pp.  17–​21). In Malaysia, there is an estimated population of 10,000 unregistered refugees over and above the official UNHCR number. The issue of urban refugees throws up new challenges for policy-​makers as often such persons have an irregular status, and unless they are registered by UNHCR they may be unable or afraid to access health services. In this environment, UNHCR often needs to negotiate with governments for access of refugees to health care (as in Malaysia; see Chapter 7). Further, many of these

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urban settings are in the same region as the refugee’s place of origin, typically a developing country. UNHCR policy on urban refugees considers the often limited resources of host countries. UNHCR’s figures for 2017 show that 30% of displaced people are hosted in Africa, 26% in the Middle East and North Africa, and 11% in Asia and the Pacific region. Fifty-​five per cent came from just three countries, namely South Sudan, Syria, and Afghanistan. The health needs of urban populations vary depending on the composition of the group and the conditions in the host country. For example, the situation of Syrian refugees in Turkey varies markedly from those in Jordan or Lebanon (Sanduvac, 2013, pp. 24 and 28). Many studies suggest that urban refugees have significant physical and mental health problems (El-​Shaarawi, 2016), which in turn can create difficulties in establishing livelihoods, particularly when they compete for resources with other urban poor (Jacobsen, 2006, pp. 276). In relation to health care, features of urban populations are lack of community support and knowledge about how to access services, exclusion from health insurance or social security schemes, and insufficient disposable income to access health care. Urban refugees are the focus of Chapter 7 by Verghis et al., where several of the difficulties highlighted are discussed in greater depth.

2.4.1 The policies of UNHCR The issue of resources is at the forefront of UNHCR’s policies, which date from 2009. UNHCR has adopted a three-​pronged strategy of policy for urban refugees which impacts on access to health. These prongs are: advocating for refugees to have access to public services including health services on a similar basis to nationals; supporting and augmenting the capacity of existing public health services; and monitoring refugees’ utilization of health, education, and social welfare services (UNHCR, 2009; UNCHR, 2011). This policy displays a concern with ensuring that urban refugees do not become a source of friction in the host state. As the 2009 policy stated, ‘Protection must be provided to refugees in a complementary and mutually supportive manner, irrespective of where they are located (para. 16)’. The policy also privileges in particular ‘the well-​being of pregnant and lactating women’ and the needs of especially vulnerable people such as those suffering from trauma, the mentally ill, and victims of gender-​ based violence (UNHCR, 2009, para. 115). Although UNHCR avoids setting up separate and parallel services (Spiegel, 2010, p. 23) it is not always possible to maintain this policy, due to lack of local government support or unwillingness to provide services (as in the case of Israel; see Gottlieb et al. (2012) and Chapter 11). Often UNHCR itself and other humanitarian and religious organizations are directly involved in providing services, which has an impact on their core roles and how they are perceived.

Urban refugees

For example, in Thailand, many urban refugees now depend on assistance from churches to survive, and this has presented a challenge to the churches themselves which have limited resources (Larribeau and Broadhead, 2014). In Malaysia, UNHCR works in partnership with two organizations that provide health care: ACTS (A Call to Serve), which is an non-​governmental organization (NGO), and the Taiwan Buddhist Tzu Chi Foundation (Crisp et al., 2012, p. 29). UNHCR’s main role in Malaysia is to register refugees: unregistered refugees are vulnerable to detention and deportation. However, in 2016 it reported that it had facilitated 32,400 medical consultations in comparison to 16,900 registrations. In many countries, access to health services is dependent on being registered with UNHCR as a refugee, and this can present a practical problem in many situations such as for Syrian refugees in Jordan (Amnesty International, 2016, pp. 17–​21).

2.4.2 Vulnerability and urban refugees In South East Asia, the vulnerability of urban refugees is exacerbated by the fact that states in the region are not signatories to the Refugee Convention, and refugees are treated as irregular migrants. In Thailand and Malaysia refugees report being too scared to visit doctors or hospitals out of a fear of arrest and lack of financial means (see Chapter 7). Although UNHCR has negotiated concessions for health care for registered refugees in Malaysia, those who are not yet registered may be reluctant to go to a hospital. There are reports of doctors reporting irregular migrants to the authorities. Of this vulnerable population, women and children are the most vulnerable. For example, in Malaysia, reproductive health services, family planning, and immunization are also only accessible to those with a refugee card (Health Equity Initiatives, 2010, pp. 14–​17). Children face obstacles in accessing education, often due to lack of financial resources. Refugee women are particularly vulnerable if they lack refugee status and/​or have no right to work in Malaysia. One study has shown that refugee women often find employment in the informal and less regulated sectors of the economy, for example in restaurants as waitresses and dishwashers. Without the protection that legal status and documentation provide, refugee women are at the mercy of their employers, who frequently withhold pay or sexually harass and exploit them. Other refugee women stay at home and do the domestic work of cooking and cleaning for male household members, who are generally not related to them but come from the same ethnic group. One report showed that as many as 25 workers resided in a single apartment and collectively covered the rent for a refugee woman who agreed to tend to their domestic needs. While this protects the women from the

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potential arrest and deportation she might face while going out, it puts her at risk of sexual exploitation from unrelated male household members who share overcrowded living quarters (Buscher and Heller ,2010).

2.5 Conclusions In the current context of perceived unprecedented levels of human mobility1 it has been suggested that ‘health-​care providers are not only reconfigured as border guards patrolling the (welfare) state borders but are becoming petty sovereigns defining the threshold of exclusion in their everyday encounters’ with displaced persons (Karlsen, 2016, pp.  137). This leads to difficult moral and ethical issues for doctors and health workers, arising from divided loyalties. In this climate, health care and immigration policy are conflated and both are perceived as areas of public policy. The consequence is that the rights of refugees and asylum seekers are assessed in collective rather than individual terms. In other words, there is a tension between the individual human rights of refugees and asylum seekers and their migration status, which suggests the need for a more humanitarian approach to the right to health care. In this context, it is important to understand the individual human rights of refugees and asylum seekers, including their ‘right to health’ at all stages of displacement. I argue that there is a clear link between access to health services and the right to seek asylum, to have meaningful access to an asylum procedure. However, states exploit the link between the individual human rights to health and the right to social security. Because refugees and asylum seekers are often discriminated against in transit and on arrival based on migration status, denial of access to health services is used as an indirect means to deny the right to seek asylum.

Note 1. The ‘Report of the Special Rapporteur on the human rights of migrants on a 2035 agenda for facilitating human mobility’ A/​HRC/​35/​25—​28 April 2017 points out that the figures used account for only 3.3% of the global population in 2015, against 2.8% in 2000, and that the rate of migration actually slowed down during the period from 2010 to 2015, in contrast to the previous five-​year period. See para 20.

References Primary sources HCA. (2000). Chen Shi Hai v Minister for Immigration and Multicultural Affairs, [2000] HCA 19; 201 CLR 293. ECR. (2014). Fedasil v Saciri and Others (C-​79/​13) [2014] ECR 103.

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EWHC. (2003). R (on the application of Q) v Secretary of State for the Home Department [2003] EWHC 195. EWCA. (2005). R (on the application of Limbuela) v Secretary of State for the Home Department [2004] QB 1440; [2005] 3 All ER 29; [2004] EWCA Civ 540.

Reports and official documents Amnesty International. (2016). Barriers faced by Syrian refugees in accessing health care in urban areas. Chapter 5 in Living on the Margins: Syrian Refugees in Jordan Struggle to Access Health Care London: Amnesty International. CAT. (1984). Convention Against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment. New York, 10 December 1984, in force 26 June 1987, UN Doc. A/​39/​51 1465 UNTS 85, Art. 3. CEDAW. (1979). Convention on the Elimination of All Forms of Discrimination Against Women. New York, 18 December 1979, in force 3 September 1981, UN Doc. A/​34/​46, 34 UN GAOR Supp. (No. 46) at 193. CESCR. (2000). Committee on Economic, Social and Cultural Rights. General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 9). 11 August, E/​C/​ 2000/​4. CESCR. (2008). Committee on Economic, Social and Cultural Rights General Comment No. 19: The Right to Social Security (Art. 9 of the Covenant). 4 February. E/​C.12/​GC/​19. CESCR. (2016). Committee on Economic, Social and Cultural Rights.Concluding Observations on the Sixth Periodic Report of the United Kingdom of Great Britain and Northern Ireland. UN Doc E/​C.12/​GBR/​CO/​6, 14 July. http://​www.un.org/​en/​ga/​search/​ view_​doc.asp?symbol=E/​C.12/​GBR/​CO/​6 CRC. (1989). Convention on the Rights of the Child, New York, 20 November 1989, in force 2 September 1990, UN Doc. A/​44/​49, 44 UN GAOR Supp. (No. 49) at 167. Crisp, J, Obi, N., and Umlas, L. (2012). But When Will Our Turn Come? A Review of the Implementation of UNHCR’s Urban Refugee Policy in Malaysia. (Policy Development and Evaluation Service’s New Issues in Refugee Research Series. Geneva: UNHCR. De Boer, R (2013). Health Care for Asylum Seekers on Nauru and Manus Island. Research Report. Canberra: Parliament of Australia Social Policy Unit, 28 June. EU Qualification Directive. (2011). Directive 2011/​95/​EU of 13 December 2011 on standards for the qualification and of third-​country nationals or stateless persons as beneficiaries of international protection, for a uniform status for refugees or persons eligible for subsidiary protection, and for the content of the protection granted (recast), OJ 2011 L337/​9, 20.12.11, Chapter VI. EU Reception Conditions Directive. (2013). Directive 2013/​33/​EU of the European Parliament and Council of 26 June 2013 laying down standards for the reception of applicants for international protection, (recast Reception Conditions Directive 2013) L180/​96. Health Equity Initiatives. (2010). Between a Rock and a Hard Place: Afghan Refugees and Asylum Seekers in Malaysia. http://​www.aprrn.info/​1/​pdf/​Afghan_​RNA_​final%20_​ report_​June%20_​2010.pdf ICCPR. (1966). International Covenant on Civil and Political Rights, New York, 16 December 1966, in force 23 March 1976, UN Doc. A/​6316 (1966), 999 UNTS 171.

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ICESCR. (1966). International Covenant on Economic, Social and Cultural Rights, New York, 16 December 1966, in force 3 January 1976, UN Doc. A/​6316 (1966), 99 UNTS 3. ICRMW. (1990). International Convention on the Protection of the Rights of All Migrant Workers, opened for signature 18 December 1990, 2220 UNTS 3 (entered into force 1 July 2003). Sanduvac, Z. M. T. (2013). ‘Needs Assessment Report of Syrian Non-​Camp Refugees in Sanliurfa/​Turkey’ (Concern Worldwide, Mavi Kalem Social Assistance & Charity Association), available at http://​www.alnap.org/​resource/​12624 Türk, V. (2016). Statement by Assistant High Commissioner for Protection UNHCR, 67th Session of the Executive Committee of the High Commissioner’s Agenda point 4(a), 5 October 2016. UN. (2016). New York Declaration for Refugees and Migrants, United Nations General Assembly A/​71/​L.1 (13 September 2016). UNHCR. (1992). Handbook on Procedures and Criteria for Determining Refugee Status under the 1951 Convention and the 1967 Protocol relating to the Status of Refugees. Geneva: UNHCR, 1979, re-​edited 1992. UNHCR. (2009). UNHCR Policy on Refugee Protection and Solutions in Urban Areas. United Nations High Commissioner for Refugees. http://​www.refworld.org/​docid/​4ab8e7f72.html. UNHCR. (2011). Ensuring Access to Health Care: Operational Guidance on Refugee Protection and Solutions in Urban Areas. United Nations High Commissioner for Refugees. http://​www.unhcr.org/​uk/​protection/​health/​4e26c9c69/​ensuring-​access-​ health-​care-​operational-​guidance-​refugee-​protection-​solutions.html. UNHCR. (2017). Figures at a glance. United Nations High Commissioner for Refugees, 31 May. http://​www.unhcr.org/​en-​au/​figures-​at-​a-​glance.html. Universal Declaration of Human Rights, Paris, 10 December 1948, GA Res. 217 A (III), UN Doc. A/​810.

Secondary literature Asgary, R., and Smith, C. (2013). Ethical and professional considerations providing medical evaluation and care to refugee asylum seekers. Am J Bioethics, 13(4),  3–​12. Biswas, D., Toebes, B., Hjern, A., et al. (2012). Access to health care for undocumented migrants from a human rights perspective: a comparative study of Denmark, Sweden, and the Netherlands Health Hum Rights, 14(2),  49–​60. Briskman, L. and Zion, D. (2014). Dual loyalties and impossible dilemmas: health care in immigration detention. Public Health Ethics, 7(3), 277–​286. Buscher, D. and Heller, L. (2010). Desperate lives: urban refugee women in Malaysia and Egypt. Forced Migration Rev, 1(34),  20–​21. Coffey, G. (2003). The credibility of credibility evidence at the refugee review tribunal. Int J Refugee Law, 15, 377. Cohen, S., Humphries, B., and Mynott, E (eds.) (2002). From Immigration Controls to Welfare Controls. Abingdon: Routledge. Durham, J., Brolan, C. E., Lui, C. W., and Whittaker, M. (2016). The need for a rights-​ based public health approach to Australian asylum seeker health. Public Health Rev, 37(6),  1–​24.

references

El-​Shaarawi, N. (2016)/​Life in transit: mental health, temporality, and urban displacement for Iraqi refugees. In B. A. Kohrt and E. Mendenhall (eds.), Global Mental Health: Anthropological Perspectives, pp. 73–​86. Abingdon: Routledge. Essex, R. (2016) Healthcare and clinical ethics in Australian offshore immigration detention. Int J Hum Rights, 20(7), 1039–​1053. Foster, M. (2007). International Refugee Law and Socio-​Economic Rights. Cambridge: Cambridge University Press. Fazel, M. and Silove, D. (2006). Detention of refugees. BMJ, 332(7536), 251–​252. Ghanea, N. (2007). Europeanisation of citizenship and asylum policy: a case study of the UK. In S. Kneebone and F. Rawlings-​Sanaei (eds.), New Regionalism and Asylum Seekers: Challenges Ahead, Chapter 5. Oxford: Berghahn Books. Goodwin-​Gill, G. and McAdam, J. (2007 ). The Refugee in International Law, 3rd edition. Oxford: Oxford University Press. Gottlieb, N., Filc, D., and Davidovitch, N. (2012). Medical humanitarianism, human rights and political advocacy: the case of the Israeli open clinic. Soc Sci Med, 74(6), 839–​845. Hall, B. (2016). ‘A huge win for doctors’: Turnbull government backs down on gag laws for doctors on Nauru and Manus. Sydney Morning Herald, 20 October. http://​www.smh. com.au/​federal-​politics/​political-​news/​a-​huge-​win-​for-​doctors-​turnbull-​government-​ backs-​down-​on-​gag-​laws-​for-​doctors-​on-​nauru-​and-​manus-​20161019-​gs6ecs.html. Hathaway, J. (1991). The Law of Refugee Status (Toronto: Butterworths Canada). Hathaway, J. and Foster, M. (2014) The Law of Refugee Status, 2nd edition. Cambridge: Cambridge University Press. Herlihy, J. and Turner, S. W. (2009). The psychology of seeking protection’ Int J Refugee Law, 21, 171–​192. Jacobsen, K. (2006). Refugees and asylum seekers in urban areas: a livelihoods perspective. J Refug Stud, 19(3), 273–​286. Karlsen, M.-​A. (2016). Migration control and children’s access to healthcare. In F. Thomas (ed.), Handbook of Migration and Health. Cheltenham: Edward Elgar. Khan, F. and Amatya, B. (2017) Refugee health and rehabilitation: challenges and response. J Rehab Med,49(5), 378–​384. Kneebone, S. (2006). The Pacific plan: the provision of ‘effective protection’? Int J Refugee Law, 18, 696–​721. Kneebone, S. (ed.) (2009). Refugees, Asylum Seekers and the Rule of Law: Comparative Perspectives. Cambridge: Cambridge University Press. Kneebone, S. (2010). Refugees and displaced persons: the refugee definition and ‘humanitarian’ protection. In S. Joseph and A. McBeth (eds.), Research Handbook on International Human Rights Law, pp. 215–​240. Cheltenham: Edward Elgar. Larribeau, S., and Broadhead, S. (2014). The cost of giving and receiving: dilemmas in Bangkok. Forced Migration Rev, 48  51–​53. Lester, E. (2011). Part Five Welfare, Art. 23’ and ‘Part Five Welfare, Art. 24. In A. Zimmermann (ed.), The 1951 Convention Relating to the Status of Refugees and its 1967 Protocol: a Commentary. Oxford: Oxford University Press. Lougarre, C. (2016). Using the right to health to promote universal health coverage: a better tool for protecting non-​nationals’ access to affordable health care? Health Hum Rights J, 18(2),35–​47.

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Mousourakis, M. (2016). The reception of asylum seekers in Europe: failing common standards. EU Immigration and Asylum Law and Policy, 20 April http://​ eumigrationlawblog.eu/​the-​reception-​of-​asylum-​seekers-​in-​europe-​failing-​common-​ standards/​(accessed 24 August 2017). Eileen Pittaway & Emma Pittaway (2017) ‘Refugee woman’: a dangerous label, Australian Journal of Human Rights, 10:1, 119–​135, DOI: 10.1080/​1323238X. 2004.11910 773 Rahman, A. A. (2017). Rising up to the challenge: strategies to improve health care delivery for resettled Syrian refugees in Canada. UnivToronto Med J, 94(1), 42–​44. Raza, D. (2012). A moral duty: why Canada’s cuts to refugee health must be reversed. Can Fam Physician, 58, 728–​729. Rousseau, C. and Crepeau, F., Foxen, P. and Houle, F. (2002). The complexity of determining refugeehood: a multidisciplinary analysis of the decision‐making process of the Canadian Immigration and Refugee Board J Refug Stud, 15, 43. Sanggaan, J.-​P., Ferguson, G., and Haire, B. (2014). Ethical challenges for doctors working in immigration detention. Med J Aust, 201(7), 377. Simich, L. (2006). Hidden meanings of health security: migration experiences and systemic barriers to mental well-​being among non-​status migrants in Canada. Int J Migr Health Soc Care, 2(3/​4),16–​27. Spiegel, P. (2010). Urban refugee health: meeting the challenges. Forced Migration Rev, 34,  22–​23. Taylor, K. (2013). Asylum seekers, refugees, and the politics of access to health care: a UK perspective. In M. Grodin et al. (eds.), Health and Human Rights in a Changing World, pp. 289–​300. Abingdon: Routledge.

Chapter 3

Social exclusion, othering, and refugee health policy Daniel D. Reidpath and Pascale Allotey

Refugees are amongst the most vulnerable people in the world. To survive and thrive they depend on the kindness of strangers. Kindness, however, is fickle and governments have sought more certain and universal protection for refugees in agreements between state parties. A process that began in the aftermath of World War I culminated in a convention (1951) and subsequent protocol (1967), to which 148 countries are signatories to at least one of the two documents and 142 countries are signatories to both (UNHCR, 2011).1 Fundamentally the convention provides for refuge, a safe haven in another country. The convention also ensures that the life in the host country is liveable. Provision is made for housing (Art. 21), employment (Art. 17), and education (Art. 22), freedom of movement (Art. 26), and protection from discrimination based on race, religion, or country of origin (Art. 3). Most significantly, states are expected to go beyond simply helping refugees to survive; they are expected to welcome them as future members of the community with all the rights that may entail. States shall as far as possible facilitate the assimilation and naturalization of refugees. They shall, in particular, make every effort to expedite naturalization proceedings and to reduce as far as possible the charges and costs of such proceedings (Art. 34).

This is an extraordinary provision because, as Michael Walzer observed, to distribute membership of the community is to distribute the primary good that structures all other distributive choices (Walzer, 1981). As early as the year 2000, however, the international legal frameworks for supporting refugees were being identified as anachronistic—​not suited to the massive movements of people generated by major conflicts and natural disasters in Asia, the Middle East, and Africa (see Millbank, 2000). First, many refugees were not convention Refugees (distinguished in this chapter by the use of the capital R), and countries did not have the same obligation towards them. Second, potential host countries began to fear that the arrival of large numbers

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of refugees would have a negative impact on their social, economic, and cultural quality of life. Supporting refugees (or at least being seen to support refugees) was a good thing, but only to the extent that it did not have a discernible, negative impact. Distributing the goods of society to help the most vulnerable of strangers was beginning to lose its appeal. How then might governments reframe the proposition so that in denying refugees what they most needed—​refuge—​governments could nonetheless project their actions as rational and compassionate? In exploring the answer to this question, we draw heavily on an earlier article we wrote on social exclusion and extend it into a contemporary discussion of forced migration (Reidpath et al., 2005). This discussion is most relevant to high-​income countries rather than low-​and middle-​income countries, or more precisely it is most relevant to what would ordinarily be third-​country resettlement.

3.1 Risk and resource pooling One of the reasons that communities succeed is because they provide frequent and substantial opportunities for risk pooling. In small communities, risk pooling can protect individuals against an idiosyncratic shock, such as an individual harvest failure, or (to a lesser extent) against a community-​wide shock such as drought (Cherry et al., 2015). The larger the community, the greater the potential of a risk pool to limit the variance of shocks. At any one time, some people may require assistance (drawing from the pool), while many others will be succeeding and can contribute to the pool. Large risk pools decrease the probability of community-​wide shocks. The risk pool can only support a community-​wide shock if there are savings within the pool, or community members have individual resources that they can (and do) contribute to the pool (or directly to individuals in need). National and provincial governments often engage in risk pooling (although it is described in other terms) through taxation and government benefits. Risk pooling is also an important component for financing universal health coverage (UHC). At an international level, treaties and conventions form a kind of risk pooling, as does the network of multilateral development banks. We will be there to support the citizens of your country in their time of need if you are here to support the citizens of my country in our hour of need. The idea of risk pooling has inherent, general appeal. However, the nature and composition of the risk pool may differ substantially (Greene, 2013). The psychologist Joshua Greene suggested that one of the fundamental differences between the left and right wings of politics is how large they believe the risk pool should be. In the United States, the Democrats, broadly, like the idea of

Risk and resource pooling

large, all-​encompassing risk pools, which include the poor, the vulnerable, and those most in need. These large risk pools succeed because they include lots of people who contribute to the pool, but are unlikely to draw from the pool. The Republicans prefer a smaller risk pool that may include no more individuals than the immediate family. Large risk pools require higher taxes because they include sick and vulnerable people. Smaller risk pools can be composed in such a way that they are cheap (including only those who are unlikely ever to draw on the pool), or expensive (including the vulnerable and the at-​need), or unsustainable (too many vulnerable people and too few non-​vulnerable contributors). The pooling provided by communities also extends beyond risk pooling (protection against shocks) and includes broader resource pooling to functional governance, infrastructure, and services. Education systems, health systems, a judicial system, functional roads, water and sewerage, are all part of the pooled resources of a community. With this kind of risk and resource pooling in mind, Michael Walzer’s statement comes into sharper focus, that in distributing community membership we also determine with whom we make distributive choices and to whom we allocate goods and services—​ we decide who is allowed to be a part of our risk or resource pool. In the words of Joshua Greene, we decide on the membership of our moral tribe (Greene, 2013). Resource and risk pooling ultimately relies on elements of reciprocity. Individuals have an expectation that if they are contributing to a pool, they should be entitled to draw from that pool. To maintain that expectation, however, there must be simultaneous expectations that (1)  the great majority of people have in the past, currently do, or will in the future be able to contribute to the pool, and (2) people will not cheat and draw fraudulently on the pool either by taking when they do not need, or by taking from the pool knowing they never intend contributing to the pool. In times of hardship, to whom do we owe an obligation of care? The philosopher Robert E. Goodin described the particularity of obligation: family, friends, and community first (Goodin, 1985). This ordered list of obligations parallels the notion of moral tribes and brings us back to the question of who should be allowed to join the community. Historically, poor laws were used to prevent the vulnerable from moving for a better life beyond raw survival (Waxman, 1983). The vulnerable were geographically located, and it was the community of origin, and only that community, that held the obligation for their care (or lack of care). This legal constraint on movement ensured that other communities were not faced with the possibility of having to pool with someone unworthy—​ literally a person without worth, no value.

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3.2 Migration and sharing community A state’s control of its borders ensures that it can also control who may and who may not join the national community. Depending on the national policy, modern migration laws carry the potential to become the old poor laws writ large—​a mechanism for excluding the vulnerable. Points-​based (or merit-​ based) immigration systems are the clearest examples of a systematized approach to valuing potential migrants. Unsurprisingly, no two countries will agree on how to allocate points, because each country has to develop a system that responds to its own, current national circumstance and its future, projected needs. One country might need technically qualified labour, another country might need people with pre-​existing wealth, and a third country might seek potential in tertiary qualifications (Donald, 2016).2 The ideal migrant is the person who offers something to the risk or resource pool. The ideal migrant is either able to contribute immediately or is perceived as a potentially strong contributor in the future. With the possible exception of migration for family reunion, no country in its immigration policies is seeking opportunities to expose the risk pool to a net loss. Even here, however, families may be required to guarantee that they will not draw from the pool. The Refugee Convention turns on its head the evaluative process for determining who can join a community. The convention obliges signatory countries to give certain rights to convention Refugees and removes from those countries the opportunity to exclude Refugees from the risk or resource pool. A  Refugee may be poor, illiterate, disabled, culturally and linguistically dissimilar, unskilled, or suffering from a chronic disease. In short, they carry with them a greater risk of exposing a country’s internal risk pool to a net loss than does a ‘full points’ migrant. In late 2001 the town of Young in rural New South Wales, Australia received 89 Afghan (Hazara) ‘boat people’—​asylum seekers who entered Australia ‘illegally’ and were then granted ‘temporary protection’ (O’Rourke, 2002; Stilwell, 2003). They were employed in the local abattoir—​Burrangong Meat Processors—​at a little above minimum wage, doing a job that locals were not interested in doing. The Hazaras were in the process of applying for convention Refugee status, a situation which was opposed by 150 ‘angry locals’ who wanted the city council of Young ‘to stop supporting the men [these ‘illegal asylum seekers’] gaining legal refugee status.’ The mayor of Young, John Walker, had been openly supportive of the Hazara refugees coming to the town. In response to negative community comments, he placed a book in the council offices and invited local members of the community to note their views, in writing. In late 2002, we sent a research officer, Vanessa

A social exclusion ‘how to’

Johnston, to Young to review the comments. While the book was a public document, and open to view, she was not permitted to make a copy. Nonetheless, she was able to take notes about the contents, and these were illuminating. Comments were not universally negative. In fact, they were split about 50–​50. What was instructive about the negative comments, however, were that they were largely concerned with the loss of resources. Jobs would be lost to the local community. Council money (needed to ‘fix the footpath outside my door’) would be diverted to the refugees. They would bring crime into the community. It had already been established in some people’s minds that they were criminal because they were ‘illegal asylum seekers’. The Hazara refugees had, by every account, experienced intolerable persecution at the hands of the Taliban in Afghanistan (Human Rights Watch, 1998), with one Taliban commander in the mid-​1990s declaring, ‘Hazaras are not Muslims, you can kill them’ (Hucal, 2016). And yet, by the time 89 Hazaras had arrived in Australia, they were not convention Refugees, they were ‘illegal’ asylum seekers. They were not welcomed into the community as part of Australia’s global risk-​pooling obligations.

3.3 A social exclusion ‘how to’ Finesse is required to move a person from the humanitarian space of a country’s obligation to protect into the reasoned space of the socially excluded. The person seeking refuge needs to be marginalized and ‘othered’ so that they cannot be a part of a discourse of refugees and protection. Managed successfully, a country can remain a righteous global citizen, while acting in an incommensurately uncaring fashion.

3.3.1 How? In our earlier work (Reidpath et al., 2005), we identified a series of markers (stigmata) that identified a person as someone of such low value that they could legitimately be excluded from the community—​excluded from the risk or resource pool. When governments manipulate and manage those stigmata, they can ensure a form of acceptable social exclusion, because stigmata align with community expectations about the kinds of people who should be excluded. In civil discourse, defamation is a serious offence. It is serious because unless people know you personally, it is your reputation that marks your value. To defame someone is to declare them to be a forger, a felon, a quack, a bankrupt, or a knave—​marking the person as someone unworthy of social investment, a person to be excluded from, or never permitted to enter, the community (Odgers, 1881). As Thomas Paine observed, ‘character is much easier kept than recovered’, which is why defamation laws can be so harsh.

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From the perspective of the community, the untrustworthy (the cheat or criminal) would draw from the risk pool and do so without any sense of reciprocal obligation. Similarly, people incapable of working have a limited capacity to contribute to the risk or resources pool. This would include, for instance, people who are elderly, frail, disabled, or unemployable. Furthermore, those not likely to remain in the community for very long have limited capacity to return to the risk or resource pool (the migrant, refugee, temporary resident). These suggest three primary stigmata attached to people unworthy of community membership. In soliciting popular support for excluding people from becoming members of the national community, governments have marked refugees and asylum seekers as members of one, or ideally more than one, of these unworthy groups. In the early 2000s under the leadership of Prime Minister John Howard, Australia was a pioneer in adopting these techniques to marginalize and socially exclude refugees: Step 1 Identify refugees as cheats, criminals, and lawbreakers. This was done by creating two kinds of refugees. The first type was the one who queued politely, waiting to be called by the Australian government. The second type was the refugee who arrived (or attempted to arrive) unannounced and usually by boat. The Australia government declared this second type of refugee to be a queue jumper and a criminal. Their criminality related solely to their attempt to find refuge, even though the convention explicitly recognizes that refugees should not be penalized for their illegal entry or stay. Nonetheless, the government discourse contrasted a well-​mannered and orderly refugee against a criminal and a cheat. More recent statements from the United States government about refugees from Middle Eastern and African countries reflect this discourse. Step 2 Ensure that the person cannot contribute to society and is identifiable as a social parasite. While a convention Refugee has a right to work, a non-​ convention refugee has no such right. By limiting the right to work, governments can limit the extent to which a refugee could even have a chance of becoming a true member of a community. To the extent permitted by law, they can draw from the resource pool, but they are legally prohibited from contributing to the pool. Step 3 Limit the time the person will be allowed to remain. The ‘temporary protection visa’, the visa category under which many asylum seekers were permitted to remain in Australia in the early 2000s, was, as the name implied, time-​limited. Thus, before the refugee had time to think about rebuilding their life, it was declared that their time in Australia would be time-​limited.

A social exclusion ‘how to’

The classic, social capital, community-​building activities that create ties and bonds are curtailed by law. The refugee would be in the community for a relatively brief time—​just long enough to consume resources, and not long enough to contribute. By combining the defamatory narrative of the unworthy and legal restrictions to prevent refugees contributing to the community with latent xenophobia, social exclusion is all but guaranteed.

3.3.2 Recent social exclusion In the forewords of three recent Global Reports, the United Nations High Commissioner for Refugees referred to increasing xenophobia: In some countries, populist politicians played upon xenophobia and racism to mobilize electoral support . . . leading to growing hostility towards refugees, asylum seekers, migrants and ethnic minorities. (Global Report, 2010) Asylum space came under pressure in some countries, with an increased focus on border management at the expense of protection concerns. There were more reports of push-​backs and prevention of entry, and the rising sentiments of xenophobia and intolerance in several parts of the world deeply affected the well-​being of refugees. (Global Report, 2014) In many parts of the world, we also witnessed threats to the international protection regime, sometimes fuelled by dangerous anti-​foreigner rhetoric giving rise to xenophobic attitudes. (Global Report, 2015)

In 2017, a public health law specialist, Lawrence Gostin, wrote of the impact of the ‘America First’ doctrine of President Donald J. Trump, which included a ban on Syrian refugees and other migrants from seven Muslim countries. Gostin suggested that Trump’s doctrine ‘betray[ed] American values of tolerance, inclusiveness, and diversity’ (Gostin, 2017, p. 225). Unfortunately, it also revealed a significant element of intolerance, exclusiveness, and a longing for imagined cultural homogeneity. Trump’s condemnation of a bipartisan immigration proposal made in January 2018 emphasized the dissonance between the tolerant and the intolerant (Gambino, 2018). He condemned ‘shit-​hole countries’, specifically naming El Salvador and Haiti, and stated a preference for migrants from Norway. El Salvador continues to experience ‘shocking levels of gang violence’ (Global Report, 2015)  and her citizens seek refuge in other countries (including the United States). The ‘America First’ doctrine has created a situation where Haitian, El Salvadorean, and Sudanese refugees in the United States are now seeking refuge in Canada (Klein, 2017). An analysis of the corpus of words used and the style of discourse in Trump’s Facebook conversations during the 2016 presidential campaign revealed many

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of the elements of social exclusion discussed above (Knoblock, 2017). At a time when the majority of new refugees were coming out of the Middle East, ‘Muslims’, a homogenous population in the minds of the contributors, were a ‘dangerous, violent group, who are unable or unwilling to integrate in a democratic society and who threaten peaceful Americans and need to be kept out’ (Knoblock, 2017, p. 312). The point about the rising levels of xenophobia is not that it marks a different kind of social exclusion, a new way of ‘othering’ refugees. It is a more overt and thuggish version of the same kind of social exclusion. Trump himself identified Central and South American migrants and Muslim migrants from the Middle East and Africa as criminals, murderers, and terrorists—​people unworthy of being a part of the host-​country community—​thus justifying a selective utilization of the Convention on Refugees. Strategic, political discourse of social exclusion results in a small, bulwarked, moral tribe that is reluctant to expand the risk pool even for those most in need, and it is, tragically, resistant to reasoned counter-​argument (Ferwerda et al., 2017).

3.3.3 Social exclusion and health outcomes We have explored the issue of social exclusion and ‘othering’ as an active process that may be directed against refugees. Social exclusion, however, can layer (Reidpath and Chan, 2005). A refugee is more likely to be economically worse off than the average person in the host country. Depending on the refugee’s country of origin, they may on average have less education, they may be linguistically more isolated from the host country, and are likely to be a part of an ethnic minority. Even if a host country presents a relatively benign or even welcoming environment, for structural reasons not directly related to a person’s refugee status, they are more likely to experience some forms of social exclusion which may make it harder for them to find employment, gain an education, or access goods and services. The effects of social exclusion on health are more than just the effects of social exclusion because of a person’s refugee status. The effects are compounded by forms of social exclusion induced by poverty, class, ethnicity, religion, occupation, etc. (O’Donnell et al., 2018), a phenomenon described as intersectionality. These effects in combination are all the more challenging in the context of the increasingly hostile environment of many host countries. While we broadly focus on the health effects of social exclusion on refugees, it needs to be kept in mind that we are often writing about the negative effects of a general social disadvantage on health.

Access and utilization

There is a substantial literature on the effects of social disadvantage on health, and it appears to affect health outcomes in four distinct ways: 1. People who are socially disadvantaged have poorer access to available health services (WHO, 2008). 2. People who are socially disadvantaged are less likely to access the health services that are available to them (i.e. lower rates of health-​seeking behaviour) (WHO, 2008). 3. Social disadvantage induces stress which causes and exacerbates negative health outcomes (Berkman et al., 2014). 4. People who are socially disadvantaged are more likely to engage in activities that carry higher risks of negative health outcomes—​often shaped by circumstance and environment (Lynch et al., 1997; Wilkinson and Marmot, 2003). The pathways are, of course, ‘on average’ and they interact. Social determinants of health are complex, and there will be occasions when a more socially disadvantaged person is less exposed to a particular risk than a less socially disadvantaged person (Reidpath and Moyer, 2008).3 On average, however, more socially disadvantaged people (i.e. more socially excluded people), tend also to be more health disadvantaged (Popay et al., 2008).

3.4 Access and utilization Access to health care is a fundamental human right, protected by various legal instruments, including the International Covenant on Economic, Social and Cultural Rights (ICESCR) (Lougarre, 2016). Who has the right to access those services, however, is contested under national law based on citizenship. Notwithstanding any disagreement about the right to health care, it is apparent that Refugees can face barriers to health care (Batista et al., 2018), although the extent and nature of the barriers are also driven by structural factors within the host countries (Stanciole and Huber, 2009). In Israel, a migrant of Jewish descent is immediately entitled to citizenship complete with access to the National Health Insurance (NHI) scheme (Gottlieb et al., 2017, p. 2). In marked contrast to this, for non-​Jewish migrants, there are few pathways to permanent legal status and therefore no eligibility to join the NHI scheme. For 50,000 Eritrean asylum seekers in Israel, these socially exclusive policies effectively restrict access to health care. There is no ‘one size fits all’ outcome to guarantee access to health, but it is possible in some settings. From 1957 to 2012 the Canadian government provided comprehensive health-​care insurance to all refugees. From 2012 to 2016 it introduced ‘reforms’ that sought to restrict the access of refugees to health-​care

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services ‘unless their illness was a threat to public health’ (Antonipillai et al., 2018, p. 203). The reforms went against a decades-​long tradition of providing pro-​refugee health-​care services and were based on a clear social exclusion principle. We do not value you; we are not aiding you, we are aiding only ourselves—​ your benefit is a side-​effect. [The] restricted health services to refugees, promot[ed] poor health outcomes for refugee claimants by exacerbating existing barriers to access the healthcare system. Studies in Canada have found that refugees frequently face difficulties accessing healthcare due to a combination of barriers including language, transportation, cultural differences and precarious legal status. Discrimination is another barrier to accessing healthcare, as refugee mothers reported perceiving discriminatory attitudes and experiences from their healthcare providers. Socioeconomic factors, such as low income and poor education, compel refugee claimants to avoid seeking healthcare services. (Antonipillai et al., 2018, p. 208)

Facing mounting public criticism, the new Liberal government reversed the changes to refugee health-​care cover in 2016. A recent paper on obstetric health-​seeking behaviour of Syrian refugees in Jordan and Lebanon found that there were high rates of antenatal service utilization: 82% in Jordan and 89% in Lebanon. Nearly all births occurred in health facilities: 98% in Jordan and 94% in Lebanon (Tappis et al., 2017). Most services, however, required out-​of-​pocket payment and the authors noted the following: This and other studies show that the refugee populations outside of camps live under considerable financial stress. While maternal health services may be widely available in the public and private sectors of both countries [Lebanon and Jordan], costs remain a substantial factor in care-​seeking decisions and locations. (Tappis et al., 2017, p. 1805)

They went on to observe that as long as the refugees lack a legal right to work, financial challenges will remain a barrier to accessing services. A second paper looked at health service utilization by refugees in Lebanon for non-​communicable diseases and contrasted the results with an equivalent sample of host-​country citizens (Doocy et al., 2016). There were similar rates of health service utilization by Syrian refugees and Lebanese nationals, with the refugees exceeding the utilization rates of the host community in some areas. The pattern of utilization, however, was quite different. The refugees tended to access public sector, primary health-​care clinics while the Lebanese tended to seek care in private clinics. ‘Lebanon’s health system is largely privatized, and the private sector is poorly regulated; the public sector is over-​burdened, and the perceived quality of care is lower’ (Doocy et al., 2016, p. 16). While it is not possible to say definitively whether some of the difference in the experience of Syrian refugees in Lebanon and Jordan compared with the Eritrean experience in Israel can be explained by degrees of social exclusion,

Refugee health policy

there are some reasons to believe that this might be the case. First, the Syrians, Lebanese, and Jordanians are more culturally similar than are the Israelis and Eritreans. They also share the Arabic language, with some variations in accent and dialect. Historical pan-​Arabic movements are also likely to engender a more expansive sense of the moral tribe. Second, Israel recently announced that it would forcibly expel African refugees and asylum seekers originating from Eritrea and Sudan, against the express appeals of UNHCR (Schlein, 2018). The language used by the government to describe the refugees (‘infiltrators’) is completely consistent with strategic social exclusion. Furthermore, the government has said that, if the refugees do not leave Israel, they will be physically excluded from the community by permanent detention (Gorenberg, 2018).

3.5 Refugee health policy One of the most important developments in the refugee health policy space has been the concept of universal health coverage (UHC) as laid out by the World Health Organization (WHO) in the 2010 World Health Report (WHO, 2010), and its recent evolution under the umbrella of the Sustainable Development Agenda (UN, 2015). UHC enables the creation of health financing models within countries that support large risk pools and prepayment mechanisms that allow people to access health care without incurring catastrophic expenditure at the point of needed care. The WHO’s position is that, ‘whatever [health financing] system is adopted, some general government revenues will be needed to ensure that the people who cannot afford to contribute can still access health services, by subsidizing their health insurance premiums or by not imposing direct payments’ (WHO, 2010, p. 50). The provision is, thus, created for the socially vulnerable to be able to draw on a risk pool from which they were otherwise excluded. The provision of coverage under UHC for those not able to afford health care could potentially be extended to refugees (as occurred in Canada before 2012 and after 2016). However, the original formulation was silent on the question of non-​citizens and spoke more directly to a country’s citizenry. Indeed, the 2010 World Health Report addressed the need for a health financing system to be perceived to be ‘fair’, highlighting the dangers in extending the scope of the risk pool too wide if contributors saw non-​contributors gaining too great a benefit. The Sustainable Development Agenda and its associated sustainable development goals (SDG) were explicit about an agenda of ‘leaving no one behind’; i.e. an inclusive development agenda (UN, 2015). Under the health SDG, UHC ‘for all’ is an explicit indicator of performance (SDG3, Target 3.8), without a

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‘citizens only’ caveat. The target, in full, is even more expansive because it moves beyond financing to include a range of public health, primary care measures: Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all (Target 3.8).

The First Global Monitoring Report on UHC in which there is a discussion of what needs to be monitored to assess the achievement of UHC under SDG3, notes two key points that are relevant to a refugee health policy (WHO/​World Bank, 2015, p. 59): ◆ Data need to be ‘disaggregated to assess progress in the most disadvantaged population groups’. ◆ It will be ‘essential to have at least two indicators under UHC, one on financial protection (presenting both catastrophic and impoverishing health expenditures) and one on intervention coverage’. This means (1)  that refugees as a key population of disadvantage should be identifiable and monitorable in a process geared to ‘leave no one behind’, and (2) the coverage of UHC available to refugees will be related to financial protection and quality service. If countries were to adopt UHC, in deed as well as in name, it could be an extremely positive step towards a health policy that supports refugees. There are, nonetheless, concerns. First, there is a question of whether the operationalization may be reduced to rhetoric—​a reflection of our values, and how we like to think of ourselves. One WHO staff member posited this in the WHO Bulletin. Universal coverage can be justified from a political perspective as a reflection of underlying values. . . . But from a narrower health systems performance perspective, UHC as defined in the World Health Report 2010 is desirable because it embodies both a final goal of health systems and intermediate objectives. . . . Strictly interpreted, UHC is a utopian ideal that no country can fully achieve. (Kutzin, 2013, pp. 607–​8)

There is no certainty that, in expressions such as ‘health for all’ and ‘leaving no one behind’, states will feel any obligation to move beyond their citizens, particularly if it is already agreed that achieving UHC is ‘utopian’—​a word that refers either to an imagined ideal or to an impractical or unrealistic scheme. In earlier work, we showed how states could effectively ‘game’ the achievement of the millennium development goals (MDGs) by focusing effort on the wealthiest quintile of the population (Reidpath et al., 2009). If UHC is considered unrealistic, then gaming the system to demonstrate progress is a risk. The obvious starting point to mask inequities is to reduce the risk in the risk pool. From the beginning a state could define the scope of the population for which it would achieve UHC, leaving out those whom it does not want to be a part of the community.

References

A recent paper by Castillo and colleagues suggested that the fundamental problem with UHC was the lack of grounding in the international legal instruments that protect health as a human right (Castillo et al., 2017). By grounding UHC so firmly in health as a health financing issue, WHO and the United Nations may have lost rather than gained opportunities to advocate for the health of the most vulnerable.

Notes 1. It is perhaps ironic that Afghanistan only became a signatory in 2005, and neither Iraq nor Syria are signatories. 2. Unfortunately, the international migration market has also meant that wealthy countries can exploit the development of capacity in poorer countries. Health workers trained in low-​and middle-​income countries move for better opportunities in high-​income countries (Crisp and Chen, 2014). This has the triple effect of removing the skill-​base from the poorer countries, transferring the cost of training from rich countries to poor countries, and attacking the development of systems and infrastructure. 3. For instance, there was some evidence from Tanzania in the mid-​2000s that the prevalence of HIV was higher in wealthiest quintile of the population and lowest in the poorest quintile (and this was not due to survival rates). The finding was in contrast to the received wisdom that HIV prevalence was always higher among the poor (Reidpath and Moyer, 2008).

References Antonipillai, V., Baumann, A., Hunter, A., et al. (2018). Health inequity and ‘restoring fairness’ through the Canadian refugee health policy reforms: a literature review. J Immigr Minor Health, 20, 203–​213. Batista, R., Pottie, K., Bouchard, L., et al. (2018). Primary health care models addressing health equity for immigrants: a systematic scoping review. J Immigr Minor Health, 20, 214–​230. Berkman, L. F. and Kawachi, I.A Historical Framework for Social Epidemiology: Social Determinants of Population Health. In Berkman, L. F., Kawachi, I., and Glymour, M. M. (eds.) (2014). Social Epidemiology, 2nd edition. New York, NY: Oxford University Press. 3–12. Castillo, C. H. M., Garrafa, V., Cunha, T., et al. (2017). Access to health care as a human right in international policy: critical reflections and contemporary challenges. Cien Saude Colet, 22, 2151–​2160. Cherry, T. L., Howe, E. L., and Murphy, J. J. (2015). Sharing as risk pooling in a social dilemma experiment. Ecol Soc, 20, 68. https://​www.ecologyandsociety.org/​vol20/​iss1/​ art68/​ Crisp, N. and Chen, L. (2014). Global supply of health professionals. New Engl J Med, 370, 950–​957. Donald, A. (2016). Immigration points-​based systems compared. BBC News, 1 June. http://​ www.bbc.com/​news/​uk-​politics-​29594642.

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Doocy, S., Lyles, E., Hanquart, B. and Woodman, M. (2016). Prevalence, care-​seeking, and health service utilization for non-​communicable diseases among Syrian refugees and host communities in Lebanon. Confl Health, 10, 21. Ferwerda, J., Flynn, D. J., and Horiuchi, Y. (2017). Explaining opposition to refugee resettlement: The role of NIMBYism and perceived threats. Sci Adv, 3, e170081. http://​ advances.sciencemag.org/​content/​advances/​3/​9/​e1700812.full.pdf Gambino, L. (2018). Trump pans immigration proposal as bringing people from ‘shithole countries’. Guardian, 12 January. http://​www.theguardian.com/​us-​news/​2018/​jan/​11/​ trump-​pans-​immigration-​proposal-​as-​bringing-​people-​from-​shithole-​countries Goodin, R. E. (1985). Protecting the Vulnerable: A Reanalysis of Our Social Responsibilities. Chicago: University of Chicago Press. 42–108. Gorenberg, G. (2018). Opinion | Israel is betraying its history by expelling African asylum-​seekers. Washington Post, 29 January. https://​www.washingtonpost.com/​news/​ global-​opinions/​wp/​2018/​01/​29/​israel-​is-​betraying-​its-​history-​by-​expelling-​african-​ asylum-​seekers/​. Gostin, L. O. (2017). ‘America First’: prospects for global health. Milbank Q, 95, 224–​228. Gottlieb, N., Weinstein, T., Mink, J., et al. (2017). Applying a community-​based participatory research approach to improve access to healthcare for Eritrean asylum-​ seekers in Israel: a pilot study. Isr J Health Policy Res, 6, 61. Greene, J. D. (2013). ‘The Tragedy of the Commons.’ in Moral Tribes: Emotion, Reason, and the Gap Between Us and Them. New York, NY: Penguin. 19–​27. Hucal, S. (2016). Afghanistan: Who are the Hazaras? Aljazeera, 28 June. http://​www. aljazeera.com/​indepth/​features/​2016/​06/​afghanistan-​hazaras-​160623093601127.html. Human Rights Watch. (1998). The massacre in Mazari-​I Sharif. Human Rights Watch, 10(7). https://​www.hrw.org/​legacy/​reports98/​afghan/​ Klein, N. (2017). Canada prepares for a new wave of refugees as Haitians flee Trump’s America. The Intercept, 22 November. https://​theintercept.com/​2017/​11/​22/​ canada-​prepares-​for-​a-​new-​wave-​of-​refugees-​as-​haitians-​flee-​trumps-​america/​ Knoblock, N. (2017). Xenophobic trumpeters: a corpus-​assisted discourse study of Donald Trump’s Facebook conversations. Journal of Language Aggression and Conflict, 5(2), 295–​322. Kutzin, J. (2013). Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ, 91, 602–​611. Lougarre, C. (2016). Using the right to health to promote universal health coverage: a better tool for protecting non-​nationals’ access to affordable health care? Health Hum Rights, 18,  35–​48. Lynch, J. W., Kaplan, G. A., and Salonen, J. T. (1997). Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med, 44, 809–​819. Millbank, A. (2000). The Problem with the 1951 Refugee Convention (text No. 5 2000–​01), Canberra: Social Policy Group, Parliament of Australia. https://​www.aph.gov.au/​About_​ Parliament/​Parliamentary_​Departments/​Parliamentary_​Library/​pubs/​rp/​rp0001/​ 01RP05 Odgers, W. B. (1881). A Digest of the Law of Libel and Slander. London: Stevens and Sons. https://​archive.org/​stream/​digestoflawoflib00odge/​digestoflawoflib00odge_​djvu.txt O’Donnell, P., O’Donovan, D., and Elmusharaf, K. (2018). Measuring social exclusion in healthcare settings: a scoping review. Int J Equity Health, 17, 15.

References

O’Rourke, J. (2002). Residents sign up to have refugees’ welcome removed. The Sun-​Herald (Sydney), 12 May. http://​www.smh.com.au/​articles/​2002/​05/​11/​ 1021002403226.html Popay, J., Escorel, S., Hernández, M., et al. (2008). Understanding and Tackling Social Exclusion. Final report to the WHO Commission on Social Determinants of Health from the Social Exclusion Knowledge Network. Geneva: World Health Organization. Reidpath, D. and Moyer, E. (2008). The Social Determinants of HIV: a Review (SSRN Scholarly Paper No. ID 2436246). Rochester, NY: Social Science Research Network. Reidpath, D. D. and Chan, K. Y. (2005). A method for the quantitative analysis of the layering of HIV-​related stigma. AIDS Care, 17, 425–​432. Reidpath, D. D., Chan, K. Y., Gifford, S. M., and Allotey, P. (2005). ‘He hath the French pox’: stigma, social value and social exclusion. Sociol Health Illn, 27, 468–​489. Reidpath, D. D., Morel, C. M., McCaskey, J. W., and Allotey, P. (2009). The Millennium Development Goals fail poor children: the case for equity-​adjusted measures. PLoS Med, 6, e1000062. Schlein, L. (2018). UNHCR urges Israel not to forcibly deport African refugees, asylum seekers. VOAnews, 9 January. https://​www.voanews.com/​a/​unhcr-​urges-​israel-​not-​to-​ forcibly-​deport-​african-​refugees-​or-​asylum-​seekers/​4199694.html Stanciole, A. E. and Huber, M. (2009). Access to health care for migrants, ethnic minorities, and asylum seekers in Europe. Policy Brief 5/​2009. Vienna: European Centre. https://​ www.euro.centre.org/​publications/​detail/​380 Stilwell, F. (2003). Refugees in a region: Afghans in Young, NSW. Urban Policy Res, 21, 235–​248. Tappis, H., Lyles, E., Burton, A., et al. (2017). Maternal health care utilization among Syrian refugees in Lebanon and Jordan. Matern Child Health J, 21, 1798–​1807. UN. (2015). General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development, A /​RES/​70/​1. http://​www.un.org/​sustainabledevelopment/​ sustainable-​development-​goals/​ UNHCR. (2011). The 1951 convention relating to the status of refugees and its 1967 protocol (No. UNHCR/​DIP•1951 Conv./​Q&A A.8/​ENG1). Geneva: UN High Commissioner for Refugees. Walzer, M. (1981). The distribution of membership. In P. G. Brown and H. Shue (eds.), Boundaries, National Autonomy and Its Limits, pp. 1–​78. Totowa, NJ: Rowman and Littlefield. Waxman, C. I. (1983). The Stigma of Poverty: a Critique of Poverty Theories and Policies, 2nd edition. New York, NY: Pergamon Press. WHO. (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report. Geneva: World Health Organization. WHO. (2010). The World Health Report: Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization. WHO/​World Bank. (2015). Tracking Universal Health Coverage: First Global Monitoring Report. Geneva: World Health Organization. Wilkinson, R. and Marmot, M. (eds.) (2003). Social Determinants of Health: the Solid Facts, 2nd edition. Copenhagen: World Health Organization Regional Office for Europe. 12–​13.

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Chapter 4

Health in humanitarian crises Mike Toole

4.1 Introduction When the first edition of this book was published in 2003, the combined number of refugees, asylum seekers, and internally displaced persons (IDPs) worldwide was just less than 40 million. By the end of 2016, the number had increased to more than 65 million, which is the highest number since the end of World War II (UNHCR, 2017). Furthermore, some 5 million Palestinian refugees, assisted by the United Nations Relief and Works Agency (UNRWA), are to be found in Jordan, Lebanon, Syria, the West Bank, and the Gaza Strip (UNRWA, n.d.). These populations have fled armed conflicts and long periods of deprivation in their homelands, often to be housed in large sprawling camps that have sometimes lacked the basic requirements for health, such as adequate food, clean water, and sanitation. In other cases, they have sought shelter wherever possible in local communities in the host country. In this chapter, we review the magnitude of the international refugee problem, examine the major health problems affecting refugees, and summarize the most important public health priorities in refugee assistance programmes. There were several large mass migrations in the last decade of the twentieth century, such as the Kurdish refugees who fled Iraq for Iran or Turkey in 1991, the 1.5 million refugees or displaced persons within the republics of the former Yugoslavia in 1993, the estimated 2 million Rwandan refugees who fled into Tanzania, eastern Zaire (now the Democratic Republic of the Congo), and Burundi in 1994, and approximately 780,000 ethnic Albanians who fled the then Serbian province of Kosovo in 1999. However, during the first decade of the new millennium, the number of refugees and IDPs remained relatively stable. This trend changed dramatically following the events of the so-​called Arab Spring in 2011, especially in Syria, Iraq, and Yemen, where fierce armed conflict erupted and continues to this day. In March 2017, the number of registered Syrian refugees exceeded 5 million, the majority in Turkey, Jordan, and Lebanon (UNHCR, n.d.a). Furthermore, an estimated 6.6 million Syrians were internally displaced. Other major sources

Introduction

of refugees and IDPs in 2017 were chronically conflict-​affected Afghanistan, Somalia, the Democratic Republic of the Congo (DRC), and Colombia, as well as countries recently affected by conflicts, such as South Sudan, the Central African Republic, and Yemen. Under the International Refugee Convention, the Office of the United Nations High Commissioner for Refugees (UNHCR) is responsible for protection and assistance to refugees (Figure 4.1). Before 1990, most of the world’s refugees had fled countries that ranked among the poorest in the world, such as Afghanistan, Cambodia, Mozambique, Somalia, and Ethiopia. However, during the following decade, a significant number of refugees originated in relatively more affluent countries, such as Kuwait, Iraq, the former Yugoslavia, Armenia, Georgia, Russia, and Azerbaijan. Since 2011, there have been large migrations of people from middle-​income countries in the Middle East, such as Syria and Iraq. Nevertheless, the reasons for the flight of refugees remain the same:  war, civil strife, and persecution. Hunger, while sometimes a primary cause of population movements, is all too frequently only a contributing factor. In addition to those persons who meet the international definition of refugees, millions of people have fled their homes for the same reasons as refugees but remain internally displaced in their countries of origin. It has not proven easy to ascertain the number and location of the world’s IDPs. This is due not only to definitional difficulties but is also the result of institutional, political, and operational obstacles. Despite these difficulties, there was a broad consensus that the global population of IDPs has increased from somewhere in

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Figure 4.1  Trend of global displacement and proportion displaced, 1997–​2016. Reproduced with permission UNHCR. Global Trends: Forced Displacement in 2016. Geneva, Switzerland: UNHCR. Copyright © 2017 UNHCR.

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the region of 20 million at the end of 2000 to more than 40 million at the end of 2016. At the end of 2016, the largest IDP populations were in Syria, Colombia, Sudan, DRC, and Iraq. IDPs lack the protection afforded by the international conventions and protocols on refugees. Nevertheless, the Geneva Conventions and certain articles of the United Nations Charter afford some protection. Since 2005, UNHCR has been officially responsible for the provision of assistance to IDPs.

4.2 Health consequences of displacement Prior to the recent conflicts in eastern Europe and the Middle East, the most common response to mass population movements was to establish camps or settlements; conditions in these camps have varied enormously. For example, camps for Rwandan refugees in eastern Zaire (as the DRC was then known) in 1994 contained up to 300,000 persons; they were poorly planned and laid out, with inadequate sanitation and poor access to clean water. It was difficult if not impossible to establish equitable distribution systems of food and shelter materials, and there was a high frequency of violence and other crimes. By contrast, smaller refugee camps in Burundi were more easily managed and suffered fewer health consequences related to environmental conditions. However, since 2011, most Syrian and Iraqi refugees have been housed outside camps. For example, the majority of the 3 million Syrian refugees in Turkey live in urban areas, with around 260,000 accommodated in the 21 government-​run refugee camps (UNHCR, n.d.b). In Jordan, over 655,000 Syrian men, women, and children are currently trapped in exile. Approximately 80% of them live outside camps, while more than 140,000 have found sanctuary at the camps of Za’atari and Azraq. There are no formal refugee camps in Lebanon and, as a result, more than a million registered Syrians are scattered throughout more than 2,100 urban and rural communities and locations, often sharing small basic lodgings with other refugee families in overcrowded conditions. Syrian refugees have also fled to Europe, with many crossing the Mediterranean Sea to reach European Union (EU) member nations, mainly Greece, then travelling north. By late 2016, about 1 million Syrian refugees had requested asylum in Europe. Germany, with more than 300,000 cumulated applications, and Sweden with 100,000, are the EU’s top receiving countries (European Union, n.d.). In low-​income countries, refugees and displaced populations have commonly experienced high rates of communicable diseases and malnutrition resulting in significant excess mortality (Gayer et al., 2007). However, in middle-​income

Health consequences of displacement

countries, the most common causes of morbidity and mortality have been non-​ communicable diseases (NCDs) and injuries (Strong et al., 2015). The health status of IDPs may be worse than that of refugees because access to these populations by international relief agencies is often difficult and dangerous. Also, IDPs may suffer more injuries because they are usually located closer to zones of conflict than are refugees; however, both refugees and IDPs are often victims of landmines, particularly as they cross international borders.

4.2.1 Elevated mortality The most severe health consequences of conflict and population displacement have occurred in the acute emergency phase, during the early stage of relief efforts, and have been characterized by extremely high mortality rates. Although the quality of the international community’s disaster response efforts has steadily improved, death rates associated with forced migration have often remained high, as demonstrated by several emergencies during the 1990s (Figure 4.2). For example, the exodus of almost 1 million Rwandan refugees into the eastern Zaire town of Goma in 1994 resulted in crude mortality rates (CMR) that were more than 30 times the rates experienced prior to the conflict in Rwanda (Goma Epidemiology Group, 1995). By contrast, the CMR among Kosovar refugees in Albania in 1999 was lower than the internationally recognized threshold of ‘severe’ (1 death per 10,000 population per day; Toole and Waldman, 2012). In the twenty-​first century, the highest mortality rates have been documented among IDPs in Darfur (western Sudan). Degomme and Guha-​Sapir (2010)

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Figure 4.2 Mortality rates for selected refugee and internally displaced populations, 1991–​2014. Reproduced courtesy of the author.

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reviewed 63 retrospective mortality surveys from early 2004 to the end of 2008. The highest CMR was 4 per 10,000 per day in early 2004; the most common cause of death was injuries due to violence. The study showed significant reductions in mortality rates from early 2004 to the end of 2008, although rates were higher during deployment of fewer humanitarian aid workers. Also, the main causes of death evolved from violence to communicable diseases. The study estimated that there were just fewer than 300,000 excess deaths related to conflict and displacement during the 4 year study period. In situations where armed conflict has been widespread within a country, such as Syria, Somalia, Yemen, and Iraq, it has been almost impossible to enumerate the number of deaths among IDPs as opposed to the general population. However, retrospective mortality surveys in Iraq and DRC demonstrated significant increases in mortality related directly and indirectly to conflict. In Iraq (2004), the survey compared pre-​invasion and post-​invasion mortality (all ages) and found that the risk of death was 2.5-​fold higher after the invasion than in the pre-​invasion period (Roberts et al., 2004). Most of the 100,000 excess deaths were reported to be due to violence. A series of large sample surveys were conducted in DRC between 2001 and 2004. The fourth survey found that the national CMR of 2 deaths per 1000 per month was 67% higher than that reported before the war (Coghlan et al., 2006). Mortality rates were highest in the chronically conflict-​affected east of the country. The total death toll from the conflict (1998–​2004) was estimated to be 3.9 million. Somalia has the seventh-​largest internally displaced population in the world. It is the scene of one of the world’s longest continuous humanitarian assistance operations, dating back to the late 1980s. A reliably accurate count of IDPs does not exist. However, in 2014, estimates of the displaced population were around 1.1 million, including some 370,000 in the capital Mogadishu and its outskirts. The last mortality estimate, in 2010, found that displaced children suffered mortality rates 60% higher than other Somali children (Internal Displacement Monitoring Centre, 2010). Trends in death rates over time have varied from place to place. In refugee populations, such as Cambodians in eastern Thailand (1979) and Iraqis on the Turkish border (1991) where the international response has been prompt and effective, death rates have declined to baseline levels within one month. Among refugees in Somalia (1980) and Sudan (1985), death rates were still well above baseline rates 6–​9 months after the influx of refugees occurred (Toole and Waldman, 1990). In the case of 170,000 Somali refugees in Ethiopia in 1988–​89, death rates increased significantly 6 months after the influx. This increase was associated with elevated malnutrition prevalence, inadequate food rations, and high incidence rates of certain communicable diseases. Although initial death rates among Rwandan refugees in eastern

Health consequences of displacement

Zaire were extremely high, they declined dramatically within 1–​2  months (Toole and Waldman, 1990). In Darfur, Sudan, the study cited earlier found an overall decline in the CMR between 2004 and 2008 (Degomme and Guha-​ Sapir, 2010). However, during the period between July 2006 and September 2007, when there was heightened insecurity, an increase in IDPs, and an exodus of humanitarian workers, the CMR increased significantly. In humanitarian crises in low-​income countries, most deaths have occurred among children under 5 years of age; for example, 65% of deaths among Kurdish refugees on the Turkish border occurred in the 17% of the population less than 5 years of age (Yip and Sharp, 1993). However, in some refugee situations, such as Goma during the first month after the refugee exodus, mortality rates were comparable in all age groups because the major cause of death was cholera, which is equally lethal at any age (Goma Epidemiology Group, 1995). Among Syrian and Iraqi refugees, mortality rates have been higher in older age groups than children. Communicable diseases and neonatal disorders remain the largest cause of excess mortality in conflict settings of low incomes and life expectancies. However, burgeoning, overcrowding-​ related epidemics (e.g. cholera, shigella, and measles) might be arising less frequently than previously because an increasing number of populations live in non-​camp-​like settings (Spiegel et al., 2010). The major reported causes of death among refugees and displaced populations in low-​income countries have been diarrhoeal diseases, measles, acute respiratory infections, and malaria, exacerbated by high rates of malnutrition. Other communicable diseases, such as meningitis and hepatitis E, have also contributed to mortality in some settings. In eastern European conflicts, a high proportion of mortality among civilians has been caused by injuries associated with the violence. Nevertheless, there has also been increased mortality in these conflicts due to the collapse of the public health system. Chronic conditions, such as cardiovascular diseases, cancer, and renal conditions have been inadequately treated because the health system has focused on the management of war-​related injuries. Medical services in most parts of Bosnia and Herzegovina were overwhelmed by the demands of war casualties. The major hospital in Zenica reported that the proportion of all surgical cases associated with trauma steadily increased following the beginning of the war in April 1992, reaching 78% in November of the same year (Toole et al., 1993). Preventive health services, including childhood immunization and antenatal care, ceased in many areas. The collapse of health services in Bosnia and Herzegovina had significant public health effects. For example, perinatal mortality increased in Sarajevo from 16 deaths per 1,000

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live births in 1991 to 27 per 1,000 during the first 4 months of 1993 (CDCP, 1993). The rate of premature births increased from 5.3% to 12.9%, the stillbirth rate increased from 7.5 per 1,000 to 12.3 per 1,000, and the average birth weight decreased from 3,700 g to 3,000 g during the same period.

4.2.2 Malnutrition Among refugees and IDPs, many factors might lead to high rates of nutritional deficiency disorders, including prolonged food scarcity prior to and during displacement; delays in the provision of complete rations; problems with registration and estimation of the size of an affected population; and inequitable distribution systems. In general, the prevalence of acute malnutrition, or wasting, among children less than 5 years of age in low-​income countries is between 5% and 8%. However, in refugee camps, the prevalence has often been between 20% and 50%, accounting for the high case fatality rate for common infectious diseases among children in these settings (Figure 4.3). In contrast, acute malnutrition has been unusual among children in refugee and displaced populations in eastern Europe and the Middle East where food scarcity has more commonly affected the elderly. However, severe acute malnutrition has occurred in certain cities in Syria that have been subjected to blockades by either government or rebel forces. One of the most notorious examples was the town of Madaya in 2016. Syrian government forces had laid siege to the town, in Syria’s Rural Damascus Governorate, depriving roughly 40,000 residents of food and medicine for almost a year. The

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Figure 4.3  Prevalence of acute malnutrition in children under 5 years of age in selected refugee and displaced populations, 1992–​2017. Reproduced courtesy of the author.

Health consequences of displacement

town was surrounded by an estimated 12,000 landmines. Between November 2015 and May 2016, 86 people died from siege-​related causes since the siege on Madaya began—​65 from malnutrition and starvation, 14 from landmines, 6 from snipers, and 1 from a chronic health condition (PHR/​SAMS, 2016). The civil war in Yemen has exacerbated the country’s pre-​existing challenges including poverty, poor health, and a shortage of basic necessities such as water, fuel, and medications. In late 2016, UNICEF estimated that about half of children in Yemen were affected by stunting (chronic malnutrition) and about 460,000 of Yemen’s children were suffering from severe acute malnutrition (Eshaq et al., 2017). In some settings, refugee children who were adequately nourished upon arrival in camps have developed acute malnutrition due either to inadequate food rations or to severe epidemics of diarrhoeal disease. In the Hartisheik refugee camp in eastern Ethiopia, for example, the prevalence of acute malnutrition increased from less than 10% to almost 25% during a 6 month period in late 1988 and early 1989 due to inadequate food rations (Toole and Bhatia, 1992). In early 1991, the prevalence of acute malnutrition among Kurdish refugee children aged 12–​23 months increased from less than 5% to 13% during a 2 month period following a severe outbreak of diarrhoeal disease (Yip and Sharp, 1993). In Rwandan refugee camps in eastern Zaire, the prevalence of acute malnutrition was between 18% and 23% following severe cholera and dysentery epidemics during the first month after the influx (Goma Epidemiology Group, 1995). Children with a history of dysentery within 3 days prior to the survey were three times more likely to be malnourished than those with no history of recent dysentery. Also, children in families headed by a woman were at significantly higher risk of malnutrition than those children in households headed by an adult male. High incidence rates of several micronutrient deficiency diseases have been reported in refugee camps, especially in Africa. Frequently, famine-​affected and displaced populations have already experienced low levels of dietary vitamin A intake and may therefore have very low vitamin A reserves. Furthermore, the typical rations provided in large-​scale relief operations lack vitamin A, putting these populations at high risk. Also, those communicable diseases that are highly incident in refugee camps, such as measles and diarrhoea, are known to deplete vitamin A stores rapidly. Consequently, young refugee and displaced children are at high risk of developing vitamin A deficiency. In 1990, more than 18,000 cases of pellagra, caused by food rations deficient in niacin, were reported among Mozambican refugees in Malawi. Numerous outbreaks of scurvy (vitamin C deficiency) were documented in refugee camps in Somalia, Ethiopia, and Sudan between 1982 and 1991 (Desenclos et  al.,

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1989). The prevalence of scurvy was highly associated with the period of residence in camps, a reflection of the time exposed to rations lacking in vitamin C. While vitamin A deficiency remains common in young children in low-​and middle-​income countries and requires regular supplementation, outbreaks of pellagra and scurvy have been uncommon since the turn of the century. This is mainly because food rations provided by the World Food Programme and other aid agencies now routinely include food items containing micronutrients.

4.2.3 Communicable diseases The specific causes of mortality, and their age and gender distribution, do not differ from those that prevail in non-​refugee populations. Accordingly, acute respiratory infections, diarrhoea, measles, and malaria have been most frequently cited as proximate causes. Substandard conditions found in camps do not change the diseases that account for most of the morbidity and mortality among refugees, but they do alter epidemiological patterns in two important ways. The incidence, or attack rates, of commonly occurring and potentially fatal diseases increase, and the case fatality rates (CFR) are higher than usual, probably because of increased malnutrition. 4.2.3.1 Measles Of the common communicable diseases affecting young children, most progress has been made in reducing the incidence of measles, at least in accessible populations. Measles had traditionally been among the most feared of communicable diseases in refugee camps. During the 1970s and 1980s, high incidence rates, particularly in populations with low levels of vaccination prior to displacement, high mortality rates, and unusually high CFRs, were typical of measles outbreaks among refugees. In an epidemic that occurred in the Wad Kowli refugee camp in eastern Sudan in 1985, more than 3,000 people out of a population of 80,000 died of this preventable condition during a 6  month period (Toole et al., 1989). In well-​vaccinated populations, such as Bosnian and Kosovar refugees in the Balkans, Kurds in northern Iraq (1991), and Rwandans in Tanzania and eastern Zaire (1994), measles was a less prominent public health problem. Nevertheless, measles remains a significant problem in populations that cannot be reached for immunization because of armed conflict, or, in the case of Somalia, because child immunization has been banned by the radical Jihadist group Al Shabaab. There have been major outbreaks of measles in Somalia with thousands of cases in 2014 and 2016, continuing into 2017 (WHO, 2017a). Prior to Syria’s civil war, some 99% of children were vaccinated against measles. Of the 1.8 million Syrian children born since the conflict, over 50% are

Health consequences of displacement

unvaccinated against measles. Measles has swept through Syria, including Aleppo and the northern regions, with over 7,000 confirmed cases between 2015 and 2016 and also cases in refugee camps in Jordan and Lebanon. Large outbreaks of measles have also occurred in war-​torn South Sudan and Yemen (UNICEF, 2017). In South Sudan, by the end of 2016, a total of 2,294 suspected measles cases including at least 28 deaths had been reported countrywide (Relief Web, 2015). 4.2.3.2 Diarrhoea Unlike measles, which can be easily prevented by a vaccine, diarrhoeal diseases remain one of the top three causes of mortality among refugees in low-​ and middle-​income countries. In Somalia (1979–​81), Ethiopia (1982), Sudan (1985), Malawi (1988), northern Iraq (1991), and Goma (1994), diarrhoeal diseases were responsible for between 25% and 85% of all mortality (Toole and Malkki, 1992). Although diarrhoeal disease is most often a condition of young children, cholera and dysentery, the major epidemic forms of diarrhoea, affect people of all ages. Of all disease conditions, diarrhoea is the most closely linked to poor sanitation, inadequate water quantity, contaminated water, and poor hygiene. Cholera epidemics have frequently occurred in refugee and displaced populations. Although deaths due to non-​cholera watery diarrhoea have been far more numerous, cholera, in addition to being able to cause death rapidly from dehydration, incites fear and even panic in many populations. Its ability to affect other relief activities, and to divert health personnel and supplies from other activities, may even contribute to higher death tolls due to other diseases. Outbreaks of cholera have occurred in all parts of the world; large outbreaks were recorded among refugees in India (1971), Thailand (1979), Sudan (1985), Somalia (1985), Ethiopia (1984), Malawi (1988–​91), northern Iraq (1991), Goma (1994), and Rwanda (1996). In the twenty-​first century there have been some outbreaks of cholera in conflict-​affected populations and in countries hosting large numbers of refugees, including Tanzania, Ethiopia, and Iraq in 2015 and South Sudan, Somalia, and Yemen in 2016. For example, in Yemen, the World Health Organization (WHO) reported that as of 13 December 2016, there had been a cumulative total of 10,148 cases of cholera including 92 associated deaths (WHO EMRO, 2017a). In the first 3 months of 2017, WHO reported a cumulative number of 17,211 cases and 388 deaths from cholera in Somalia with a CFR of 2.25% (WHO EMRO, 2017b). Cholera is widespread in South Sudan. As of May 2017, cumulatively, 7,735 cholera cases including 246 deaths (CFR 3.23%) have been reported in South Sudan involving 19

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counties in 11 states since the initial case was reported on 18 June 2016 (WHO, 2017b). 4.2.3.3 Malaria Out of a total of about 11 million refugees protected and assisted by UNHCR globally in 2011, 7 million (67.5%) lived in areas in which malaria is either present throughout the year or occurs seasonally (Williams et al., 2013). By 2017, this proportion had probably decreased because of the high number of refugees from non-​endemic areas, such as Syria. In endemic areas, including South East Asia, the Indian subcontinent, and most of sub-​Saharan Africa, malaria is consistently among the leading causes of morbidity and mortality. It was the leading cause of mortality among Cambodian refugees in Thailand in 1978, Ethiopian refugees in Sudan in the mid-​1980s, and Mozambican refugees in Malawi in the 1980s. It has been well established that populations that are displaced to areas where malaria is more highly endemic than their place of origin have higher incidence rates and higher mortality. Following the collapse of health services and mass population displacement during and following the conflict in East Timor, the incidence of malaria increased significantly. In October 1999, approximately 30% of all morbidity was attributed to malaria compared with 10% the previous year (WHO, 1999). Anderson et al. (2011) studied refugee sites in Burundi, Chad, Cameroon, Ethiopia, Kenya, Sudan, Tanzania, Thailand, and Uganda, describing trends in malaria incidence and mortality. An average of 1.18 million refugees resided in 60 refugee sites with at least 50 cases of malaria per 1000 refugees during the study period (2008–​9). The highest incidence of malaria was in refugee sites in Tanzania, where the annual incidence of malaria was 399 confirmed cases per 1,000 refugees and 728 confirmed cases per 1,000 refugee children younger than 5 years. Annual malaria mortality rates were highest in sites in Sudan (0.9 deaths per 1,000 refugees), Uganda, and Tanzania (0.7 deaths per 1,000 refugees each). Malaria was the cause of 16% of deaths in refugee children younger than 5 years of age across all study sites. Major risk factors for malaria in refugee situations include the lack of adequate housing, poor siting of camps (especially when they are placed in marshy areas), overcrowding, proximity to livestock (which may be the primary targets of mosquito vectors), and a general lack of competently trained health personnel. Although it has not been documented systematically in emergencies, the association of malaria with low birth weight (especially in the offspring of first and second pregnancies) and with iron-​deficiency anaemia may cause increases in incidence and CFR from a variety of causes, especially in children.

Health consequences of displacement

4.2.3.4  Other communicable diseases 4.2.3.4.1 Meningitis Although not a consistent problem in refugee camps, the threat of Group A  meningococcal meningitis is a formidable one. Overcrowding, especially during the drier seasons of the year, can be an important risk factor for this disease, which is transmitted via the respiratory route. Large outbreaks have occurred among refugees in Thailand (1980), Sudan (1989), Ethiopia (1993), Guinea (1993), and Goma (1994). In early 2005, an outbreak of the emerging W135 strain of meningococcus led to the vaccination of more than 150,000 Sudanese refugees in Chad (Médecins sans Frontières, 2005). Outbreaks of meningitis tend to be protracted, lasting 1–​2 months. Unless they are detected and controlled at an early stage, they can be directly responsible for high mortality; in addition, they can be resource-​intensive and detract attention from other high-​priority health programmes. In December 2010, a new cheap and effective meningococcal A conjugate vaccine was introduced, first in Burkina Faso and selected regions of Mali and Niger, with a total of 20 million persons vaccinated followed by another 35 million persons immunized across Mali, Niger, Cameroun, Chad, and Nigeria. All 26 countries in the African meningitis belt had introduced this vaccine by 2016. High coverage of the target age group of 1–​29 years is expected to eliminate meningococcal A epidemics from this region of Africa. 4.2.3.4.2  Hepatitis E There is a high incidence of hepatitis E in Central Asia, India, China, and Nepal. It has become more common in South East Asia (e.g. Myanmar), Mexico, and East Africa. There have been numerous outbreaks in refugee camps in East Africa since 1986. A rapid diagnostic test is now available for both recent and past infection by the virus. If an epidemic of hepatitis affecting adults occurs in a low or middle-​income country, it is probably due to hepatitis E infection. Like meningitis, outbreaks of hepatitis E have not been frequent occurrences in refugee camps but have had major consequences when they occurred, especially among women. An enteric-​transmitted disease, usually linked to contaminated drinking-​water, hepatitis E is associated with a particularly high CFR in pregnant women. Clinical attack rates appear to be higher in adults, with children relatively spared. Large outbreaks have occurred in Somalia (1985), Ethiopia (1989), and among Somali refugees in Liboi Camp, Kenya (1991). In the latter outbreak, the overall case fatality rate was 3.7%, but among pregnant women it was 14% (Mast et al., 1994). In 2004, a severe epidemic occurred among IDPs in Darfur, Sudan, and refugees from Darfur in Chad (Guthmann et al., 2006). In Darfur, there were 2,431

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cases and 41 deaths and in Chad 1,442 cases and 46 deaths. The CFR among pregnant women was 8.2%. The investigation was aided by the use of the newly licensed rapid diagnostic test. From 1 September 2016 until 13 January 2017, a total of 693 cases including 11 deaths of acute jaundice syndrome, diagnosed as hepatitis E, were reported in south-​east Chad (WHO, 2017c). Soon after, in April 2017, an outbreak was reported among IDPs in Niger (WHO, 2017d). As of 3 May 2017, a total of 282 suspected cases including 27 deaths had been reported. All reported deaths except for one were among pregnant women (CFR 9.6%). These two outbreaks pose a threat to the entire Lake Chad basin, which hosts hundreds of thousands of refugees and IDPs in response to violence by the extremist Boko Haram group. 4.2.3.4.3 Tuberculosis Tuberculosis (TB) is one of the most important communicable diseases to control in the post-​emergency phase. Its re-​emergence as a public health problem in many parts of the world is characterized by its close association with immune deficiency disorders, especially HIV infection, and with the identification of multiple drug-​resistant strains. TB can be quite common in some post-​emergency situations. It is highly prevalent during the emergency as well, but because of the difficulties in developing programmes to control its transmission, to diagnose and to reliably treat for adequate periods, other more acute conditions are appropriately accorded priority. Before the large movements of refugees in the Middle East, more than 85% of refugees originated from, and remained within, countries with high burdens of TB (Connolly et al., 2007). Particularly high burdens of disease affect refugees from, and IDPs within, Nigeria, Pakistan, DRC, Ethiopia, Myanmar, Tanzania, Mozambique, Kenya, Uganda, Afghanistan, and South Sudan. In populations displaced by conflict in the Middle East, TB has been a lesser problem. For example, TB screening of 69,000 Syrian refugees in Jordan from January to June 2014 found only 3 smear-​positive cases and a total of 33 culture-​ confirmed cases. Of those screened 45% were children, and children under 15  years of age had significantly lower disease prevalence than the general screened population (Cookson et al., 2015). 4.2.3.4.4 Poliomyelitis The world is very close to eradicating polio. In 2016, just 37 cases were reported in three countries—​Afghanistan, Nigeria, and Pakistan—​all in conflict-​affected areas. When armed conflicts lead to a cessation of vaccination activities, it does not take long until population immunity to the poliovirus declines to dangerous levels. This was demonstrated in 2013 when the first polio case since 2007 was

Health consequences of displacement

reported in Somalia after several years when Al Shabaab militants forbade child vaccination in the zones that they controlled. As a result, 194 cases of polio were reported in Somalia, as well as cases in neighbouring Ethiopia and Kenya. In Syria, polio vaccination coverage declined from 83–​99% pre-​conflict to 52–​68% in 2014. After eradication in 1999, polio re-​emerged in Syria in October 2013 with 35 confirmed cases in 2013 and one case in 2014 (WHO EMRO, 2014). Two cases have been reported in Syrian refugees in Iraq. Mass vaccination campaigns in Syria, Iraq, Jordan, Turkey, and Lebanon brought the outbreak to an end. 4.2.3.4.5  Sexually transmitted infections HIV and other sexually transmitted infections (STIs) are major problems among persons displaced from areas where there is a high prevalence of these conditions. Factors that increase the vulnerability to HIV infection among conflict-​affected populations include a breakdown in social structure, sexual violence against women, and a lack of health infrastructure and education. However, in many cases, refugees have improved access to health care and little contact with host communities outside camps. Some studies have found that conflict constrains the spread of HIV because of reduced mobility and travel to high-​prevalence urban areas, citing low HIV prevalence in rural areas of Angola and Sierra Leone during civil wars (Spiegel, 2004). The most important influence on the HIV prevalence in conflict-​affected and displaced populations is the HIV prevalence prior to the conflict or prior to displacement. During the initial emergency phase, efforts to control HIV should focus on blood safety, universal precautions in clinical settings, the provision of condoms, and the dissemination of relevant information on prevention. As soon as possible, a treatment programme using antiretroviral drugs should be established. Other communicable diseases that have occurred in emergency or post-​ emergency settings have had a relatively minor impact in the individual setting in which they occur. However, they command an important allocation of resources and may be important contributors to morbidity and mortality. Yellow fever, typhoid fever, relapsing fever, Japanese B encephalitis, dengue haemorrhagic fever, typhus, and leptospirosis are all real threats. Cutaneous leishmaniasis outbreaks have occurred not only in Syria since the conflict began but also in Turkey, Jordan, and Lebanon (Ozara et al., 2016). Nevertheless, morbidity and mortality has been shown time and again to be due to the same conditions that are responsible for the bulk of the disease burden in low-​income countries in non-​emergency settings.

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4.2.4 Injuries Injuries are widespread in all populations and are responsible for significant mortality, morbidity, and disability. Conflicts typically lead to substantial morbidity and mortality among civilians, caused by a wide range of weapons. As noted earlier in section 4.2.1, civilian death rates have been very high in some conflicts. Estimates in 2016 suggested that 470,000 direct or indirect deaths had occurred due to the Syrian conflict, which began in 2011, and 11.5% of the population had been killed or injured, with 1.9 million people wounded (SCPR, 2016). Around 10% of deaths occurred among IDPs. The CMR in Syria increased from 4.4 per 1,000 in 2010 to 10.9 per 1,000 in 2014, accounting directly and indirectly for the death of about 1.4% of the total population (SCPR, 2016). Injuries, aside from those that are directly conflict-​related, are typically neglected in preference for an emphasis on communicable diseases. This is unfortunate given the widespread occurrence of intentional (homicide, war, suicide) and unintentional (falls, traffic injuries, drowning, poisoning) injuries in many populations affected by conflict. In situations where injuries are shown to be major causes of morbidity and mortality, they should be addressed as vigorously as communicable diseases and malnutrition. In the late twentieth century, much attention focused on landmine injuries, an area in which notable international successes have been achieved. Evidence of the harmful effects of antipersonnel landmines and their concentration in the world’s poorest countries such as Angola, Ethiopia, Cambodia, and Afghanistan, resulted in the Ottawa process which led in 1997 to a ban on the production and distribution of antipersonnel mines. Despite this ban, landmines continue to be used in some civil conflicts, such as in Syria.

4.2.5 Non-​communicable diseases Other than malnutrition, NCDs had not been the focus of much attention in conflict-​affected and refugee populations until the conflicts in Iraq and Syria in the early twenty-​first century. A systematic review in 2014 found that, overall, the prevalence of NCDs was high among urban refugees in the Middle East, ranging from 9% to 50%, compared to the prevalence among urban refugees in Asia and Africa, where the prevalence was between 1% and 30% (Amara and Aljunid, 2014). Before the conflict, 77% of deaths in Syria were due to NCDs. The prevalence of diabetes in Syria was 8.9% (adults aged 20–​79) prior to the conflict, comparable to New Zealand, and the prevalence of hypertension was 28% (Amara and Aljunid, 2014). More than half of the public hospitals in Syria are either only partially functional or completely out of service, thus constraining the treatment of NCDs. Moreover, local production of medicines has

Health consequences of displacement

declined by 70%, associated with an increasing cost of NCD medicines. During screening before resettlement in a third country, the prevalence of hypertension among Iraqi refugees was 33%.

4.2.6 Women’s  health Over the past two decades, increasing attention has been given to sexual and reproductive health in humanitarian crises. While there is no doubt that the provision of food, water, sanitation, and shelter is the highest priority during a humanitarian emergency, steps should be taken early to ensure that other critical health needs of women, men, and adolescents are met as quickly as possible. Women are a particularly vulnerable subset of the population because the gender-​based discrimination that is all too common in stable societies is frequently exacerbated in times of societal stress and meagre resources. The Guttmacher Institute reviewed maternal deaths that occurred in 2008–​ 10 in 25 refugee camps in 10 countries (Hynes et al., 2012). Reports were available on 108 deaths, including 68 in Kenya. In every country but Bangladesh, maternal mortality ratios were lower among refugees than among the host population. The proportion of women who had had four or more antenatal care visits was lower among refugee women who had died (33%) than among the general refugee population (79%). Seventy-​eight per cent of the maternal deaths followed delivery or abortion, and 56% of those deaths occurred within 24 hours. Delays in seeking and receiving care were more prevalent than delays in reaching care. In Kenya, delays in seeking or accepting care and provider failure to recognize the severity of the woman’s condition were the most common avoidable contributing factors. Refugees and IDPs are highly vulnerable to sexual violence during conflict and subsequent displacement. The findings of a systematic review in 2014 suggest that approximately one in five refugee or displaced women in complex humanitarian settings had experienced sexual violence (Vu et al., 2014). The effects of gender-​based violence (GBV) in conflict and post-​conflict areas are numerous and severe. STI are a lasting consequence of GBV and are a major health concern for women in conflict areas. Physical harms such as injury to reproductive organs, traumatic fistulas, and infertility often accompany brutal or repeated rapes. Attempts at abortion following an unwanted pregnancy from rape may also have severe medical complications. The widespread sexual violence associated with armed conflict in eastern DRC has led it to be named the ‘rape capital of the world’. A 2014 survey conducted in North Kivu Province showed that 22% of women were victims of sexual violence within the conflict (European Parliament, 2014). In addition,

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50% of women had experienced sexual violence in a domestic context, evidence of the spread of what some call a ‘rape epidemic’. Uncontrolled violence and its aftermath are characterized by some specific features that impact negatively on reproductive health. These include the breakdown of family networks and the consequent loss of protection and safety, as well as channels of information to adolescents and women of reproductive age. Loss of revenue within the family can result in a restricted ability to make appropriate reproductive health choices and may predispose women and adolescents to risk through, for example, engagement in commercial sex work. Increased sole responsibility, as manifested by an increase in the proportion of female-​headed households, also changes the way women spend their time and money as they seek increased security and well-​being for their families. Finally, as with all members of the affected population, women tend to pay more attention to securing health services for life-​saving interventions than for non-​ emergency reproductive health services. A minimum initial package of essential reproductive health services, described later in this chapter, has been developed and is recommended by the major relevant international agencies. Interventions beyond this essential package require major investments of time and personnel that should not be diverted from the principal task of reducing excessive preventable mortality as rapidly as possible. In all cases, special care must be taken to ensure that female heads of household are given equitable quantities of food and non-​food commodities for themselves and their families.

4.2.7 Mental  health War and political violence have direct and indirect mental health consequences for victims, relatives, neighbours, and communities. Anxiety, uncertainty, and fear about the future, and about whether family members and homesteads remain alive and intact, are a substantial cause of distress for affected individuals and communities. Among those who are forced to flee either as refugees or as IDPs, the lack of knowledge about relatives and property left behind cause stress and distress. Despite ongoing challenges of maintaining lives and livelihoods, life as a refugee, especially in a camp situation, may be monotonous and conducive to stress, anxiety, and depression. In emergencies, not everyone has or develops significant psychological problems. Many people show resilience; that is, the ability to cope relatively well in situations of adversity. There are numerous interacting social, psychological, and biological factors that influence whether people develop psychological problems or exhibit resilience in the face of adversity.

Public health priorities

Depending on the emergency context, particular groups of people are at increased risk of experiencing social and/​or psychological problems. Although many key forms of support should be available to the emergency-​affected population in general, good programming specifically includes the provision of relevant supports to the people at greatest risk, who need to be identified for each specific crisis. All subgroups of a population can potentially be at risk, depending on the nature of the crisis. The following are groups of people who frequently have been shown to be at increased risk of various problems in diverse emergencies (IASC, 2007): ◆ Women (e.g. pregnant women, mothers, single mothers, widows and, in some cultures, unmarried adult women and teenage girls) ◆ Men (e.g. ex-​combatants, idle men who have lost the means to take care of their families, young men at risk of detention, abduction or being targets of violence) ◆ Children (from newborn infants to young people 18 years of age), such as separated or unaccompanied children (including orphans), children recruited or used by armed forces or groups, trafficked children, children in conflict with the law, children engaged in dangerous labour, children who live or work on the streets and undernourished and/​or under-​stimulated children ◆ Elderly people (especially when they have lost family members who were caregivers) ◆ People who have been exposed to extremely stressful events/​trauma (e.g. people who have lost close family members or their entire livelihoods, rape and torture survivors, witnesses of atrocities, etc.) ◆ People in the community with pre-​existing, severe physical, neurological or mental disabilities or disorders ◆ People in institutions (orphans, elderly people, people with neurological/​ mental disabilities or disorders) ◆ People experiencing severe social stigma (e.g. ‘untouchables’, commercial sex workers, people with severe mental disorders, survivors of sexual violence).

4.3 Public health priorities 4.3.1 Primary prevention Primary prevention is the basic strategy of public health. The provision of adequate food, shelter, potable water, sanitation, and immunization has proved

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problematic in low-​income countries disrupted by war or overwhelmed by the influx of large numbers of refugees. Moreover, the flood of Syrian refugees into urban areas of neighbouring countries has resulted in a strain on local infrastructure and social services. Primary prevention in such circumstances, therefore, means stopping the violence that is the cause of refugee flows. More effective diplomatic and political mechanisms need to be developed that might resolve conflicts early in their evolution prior to the stage when health services collapse, populations migrate, food shortages occur, and significant adverse public health outcomes emerge. Although these initiatives are beyond the direct control of health practitioners, every opportunity should be taken to advocate for political solutions to the problems that are the root cause of population migration and humanitarian crises.

4.3.2 Secondary prevention Secondary prevention is the domain of relief workers and agencies. It involves prevention of excess indirect mortality and morbidity once a population migration has taken place. Upon arrival at their destination, refugees—​most of whom tend to be women and children—​may suffer severe anxiety or depression, compounded by the loss of dignity associated with complete dependence on the generosity of others for their survival. If refugee camps are located near borders or close to areas of continuing armed conflict, the desire for security is an overriding concern. Therefore, the first priority of any relief operation is to ensure adequate protection, and camps should be placed sufficiently distant from borders to reassure refugees that they are safe. To diminish the sense of helplessness and dependency, refugees should be given an active role in the planning and implementation of relief programmes. Nevertheless, giving total control of the distribution of relief items to so-​called refugee ‘leaders’ may be dangerous. For example, leaders of the former Hutu-​ controlled Rwandan government took control of the distribution system in Zairian refugee camps in July 1994, resulting in relief supplies being diverted to young male members of the former Rwandan Army. In 2015, over 60% of the world’s refugees and 80% of IDPs lived in urban environments. As noted earlier, the majority of Syrian refugees in Turkey and Jordan live outside camps, and there are no camps for the million or so Syrians in Lebanon. Humanitarian agencies are having to adapt their tactics rapidly to identify refugee communities in urban areas and work with them. Previous ‘supply-​based’ systems of providing food, water, and shelter do not work in cities that are characterized by dense populations, complex economies, and reliance on networked infrastructure for basic services.

Public health priorities

4.3.2.1  Basic needs In the absence of conflict resolution, those communities that are solely dependent on external aid for their survival must be provided with the basic minimum resources necessary to maintain health and well-​being. The provision of adequate food, clean water, shelter, sanitation, and warmth will prevent the most severe public health consequences of complex emergencies. Public health priorities include a rapid needs assessment, the establishment of a health information system, measles vaccination, the control of diarrhoeal and other communicable diseases, maternal and child health services, and nutritional rehabilitation. Critical to the success of the response is coordination of the many agencies involved in the relief effort. Since 1998, the expected outcomes of humanitarian relief programmes have been standardized globally as a result of the Sphere Project. The Sphere handbook, The Humanitarian Charter and Minimum Standards in Disaster Response, is now in its third edition (Sphere Project, 2011) and a fourth edition will be published in late 2018. 4.3.2.2  Information for action The purposes of early rapid assessments are multiple. They can provide important information regarding the evolution of the refugee emergency, identify groups and areas at greatest risk, evaluate the existing local response capacity, determine the magnitude of external resources required, and indicate which health programmes will be required in the short and medium term (Depoortere and Brown, 2006). After the response to an initial rapid assessment has been instituted, the development and implementation of ongoing health information systems immediately becomes a high-​priority activity. 4.3.2.3  Food and nutrition In general, the goal of a refugee feeding programme is to provide adequate quantities of nutrients through the general household distribution of food rations. General food rations should contain at least 2,100 kilocalories of energy per person per day as well as the other essential nutrients (WHO, 2000). Rations should take into consideration the demographic composition of the population, the climate, the specific needs of vulnerable groups, and access by the population to alternative sources of food and income. These rations should be provided to households, and the equity of distribution needs to be carefully monitored. Experience has shown that women are fairer than men in distributing each food item in the correct quantity. Given that more than 60% of refugees live in urban areas, UNHCR and other implementing agencies have had to adapt their practices to ensure food and

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nutrition security. Food assistance remains one of the main food security tools for urban displaced populations. Where markets are well established, it is particularly important to choose the most appropriate form of food assistance (cash or vouchers). Coupons and e-​vouchers may require more from implementing agencies. Vouchers must be printed; traders identified, contracted, and managed; price collusion controlled; quality monitored; and invoices provided for goods purchased. Given the additional workload, choosing vouchers over cash needs to be justified. Longer-​term interventions, implemented in close collaboration with livelihood programmes to promote refugee self-​reliance, are another dimension of a food security response in urban areas. Further, because urban-​based refugees coexist with host populations, food security interventions must consider the needs of both groups. Wherever possible, the needs of refugees in urban settings should be met by integrating them into national food security programmes, and early collaboration with the government, the municipalities, relevant UN agencies, partners, and donors is crucial. 4.3.2.4  Management of malnutrition There may be population subgroups who either are already acutely malnourished or at high risk of becoming malnourished. These groups may require targeted feeding, or what is termed ‘selective feeding’, including food supplements for vulnerable groups and therapeutic feeding for the severely malnourished. The approach to supplementary and therapeutic feeding has changed dramatically since the first edition of this book. Following a number of randomized controlled trials that provided the evidence base, supplementary and therapeutic food is now given to malnourished children in the form of ready-​to-​use therapeutic foods (RUTF). These soft foods are a homogenous mix of lipid-​rich foods, enhanced with micronutrients, with a nutritional profile similar to the WHO-​recommended therapeutic milk formula used for in-​patient therapeutic feeding programmes (UNICEF, 2013). Typical primary ingredients for RUTF include peanuts, oil, sugar, milk powder, and vitamin and mineral supplements. The development of RUTFs has enabled community-​based nutrition rehabilitation. The only indications for in-​patient therapeutic feeding are severe anorexia and medical complications, such as hypothermia, hypoglycemia, dehydration, and sepsis (WHO, 2013).

4.4 Health services In camp settings, health services should be organized to ensure that the major causes of morbidity and mortality are addressed through fixed facilities and outreach programmes. An essential drug list and standardized treatment

Health services

protocols are necessary elements of a curative programme. Camp medical services need to ensure that women and children have preferential access and specific programmes need to provide an integrated package of growth monitoring, immunization, antenatal and postnatal care, the treatment of common ailments, and health promotion. The health system should follow the principles of primary health care. For example, refugee community health workers (CHWs) are likely to understand the cultural, behavioural, and environmental influences on health status; contribute to a growing potential for self-​care within the community; share the health service provision workload; build capacity and skills which will potentially be available after repatriation; and enhance the dignity of both the community and the health-​care providers themselves. CHWs who are relatively unskilled and trained within the community may be the mainstay of service provision. However, it is important to recognize that the presence of trained health workers within the affected community, whether they are traditional birth attendants, nurses, doctors, or others, represents an extremely valuable resource whose role should be facilitated in whatever services are developed with expatriate agency support. Given that more than 50% of refugees live in urban settings, the camp structure of health services is not appropriate. UNHCR’s aim in urban settings is for refugees to access quality health services at a level similar to that of nationals (UNHCR, 2011). UNHCR’s major role in urban settings is to advocate for and facilitate quality health services to be available to and accessed by refugees. UNHCR may directly or via a partner agency support government services in areas where large numbers of refugees live with staff, infrastructure, drugs, and supplies. Assistance may be selective, in which case vulnerable and target groups may have their services paid for or are assisted with cash or improved livelihoods. Different financing mechanisms have been used including cash assistance (which may be delivered via automated teller machines, vouchers, or mobile phone transfers), government or not-​for-​profit insurance schemes, or other innovative financing schemes that may be available to nationals. Given its scale, the influx of Syrian refugees into Jordan, Lebanon, and Turkey has presented an immense burden to their national health systems. For the refugees, out-​of-​pocket expenses have been a common problem and a reason for not accessing health services. A survey in Jordan in 2014 found that among 1043 families who sought care or treatment for a sick adult household member, 35% reported paying for a consultation, regardless of whether or not they paid for medications (Doocy et al., 2016). A total of 819 families reported receiving medications, of which 473 (58%) reported paying for the medications, regardless of whether or not they paid for a consultation. The 2015 UNHCR Health

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Access Survey found that 86.6% of households that needed care within the month preceding the survey sought care and that, despite subsidies, the cost was the primary barrier to receiving needed services which were reported by 36% of non-​care-​seekers. The situation in Lebanon is even more challenging for Syrian refugees because the health system is dominated by the private sector and very few generic medications are available, making the cost of treatment high. Those refugees registered with UNHCR and between the ages of 5 and 60 years can get access to health care in the centres managed by NGOs for a fee of approximately US$ 2–​3 per consultation (Blanchet et al., 2016). Individuals also have to pay for X-​rays and other diagnostic tests that are required for referral to hospital for further treatment, or for medicines, where these are needed. Primary health-​care services for urban refugees, especially Syrians and Iraqis, need to integrate the prevention and management of NCDs.

4.4.1 Communicable disease control Concern for the potential impact of communicable diseases has dominated the public health response in many refugee settings and has frequently been warranted. Although many of the technical interventions and public health programmes used in emergencies draw heavily from their counterparts in stable settings, a few important differences should be considered. Most important among them include addressing the needs of the local, non-​displaced, population; maintaining respect for national health policies when dealing with refugees; and promoting substantial community involvement as early as is feasible. Because of the devastating impact of measles in many refugee emergencies, it has become almost universally accepted that mass measles vaccination, regardless of vaccination history or place of provenance, should be instituted as early during an emergency as possible. Leading reference publications accord measles immunization the highest priority of all interventions and recommend that it be undertaken immediately after an initial rapid assessment regardless of the circumstances (CDCP, 1992; Médecins sans Frontières, 1997; Sphere Project, 2011). As soon as it is feasible, the other vaccines in the national routine immunization schedule should be given to all children under 5 years and, in the case of a meningococcal vaccine, up to the age of 29 years. All health personnel should be sensitized to the potential impact of diarrhoea and should be skilled in most aspects of prevention and of treatment. The key to prevention lies in providing adequate sanitation facilities, and at least the minimum recommended quantity of water of acceptable quality (Sphere Project, 2011). The mainstay of diarrhoea case management is oral rehydration therapy.

Health services

Rehydration facilities should be available in all health facilities, including health posts and outreach sites within the community. A key component of the programme is preparedness planning for the control of cholera and dysentery outbreaks. In malaria-​endemic areas, malaria prevention and case management is an urgent priority. Insecticide-​impregnated nets should be distributed to all households, with the priority being children under 5 years of age and pregnant women. Resources for case management should be procured as soon as possible, including rapid diagnostic tests and artemisinin combination therapy. Given the high prevalence of HIV infection in many countries with large refugee populations, early attention should be given to HIV prevention (see section 4.4.3). Diagnosis and treatment programmes for TB should be established as soon as the major causes of mortality have been addressed. There needs to be a dedicated TB coordinator and a guaranteed pipeline of drugs for what is a 6 month course of treatment.

4.4.2 Women and children’s health Health services oriented to the specific needs of children and women are essential in reducing morbidity and mortality within a population to a minimum level. Women’s and children’s health (WCH) care should begin within the community, at the household level, and not depend entirely on established health facilities. For children, routine growth monitoring is an essential function of WCH services. A WCH programme will also ensure that all children are vaccinated on schedule and are receiving regular supplements of vitamin A. Curative care, when required, can be offered at the household by trained CHWs or the child can be referred to health facilities. All women should be vaccinated with tetanus toxoid to prevent neonatal tetanus in their newborn. Antenatal services need to be established, and iron and folic acid should be distributed (and their ingestion monitored, if possible) to all pregnant women. Malaria chemoprophylaxis, if appropriate, should also be undertaken. In the postnatal period, counselling services should be offered to address a variety of issues, from family planning to childcare, especially about breastfeeding.

4.4.3 Reproductive health care Reproductive health care is among the crucial elements that give refugees the basic human welfare and dignity that is their right (UNHCR/​WHO/​UNFPA, 1999). The response to reproductive health problems during emergencies

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consists of a constellation of assessment, services, and regular monitoring that addresses the implementation of the following programmes: ◆ a minimum initial service package (MISP) ◆ safe motherhood ◆ prevention and treatment of sexual violence and GBV ◆ prevention and care for STIs, including HIV and AIDS ◆ family planning ◆ prevention of female genital mutilation ◆ reproductive health needs of adolescents. The components of MISP have been defined as follows: 1. Forced migration is frequently accompanied by sexual violence. To prevent unwanted pregnancies resulting from rape, emergency postcoital contraception supplies should be available to women who request them. 2. Universal precautions to prevent the transmission of HIV must be respected from the very outset of an emergency. Although chaotic conditions are frequently prevalent and although health services are implemented under very stressful conditions, the threat of HIV infection can and must be minimized. 3. To prevent unwanted pregnancies and to minimize the transmission of STIs, including AIDS, an adequate supply of condoms should be available on request to all members of the target population. 4. In a population of 2,500 with a crude birth rate of about 3%, there will be 5–​8 births per month. To deal with these deliveries, simple supplies must be made available. Simple delivery kits and midwife kits are both readily available from UNICEF and other suppliers of health supplies. 5. The last element of the MISP is planning for the provision of comprehensive reproductive health services as rapidly as is feasible. To do this, reproductive health indicators should be included in health information systems to allow for the collection of baseline data on maternal, infant, and child mortality, the prevalence of STIs, and population contraceptive prevalence rates.

4.4.4 Mental  health Armed conflicts and natural disasters cause significant psychological and social suffering to affected populations. The psychological and social impacts of emergencies may be acute in the short term, but they can also undermine the long-​term mental health and psychosocial well-​being of the affected population. These impacts may threaten peace, human rights, and development. One of the priorities in emergencies is thus to protect and improve people’s mental

Conclusions

health and psychosocial well-​being. Achieving this priority requires coordinated action among all government and non-​governmental humanitarian actors. To plan an appropriate emergency response, it is important to know the nature of local resources, whether they are helpful or harmful, and the extent to which affected people can access them. Indeed, some local practices—​ ranging from particular traditional cultural practices to care in many existing custodial institutions—​may be harmful and may violate human rights principles. The evidence base for effective and feasible mental health interventions in humanitarian crisis settings has expanded significantly over the past two decades. This has resulted in the development of comprehensive inter-​agency guidelines on mental and psychosocial health in emergencies (IASC, 2007). The guidelines propose a pyramid of interventions with four levels: 1. Basic services and security. The well-​being of all people should be protected through the (re)establishment of security, adequate governance, and services that address basic physical needs (food, shelter, water, basic health care, control of communicable diseases). 2. Community and family support. This second layer represents the emergency response for a smaller number of people who can maintain their mental health and psychosocial well-​being if they receive help in accessing key community and family supports. 3. Focused, non-​specialized supports. This third layer represents the supports necessary for the still smaller number of people who additionally require more focused individual, family, or group interventions by trained and supervised workers (but who may not have had years of training in specialized care). 4. Specialized services. The top layer of the pyramid represents the additional support required for the small percentage of the population whose suffering, despite the supports already mentioned, is intolerable and who may have significant difficulties in basic daily functioning. This assistance should include psychological or psychiatric supports for people with severe mental disorders whenever their needs exceed the capacities of existing primary/​ general health services.

4.5 Conclusions The scale of global humanitarian needs has greatly increased since the first edition of this book. The number of refugees, asylum seekers, and IDPs worldwide has more than doubled. While the major causes of morbidity and mortality

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among those populations in low-​income countries remain communicable diseases and malnutrition, the massive exodus of refugees from middle-​income countries like Syria and Iraq has led to a greater emphasis on NCDs. More than half the world’s refugees now reside outside camps in urban areas, necessitating adaptations of traditional camp-​based relief services. Significant progress has been made during the past two decades towards the provision of effective, focused, needs-​based humanitarian assistance to conflict-​affected populations. Greater emphasis is now placed on the impact, including health outcomes, of international aid. The quantity of aid delivered is no longer considered a valid indicator of effectiveness; its relevance, quality, coverage, and equitable distribution are now accepted as more pertinent. There have been some significant technical achievements; for example, community-​ based nutritional rehabilitation with RUTF. New, evidence-​based guidelines on reproductive health and mental health have provided more tools to humanitarian workers. Many NGOs are engaged in providing humanitarian assistance to refugees and displaced persons; they include national Red Cross and Red Crescent societies, international secular and religious agencies, and local churches and community-​based organizations in the affected country. The level of technical skills, experience, management, and logistics capacity of NGOs varies enormously. To promote coordination and best practice among NGOs, some initiatives have been taken. These include the Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Response and the Sphere Project’s handbook. As public health in refugee settings has developed as a specialized technical field, some relief agencies, especially NGOs, have developed technical manuals, field guidelines, and targeted training courses. Nevertheless, these initiatives will not be effective unless the international community adopts a more consistent approach to the early prevention and mitigation of conflict-​related emergencies. The failure of the international community to stop the vicious conflict in Syria is a sobering reminder.

References Amara, A. H. and Aljunid, S. M. (2014). Non-​communicable diseases among urban refugees and asylum-​seekers in developing countries: a neglected health care need. Global Health, 10, 24. Anderson, J., Doocy, S., Haskew, C., et al. (2011). The burden of malaria in post-​emergency refugee sites: a retrospective study. Confl Health, 5, 17. Blanchet, K., Fouad, F. M., and Pherali, T. (2016). Syrian refugees in Lebanon: the search for universal health coverage. Conflict and Health, 10, 12.

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disease expression, and new serologic assays. In K. Nishioka, H. Suzuki, S. Mishiro, and T. Oda (eds.), Viral Hepatitis and Liver Disease, pp. 375–​378. Tokyo: Springer. Médecins sans Frontières. (1997). Refugee Health: An Approach to Emergency Situations. London: Macmillan. Medécins sans Frontières. (2005). Meningitis outbreak in eastern Chad among refugees from Darfur. Medécins sans Frontières, 28 January. http://​www.doctorswithoutborders. org/​news-​stories/​press-​release/​meningitis-​outbreak-​eastern-​chad-​among-​refugees-​ darfur (accessed 10 May 2017). Ozara, R., Leblebicioglu, H., Sunbul, M., et al. (2016). The Syrian conflict and infectious diseases. Expert Rev Anti Infect Ther, 14(6), 547–​555. PHR/​SAMS (2016). Madaya: portrait of a Syrian town under siege. Physicians for Human Rights and Syrian American Medical Society, July 2016. http://​ physiciansforhumanrights.org/​library/​reports/​madaya-​portrait-​of-​a-​syrian-​town-​ under-​siege.html (accessed 9 May 2017). Relief Web (2017). Sudan/​South Sudan: Measles Outbreak—​Mar 2015. http://​reliefweb.int/​ disaster/​ep-​2015-​000038-​sdn (accessed 10 May 2017). Roberts, L., Lafta, R., Garfield, R., et al. (2004). Mortality before and after the 2003 invasion of Iraq: cluster sample survey. Lancet, 364, 1857–​64. SCPR. (2016). Forced Dispersion: A Demographic Report on Human Status in Syria. Syrian Center for Policy Research. http://​scpr-​syria.org/​publications/​ forced-​dispersion-​syrian-​human-​status-​the-​demographic-​report-​2016/​ Sphere Project. (2011). Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response. http://​www.refworld.org/​docid/​4ed8ae592.html (accessed 11 May 2017). Spiegel, P. (2004). HIV/​AIDS among conflict-​affected and displaced populations: dispelling myths and taking action. Disasters, 28(3), 332–​39. Spiegel, P. B., Checchi, F., Colombo, S., and Paik, E. (2010). Health-​care needs of people affected by conflict: future trends and changing frameworks. Lancet, 375, 341–​345. Strong, J., Varady, C., Chahda, N., et al. (2015). Health status and health needs of older refugees from Syria in Lebanon. Confl Health, 9, 12. Toole, M. J. and Bhatia, R. (1992). A case study of Somali refugees in Hartisheik A camp, eastern Ethiopia: health and nutrition profile, July1988–​June 1989. J Refug Stud, 5, 313–​26. Toole, M. J. and Malkki, R. M. (1992). Famine-​affected, refugee, and displaced populations: recommendations for public health issues. MMWR, 41, RR-​13 (Reports and Recommendations Issue). Toole, M. J. and Waldman, R. J. (1990). Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA, 263, 3296–​3302. Toole, M. J. and Waldman, R. J. (2012). Complex emergencies. In M. Merson, R. Black, and A. Mills (eds.), Global Health, 3rd edition. pp. 539–614. New York, NY: Jones and Bartlett. Toole, M. J., Galson, S., and Brady, W. (1993). Are war and public health compatible? Report from Bosnia-​Herzegovina. Lancet, 341, 1193–​96. Toole, M. J., Steketee, R. W., Waldman, R. J., and Nieburg, P. (1989). Measles prevention and control in emergency settings. Bull World Health Organ, 67(4), 381–​388.

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UNHCR. (2011). Ensuring Access to Health Care: Operational Guidance on Refugee Protection and Solutions in Urban Areas. Geneva: United Nations High Commissioner for Refugees. http://​www.unhcr.org/​uk/​protection/​health/​4e26c9c69/​ensuring-​access-​ health-​care-​operational-​guidance-​refugee-​protection-​solutions.html UNHCR. (2017). Global trends: forced displacement in 2016. http://​www.unhcr.org/​en-​au/​ statistics/​unhcrstats/​5943e8a34/​global-​trends-​forced-​displacement-​2016.html (accessed 27 July 2018). UNHCR. (n.d.a). Syria regional refugee response update. http://​data.unhcr.org/​ syrianrefugees/​regional.php (accessed 8 May 2017). UNHCR. (n.d.b). Syrian emergency. http://​www.unhcr.org/​en-​au/​syria-​emergency.html (accessed 8 May 2017). UNHCR/​WHO/​UNFPA. (1999). Reproductive Health in Refugee Situations: An Inter-​ agency Field Manual. Geneva, United Nations High Commissioner for Refugees. http://​ www.unhcr.org/​uk/​publications/​operations/​3bc6ed6fa/​reproductive-​health-​refugee-​ situations-​inter-​agency-​field-​manual-​unhcrwhounfpa.html UNICEF. (2013). Ready-​to-​use therapeutic food for children with severe acute malnutrition. Position Paper, June 2013. https://​www.unicef.org/​media/​files/​Position_​ Paper_​Ready-​to-​use_​therapeutic_​food_​for_​children_​with_​severe_​acute_​malnutrition_​ _​June_​2013.pdf (accessed 11 May 2017). UNICEF. (2017). UNICEF Yemen humanitarian situation report (January 2017). http://​ reliefweb.int/​report/​yemen/​unicef-​yemen-​humanitarian-​situation-​report-​january-​ 2017-​enar (accessed 10 May 2017). UNRWA. (n.d.). United Nations Relief and Works Agency. What We Do. https://​www. unrwa.org/​what-​we-​do (accessed 9 May 2017). Vu, A., Adam, A., Wirtz, A., et al. (2014). The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-​analysis. PLoS Currents, 18, 6. WHO. (1999). Health Information Network for Advanced Planning (HINAP). Health Situation Report—​East Timor, October 20, 1999. World Health Organization. WHO. (2000). The Management of Nutrition in Major Emergencies. Geneva: World Health Organization. http://​www.who.int/​nutrition/​publications/​emergencies/​9241545208/​en/​ WHO. (2013). Updates on the Management of Severe Acute Malnutrition in Infants and Children: Guideline. Geneva, World Health Organization. http://​apps.who.int/​iris/​ bitstream/​handle/​10665/​95584/​9789241506328_​eng.pdf?sequence=1 WHO. (2017a). World Health Organization. 27 February 2017. http://www.emro.who.int/ media/news/who-scales-up-response-in-somalia-as-drought-affected-populationsface-difficult-situation.html WHO. (2017b). Situation report #119 on cholera in South Sudan as at 23:59 hours, 5 May 2017. http://​www.who.int/​hac/​crises/​ssd/​sitreps/​south-​sudan-​cholera-​update-​ 5may2017.pdf (accessed 10 May 2017). WHO. (2017c). Hepatitis E—​Chad. http://​www.who.int/​csr/​don/​24-​january-​2017-​ hepatitis-​e-​chad/​en/​ (accessed 10 May 2017). WHO. (2017d). Hepatitis E—​Niger. http://​www.who.int/​csr/​don/​05-​may-​2017-​hepatitis-​e-​ niger/​en/​ (accessed 10 May 2017).

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WHO EMRO. (2014). Polio Eradication Initiative. The Syrian Arab Republic. World Health Organization, Eastern Mediterranean Regional Office. http://​www.emro.who.int/​polio/​ countries/​syrian-​Arab-​republic.html (accessed 11 May 2017). WHO EMRO. (2017a). World Health Organization, Eastern Mediterranean Regional Office. http://applications.emro.who.int/docs/EMROPub_2017_EN_20214.pdf WHO EMRO. (2017b). Weekly update: cholera in Somalia, 26 March 2017. World Health Organization, Eastern Mediterranean Regional Office. www.emro.who.int/​surveillance-​ forecasting-​response/​surveillance-​news/​weekly-​update-​cholera-​in-​Somalia-​26-​march-​ 2017.html (accessed 10 May 2017). Williams, H. A., Hering, H., and Spiegel, P. (2013). Discourse on malaria elimination: where do forcibly displaced persons fit in these discussions? Malaria J, 12, 121. Yip, R. and Sharp, T. W. (1993). Acute malnutrition and high childhood mortality related to diarrhoea. JAMA, 270, 587–​590.

Part 2

Health concerns

Chapter 5

Populations in transition and post-​settlement: an infectious diseases and travel medicine perspective Kudzai Kanhutu, Karin Leder, and Beverley Ann Biggs

5.1 Introduction The scope and diversity of the current global refugee cohort are unprecedented, encompassing multiple geographic, political, cultural, and economic divides. With traditional lead agencies such as the United Nations reporting multi-​ billion-​dollar budget shortfalls, those in need also cannot rely on a coordinated and collaboratively funded response. Ironically, the non-​governmental sector has also become more reliant on the proceeds of emergency crisis relief fundraising efforts to support established development programmes. In this shifting landscape, the global refugee crisis has exposed weaknesses in even the most highly evolved health systems. Addressing the health needs of the refugee diaspora is an increasingly complicated task.

5.2 Infectious diseases in refugee settings—​the

canary in the coalmine The refugee journey frequently entails environments that are highly conducive to infection transmission. Overcrowding, malnutrition, inadequate hygiene, and lack of access to potable water and health care services compound this risk (Pavli and Maltezou, 2017). Regardless of the setting, management and control of communicable diseases are paramount, not only for refugee asylum seekers themselves but also the host community. The potency of infectious diseases in accelerating morbidity and mortality in humanitarian settings is well acknowledged (Thomas and Thomas, 2004; Mayer

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et al., 2011). However, recent experiences have also highlighted that infectious diseases can be a signal of failing governance and crumbling health systems. The ongoing Syrian conflict is a pertinent example of the manner in which the decimation of critical health system infrastructure has contributed to the emergence of infectious diseases (Table 5.1). Table 5.1  Syria: health system building blocks in decline 2010–​16 WHO Health System building blocks

Critical events

Consequences

Health workforce

>730 medical doctors killed

Nationwide decline in: Health and equity Responsiveness Social and financial risk protection Efficiency

Service delivery

78% of ambulances destroyed or damaged 57% of public hospitals destroyed 38% of primary care centres destroyed or damaged 382 attacks on medical facilities

Health information systems

Breakdown of epidemiological surveillance infrastructure

Leadership governance

Civil war involving regional and international powers. Two most populous cities of Damascus and Aleppo continue to be subject to active military engagement

Financing

Poverty rate at 83% in 2014 Revenues from oil exports decreased from US$ 4.7 billion in 2011 to an estimated US$ 0.14 billion in 2015 Syrian pound loses 80% of value 2015

Access to essential medicines

Pre-​2011 90% of pharmaceuticals locally produced, now only 10%

Sources: WHO (2009); Sharara and Kanj (2014); Ben Taleb et al. (2015); BBC News (2015); World Bank (2016a); World Bank (2016b); Akbarzada and Mackey (2017); Aljazeera (2017).

Infectious diseases in emergency settings

5.3 Infectious diseases in emergency settings Widespread gaps in vaccination and suboptimal sanitation in emergency settings contribute to a heightened risk of vaccine-​preventable illnesses. Hence routine vaccination and early establishment of water, sanitation, and hygiene measures (WASH) for refugee cohorts should be a mainstay of infectious diseases control planning in the acute setting.

5.3.1 Measles Measles virus infection (rubeola) is highly contagious, with a secondary attack rate exceeding 90% in susceptible individuals (CDC, 2015). High vaccination rates of more than 95% of the population must be maintained to achieve herd immunity (Cockman et al., 2011). Fortunately, vaccination is highly effective, and in countries with well-​established vaccination programmes the incidence of measles has remained consistently low and endemic disease transmission has been interrupted. Syndromic diagnosis of measles is dependent on the finding of classical early prodromal symptoms which include fever, malaise, anorexia, conjunctivitis in association with a cough, and coryza. Pathognomic oral Koplik spots are not seen in all patients and may be missed owing to their transitory nature. The maculopapular measles rash appears 7–​21 days (on average 14 days) after initial exposure, typically beginning at the hairline then spreading to the torso and extremities (CDC, 2015). Most concerning for refugee populations is a reported increase in severe complications of measles such as pneumonia, encephalitis, seizures, and death. Vitamin A  supplementation, nutrition programmes, and oral rehydration therapy have been recommended to mitigate measles case severity (Lam et al., 2015). A  target of over 95% vaccination coverage with a two-​dose regimen should be instituted to reduce outbreak risk. This highlights the need to ensure immunity after settlement and before future travel.

5.3.2 Polio Polio is a highly infectious viral disease which is transmitted via the faecal–​oral route. The virus multiplies in the intestine and can invade the nervous system to cause paralysis. Early symptoms of infection are non-​specific, including fever, fatigue, headache, and vomiting. A small proportion of cases also develop paralysis. There are two effective vaccines against polio, an oral vaccine (POV) and an injectable vaccine (IPV). The Global Polio Eradication Initiative is ongoing, despite an initial polio eradication target of 2018

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Before the events of the 2011 Arab Spring, Syria had not recorded any poliomyelitis (polio) cases in close to two decades (Sharara and Kanj, 2014; Al-​Moujahed et al., 2017). Estimates in 2014 placed the population of polio-​ infected Syrians at over 7,600 (Sharara and Kanj, 2014). Breakdown of sewerage management meant that chlorination of sewage-​contaminated water in the river Euphrates ceased, in tandem with a decline of more than 40% in childhood polio vaccination (Ismail et al., 2016). Thus downstream populations reliant on river water for drinking and hygiene were placed at risk. In response to the Syrian situation, a coalition of eight non-​governmental organizations (NGOs) combined efforts to form the Polio Control Task Force (PCTF). Beginning in 2013 the PCTF successfully vaccinated 2.7 million Syrian children and 23 million in surrounding nations (Sharara and Kanj, 2014). In spite of this coordinated mass vaccination campaign, civil war, limited frontline services, and the itinerant nature of the population have hampered efforts to achieve elimination or—​better yet—​a return to eradication status (Al-​ Moujahed et al., 2017).

5.3.3 Diarrhoeal disease Diarrhoeal disease is still the second leading cause of death in children under the age of 5 years (WHO, 2013). Simple, effective and cheap, oral rehydration therapy remains a cornerstone of acute management. Newer strategies like oral cholera vaccine have been implemented in emergency settings, but logistical constraints including cold chain and human resources coordination are a major obstacle to standardization of this approach. Case study: Cholera and chaos in Dadaab Kenya The Dadaab refugee complex in Kenya consists of five camps housing some 338,000 people. In November 2015, increased rainfall linked to the El Niño effect contributed to contamination of water sources. By December 2015, 10 people had died from cholera with 1,000 documented cases. Local agencies responded with an intensification of hand hygiene and water sanitation measures. Kenya’s interior ministry later announced that it would be closing the Dadaab complex, citing national security risks. Some Somali nationals have since returned home, only to be faced with chronic food, shelter, and health service shortages. The fate of Dadaab’s refugees hangs in the balance, with a 2017 ruling by the Kenyan high court declaring the earlier eviction notice to be illegal. (CNN 2015; MSF 2015; UNHCR 2015; BBC News, 2016; Future Directions 2016; UNHCR, 2016; ABC News 2017).

In the case of asylum seekers, it is important to note that most will not have received any formal health screening or empiric treatment for common

Common and chronic infectious diseases in mobile populations

gastrointestinal infections. We recommend early health assessments including a faecal examination for culture and parasites. Targeted treatment of asylum seeker populations is recommended while they are awaiting the determination of their refugee status.

5.4 Common and chronic infectious diseases

in mobile populations 5.4.1 Hepatitis  C The 2013 Global Burden of Disease survey ranks viral hepatitis among the top 10 causes of death and disability worldwide (Stanaway et al., 2016). At the same time as we have witnessed improvements in HIV outcomes, deaths from viral hepatitis rose 63% between 1990 and 2013. The incidence of hepatitis C (HCV) infection has traditionally been concentrated among marginalized populations, notably people who inject drugs, prisoners, and indigenous people. Other HCV risk factors include unsterile tattooing, piercings, history of blood transfusion, or surgical procedures, particularly those performed in a high-​prevalence country (Chaves et al., 2016). Practitioner knowledge gaps and reluctance to manage people who inject drugs have been cited as obstacles to treatment (Zeremski et al., 2013). Pre-​2016 treatment regimens typically included interferon, which has a range of well-​described neuropsychiatric side effects. The common occurrence of fatigue, depressive mood, and flu-​like symptoms has been a relative contraindication to treatment for some patients and contributes to poor adherence. In addition to not being universally effective, standard treatment courses approached 12  months’ duration or more. However, the arrival of interferon-​free treatment regimens represents a welcome turning point for HCV control efforts. Notwithstanding cost constraints and limited global availability of directly acting antivirals, new regimens can deliver cure rates in excess of 90% and should be made available to refugees wherever possible. Stigmatization and discrimination against people with HCV are associated with lower rates of engagement in clinical care, with known flow-​on effects to refugee groups in whom transmission of hepatitis occurs at an endemic level in the absence of illicit activities. A prime example of this is in Egypt, which has extremely high HCV seroprevalence and a sizeable refugee population. Equipment contamination and spread through community-​wide injectable antischistosomal treatments in the mid-​1900s has been suggested as the principal driver (Mohamoud et al., 2013).

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We recommend offering HCV testing to all persons with epidemiological risk factors or uncertain travel history. If HCV antibody is detected on screening assessment, this should be followed by an HCV RNA test to confirm chronic disease (Chaves et al., 2016). Referral and treatment may then be coordinated by a suitably qualified clinician.

5.4.2 Hepatitis  B Almost four decades after the deployment of the first commercially available hepatitis B (HBV) vaccine, chronic HBV infection still affects approximately 350  million people worldwide (Coleman, 1984; Basnayake and Easterbrook, 2016). In the case of refugees resettling in developed world nations, their HBV prevalence is likely to be higher than that observed in the host community. Management and screening recommendations for HBV in refugees vary across the developed world (Evlampidou et  al., 2016). Some jurisdictions pursue a vaccination-​only policy without the requirement to screen for chronic HBV infection (Jazwa et al., 2015). There is evidence to support a combined approach incorporating screening, vaccination, and initiation of treatment (SVIM; Wong et al., 2011; Hahne et al., 2013; Jazwa et al., 2015) The goal is to prevent vertical and horizontal transmission and HBV-​related liver failure and hepatocellular carcinoma. SVIM entails universal testing of all humanitarian arrivals with HBsAg, HB surface antibody (HBsAb), and HBV core antibody (HBcAb). Serology for blood-​borne virus coinfection should also be completed, testing for hepatitis A (HAV), HCV, hepatitis D (HDV), and HIV antibodies. Vaccination can then be delivered to HBV/​HAV susceptible individuals with early engagement in chronic disease surveillance in primary or specialist care centres to avert the long-​term sequelae of untreated chronic HBV infection.

5.4.3 Tuberculosis An estimated one-​third of the world’s population is infected with Mycobacterium tuberculosis (TB). The majority of these people will be subject to latent infection marked by the absence of infectivity or clinical disease. The lifetime risk of progressing to a state of active infection is stated to be around 10%, but it varies depending on the host and environmental factors. In people with immune defects, e.g. immunosuppressive drug therapy or HIV coinfection, the risk of conversion from latent to active TB infection is especially high. A systematic review of TB in conflict settings observed a 20-​fold greater risk of active TB occurrence in these settings when compared to peacetime population parameters (Kimbrough et al., 2012). One of the defining challenges of the current era is the emergence of drug-​resistant TB in the face of limited therapeutic options (Table 5.2).

Common and chronic infectious diseases in mobile populations

Table 5.2.  Summary of TB terminology and estimated prevalence Tuberculosis (TB)

Laboratory definition

TB worldwide

Global ­figures 2015 10.4 million cases 1.8 million deaths

Fully susceptible TB

Susceptible to pyridoxine, isoniazid, pyrazinamide, ethambutol

~9.9 million cases

Multi-​drug-​resistant (MDR) TB

M. tuberculosis that 480,000 cases is resistant to at least isoniazid and rifampin and possibly additional agents

Extensively drug-​resistant (XDR) TB

M. tuberculosis that is resistant to at least isoniazid, rifampin, and fluoroquinolones as well as either aminoglycoside (amikacin, kanamycin) or capreomycin or both

117 countries reported at least 1 case of XDR TB 9.5% of reported MDR cases may be XDR

◆ Active TB:  The classical pulmonary TB presentation with fever, cough, and weight loss is relatively easy to identify, but TB can infect any organ system. Common sites of extrapulmonary disease include the bones, joints, and lymph nodes. Thus active TB should be considered in the differential diagnosis of any person with epidemiological risk factors who presents with signs or symptoms consistent with TB syndrome, e.g. fever, weight loss, malaise, or failure to thrive in children. ◆ Latent TB: Refugee populations should be screened and treated for latent TB according to local guidelines. In many developed countries, screening for latent TB with a subsequent offer of medication (e.g. isoniazid for 6–​9 months or rifampicin for 4 months) to reduce the chances of future reactivation is recommended. Increased use of short-​course and directly observed latent TB treatment regimens may contribute to improved adherence rates (Sandgren et al., 2016). The Mantoux test or tuberculin skin test (TST) was once considered the gold standard for diagnosing latent TB infection, but newer immunological assays (interferon gamma release assays, IGRA) have become the mainstay in resource-​rich settings. The decision as to which modality to employ will be guided by patient factors and logistical considerations (Chaves et al., 2016). The TST requires a suitably trained workforce and return visits for patient assessment. Some guidelines still advise the use of the TST in young children (under the age of 2 years) whereas

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IGRA may have preferable performance characteristics in people with previous vaccination owing to greater specificity.

5.4.1 Schistosomiasis (bilharzia) The global burden of schistosomiasis is concentrated in Africa, with 95% of the estimated 250 million cases per year originating in this continent (Hotez et al., 2014; Chaves et al., 2016). Some parts of South East Asia and the Middle East also have areas of high endemicity. Studies of refugees in the United States and Australia corroborate this, with a high proportion of African refugees returning positive schistosomiasis serological testing results (range 12–​73%) (Posey et al., 2007; Chaves et al., 2016). Parasitic flukes of the genus Schistosoma have a complex life cycle. Human transmission occurs via contact with Schistosoma cercariae in contaminated fresh water. Infection is asymptomatic in the early stages. Death or significant complications occur in later stages with extensive involvement of gastrointestinal tract and genitourinary tract. Testing is easy (blood test for serology ± stool and urine microscopy), so screening, and treatment should be provided for all refugees from endemic regions. Praziquantel-​based therapy is both cheap and highly effective for all five major species of Schistosoma (S. haematobium, S. mansoni, S. intercalatum, S. japonicum, and S. mekongi) (Chaves et al., 2016). Specialist advice should be sought for the management of young children, pregnant women, or those with pre-​existing end-​organ failure, e.g. liver failure or bladder abnormalities.

5.4.4 Strongyloides Undiagnosed intestinal parasitosis with Strongyloides stercoralis is common in refugees and infection can remain asymptomatic for decades (De Silva et al., 2002, Gurry et  al., 2015). However, the fatal disseminated disease occurs in the setting of immune compromise. Screening should therefore be offered to all refugees, due to the wide global distribution of S. stercoralis. Incidental finding of eosinophilia in a person with a history of travel or habitation in an endemic area should also prompt testing for strongyloidiasis with a blood test for S. stercoralis antibodies ± stool microscopy examining for larvae. Treatment with ivermectin achieves high cure rates, but expert guidance should be sought for the management of pregnant women or young children. Case study: Strongyloides infection in Australian refugees Australia received a wave of refugees from South East Asia between 1974 and 1991. Many of these refugees arrived before the establishment of formalized government-​sponsored refugee health services. Subsequent cross-​sectional surveys have identified a high rate of chronic

HIV and sexually transmissible infections

undiagnosed infection among Laotian, Cambodian, and Vietnamese refugees. In one cohort, 42% of Cambodian refugees were found to be seropositive or equivocal for Strongyloides infection. (Caruana et al., 2006).

5.4.5 Malaria Malaria remains a cause of significant morbidity and mortality. There is also mounting evidence of the role of climate change in extending the transmission range of malaria (Achieng Onyango et al., 2016). Malaria transmission occurs when mosquitos carrying causative Plasmodium species bite a human host. Five species of Plasmodium contribute to human disease: P. vivax, P. ovale, P. malariae, P. falciparum, and P. knowlesi. Plasmodium parasites infect and damage red blood cells. P. vivax and P. ovale are also capable of remaining in the body for months to years in a dormant ‘hypnozoite’ state (Figure 5.1). Testing algorithms should include both thick and thin blood films and a rapid antigen-​based diagnostic test. Where local clinicians have limited experience in malaria care, advice should be sought from services with relevant expertise. Pregnant women, children, and those with immune deficiencies are at higher risk of severe malaria and death. In the case of non-​falciparum malaria, relapse can occur many years after leaving an endemic area. Treatment of uncomplicated non-​life-​threatening malaria can be completed with oral medication in the ambulatory setting. Severe cases should be referred for hospital management. Artemether/​lumefantrine, atovaquone/​ proguanil, or combination quinine-​based therapy is the mainstay of therapy. For P.  vixax and P.  ovale, hypnozoite eradication with primaquine can be completed once glucose 6-​phosphate dehydrogenase (G6PD) deficiency has been excluded.

5.5 HIV and sexually transmissible infections The essential provision of sexual and reproductive health (SRH) services in humanitarian settings is enshrined in international disaster relief management protocols. During conflict and crisis, escalations in sexual and gender-​based violence can contribute to increased prevalence of sexually transmissible infections (STIs) in refugee settings (Kerimova et al., 2003; Warren et al., 2015). Some evidence of efficacy has been demonstrated for a small number of SRH-​ related interventions. These include impregnated bed nets for pregnant women, subsidized refugee healthcare, female community health workers, and tiered community reproductive health services (Warren et al., 2015).

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Test all within 3 months of arrival even if asymptomatic

Within 12 months of arrival in those with symptoms ± signs of malaria, e.g. FEVER. Jaundice, anaemia, oliguria, hypoglycaemia, altered consciousness, parasite count >2% are markers of severe infection

Figure 5.1 When to test for malaria in recently arrived refugees with history of transit or residence in endemic countries Source: data from Chaves, N. J. et al., on behalf of the Australasian Society for Infectious Diseases and Refugee Health Network of Australia Guidelines writing group. Recommendations for Comprehensive Post-​Arrival Health Assessment for People from Refugee-​Like Backgrounds, 2nd ed. Surry Hills, Australia: Australasian Society for Infectious Diseases. © 2016 Australasian Society for Infectious Diseases Inc.

Completion of a sexual history warrants a sensitive approach, especially where practitioner/​patient language barriers exist. The need for physical examination should be guided by clinical urgency, as a screening STI evaluation can be successfully performed with a number of self-​collected samples in the first instance (Sultana et  al., 2016), e.g. first-​pass urine, vaginal swab for human papillomavirus (HPV). Advances in HIV care now mean that infection can be managed as a chronic disease. Substantial epidemiological differences underscore the risk profile for HIV-​positive refugees when compared with other HIV-​affected groups in the developed world. Heterosexual transmission through unprotected sexual contact remains the primary mode of acquisition in most refugee cohorts. In developed countries where the epidemic has centred on people who inject drugs or men who have sex with men, this may have adverse implications on accessibility and suitability of existing HIV service provision (Palmer et al., 2009). HIV serological testing and STI screening should be offered to refugees with risk factors for acquisition. Early diagnosis of HIV can permit expedited treatment and prevent the development of AIDS-​related complications. Similarly, the detection of chronic STIs (syphilis, gonorrhoea, chlamydia) can prevent secondary complications such as infertility or other end-​organ damage, e.g. neurosyphilis.

Emerging infectious diseases

5.6 Emerging infectious diseases considerations 5.6.1 Do refugees contribute to host-​country spread of drug-​resistant organisms? A number of studies have attempted to quantify the burden of multidrug resistant (MDR) organisms attributable to travellers and medical tourism, with mixed findings (Rogers et  al., 2012; Ruppe et  al., 2015). Relevant to refugee populations, recent data has largely been limited to observational or clinical audit studies. A recent study reported carriage of ‘unusual’ Gram-​negative bacteria (GNB) in Syrian refugees including some GNB with markers of drug resistance (Angeletti et al., 2016). A retrospective audit of German intensive care patients found increased MDR-​ GNB among refugees when compared with local-​ born patients (Reinheimer et al., 2017). Substantial intergroup demographic and clinical heterogeneity were apparent. No commentary was made in either setting as to the clinical relevance, if any, of the MDR-​GNB isolates, but the potential for development of infections that are very difficult to treat, or for secondary spread of highly resistant organisms, is concerning. To date, there is still insufficient evidence to substantiate a claim that refugees pose a high MDR risk to host populations. The European Centre for Disease Prevention and Control (ECDC) suggests screening for hospitalized patients with epidemiological risk factors for MDR-​GNB carriage. They conclude that the risk of infectious disease outbreaks in the European Union due to the refugee influx is extremely low (ECDC, 2015). The focus should be directed towards ensuring that refugees receive catch-​up vaccinations to render them less vulnerable to circulating illnesses.

5.6.2 Leishmaniasis: an old foe Considered a neglected tropical disease, leishmaniasis is endemic to parts of the Mediterranean basin and tropical and subtropical regions. Human transmission occurs via a bite from the arthropod vector, the female phlebotomine sand fly. Untreated infection by Leishmania parasites can result in papules, disfiguring non-​healing nodules, mucocutaneous scarring, and potentially life-​threatening visceral leishmaniasis. Two million cases are reported annually with enhanced risk in situations of malnutrition and overcrowding (Alawieh et al., 2014). Case study: Leishmaniasis in Lebanon Before 2011 Lebanon reported on average 0–​6 cases of leishmaniasis per year, but 2013 saw an upsurge of disease notifications to 1,033. The vast majority, more than 95%, were reported

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in Syrian refugees. At the same time, Syria documented 41,000 cases, an increase of over 40% above the baseline rate of approximately 23,000 noted in preceding years. (Alawieh et al., 2014; Al-​Salemet al., 2016)

In the absence of a vaccine, management is targeted at optimizing population nutrition, housing, vector control, and early institution of antiparasite chemotherapy for people with complex disease.

5.7 The long journey home—​travel-​related

infections in those visiting family and relatives Preventable travel-​related illness is an all too frequent occurrence, with many people failing to obtain recommended vaccinations and advice before they travel (Leder et  al., 2013; Heywood et  al., 2016). Travellers visiting family and relatives (VFR) have been found to be subject to higher risk exposures including longer duration of stay abroad, multiple return trips, and visits to rural locations. Lack of control over dietary intake while staying with family or friends may also predispose to consumption of unsafe food and water (Seale et al., 2016). In spite of the heightened infection risk for VFR, they are often less likely to attend for pre-​travel checks. For example, although there are some data to suggest that VFR exhibit less severe disease patterns and malaria mortality risk when compared to travel tourists (Pistone et  al., 2014; Lüthi and Schlagenhauf, 2015), VFRs may falsely believe that they are completely immune to malaria even after many years living outside the destination country (Pavli and Maltezou, 2010). For VFR travellers who become unwell, differences between refugees and non-​refugees have been found for the aetiology of infectious illness. A large clinic-​based Australian audit found that when compared with non-​refugees, refugee travellers were significantly more likely to present with leprosy (31 times), chronic hepatitis (30 times), tuberculosis (21 times), schistosomiasis (4 times), and helminthic infection (3 times) (O’Brien et al., 2006). Recommendations for VFR refugees should emphasize the need to comply with usual destination-​specific travel advice, with a focus on vaccination and prophylaxis.

5.8 Where is the best evidence for refugee health

infection assessments? There are currently no international consensus guidelines to inform refugee care practices (Barnett et al., 2013). Where guidelines exist, compliance with

Where is the best evidence?

specific infection-​related recommendations has been found to be less than 50% even in high-​resource settings (Waldorf et al., 2014). A recent bibliometric analysis demonstrates a doubling in refugee health-​related literature between 2011 and 2015, with considerable reach into high impact factor peer-​reviewed publications (Sweileh, 2017). The United States, Australia, and the United Kingdom accounted for 53% of the total publication output. However, evidence gaps have been identified in refugee health policy and programme evaluation (Banatvala and Zvi, 2000; Warren et al., 2015; Mipatrini et al., 2017). Unfortunately, the pace of the academic publication cycle will likely fail to keep up with the rapid changes under way in the refugee health space. This poses a challenge for practitioners seeking to adopt evidence-​based algorithms for refugee care in the acute and post-​settlement phases (ECDC, 2015; Napoli et  al., 2015; Redditt et al., 2015; Chaves et al., 2016; Kevin et al., 2017). Internationally, a number of barriers to achieving optimal refugee health outcomes have been identified, including: ◆ Low health literacy: The term ‘health literacy’ refers to ‘how people understand information about health and health care, and how they apply that information to their lives, use it to make decisions and act on it.’ (ACSQHC, 2014) Low health literacy is associated with poorer health outcomes (Riggs et al., 2016). ◆ Language barriers: Many refugees will have limited proficiency in the local language of the country of settlement. Unfortunately, interpreter services remain a grossly underutilized health care delivery aid (Yelland et al., 2016). Use of interpreters has been shown to enhance patient satisfaction, enhance the accurate flow of communication, and reduce medication errors (Chaves et al., 2016). ◆ Workforce and service provision: Qualitative studies examining clinicians’ willingness to engage in the care of refugees point to concerns relating to self-​efficacy, particularly lack of timely access to relevant resources, professional development/​skills training, and supervision (de Crespigny et al., 2015). Suboptimal care coordination and health practitioner communication have further been implicated in increased morbidity and mortality for chronic infections, e.g. HBV, HCV, and HIV (Allard et al., 2015; Kay et al., 2016; Hajarizadeh et al., 2017). Unfortunately, loss to follow-​up and fragmentation of the patient journey continue to be problematic in the absence of unified patient information management systems across a siloed health system (Hofmarcher et al., 2007). Adopting a health systems approach to the challenges confronting refugee health policy-​makers uncovers some common enablers (Box 5.1).

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Box 5.1.  Suggested health systems approach to facilitate infection detection, prevention and treatment in refugee cohorts (regional and national level) Health workforce Professional body and health organization level stewardship in maintaining currency of refugee health workforce skill sets

Service delivery Multidisciplinary approaches to care to address complexity of health needs Reception centres/​systems for new humanitarian entrants order to assure health assessments immediately upon arrival Incorporation of protocols, standing orders to facilitate comprehensive  care Language and culture appropriate services—​bilingual staff and use of interpreters Focus on social determinants of health including adequate housing

Health information systems Health literacy and patient engagement Use of ICT infrastructure, e.g. electronic health records to manage patient information in real time Maintenance of surveillance networks to monitor trends in communicable disease epidemiology

Leadership governance Development of regional/​global consensus guidelines and protocols on best-​ practice approaches for communicable diseases management in refugee cohorts

Financing Proactive regional and national level dedicated funds and financing targets to cover current and future care needs

Access to essential medicines Advocacy for affordable access to medications for neglected tropical diseases and other chronic infectious diseases Research and development for novel therapeutics (Waldorf et al., 2014; Semenza et al., 2016)

references

Based on current trends, the cycle of contemporaneous human-​made and natural disasters will continue to fuel the global refugee crisis. Scientists and public health practitioners alike will continue to be challenged to meet the demands of this emerging global norm.

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Pistone, T., Diallo, A., Mechain, M., et al. (2014). Epidemiology of imported malaria give support to the hypothesis of ‘long-​term’ semi-​immunity to malaria in sub-​Saharan African migrants living in France. Travel Med Infect Dis, 12,  48–​53. Posey, D. L., Blackburn, B. G., Weinberg, M., et al. (2007). High prevalence and presumptive treatment of schistosomiasis and strongyloidiasis among African refugees. Clin Infect Dis, 45(10), 1310–​1315. Redditt, V. J., Janakiram, P., Graziano, D., and Rashid, M. (2015). Health status of newly arrived refugees in Toronto, Ont: Part 1: infectious diseases. Can Fam Physician, 61, e303-​e309. Reinheimer, C., Kempf, V. A. J., Jozsa, K., et al. (2017). Prevalence of multidrug-​resistant organisms in refugee patients, medical tourists and domestic patients admitted to a German university hospital. BMC Infect Dis, 17, 17. Riggs, E., Yelland, J., Duell-​Piening, P., and Brown, S. J. (2016). Improving health literacy in refugee populations. Med J Aust, 204(1),  9–​10. Rogers, B. A., Kennedy, K. J., Sidjabat, H. E., et al. (2012). Prolonged carriage of resistant E. coli by returned travellers: clonality, risk factors and bacterial characteristics. Eur J Clin Microbiol Infect Dis, 31, 2413–​20. Ruppe, E., Armand-​Lefevre, L., Estellat, C., et al. (2015). High rate of acquisition but short duration of carriage of multidrug-​resistant enterobacteriaceae after travel to the tropics. Clin Infect Dis, 61, 593–​600. Sandgren, A., Vonk Noordegraaf-​Schouten, M., Van Kessel, F., et al. (2016). Initiation and completion rates for latent tuberculosis infection treatment: a systematic review. BMC Infect Dis, 16, 204. Seale, H., Kaur, R., Mahimbo, A., et al. (2016). Improving the uptake of pre-​travel health advice amongst migrant Australians: exploring the attitudes of primary care providers and migrant community groups. BMC Infect Dis, 16,  1–​7. Semenza, J. C., Carrillo-​Santisteve, P., Zeller, H., et al. (2016). Public health needs of migrants, refugees and asylum seekers in Europe, 2015: Infectious disease aspects. Eur J Public Health, 26(3),  372–​3. Sharara, S. L. and Kanj, S. S. (2014). War and infectious diseases: challenges of the Syrian civil war. PLoS Pathog, 10, e1004438. Stanaway, J. D., Flaxman, A. D., Naghavi, M., et al. (2016). The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013. Lancet, 388, 1081–​1088. Sultana, F., English, D. R., Simpson, J. A., et al. (2016). Home-​based HPV self-​sampling improves participation by never-​screened and under-​screened women: Results from a large randomized trial (iPap) in Australia. Int J Cancer, 139(2), 281–​290. Sweileh, W. M. (2017). Bibliometric analysis of medicine—​related publications on refugees, asylum-​seekers, and internally displaced people: 2000–​2015. BMC Int Health Hum Rights, 17(1), 7. Thomas, S. L. and Thomas, S. D. M. (2004). Displacement and health. Br Med Bull, 69, 115–​127. UNHCR. (2015). UNHCR battles cholera at world’s largest refugee complex. http://​www. unhcr.org/​afr/​news/​latest/​2015/​12/​5685137c9/​unhcr-​battles-​cholera-​worlds-​largest-​ refugee-​complex.html

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UNHCR. (2016). Dadaab Camp population statistics. http://​reliefweb.int/​sites/​reliefweb.int/​ files/​resources/​CampPopulationbyCoOSexAgeGroup_​July2016.pdf Waldorf, B., Gill, C. and Crosby, S. (2014). Assessing adherence to accepted national guidelines for immigrant and refugee screening and vaccines in an urban primary care practice: a retrospective chart review. J Immigr Minor Health, 16, 839. Warren, E., Post, N., Hossain, M., et al. |(2015). Systematic review of the evidence on the effectiveness of sexual and reproductive health interventions in humanitarian crises. BMJ Open, 5, e008226-​e008226. WHO. (2009). Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. Framework for Action. Geneva: World Health Organization. WHO. (2013). Diarrhoeal diseases. http://​www.who.int/​mediacentre/​factsheets/​fs330/​en/​ Wong, W. W., Woo, G., Heathcote, E., et al. (2011). Cost effectiveness of screening immigrants for hepatitis B. Liver Int, 31, 1179–​90. World Bank. (2016a). Syria Country Overview. http://​www.worldbank.org/​en/​country/​ syria/​overview (accessed 29 April 2017). World Bank. (2016b). Syrian Arab Republic. http://​pubdocs.worldbank.org/​en/​ 925291475460799367/​Syria-​MEM-​Fall-​2016-​ENG.pdf (accessed 26 April 2017). Yelland, J., Riggs, E., Szwarc, J., et al. (2016). Compromised communication: a qualitative study exploring Afghan families and health professionals’ experience of interpreting support in Australian maternity care. BMJ Qual Saf, 25,  e1-​e1. Zeremski, M., Zibbell, J. E., Martinez, A. D., et al. (2013). Hepatitis C virus control among persons who inject drugs requires overcoming barriers to care. World J Gastroenterol, 19, 7846–​7851.

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Chapter 6

Mental health of refugees Peter Ventevogel, Xavier Pereira, Sharuna Verghis, and Derrick Silove

6.1 Introduction Among the plethora of health problems confronted by refugees, recognition of mental health needs has dramatically increased over the last decades. Within the popular media and the academic literature, the topic of mental health is now seen as one of the priorities for refugees, even though this growing interest in the subject is not always matched by a commensurate increase in allocation of resources, either financial or in terms of personnel. Forced displacement is a cause of pervasive psychological and social stress for refugees, at both an individual and a collective level (families and communities). Distress is not exclusively rooted in atrocities experienced in the homeland or during flight, but is also influenced by ongoing living conditions and expectations regarding the future once refugees have reached situations of relative safety (Schweitzer et al., 2006; UNHCR, 2015). For many refugees, psychological reactions to disruptive situations should be regarded as normative, and can be overcome with time. Most people cope with difficult experiences, and in some instances confronting these challenges may increase resilience, a potential outcome that is more likely within a supportive family and community environment. Conversely, refugees are more vulnerable to mental health conditions if they have lost, or are separated from, trusted family members and supportive community structures. In refugee settings, support systems that were functional before the flight, such as extended family systems and informal community networks, may have been eroded or—​at worst—​have broken down. In spite of these challenges and the expectable distress they cause, most refugees do not develop frank mental disorders, although a sizeable minority will do so; and people with pre-​existing mental disorders may experience exacerbation of their symptoms.

The range of mental health conditions among refugees

6.2  Key concepts There now is an international consensus surrounding the use of the composite term ‘mental health and psychosocial support’ (MHPSS) to indicate any type of local or outside support that aims to protect or promote psychosocial well-​being and/​or prevent or treat mental disorder. This may include support interventions in health, education, or community-​based protection as well as in other institutional and non-​institutional contexts. The term ‘MHPSS problems’ is generic and may include social problems, emotional distress, common mental disorders (such as depression and post-​traumatic stress disorder), severe mental disorders (such as psychosis), alcohol and substance use disorders, and intellectual disability or other developmental problems (Inter-​Agency Standing Committee, 2007). Other key concepts in the emerging literature on refugee mental health are ‘coping’, ‘social support’, and ‘resilience’. The latter concept is best understood not merely as a trait inherent to the individual but rather as the outcome of an interaction of factors in the individual, the family, and the wider social environment which in concert contribute to the process of positive adaptation in spite of significant life adversity (Ungar, 2011; Masten, 2014). The emergence of resilience theory has important implications for the type of interventions that should be prioritized, especially because, to date, the field has yet to make a shift from interventions focused on deficits and dysfunction in individuals towards those that strengthen the capacity of social environments to prevent and mitigate mental health problems.

6.3 The range of mental health conditions

among refugees Refugees are at greater risk of mental health problems than are non-​displaced, civilian populations. Among the key determinants of mental health conditions are the adversities refugees commonly face in their homelands, the effects being moderated by insecure living conditions and ongoing stress after flight (Porter and Haslam, 2005). Exact prevalence figures of mental health conditions remain elusive. Some studies find high prevalence estimates of depression and anxiety disorders among war-​affected populations. For example, Mollica et al. (1993) estimated that more than two-​thirds of Cambodian refugees living on the Thai–​Cambodian border suffered from major depressive disorder, with similar rates found in other populations (De Jong et al., 2000; Mollica et  al., 2004). Other studies found considerably lower but still high prevalence estimates (de Jong et al., 2003). A review of studies on long-​term

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mental health problems among war-​affected refugees found substantial heterogeneity in estimated prevalence rates of depression (ranging from 2.3% to 80%), post-​traumatic stress disorder (PTSD; 4.4% to 86%), and unspecified anxiety disorder (20.3% to 88%) (Bogic et al., 2015). Epidemiological surveys using only symptom scales, without additional criteria such as functional disability, clinical evaluation, and symptom stability over time, are likely to significantly overestimate prevalence of mental disorders by conflating non-​ disordered distress with mental health disorders. Such surveys therefore need to be interpreted with caution (Rodin and van Ommeren, 2009; Ventevogel, 2016). Moreover, small studies and studies with non-​representative samples tend to find higher prevalence rates. A widely cited meta-​analysis estimated prevalence rates for PTSD and depression among forcibly displaced populations to be in the order of 30% (Steel et al., 2009). A more recent meta-​analysis using more stringent inclusion and exclusion criteria and advanced statistical approaches found an age-​ standardized pooled prevalence of PTSD of 12.9% and of major depression of 7.6% (Charlson et al., 2016). These are considerably lower than previous estimates but still more than double than that of these disorders in non-​refugee populations in the Global Burden of Disease Study (3.7% for anxiety disorders and 3.5% for depression). Risk factors that increase the likelihood of developing a mental disorder among refugees can occur in various phases of the refugee process:  Some factors are linked to the situation in the country of origin, such as loosening of social cohesion and societal stability. Other factors are related to the events that prompt a person to flee, such as war, torture, or destruction of livelihood. Events that are related to strong violations of the physical and mental integrity of a person, such as torture and rape, are known to be predictive of chronic and disabling mental health conditions (Shrestha et  al., 1998; Pérez-​Sales, 2016).

6.3.1  Mental health of refugee children Refugee children have increased levels of anxiety, PTSD, and depression related to exposure to violence, pre-​existing psychological problems, post-​ migration detention, and insecure asylum status (Silove et  al., 2007; Fazel et al., 2012; Zwi et al., 2018). In children, even more than in adults, social support and family security are associated with improved psychological functioning and reduced rates of mental health problems (Reavell and Fazil, 2017). For children, the parental mental health status (particularly emotional well-​ being of the parent) and stable familial relationships are strongly protective

Specific contexts

(Almqvist and Broberg, 1999; Jones and Kafetsios, 2002). Unaccompanied asylum-​seeking minors on the move are particularly vulnerable given their separation from parents, overall absence of caretakers, instability of residence, risk of exploitation, the overall instability of their social environment, and ultimate risk of deportation after reaching the age of majority. Equally, certain subgroups of refugee children, for example, those with intellectual disabilities or who are victims of human trafficking or forced into recruitment as child soldiers, experience special challenges in their psychological and moral development (Lustig et al., 2004).

6.4  Specific contexts 6.4.1  Acute displacement versus protracted settings In the acute aftermath of forced displacement, when refugees and asylum seekers arrive in neighbouring countries, psychological stress levels are usually very high, the newcomers experiencing an overwhelming sense of being uprooted while struggling to meet their basic needs (De Jong et al., 2000). Stress is increased by disrupted systems for social and family support (van Ommeren et al., 2005). In protracted settings, where refugees are forced to reside in camps for many decades, such as among Darfuri refugees in eastern Chad, Malian refugees in Burkina Faso, Rohingya refugees who arrived in Bangladesh in the 1990, or Somali refugees in Ethiopia and Kenya, people increasingly lose hope in the potential for their situation to improve over time (Riley et al., 2017; Carta et al., 2018). This pervasive sense of demoralization and hopelessness undoubtedly contributes to the commonly observed increase in social problems including intimate partner violence, child abuse, and substance use disorders and alcoholism.

6.4.2 MHPSS problems ‘in transit’ and with people ‘on the move’ People with severe mental disorders are often at risk of abuse, neglect, and functional difficulties during times of displacement and mobility (Ullmann et al., 2015). The disruption may leave them without access to medication, social support, and protection, as social support networks and health systems break down. Other high-​risk groups in these situations include elderly people, those who have experienced torture, trafficking, or sexual and gender-​based violence (SGBV), persons with diverse sexual orientation and gender identity, and people with disabilities (Ventevogel et al., 2015a). The journey to safe countries is commonly beset with legal obstacles and harsh and restrictive life conditions

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in countries of transit, challenges that generate high levels of despair and a sense of ‘being trapped’ (Human Rights Watch, 2017).

6.4.3  Urban settings The majority (60%) of refugees currently live in ‘out-​of-​camp’ settings (UNHCR, 2017b), primarily in developing countries such as Turkey, Lebanon, Jordan, Egypt, Malaysia, Pakistan, and Iran. Refugees in urban areas share many characteristics with the urban poor of the host society including destitution, exploitation, and unemployment (Crisp et  al., 2012, and see Chapter  7 of this volume). However, in many instances, they are set apart by their insecure legal status arising from lack of recognition of their refugee claims. Formal exclusion from the labour sector, the health system, and educational opportunities are common, many refugees being legally categorized as undocumented persons and hence not being entitled to protection or assistance while facing the ongoing risk of refoulement (Hoodfar, 2004; White, 2010; Jesuit Refugee Service, 2012). Such situations may promote maladaptive coping styles including voluntary isolation, mental disengagement or avoidance through alcohol or drug use, or socially problematic behaviours, including parents giving up young girls for premature marriage or withdrawing children from school to work in the sex trade or in begging, simply to ensure family survival (Boswall and Al Akash, 2015; Stevens, 2016; CARE Jordan, 2017).

6.4.4  Refugees in Western countries Post-​displacement conditions significantly moderate mental health outcomes. The worst outcomes are evident in refugees living in institutional accommodation where they experience restricted economic opportunities, and/​or have limited options to develop supportive social networks (Carlsson et al., 2005; Porter and Haslam, 2005) and among asylum seekers with insecure residency status, who are held in forced detention (Robjant et al., 2009) or who face long and difficult asylum procedures (Laban et  al., 2004). Restrictive conditions based on policies of deterring asylum seekers not only prolong and worsen mental distress, but also impede the process of resettlement, integration, and acculturation, thereby disadvantaging both refugees and the host country in terms of increased costs (e.g. of detention) and loss of the potential contributions that refugees could make to society (Steel et al., 2011; Sundram and Ventevogel, 2017). Refugees experiencing long transitional periods in which they are refused refugee status can develop disabling sociosomatic reaction, as exemplified by the Uppgivenhetssyndrom (‘resignation syndrome’) that is observed among rejected refugees in Sweden (Aviv, 2017).

Clinical issues

6.5  Clinical issues 6.5.1  Acute stress and daily stress Being exposed to massive adversity, as is the case for many refugees who are forced to flee their homes and loved ones, leads to a wide range of emotional, cognitive, behavioural, and somatic reactions. In most cases, these are normative reactions that are self-​limiting, impacting only temporarily on functioning and not developing into frank mental disorder. In a minority, mental health symptoms persist and interfere with social and occupational functioning, thereby manifesting as more clear-​cut disorders may become evident. For refugees, major sources of distress are related to worries about the well-​being of families left behind and the difficulties experienced in reuniting with family members. Feelings of helplessness contribute to mixed emotions around resettlement, including guilt about leaving families in settings of danger and deprivation (Miller et al., 2017).

6.5.2  Post-​traumatic stress disorder Under adverse conditions, exposure to potentially traumatic events can precipitate PTSD, a distinct syndrome characterized by symptoms of re-​experiencing (nightmares, flashbacks, reliving past experiences as if they are real), avoidance and numbing, and high levels of arousal reflecting a heightened sense of current threat, a combination of reactions that can lead to difficulties in daily functioning. Rates of PTSD are considerably higher among refugees than in other populations. Although PTSD is consistently identified among refugee populations there are strong indications, both in clinical practice and in epidemiological research, that a wider range of trauma-​related symptoms are common among refugees including, among others, interpersonal difficulties, problems in modulating emotions, dissociative experiences (where the person feels out of touch with themselves and reality), and anger-​related symptoms, a constellation of reactions broadly referred to as complex PTSD (Tay et al., 2015).

6.5.3  Grief reactions Remarkably little attention has been given to the effects of traumatic loss on mental health in the refugee literature. This is surprising, because while many but not all refugees have faced potentially traumatic events, all refugees have to cope with significant losses, from loss of loved ones to loss of homeland, livelihoods, and a secure future. The multi-​level losses faced by refugees have prompted a proposal to apply a concept of ‘cultural bereavement’ as a potential alternative formulation to PSTD (Eisenbruch, 1991). Many refugees face

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ambiguous losses characterized by uncertainty about what happened to their beloved ones, which complicates bereavement (Boss, 2009). Complicated and prolonged grief are issues of significant clinical concern in refugees. In West Papuan refugees complicated grief disorder was found to be a highly relevant diagnostic category with symptom clusters related to yearning/​ preoccupation, emotional distress, interpersonal dysfunction, shock and disbelief, negative appraisal, anger/​bitterness, behavioural change, estrangement from others and impairment, and confusion and diminished sense of identity (Tay et al., 2016). In addition to complicated grief, traumatic losses (especially in settings of gross injustice and ongoing deprivations), can generate wider symptoms of anger and separation anxiety (Silove et al., 2010; Rees et al., 2017).

6.5.4  Depression and anxiety As mentioned earlier, levels of depressive and anxiety symptoms among refugees are often high, particularly among those who live in insecure circumstances such as crowded refugee camps or poor urban neighbourhoods (Heptinstall et al., 2004; Acarturk et al., 2018). Longitudinal studies show that while there is a significant stability of depressive symptoms (Bean et al., 2007; Bronstein and Montgomery, 2011), the persistence of such symptoms is partially mediated by daily life stress (Keles et al., 2017; Kaltenbach et al., 2018).

6.5.5  Severe mental disorders Refugee men have higher rates of severe mental disorders than host populations, and non-​refugee migrants appear to experience higher rates of psychotic disorders (Hollander et al., 2016; Dapunt et al., 2017). There is a risk, however, that dissociative post-​traumatic symptoms among refugees from diverse cultures may be mistakenly diagnosed as psychotic symptoms (Adeponle et al., 2012). Nevertheless, there are increasing indications that conflict-​related traumatic experiences can induce psychotic phenomena in refugees (Kinzie and Boehnlein, 1989; Silove et al., 2014). Persons with psychotic symptoms are often extremely vulnerable in humanitarian settings and are at grave risk of exploitation, human rights abuses, and neglect (Silove et al., 2000; Jones et al., 2009).

6.5.6  Intellectual and developmental disabilities Issues related to developmental and intellectual delay are very much neglected in the literature and in programmes for intervention. Much more attention should be given to this issue because refugee children with intellectual disabilities are at risk of violence, including SGBV in all stages of the refugee cycle (Women’s Refugee Commission, 2013; Barrett and Marshall, 2017). Refugees

Responses

with intellectual disabilities may be subject to restrictive practices such as being chained and locked up, and their needs often remain invisible even within health care and social services while on the move (Women’s Refugee Commission, 2013; Soldatic et al., 2015).

6.5.7  Alcohol and substance use Harmful use of alcohol and substances among refugees is another often-​ neglected problem (Hanna, 2017). Some refugees may seek to cope with past and existing stressors using drugs or alcohol (Weaver and Roberts, 2010; Ezard, 2012). Among the factors that could drive people to abuse of alcohol and substances is lack of livelihood and loosening of supportive social networks. Particularly at risk are men, those who have been exposed to war and abuse, and people with coexisting mental health problems (Ezard et al., 2011; Luitel et al., 2013).

6.6 Responses 6.6.1  Diverse paradigms Several conceptual frameworks have been proposed to formulate the mental health and psychosocial problems experienced by refugees, such as the trauma approach, the community-​based psychosocial approach, and the global mental health approach (Silove et al., 2017; Ventevogel, 2018). 6.6.1.1 Trauma approach This approach postulates ‘psychological trauma’ as the paradigmatic issue of refugee mental health and, consequently puts trauma-​focused interventions at the centre of the humanitarian mental health response. Over the years, various therapeutic approaches with an explicit trauma focus have been adapted for use with refugees, generating a strong evidence base in terms of demonstrating positive outcomes (Neuner et al., 2014). Among humanitarian agencies, however, there are reservations about an overweening trauma/​PTSD focus, based on the realization that the latter diagnosis is not the only or necessarily most disabling mental health problem observed among refugees (Ventevogel, 2014). 6.6.1.2  Psychosocial approach The psychosocial approach emphasizes the close relationship for refugees between individual emotional well-​being and the social environment (Strang and Ager, 2003). This approach is strongly influenced by research focusing on social-​ecological perspectives which locate the psychosocial needs of individuals within the social context of a family or household which, in turn, is located

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within communities (Tol, 2015). Consequentially, a priority is to heal social ties between people. 6.6.1.3  Global mental health approach The third paradigm is rooted in the ‘global mental health’ movement that emphasizes the importance of providing appropriate health interventions for a range of mental health issues including those not typically emphasized in humanitarian settings such as psychotic disorders, bipolar disorder, alcohol and substance use problems, dementia, and intellectual disability. In refugee settings, health-​care providers are often overwhelmed by the massive health needs of the population, so there is a risk that mental health problems are overlooked or under-​emphasized in spite of evidence that many visits to health facilities are related to mental health issues (Kane et al., 2014). Consequently, the health system needs to be made more responsive to the needs of people with mental disorders, particularly the severe and disabling forms which undermine social functioning and pose major protection risks for the affected persons (Ventevogel et al., 2015b).

6.6.2  Integrative models Over the past 15 years various attempts have been made to develop integrative models of refugee mental health that extend beyond the narrow confines of the paradigms described above. Examples are: • the conservation of resources theory that postulates the loss of and conservation of (social and material) resources as being central to the development of symptoms in individuals (Hobfoll., 2014) • the socioecological model that highlights the role of daily stressors in the genesis of ongoing distress (Miller and Rasmussen, 2014) • the public mental health model of the Transcultural Psychosocial Organization that emphasizes the interaction between societal, community, family, and individual levels (de Jong, 2002) • the ADAPT model (Silove, 2013; Tay and Silove, 2017) that identifies five psychosocial pillars that are eroded by mass conflict and displacement and that require repair to achieve optimal mental health outcomes in refugees including (1) safety, (2) interpersonal bonds, (3) justice, (4) roles and identities, and (5) existential meaning. Although distinctive, these models share key elements. They all assume a multisystem, ecosocial framework in which mental disorder is regarded as the outcome of an imbalance between (social) environmental and individual factors rather than solely as an expression of innate or intrapsychic problems at

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an individual level (notwithstanding the acknowledged influence of biological factors and early development). Consequently, the distinction between the normal and pathological response is regarded as fluid, strongly influenced by the sequential changes in the social environment, considerations that extend beyond a strictly individualized clinical approach to assessment and intervention (Jordans et al., 2016).

6.6.3 Policy guidelines to improve mental health and psychosocial well-​being of refugees Within the world of humanitarian aid, significant progress has been made in formulating and generating a consensus regarding policies and guidance for assisting populations in humanitarian settings, many of them refugees and internally displaced persons (Ventevogel, 2018). One of the most important initiatives is the Sphere Project, a joint initiative of large international non-​ governmental organizations (NGOs) to strengthen the quality of work of humanitarian agencies, and their accountability. Since 2004, the handbook has contained a standard for mental health. In 2007, the Inter-​Agency Standing Committee (IASC), the global platform for coordination of humanitarian assistance, established guidelines with principles and actions to improve mental health and psychological well-​being of people in emergency settings (IASC, 2007). A central tenet of these guidelines is that interventions must be multi-​ sectoral and be pragmatically ordered around four interrelated levels (with different levels of intensity): 1. Social considerations in basic services and security: It is important that the provision of basic needs and essential services (food, shelter, water, sanitation, basic health care, control of communicable diseases) and security are provided in ways that facilitate the dignity of people. 2. Strengthening community and family supports:  Activities to foster social cohesion among refugee populations, including supporting the re-​ establishment or development of refugee community-​based structures can greatly diminish psychological distress and foster a sense of self-​efficacy. 3. Focused psychosocial support: Some refugees will need help from outsiders, but these do not necessarily need to be mental health professionals. With appropriate training, others can also provide targeted emotional and practical support. Usually, non-​specialized workers in health, education, or community services deliver such interventions, after training and with ongoing supervision. 4. Clinical services: The few mental health professionals that are available in refugee settings need to focus their efforts on delivering clinical services to

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those with severe symptoms or an intolerable level of suffering, rendering them unable to carry out basic daily functions. In 2013, UNHCR published an ‘Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations’ (UNHCR, 2013)  which is a refugee-​ specific operationalization of the IASC guidelines. UNHCR distinguishes between an ‘MHPSS approach’ and ‘MHPSS interventions’: • Adopting an MHPSS approach means providing a humanitarian response in ways that are beneficial to the mental health and psychosocial well-​being of the refugees. This is relevant for all actors involved in the assistance to refugees. • MHPSS interventions consist of one or several activities with a primary goal to improve the mental health and psychosocial well-​being of refugees. MHPSS interventions are usually implemented in the sectors for health, community protection, and education. UNHCR supports health programmes for refugees in low and middle-​income countries (LMICs) and strives to provide services that conform to international standards and are equitable with health systems for the host population in the country. Key actions as defined in UNHCR’s Operational Guidance include: • training and supervision of primary health-​care providers in identification and management of priority mental health problems, with the mhGAP Humanitarian Intervention Guide (WHO/​UNHCR, 2015; see Box 6.1) • regular support visits by a mental health professional for supervision and mentoring • providing essential drugs and integrating mental health into the refugee health information system. Health systems in many LMICs struggle with constraints in financing, availability and supply of medication, human resources and skills, and system development, including integration of mental health into national health systems. Importantly, the example set by the integration of mental health within the general health framework in humanitarian settings can provide a nucleus on which further mental health-​care development and reform can be grounded (Pérez-​ Sales et al., 2011; El Chammay and Ammar, 2014; Epping-​Jordan et al., 2015).

6.6.4  Psychotherapy with refugees Although psychotherapy is indicated for refugees with common mental disorders such as depression, anxiety disorders, and PTSD, only a small minority have access to these interventions, even in high-​income settings. The prevailing modalities for treating PTSD are derived from cognitive behavioural therapies

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Box 6.1.  Modules in the mhGAP Humanitarian Intervention Guide • Acute stress • Grief • Moderate–​severe depressive disorder • Post-​traumatic stress disorder (PTSD) • Psychosis • Epilepsy/​seizures • Intellectual disability • Harmful use of alcohol and drugs • Suicide • Other significant mental health complaints (WHO/​UNHCR, 2015a).

(CBT) in their various forms including trauma-​focused CBT, cognitive processing therapy, and eye movement desensitization and reprocessing (Crumlish and O’Rourke, 2010). For the treatment of refugees with depressive disorders, CBT and Interpersonal Therapy (IPT) have proven effective. Practitioners need to be aware of contextual and cultural factors that can strongly influence help-​ seeking behaviour, modes of engagement and interaction, the disclosure of sensitive issues, and indicators of positive or negative responses to interventions (Hassan et al., 2015; Cavallera et al., 2016). Substantial challenges remain in the adaptation of therapies for persons from diverse cultural backgrounds who have experienced multiple traumatic events and are faced with ongoing psychosocial stressors (Buhmann, 2014). Despite such difficulties, there is evidence for the effectiveness of psychotherapy for refugees with common mental disorders (Nose et  al., 2017). Research with scalable psychological therapies delivered by trained and supervised non-​specialists shows good effects of trauma-​focused therapies such as Narrative Exposure Therapy (Morkved et al., 2014) and Cognitive Processing Therapy (Bass et al., 2013) in conflict-​affected populations. Such therapies typically have an explicit trauma focus, but there is emerging evidence that therapies that do not utilize trauma reminders may also be effective in reducing PSTD symptoms (Rahman et al., 2016; Dawson et al., 2017).

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For the treatment of depression, group IPT was successfully adapted for war-​affected populations in Uganda, implemented by non-​specialist providers (Bolton et al., 2007; Verdeli et al., 2008). An eight-​session manual for group IPT has recently been launched (WHO/​CU, 2016). Transdiagnostic approaches attempt to optimize elements of psychotherapy that can work for a range of common mental disorders in order to provide ‘scalable’ psychological interventions. Examples are the Common Elements Treatment Approach (Bolton et  al., 2014)  and Problem Management Plus (WHO, 2016). The latter combines problem-​solving and counselling with stress management, behavioural activation, and strengthening of social supports. It addresses depressive and anxiety symptoms (Dawson et al., 2015) and large-​ scale research efforts are on the way for adapting, testing, and scaling up of this method for Syrian refugees in the Middle East, North Africa, and Europe (Sijbrandij et al., 2017). Favourable outcomes in psychological interventions with refugees are influenced by the relationship of trust between therapist, patient, and interpreter. Thus, the development of trust and a good working alliance are critical factor for success (Mirdal et al., 2012). Despite the emerging optimism around scalable psychological therapies, it is important to realize that a significant minority of persons with severe and chronic mental health problems do not respond to brief psychotherapy, and some may be resistant even to more intensive treatment modalities. Risk factors for non-​response include extensive exposure to torture, chronic pain, comorbid depression and PTSD, and being socially isolated and unemployed (Buhmann et al., 2016; Haagen et al., 2017). This small but disabled minority may require more comprehensive approaches to rehabilitation although the challenges in establishing resources for such programmes remain formidable.

6.6.5  Psychosocial support in the community Clinical approaches to refugee mental health should be accompanied by approaches that foster the provision of pragmatic and social support in contexts of ongoing instability. Such non-​specific buffering interventions are emphasized in humanitarian settings in LMICs, but are also important in the immediate post-​flight context, when refugees and asylum seekers need to confront threats related to safety, identity, and re-​establishing meaning (Chase and Rousseau, 2018). The renewed attention given to contextual interventions aligns closely with the emerging theoretical frameworks in refugee mental health that emphasize the strengthening of the sense of agency among refugees and stress the protective role of local social ecologies.

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In many refugee settings, community and family networks have been significantly affected: family members are separated, neighbours do not know one another, trust among community members has been shattered, and people who would normally support each other are not able to do so because they are in grief and pain themselves. It is important, therefore, to help refugees to support each other and to foster social cohesion in the newly assembled community. An important challenge is to repair systems, such as extended family systems and informal social networks, which often regulate community well-​being, but which have become dysfunctional or absent (Weine et  al., 2004; Strang and Ager, 2010). A key action to support emotional well-​being of refugees should thus be to revive or recreate supportive social networks that provide a sense of connectedness and solidarity and can help to buffer against such acculturative and resettlement stressors (Betancourt et al., 2015). Fostering community initiatives can encourage a greater sense of control and improve refugees’ capacity for self-​ directed recovery, particularly in settings such as refugee camps, where the context fosters an attitude of dependency and a sense of a blocked future, and may create divisions among different segments of the refugee community. Key activities initiated to address these issues aim to revitalize this mutual support among refugees, and between refugees and host communities (UNHCR, 2017a). As such, punitive legal and policy environments that criminalize refugees for the lack of legal status (Hoffstaedter, 2014) can pose challenges to activities that aim foster connectedness and social interaction at the community level. Nevertheless, community interventions can create logical entry points to identify those in need of more intensive clinical mental health care. Such interventions can take various forms, from those that are applied to a whole population, including peace and reconciliation activities, and community mobilization to more targeted interventions for people of people who have specific vulnerabilities or specific problems, such as children associated with armed forces, survivors of SGBV, or female-​headed households. Examples of such approaches include establishing child-​friendly spaces, training refugee outreach volunteers, and establishing community centres (Ager et al., 2013; Mirghani, 2013). While such interventions are widely used by humanitarian agencies working with refugees, the evidence supporting their effectiveness is limited (Bangpan et al., 2017). One of the few well-​researched community-​based psychosocial interventions is community-​based sociotherapy (Richters et  al., 2008), a group approach with a primary focus on fostering connections between people, developed in Rwanda after the genocide and since then used in other settings including among refugees. Trained facilitators lead group members to share and discuss daily problems including interpersonal disputes, feelings of

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marginalization, and strategies to deal with gender-​based violence and poverty. This process fosters the development of potentially enduring forms of mutual peer support. Research on the effects of this essentially social intervention found that, apart from increases in civic participation (increased social capital), it also had positive effects on the individual mental health of those who participated (Scholte et al., 2011). There are other examples of interventions that go beyond a narrow focus on individual suffering and instead target the social connections between individuals. Multifamily interventions for refugees bring together different families suffering from the cumulative effects of traumatic stress and chronic adversity. The therapy aims to foster supportive connections among group members, creating solidarity as well as counteracting or overcoming stigmatization and social isolation. Preliminary results indicate such methods are effective in improving self-​confidence, decreasing social isolation, and increasing access to mental health services (Weine et al., 2008; Van Ee et al., 2014). While global refugee research expands rapidly by organizing clinical trials of psychological and psychiatric interventions, much more work is needed to document and research psychosocial interventions for communities and families.

6.7 Conclusion In outlining progress in the field of refugee mental health, this chapter provides the grounds for some optimism. Over the years, the mental health of refugees has been given more attention in policy development and in research. There is by now a considerable body of evidence concerning strategies that work or do not work. Nevertheless, while much is already being done to improve refugee mental health, much more remains to be done. Policy-​makers, NGOs, UN agencies, financial donors, health-​care providers, social workers, and refugee communities themselves need to work in close collaboration in order to ensure that concerted efforts are made to achieve acceptable and high standard services promoting the mental health and psychosocial social support for all refugees, all over the world.

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Part 3

Impacts of displacement

Chapter 7

Urban refugees: the hidden population Sharuna Verghis and Susheela Balasundram

7.1 Introduction Urban refugees have gained prominence in the last decade as a subgroup of refugees who share unique legal, social, and material precarity derived from the political, legal, and social contexts of their lives. This underlying theme engenders socially produced vulnerability and determines the manner in which they navigate their cities of residence. This chapter elaborates on the context of urban refugee lives within the broader context of forced displacement globally, and particular national contexts where resource constraints and stretched health-​care systems interact with refugees’ fragile legal status and precarity to influence their access to health care and health outcomes.

7.2 Who are urban refugees? The United Nations High Commissioner for Refugees (UNHCR) has no consistently applied definition of a refugee in an urban area (Obi and Crisp, 2002). But the term ‘urban refugee’ is used for any refugee who lives in an urban or periurban area, not a refugee camp which is administered by a designated authority or UNHCR and where aid and assistance are systematically granted on the basis of refugee status. Most urban refugees are self-​settled refugees. There are several factors that draw refugees to urban areas including greater access to services; more options for resettlement because of the proximity to UNHCR offices in the country; access to international links, especially to receive remittances from resettled relatives and friends overseas; the lack of personal security in certain camps (Fabos and Kibreab, 2007); access to health care which may be unavailable in camps (HRW, 2002; Women’s Refugee Commission, 2011; Jacobsen, 2012); ability to elude detection (Grabska, 2006) and enjoy the safety that the anonymity of urban areas bring (Bailey, 2004); increased livelihood opportunities; formal and informal assistance available from UNHCR

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and non-​governmental organizations (NGOs) (Grabska, 2006); and proximity to networks of fellow refugees whose social support is critical to their survival in a hostile environment. The drop in the provision of humanitarian assistance for refugee camps, attributed to compassion fatigue and the absence of lasting solutions, has also contributed to the rise in the numbers of urban refugees (Kibreab, 1993; Spiegel and Qassim, 2003; Jacobsen, 2012). Additionally, policies prohibiting formal refugee camps as in Lebanon, unequal refugee regional responsibility-​sharing (Rutinwa, 2002; UNHCR, 2011a), and the move by traditional countries of resettlement to encourage durable solutions in the refugee-​producing region (Crisp, 2003; Horst, 2006), have also led to resettlement needs exceeding the availability of resettlement quotas, and to increased numbers of urban refugees. While they end up sharing problems common to the urban poor in the form of overcrowded living conditions, violence, and poor access to health, basic services, and education (Grabska, 2006; Horst, 2006), urban refugees differ fundamentally from them and other marginalized populations in the host country because they cannot return durably to their country of origin (International Catholic Migration Commission, 2009); have lived through or witnessed violence, torture, and other human rights abuses associated with conflict and displacement (Jacobsen, 2012); frequently lack supportive social networks; and may be formally excluded from the labour market and access to health care and education (Crisp and Refstie, 2011). Table 7.1 shows a list of the top nine countries hosting urban refugees. These estimates are based on UNHCR’s geographically disaggregated data on ‘urban’ and ‘rural’ locations (and where it is unclear, under ‘various/​unknown’), and on the type of accommodation for the refugee population. As per this classification, it is estimated that 60% of the refugee population now live in urban areas, and this excludes those under the ‘unknown’ locations (UNHCR, 2017a). In 2016, data on location was available for 73% of the global refugee population. Table 7.1 indicates that the majority of countries hosting urban refugees are located in the global south, in upper and lower middle-​income countries. Some have been hosting high numbers of protracted displaced populations, often for decades. Protracted exile includes ‘a situation in which 25,000 or more refugees of the same nationality have been in exile for five years or longer in a given asylum country’ (UNHCR, 2013, p.  12). Tangentially, the so-​called ‘European refugee crisis’ pales in comparison, with Germany receiving the highest number of new asylum claims (722,400), and 37 countries led by the United States of America admitting 189,300 refugees for resettlement in 2016 (UNHCR, 2017a). Countries such as Kenya, Uganda, and Thailand also host urban refugees along with camp-​based refugees. UNHCR’s current policy is to

Who are urban refugees?

Table 7.1  Top nine countries hosting refugees and asylum seekers in urban areasa Refugees

Asylum seekers

Total

Estimated percentage outside camps

Country of origin of refugees

Lebanon

1,012,969

13,745

1,026,714

100b

Syria, Iraq, and others

Germany

669,482

587,346

1,256,828

100

Syria, Afghanistan, Iraq, Iran, and others

Malaysia

92,054

56,311

148,365

100

Myanmar, Sri Lanka, Afghanistan, Syria, Iraq, Pakistan, Yemen, Somalia, and others

Egypt

213,530

49,877

263,407

100

Syria, Sudan, Ethiopia, and others

India

197,851

9,219

207,070

100

Afghanistan, Myanmar

Iran

979,435

91

979,526

97

Afghanistan, Iraq

Turkey

2,869,421

245,955

3,115,376

90

Syria, Iraq, Afghanistan, and others

Jordan

685,197

35,615

720,812

79

Syria, Iraq, Palestine, and others

Pakistan

1,352,560

4,856

1,357,416

67

Afghanistan

Iraq

261,888

11,458

273,346

61

Syria, Turkey, Palestine, and others

Kenya

451,099

43,764

494,863

12.5

Somali, South Sudan, DRC

Thailand

106,447

5,010

111,457

7.5

Pakistan, Palestine, Syria

Uganda

940,835

41,880

982,715

2.2

South Sudan, DRC, Burundi

c

Source: UNHCR at 31 December 2016. a

Estimates of those in urban, peri-​urban, and some rural areas.

Though there are no official camps, some refugees in the Bekaa valley are living in makeshift/​unofficial camps, but the majority are in urban areas. b

Germany has arrangements for housing, but some are accommodated in stadiums/​airports due to lack of houses. c

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Urban refugees: the hidden population

pursue alternatives to camps and whenever possible to enable refugees to live in either urban or rural areas, lawfully and peacefully, so they can take responsibility for their lives (UNHCR, 2014b).

7.3 Spectrum of precarity Urban refugees inhabit a fragile protection environment. Countries hosting urban refugees which have not ratified the 1951 Refugee Convention or its 1967 Protocol generally also lack a domestic legal framework for refugee protection: see Table 7.2. Regardless of whether or not a domestic legal framework exists, in general, the common policy approach in many countries of asylum appears to be one of deterring the permanent residence of urban refugees. Countries such as Malaysia eschew a legal framework for refugees because it would make them ‘a magnet’ for undocumented migrants (Hong, 2007), with the result that refugees face the force of the law as irregular migrants. In countries like Jordan and Lebanon which are ostensibly experiencing limits to the traditional hospitality shown to refugees, examples include stringent policies regarding residency in Lebanon that make entry difficult for refugees and stateless persons from Syria (Lenner and Schmelter, 2016); or Lebanese and Jordanian governments’ requests to UNHCR to stop registering refugees in Lebanon in 2015 (Lenner and Schmelter, 2016)  and to stop issuing Asylum Seeker Certificates in Jordan in 2014 (Achilli, 2015). Such a policy approach contributes to insecure legal status for refugees that manifests in various forms:  see Table 7.2. In Turkey, the dual structure of the asylum system (see Table 7.1, note 1) confers differential entitlements on the two groups of refugees although both are fleeing persecution. Moreover, the Temporary Protection Regulation, although a step in the right direction in Turkey’s evolving asylum framework, does not allow access to refugee status determination mechanisms, precluding durable solutions of long-​term integration or resettlement (İçduygu, 2015; Yıldız and Uzgören, 2016). In Malaysia, refugees with UNHCR registration receive a 50% discount on foreigners’ rates in public hospitals although they are considered irregular migrants under the immigration law. In Lebanon, there are also two groups of refugees (see Table 7.1, note 3); they have differential work rights, and those registered by UNHCR lack legal status (Lenner and Schmelter, 2016). El-​ Meehy states that although Iran has acceded to the 1951 Refugee Convention and its 1967 Protocol, the absence of domestic legislation has led to ambiguity and a discretionary approach in according rights to refugees, including differential treatment to Afghan and Azerbaijani refugees (El-​Meehy, 2004). Moreover, limited prospects for local integration and the policy emphasis on

Spectrum of precarity

Table 7.2  International and national legal framework relating to refugees Country

Ratification of 1951 Convention relating to status of refugees

1967 protocol of the convention of rights of refugees

Domestic legislation on refugees

Formal agreement/​ MoU with UNHCR

Turkey





✓1

✓2

Lebanon







✓3

Jordan







✓4

Iraq







✓5

Egypt





✘6

✓7

Iran







✓8

Pakistan







✓9

Germany ✓





n.a.

Malaysia







✘10

Thailand





✘11

✓12

India









Kenya







✘13

Uganda







✘14

The Turkish asylum system has a dual structure: (i) a group-​based Temporary Protection Regulation system for Syrians and Palestinians from Syria, and (ii) an individual international protection system for individually arriving asylum seekers from other countries with different levels of access to basic rights and services (Yıldız and Uzgören, 2016). 1

UNHCR provides policy and technical advice to the Turkish government for refugee registration, camp management, and assistance with voluntary repatriation (Yıldız and Uzgören, 2016). 2

There are two groups of refugees; those registered by UNHCR who are not recognized by the government and must sign a pledge not to work, and those with a Lebanese sponsor who must guarantee their subsistence. UNHCR leads the humanitarian inter-​agency refugee response in close coordination with the government (Lenner and Schmelter, 2016). 3

UNHCR registers refugees on the condition that it must find places outside Jordan to resettle them within 6 months of recognizing them. UNHCR declared a Temporary Protection Regime in 2003 on behalf of Iraqi refugees in Jordan, Syria, and Lebanon based on a Letter of Understanding with the Jordanian government which is disputed by the latter (HRW, 2006). Additionally, Jordan does not identify conditions that provide eligibility for asylum, nor does it impose sanctions against asylum seekers whose entry was unauthorized (Library of Congress, 2015). It does, however, allow entry to the war wounded from Syria requiring lifesaving treatment (HRW, 2006). 4

UNHCR coordinates the humanitarian response and leads the protection, shelter and basic needs/​non-​ food items sectors; it also co-​leads the health sector with WHO and WASH with UNICEF (UNHCR, 2016a). 5

There is some fragmentary domestic legislation that regulates the legal status of refugees (Library of Congress, 2016). 6

In the absence of a national asylum system, activities related to registration, documentation, and refugee status determination (RSD), as well as the provision of assistance and the search for durable solutions, are done by UNHCR under a framework agreement signed with the government in 1954 (UNHCR, 2011c). 7

A 2002 Tripartite Agreement between the Islamic Republic of Iran, Afghanistan, and UNHCR on voluntary repatriation came back into force in 2010 and was extended in 2016 (UNHCR, 2011b; Ministry of Refugees and Repatriation, 2016). 8

(continued )

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Urban refugees: the hidden population

Table 7.2 Continued UNHCR conducts RSD on behalf of the government and facilitates third country resettlement and voluntary repatriation to Afghanistan (UNHCR, 2016b). 9

UNHCR undertakes RSD and facilitates resettlement and other assistance-​related activities in the absence of a formal status agreement between UNHCR and the Government of Malaysia. 10

Refugees of all nationalities living outside designated refugee camps for those from Myanmar are considered ‘illegal’ (HRW, 2012). 11

UNHCR is not permitted to undertake RSD for refugees from Myanmar, Laos, or North Korea. Additionally, it issues ‘Persons of Concern’ certificates in urban areas for non-​Myanmar asylum seekers which do not permit the right to work or protect against arrest (Urban Refugees, n.d). 12

13

Tripartite agreement between the governments of Kenya and Somalia, and UNHCR.

14

Tripartite agreement between the governments of Rwanda and Uganda, and UNHCR.

the repatriation of Afghan refugees since 2001 (Hugo et al., 2012) has also seen their onward movements to countries such as Malaysia and Australia (Health Equity Initiatives, 2010). The differential treatment of refugees from different countries of origin is also evidenced in India (Banerjee, 2015). Even in Uganda where refugees are given land, the right to work, and freedom of movement, they cannot own the land they cultivate or the homes they live in, precluding possibilities of a durable long-​term solution (Gardner, 2016). Prominently, underlining these diverse statuses and entitlements that flow from them is an ambiguous liminal ‘in-​between status’ (Menjívar, 2006, p.  1000) that urban refugees find themselves embodying; sometimes being neither documented or undocumented, and at other times having some of the characteristics of both forms of status, or a multiplicity of in-​between forms (Hellgren, 2012), as these examples indicate. Their precarious legal status creates vulnerability in other dimensions of their lives, such as exclusion from the labour market which has further ripple effects of engendering poverty, predisposing them to exploitation (Health Equity Initiatives, 2010; Health Equity Initiatives, 2011; Lenner and Schmelter, 2016; Yıldız and Uzgören, 2016; Sanyal, 2017), increasing dependency on humanitarian agencies (Sanyal, 2017), and perpetuating indebtedness to meet basic needs (Health Equity Initiatives, 2010). Insecurity of housing (Lenner and Schmelter, 2016), homelessness (Yıldız and Uzgören, 2016); assault and extortion by host country individuals (Health Equity Initiatives, 2010); and vulnerability to arrest, detention, and deportation (Eberle and Holliday, 2011; Hoffstaedter, 2014; Sanyal, 2017), are other ramifications of insecure legal status. As urban refugees navigate their cities of residence through adverse spatial contexts and often intransigent and protracted exile, they contend with human needs of identity, meaning, and purpose in life, long-​term uncertainty about their future and lack of formal status in society over more than a

Spectrum of precarity

single generation, and access to basic needs in the short term (Health Equity Initiatives, 2010). But the spectrum of precarity is not unique to urban refugees alone in contexts of displacement, as the Syrian case demonstrates. The World Bank reports that the Syrian crisis has had a retrograde impact on the economies of Jordan and Lebanon, in terms of strained public finances, service delivery, and rising poverty and unemployment associated with the massive refugee flows and disruption to trade and economic activity (World Bank, 2017a; World Bank, 2017b). In fact, in 2017, a heavily indebted Jordan obtained a downward re-​classification from an upper middle-​income country to a lower middle-​income country (World Bank, 2017c). The arrival of refugees has also been associated with overstretched health systems in both countries. Related to refugee presence in the country, Jordan reported an increased demand for surgical and trauma care, cancer treatment, mental health and psychosocial care (Hunter, 2016), and treatment for non-​communicable diseases (NCDs) (Doocy et al., 2016a; Doocy et al., 2016c). Additionally, there were increases in occupancy rates in hospitals, the workload at primary health care centres (by 9–​15%), demand for medical disposables, medical equipment and surgical interventions, consumption of drugs, and extra pressure on a system with existing health work force shortages (Gharaibeh, 2015). Similarly, Lebanon grapples with overburdened primary health care services and high hospital utilization by Syrian refugees (WHO, 2015) on top of rebuilding its health system in the aftermath of the civil war. Moreover, the nascent reform of health systems towards universal health coverage in many host countries is contending with an emerging dual burden of disease (WHO, 2009; Jaafar et al., 2013), a dualistic health sector with an expanding and often inadequately regulated private sector (Kronfol, 2006; WHO, 2009; Jaafar et al., 2013; SIMHA, 2017), fragmentation of service provision and funding mechanisms (Bazyar et al., 2016), dependence on foreign aid and non-​profit charities (Murshidi et al., 2013), and outbreaks of communicable diseases such as polio, measles, cholera, and leishmaniasis (Ozaras et al., 2016). This unparalleled stress on health systems in asylum countries is exacerbated by the protracted and violent nature of conflicts (McKenzie et al., 2015) with health-​care costs being higher for patients from countries with violent conflict (Bischoff et al., 2011). Strained health systems, albeit not to the same degree as in the Middle East, were also experienced in Greece, the former Yugoslav Republic of Macedonia, Serbia, and Croatia as asylum seekers travelled by sea and land to cross over to Europe in 2015–​16 (Hunter, 2016).

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Although the arrival of refugees has put a strain on the fragile health systems in some asylum countries, there are countries like Uganda where locals have benefitted from health services developed for refugees (Gardner, 2016). Overall, the intersecting spectrums of precarity of the status of refugees with precarity of health systems and of urban refugee contexts generate unique barriers to access to health care and health outcomes for urban refugees.

7.4 Restricted status, restricted access As with other aspects of urban refugee lives, knowledge of urban refugees’ access to health care is hindered by a paucity of systematic research providing comparable and robust data because of the dispersion of urban refugees in the host community which makes the identification of their needs problematic (International Catholic Migration Commission, 2009), and methodological dilemmas such as definitional challenges regarding the boundaries of an urban area, absence of a sampling frame, and heterogeneity of the refugee population (Landau, 2004). Thus, avoiding generalizations, this section provides a snapshot of the diversity in the context of access to health care for urban refugees. The access to health care of urban refugees is a function of many factors including their health needs, health and health-​care-​seeking behaviour, and documentation status, and the host countries’ health-​care policy for refugees and the state of their health systems. Table 7.3 highlights the policy on access to health care for urban refugees in public health facilities in countries with a significant urban refugee population. The emerging picture shows a plethora of arrangements and corresponding entitlements arising from these policies. Alongside the caveat that practice on the ground does not always align with formal policies, and seemingly similar policies and practices differ substantively across countries, Table 7.3 indicates an unequal distribution of health-​care services across countries and statuses (refugee or asylum seeker) in urban refugee contexts. In general, health-​ care policies favour registered refugees over asylum seekers, testifying to the salience of status and documents in the urban refugee context. Inclusion in health insurance schemes (e.g. in Turkey, Germany, and Iran) almost exclusively favours refugees, not asylum seekers. Refugees also have better opportunities than asylum seekers to access primary care. Primary care is made available to urban refugees in more countries at subsidized rates (e.g. in Lebanon, Egypt, Jordan, Thailand, and Kenya). Although highly subsidized in countries like Jordan and Egypt, the cost-​sharing even for primary health care is still unaffordable for many refugees (Mazhar, 2015; Refugee Council USA, 2015; Doocy et al., 2016b), especially those with chronic diseases

Restricted status, restricted access

Table 7.3  Policy on access to health care for urban refugees in public health facilities Country

Access to public health facilities

Turkey

Free health care only for refugees registered with the government who are included in Turkey’s general health insurance scheme. Maternal and infant care, family planning, screening of communicable disease, immunization, and TB treatment are included in primary care. The general health insurance scheme includes mental health services. For those in the process of registration, access only to emergency care, vaccination services, and treatment for communicable diseases through the primary health care institutions.1

Lebanon

Registered and unregistered refugees can access subsidized primary health care, while a private-​sector third-​party administrator manages referrals for secondary and tertiary services on behalf of UNHCR. UNHCR is unable to support chemotherapy, radiotherapy, and dialysis. Health services as described above are also available to refugees awaiting registration through UNHCR.2

Jordan

User fees for primary care for Syrian registered refugees equal to that paid by non-​insured Jordanians. Non-​registered asylum seekers pay ‘foreigner rates’ which are 35–​60% higher than non-​insured Jordanians. Referrals to secondary and tertiary care are supported by UNHCR. Free vaccination, emergency care, and treatment for communicable diseases. Allows entry for war wounded to access lifesaving treatment.3

Iraq

Refugees in Iraq have free access to government health services at all levels.4

Egypt

Access to universal primary health care for nominal fee for registered refugees (free for Egyptians). Referrals for secondary and tertiary care made/​paid through limited resources of UNCHR implementing partners and non-​profits, who often only provide emergency care to unregistered refugees and asylum seekers. Free vaccination services for children.5

Iran

Incorporates refugees into a government-​sponsored health insurance scheme called the Salamat Health Insurance, which covers hospitalization and partial hospitalization, and special diseases like haemophilia, thalassaemia, renal failure, kidney transplant, and multiple sclerosis. Health care coverage is similar to that of Iranian nationals. The insurance covers only 80% of costs of treatment. The benefits under this scheme are not equal to benefits in the insurance scheme for nationals. Asylum seekers only have access to free universal primary care which includes antenatal care, maternal and child health care, and family planning services. Secondary care for the unregistered would include out-​of-​pocket health expenditures. Free vaccination services for children.6

Pakistan

Refugees and asylum seekers have same access to health care in public hospitals as nationals. User fees involved.7

Germany Those with refugee status receive a temporary residence permit and are given the same status as Germans within the social insurance system. Asylum seekers only have access to emergency care, primary care (for adults, children, and adolescents) for acute conditions or for pain excluding chronic medical conditions, medical and nursing help and support for pregnant asylum seekers, and vaccinations.8 (continued )

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Table 7.3 Continued Country

Access to public health facilities

Malaysia

Refugees, not asylum seekers, get a 50% discount off foreigners’ rates in public hospitals; prescriptions from public hospitals are restricted to a 5-​day supply from government hospital pharmacies.9

Thailand

Refugees registered by UNHCR may access health care at public hospitals for a fee. Asylum seekers registered with UNHCR may access emergency care from UNHCR’s implementing partners.10

India

Access to free health care in public hospitals for refugees and asylum seekers on par with nationals. User fees involved.11

Kenya

User fee of US$ 0.28 in city council clinics. Payment required for drugs and treatment. Free services for children below 5 years, TB and HIV control, family planning, and free maternity services. Access to national health insurance scheme under same conditions as nationals. The insurance covers inpatients and outpatients in national and faith-​based health facilities where full fees are paid, and only part of hospitalization is covered in private facilities. Health care, including referral system, is available to both refugees and asylum seekers but does not cover expensive treatment, renal transplant, plastic surgery (including dentures and spectacles), and cancer treatment.12

Uganda

Same access as nationals to all levels of health care, some free, some at a cost, for both refugees and asylum seekers. UNHCR and international, regional, and local NGOs operate in parallel to public health facilities.13

Refugee Rights Turkey (n.d.), Landinfo (2011), Alawan (2016), Yıldız and Uzgören, (2016), (WHO, 2017). 1

2

Doocy et al. (2016c), LHIE (2014).

3

Amnesty International (2016), Ay et al. (2016), Flynn (2016).

4

Ann Burton, personal communication, 19 July 2017.

5

Hilal and Samy (2008), Giambi et al. (2017).

6

European Commission (2014), UNHCR (2014a).

7

The International News (2017).

Asylum Information Database (n.d.), Federal Ministry of the Interior (n.d.), Fox (2015), Bozorgmehr and Razum (2016), Hyde (2016). 8

9

Verghis (2015).

10

Urban Refugees (n.d.).

11

Banerjee (2015).

12

John Wagacha Burton, personal communication, 19 July 2017.

13

UNHCR (n.d.).

(Doocy et al., 2016b). It must be noted that although Jordan offered free primary care services for registered urban refugees between 2011 and 2014, it had to institute subsidized user fees after that owing to the unprecedented strain on the health system brought about by the Syrian refugee crisis (Government of Jordan, 2017). On the other hand, countries such as Malaysia charge all

Restricted status, restricted access

foreigners, including asylum seekers, the full unsubsidized cost of health care in public health facilities, while refugees get a 50% off the foreigner’s rate (Verghis, 2015). In countries like India and Pakistan where refugees and asylum seekers might be able to access health care on a par with nationals in public hospitals, albeit with some user fees, shortages of medication, equipment, and personnel pose challenges to access and present limitations to treatment options (Dawn, 2014; Parmar et  al., 2014). Further, equal treatment with nationals does not detract from problems of linguistic barriers and lack of interpreters (Parmar et al., 2014). Obtaining secondary and tertiary care is equally problematic for urban refugees and asylum seekers in most countries. Reliance on out-​of-​pocket expenditures for health care and shrinking humanitarian assistance, while largely the lot of asylum seekers, is also true in the case of registered refugees in many asylum countries for secondary and tertiary care, as was found in Malaysia, Lebanon, and Iran (Verghis and Pereira, 2009; European Commission, 2014; Refugee Council USA, 2015). Further, although many countries include urban refugee children in routine immunization and catch-​up immunization programmes, coverage is still wanting in many places (Demirtas and Ozden, 2015; Coleman et al., 2017), and health systems grapple with vaccine shortages (Francis, 2015). It has been stated that although providing vaccinations to Syrian refugees has been a significant public health endeavour in Jordan, it has also been one of the costliest (Francis, 2015). Fewer countries offer urban refugees free treatment for communicable diseases. A study on pulmonary tuberculosis (TB) with host population and refugee patients in Turkey, where secondary care and treatment for communicable diseases is free, showed that treatment goals could not be achieved in refugees due to higher rates of loss to follow-​up and transfer rates, indicating that factors other than cost could be mediating access to health care (Dogru and Doner, 2017). On the other hand, a study on HIV treatment outcomes in Malaysia found that urban refugees could achieve viral load suppression similar to the host population with equitable access to free antiretroviral therapy, albeit through the additional support of UNHCR (Mendelsohn et al., 2014). In fact, some studies have demonstrated that restrictions on health care and the lack of timely access to care for refugees and asylum seekers leads to avoidable and increased health-​care costs (Bozorgmehr and Razum, 2015; Coleman et al., 2017). A common barrier restricting access to health care for urban refugees includes unaffordable user fees and the lack of health insurance, leading to out-​of-​pocket health expenditures (Verghis and Pereira, 2009; Doocy et al., 2016a; Lyles et  al., 2016; Ravishankar and Gausman, 2016)  which may be catastrophic (Verghis and Pereira, 2009; Ravishankar and Gausman, 2016).

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Studies have shown that urban refugees often cope with meeting basic needs by not purchasing medication when they are ill, prioritizing the health-​ care needs of children and elderly people, self-​medication (Health Equity Initiatives, 2010; Doocy et al., 2016c) and purchasing medication from pharmacies (Doocy et al., 2016c; Lyles et al., 2016). Perceived discrimination in health care; fears of arrest and detention which preclude spatial mobility; and information, language, and cultural barriers (Verghis, 2013; Amara and Aljunid, 2014; Arnold et al., 2014; Parmar et al., 2014; Scott, 2014) are also frequently cited as impediments to urban refugees’ access to health care. As such, some studies reveal unmet health-​care needs among urban refugees, particularly in relation to access to family planning methods (Tanabe et al., 2017); antenatal care (Verghis, 2013); medical specialist care, medicines, and health information (Adaku et al., 2016); and long-​term physical rehabilitation care and postoperative care (de Leeuw, 2014).

7.5 Epidemiology of urban refugee health As with research on access to health care, monitoring the health and nutrition status of urban refugees is extremely challenging because they are widely dispersed in multiple geographic areas, and their exact numbers are not known. Proportional morbidity data from each facility are usually available, but not necessarily disaggregated to refugees and migrants. Moreover, the lack of accurate population denominators precludes the calculation of incidence rates for urban refugees. Other methodological challenges related to urban refugee health studies include sampling bias, diverse methodological approaches used to measure urban refugee health, data collection constraints, and the use of self-​reports (Amara and Aljunid, 2014). This section examines the available data on the epidemiology of urban refugee health within the bounds of these data limitations. Relatedly, prospective surveillance approaches are now being used by UNHCR to determine the level of health-​care access and utilization (UNHCR, 2009).

7.5.1 Non-​communicable diseases The demographics of refugee populations with advancing age and higher baseline incomes is reflected in the epidemiological shift from communicable diseases to NCDs (Spiegel et al., 2010), which are becoming a major public health issue in humanitarian settings. However, the robust assessment of NCDs in urban refugees is hampered by the inconsistency in definitions of NCDs among the studies, in addition to the other methodological limitations discussed above. Most published studies focus on refugees originating from

Epidemiology of urban refugee health

countries of the Middle East and residing in the Middle East, with a few studies covering urban refugees in Kenya, Uganda, Malaysia, and India (Amara and Aljunid, 2014). Hypertension, musculoskeletal disease, diabetes, and chronic respiratory disease were the predominant NCDs reported for urban refugees (Amara and Aljunid, 2014). In terms of mental health, the precarity and uncertainty of urban refugee contexts including intergenerational refugee status has variously been associated with elevated levels of fear, hopelessness, depression, and anxiety (Health Equity Initiatives, 2010; Health Equity Initiatives, 2011; Quosh et al., 2013; Şimşek et al., 2017; Wong et al., 2017), which has contributed to intimate partner violence, suicide attempts, self-​ harm and harm directed at others, survival sex, and child abuse (Quosh et al., 2013; Parker, 2015).

7.5.2 Infectious diseases Simultaneously, challenges remain for the optimal management of communicable diseases like TB and HIV. According to the World Health Organization (WHO), a corollary of the Syrian crisis has been the resurgence of previously controlled communicable diseases with people moving between overcrowded informal dwellings with poor access to water, sanitation, and health-​care services. Outbreaks of measles and polio in Jordan and TB, diarrhoea, measles, mumps, hepatitis A, and cholera in Lebanon remain a concern in spite of active surveillance and routine immunization (for vaccine-​preventable diseases) in the community by the authorities (WHO, 2015). Similarly, UNHCR has been responding to prevent and control the spread of cholera among refugees in Yemen (UNHCR, 2017b). In South East Asia, one study in Thailand revealed that more than half of the TB cases in the largest urban area along the Thailand–​Myanmar border were of non-​Thais (Iemrod and Kavinum, 2015). Similarly, increasing numbers of TB cases were reported among Syrian refugees in Jordan and Lebanon with prevalence rates of TB among Syrian refugees exceeding that of Jordanians, reflecting differences in TB prevalence rates between refugees’ countries of origin and asylum (Ozaras et al., 2016). Ozaras et al. also noted that the prevalence of TB among urban refugees in Turkey could be higher because of poor living conditions and homelessness (Ozaras et al., 2016). Likewise, in Germany, a prospective 12-​month surveillance study showed that TB prevalence rates were higher in newly arrived asylum seekers than in native Europeans, with higher TB prevalence rates being observed among Eritreans compared to Syrians, Afghanis, Iraqis, Iranians, and Lebanese, reflecting again the differences in TB prevalence rates in the different countries of origin as well as the host country (Meier et al., 2016).

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7.5.3 Nutritional  status Compromised nutritional status may be seen following an emergency and has also been observed in refugee populations dependent on food rations which affect frequency of meals and diet diversity. A cross-​sectional survey on the nutritional situation of Syrian refugees in Lebanon, Iraq, and Jordan, involving a mix of two camps and five urban sites, found the highest prevalence of anaemia in children and non-​pregnant women in Jordan’s Za’atri camp (48.4% and 44% respectively).This was attributed to a lack of diet diversity with the rations in the camp, although global acute malnutrition was low, less than 5% among camp and urban refugees (Hossain et al., 2016). However, a study in Turkey showed that haemoglobin levels in pregnant Syrian women and the birth weight of their neonates were lower than for Turkish citizens, with the differences attributed to nutritional inadequacies and poor prenatal care (Demirci et al., 2016).

7.6 The way forward This chapter highlights the distinctive context of life, health, and access to health care for urban refugees. It is evident that many of the challenges confronting urban refugees are related to their sequestration from national health systems and their lack of civic integration in the host countries. This is likely a combined product of the traditional nature of humanitarian assistance to refugees and reticence on the part of host countries to integrate non-​citizens into the broader economy and social fabric of the nation. The most tenable solution lies in universal and inclusive approaches that integrate the humanitarian and developmental responses in countries of origin and asylum and benefitting both refugees and host populations (UNHCR/​UNDP, 2010; Cliffe et al., 2015). Such an approach aligns with the United Nations’ Sustainable Development Goals of ‘leaving no one behind’. When refugees have formal livelihoods, they become self-​reliant, contribute productively to host countries, and can be included in national social protection strategies including access to health care. This additionally requires alignment of integrated urban development planning and implementation with national development strategies. Arguably, this would only flourish in tandem with concerted peace-​building activities. This new direction would also require a review and realignment of financial aid, and disbursement and accountability mechanisms including funding for local actors such as local NGOs and governments, who are often the primary responders in crisis situations (Lattimer and Swithern, 2017). A re-​envisioning of refugee governance would also be required. These changes need to be pursued in tandem with increased quotas for resettlement in the global north.

references

It is also evident from the many challenges faced in responding to the need for NCD care in refugee situations that an integrated approach to management of NCDs at the primary care level needs to be promoted. This model may be better positioned to meet the needs of displaced populations in an urban setting, with emphasis on health education to support prevention and control of NCDs. Community-​based health awareness activities aimed at health promotion and disease prevention are essential in incorporating a primary health-​care approach in urban refugee health programming. The training of refugees as community health workers to provide health education or home-​based care strengthens participatory approaches and also leverages the cultural familiarity and language competency of someone from the refugee community. It is also worth examining some of the key elements in HIV programming for NCD care including simplified, standardized treatment regimens; streamlined clinical and laboratory monitoring; and a focus on patient education and empowerment through counsellors, peer educators, and outreach workers (Rabkin et al., 2016). Where screening is logistically difficult in an urban setting, health systems need to carefully examine and minimize existing barriers to initial screening and subsequent treatment for TB. Efficient coordination with improved communications between the various stakeholders—​public, private, and NGOs—​is key to ensuring optimal management of communicable diseases. Shorter treatment regimens, as in the new WHO MDR-​TB regimen, promotes better adherence and is cost-​effective (WHO, 2016). Additionally, monitoring of nutrition status in an urban area is best implemented through regular nutrition surveys, either by including urban refugees in national nutrition surveys or by conducting specific surveys that observe the Standardized Expanded Nutrition Survey guidelines. When urban refugees can come out of the shadows of the informal economies, downtown ghettos, and subterranean social networks they currently subsist in, and are seen as part of the solution and not the problem, they and host countries stand to gain.

Acknowledgements The authors are grateful to Ann Burton, Herve Isambert, and John Wagacha Burton, for sharing and facilitating information from UNHCR headquarters and regional offices.

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Francis, A. (2015). Jordan’s refugee crisis. Carnegie Endowment for International Peace. http://​carnegieendowment.org/​2015/​09/​21/​jordan-​s-​refugee-​crisis-​pub-​61338 [Accessed 11 July 2017. Gardner, T. (2016). Beneath the surface of Uganda’s ‘exemplary’ refugee settlement, tensions simmer, 15 Nov 2016. Reuters. http://​www.reuters.com/​article/​us-​uganda-​refugees-​ landrights-​idUSKBN13A1UW (accessed 10 July 2017). Gharaibeh, M. (2015). Impact of refugees on the health care system in Jordan: implications for health. www.caep.ca/​sites/​caep.ca/​files/​.../​rdims_​east-​347036-​v1-​syrian_​refugees_​ jordan.pdf (accessed 11 June 2017). Giambi, C., Del Manso, M., Dente, M. G., et al. (2017). Immunization strategies targeting newly arrived migrants in non-​EU countries of the Mediterranean Basin and Black Sea. Int J Environ Res Public Health, 14, E459 doi: 10.3390/​ijerph14050459. Government of Jordan. (2017). The Jordan Response Plan 2017–​2019. https://​static1.squarespace. com/​static/​522c2552e4b0d3c39ccd1e00/​t/​588097f2bf629a0d7988da58/​1484822555053/​ JRP+2017-​2019+-​+Final+Draft+-​+190117+%28v2%29.pdf [Accessed 11 July 2017. Grabska, K. (2006). Marginalization in urban spaces of the global south: Urban refugees in Cairo. J Refug Stud, 19, 287–​307. Health Equity Initiatives. (2010). Between a Rock and a Hard Place. Afghan Refugees and Asylum Seekers in Malaysia. Kuala Lumpur: HEI. Health Equity Initiatives. (2011). Forced Labor, Human Trafficking and Mental Health. The Experiences of Refugees and Asylum Seekers in Malaysia. Kuala Lumpur: HEI. Hellgren, T. (2012). Immunization strategies targeting newly arrived migrants in non-​ EU countries of the Mediterranean Basin and Black Sea. Oxford Monitor of Forced Migration, 2,  34–​40. Hilal, L. and Samy, S. (2008). Asylum and Migration in the Mashrek. Copenhagen: Euro-​ Mediterranean Human Rights Network. Hoffstaedter, G. (2014). Place-​making: Chin refugees, citizenship and the state in Malaysia. Citizenship Stud, 18, 871-​88410.1080/​13621025.2014.964549. Hong, B. (2007). Malaysia does not want to be a refugee magnet. Malaysiakini, 17 April. http://​www.malaysiakini.com/​news/​66074 (accessed 11 June 2017). Horst, C. (2006). Introduction: Refugee livelihoods: continuity and transformations. Refug Surv Q, 25, 6–​22 doi:10.1093/​rsq/​hdi0122. Hossain, S. M. M., Leidman, E., Kingori, J., et al. (2016). Nutritional situation among Syrian refugees hosted in Iraq, Jordan, and Lebanon: cross sectional surveys. Confl Health, 10, 26 10.1186/​s13031-​016-​0093-​6. HRW. (2002). Hidden in Plain View: Refugees Living Without Protection in Nairobi and Kampala. New York: Human Rights Watch. HRW. (2006). The silent treatment. Fleeing Iraq, surviving in Jordan. Human Rights Watch. https://​www.hrw.org/​reports/​2006/​jordan1106/​5.htm (accessed 11 July 2017). HRW. (2012). Thailand: Refugee policies ad hoc and inadequate. Human Rights Watch. https://​www.hrw.org/​news/​2012/​09/​13/​thailand-​refugee-​policies-​ad-​hoc-​and-​ inadequate (accessed 11 July 2017). Hugo, G., Abbasi-​Shavazi, M. J., and Sadeghi, R. (2012). Refugee movement and development—​Afghan refugees in Iran. Migr Dev, 1, 261-​279 doi:10.1080/​ 21632324.2012.749741.

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McKenzie, E. D., Spiegel, P., Khalifa, A., and Mateen, F. J. (2015). Neuropsychiatric disorders among Syrian and Iraqi refugees in Jordan: A retrospective cohort study 2012–​ 2013. Confl Health, 9, 10 doi: 1010.1186/​s13031-​015-​0038-​5. Meier, V., Artelt, T., Cierpiol, S., et al. (2016). Tuberculosis in newly arrived asylum seekers: A prospective 12 month surveillance study at Friedland, Germany. Int J Hygiene Environ Health, 219, 811–​81510 doi:1016/​j.ijheh.2016.07.018. Mendelsohn, J. B., Schilperoord, M., Spiegel, P., et al. (2014). Is forced migration a barrier to treatment success? Similar HIV treatment outcomes among refugees and a surrounding host community in Kuala Lumpur, Malaysia. AIDS Behav, 18, 323–​33410 doi:1007/​s10461-​013-​0494-​0. Menjívar, C. (2006). Liminal legality: Salvadoran and Guatemalan immigrants’ lives in the United States. Am J Sociol, 111, 999-​doi:103710.1086/​499509. Ministry of Refugees and Repatriation. (2016). 27th Tripartite Commission Agreement signed by the Government of the Islamic Republics of Afghanistan & Pakistan and UNHCR. Islamic Republic of Afghanistan. http://​morr.gov.af/​en/​news/​62459 (accessed 11 July 2017). Murshidi, M. M., Hijjawi, M. Q. B., Jeriesat, S., and Eltom, A. (2013). Syrian refugees and Jordan’s health sector. Lancet, 382, 206–​207 doi:10.1016/​S0140-​6736(13)61506-​8. Obi, N. and Crisp, J. (2002). UNHCR policy on refugees in urban areas. Report of a UNHCR/​NGO workshop, August. EPAU/​2002/​09. Ozaras, R., Leblebicioglu, H., Sunbul, M., et al. (2016). The Syrian conflict and infectious diseases. Expert Rev Anti Infect Ther, 14, 547–​555. Parker, S. (2015). Hidden crisis: violence against Syrian female refugees. Lancet, 385, 2341–​2 doi:1016/​s0140-​6736(15)61091-​1. Parmar, P., Aaronson, E., Fischer, M., and O’Laughlin, K. N. (2014). Burmese refugee experience accessing health care in New Delhi: a qualitative study. Refug Surv Q, 33,  38–​53. Quosh, C., Eloul, L., and Ajlani, R. (2013). Mental health of refugees and displaced persons in Syria and surrounding countries: a systematic review. Intervention, 11, 276–​294. Rabkin, M., Fouad, F. M., and El-​Sadr, W. M. (2016). Addressing chronic diseases in protracted emergencies: lessons from HIV for a new health imperative. Glob Public Health, 1–​710 doi:1080/​17441692.2016.1176226. Ravishankar, N. and Gausman, J. (2016). Analysing Equity in Health Utilization and Expenditure in Jordan with Focus on Maternal and Child Health Services. Amman, Jordan: High Health Council of the Hashemite Kingdom of Jordan & UNICEF. Refugee Council USA. (2015). At the Breaking Point: Refugees in Jordan and Egypt. https://​static1.squarespace.com/​static/​577d437bf5e231586a7055a9/​t/​ 57a4dac0e6f2e1220f6a86d7/​1470421698603/​At+the+Breaking+Point+-​+RCUSA+Repo rt+on+Refugees+in+Jordan+and+Egypt.pdf. (accessed 11 July 2017). Refugee Rights Turkey. (n.d.) Health Care. Turkey. Asylum Information Database. http://​ www.asylumineurope.org/​reports/​country/​turkey/​health-​care-​0 (accessed 11 July 2017). Rutinwa, B. (2002). The end of asylum? The changing nature of refugee policies in Africa. Refug Surv Q, 21,  12–​41. Sanyal, R. (2017). A no-​camp policy: interrogating informal settlements in Lebanon. Geoforum, 84, 117–​125 doi:0.1016/​j.geoforum.2017.06.011.

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Scott, P. (2014). Black African asylum seekers’ experiences of health care access in an eastern German state. Int J Migr Health Social Care, 10, 134–​147 doi:10.1108/​ IJMHSC-​11-​2013-​0043. SIMHA. (2017). Access to Socio-​Economic Rights for Refugees: A Comparison Across Six African Countries. Cape Town: Scalabrini Institute for Human Mobility in Africa. Şimşek, Z., Yentur Doni, N., Gül Hilali, N., and Yildirimkaya, G. (2017). A community-​ based survey on Syrian refugee women’s health and its predictors in Şanliurfa, Turkey. Women Health, 1–​15 doi:10.1080/​03630242.2017.1321609. Spiegel, P. B., Checchi, F., Colombo, S., and Paik, E. (2010). Health-​care needs of people affected by conflict: future trends and changing frameworks. Lancet, 375, 341–​510 doi:1016/​s0140-​6736(09)61873-​0. Spiegel, P. B. and Qassim, M. (2003). Forgotten refugees and other displaced populations. Lancet, 362,  72–​4. Tanabe, M., Myers, A., Bhandari, P., et al. (2017). Family planning in refugee settings: findings and actions from a multi-​country study. Confl Health, 11, 9 doi:10.1186/​s13031-​017-​0112-​2. The News. (2017). 1.6 million Afghan refugees still in Pakistan. The News, 30 June. https://​ www.thenews.com.pk/​latest/​213557-​16-​million-​Afghan-​refugees-​still-​in-​Pakistan (accessed 11 July 2017). UNHCR. (2009). Designing appropriate interventions in urban settings: health, education, livelihoods, and registration for urban refugees and returnees. http://​www.unhcr.org/​ protection/​hcdialogue%20/​4b2789779/​designing-​appropriate-​interventions-​urban-​ settings-​health-​education-​livelihoods.html (accessed 11 July 2017). UNHCR. (2011a). Global Trends 2010—​Refugees, Asylum Seekers, Returnees, Internally Displaced and Stateless Persons. Geneva: UNHCR. UNHCR. (2011b). Islamic Republic of Iran. UNHCR Global Appeal 2011 Update. Geneva: UNHCR. UNHCR. (2011c). UNHCR Global Appeal 2011 Update. Egypt. http://​www.unhcr.org/​ 4cd96bae2c.pdf (accessed 11 July 2017). UNHCR. (2013). Global Trends 2012. Displacement: The New 21st Century Challenge. Geneva: UNHCR. UNHCR. (2014a). Global Trends 2013. Iran. http://​www.unhcr.org/​globaltrends2016/​ (accessed 22 June 2017). UNHCR. (2014b). UNHCR Policy on Alternatives to Camps. Geneva: UNHCR. UNHCR. (2016a). Global Focus: Iraq. http://​reporting.unhcr.org/​node/​2547 (accessed 11 July 2017). UNHCR. (2016b). UNHCR Pakistan. Fact sheet. http://​unhcrpk.org/​wp-​content/​uploads/​ 2013/​12/​UNHCR-​Pakistan-​Fact-​sheet-​April-​20161.pdf (accessed 11 July 2017). UNHCR. (2017a). Global trends. Forced displacement in 2016. http://​www.unhcr.org/​ globaltrends2016/​(accessed 22 June 2017). UNHCR. (2017b). Yemen fact sheet March 2017. https://​reliefweb.int/​report/​yemen/​ unhcr-​yemen-​factsheet-​march-​2017. UNHCR. (n.d.) Services for refugees and asylum seekers in Kampala. https://​rorypecktrust. org/​getmedia/​e226ba06-​e300-​4094-​b871-​0ee540d69724/​UNHCR-​Brochure_​Services-​ Uganda.pdf.aspx (accessed 11 July 2017).

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UNHCR/​UNDP. (2010). Transitional Solutions Initiative. Geneva: UNHCR. Urban Refugees. (n.d.) Case Studies. Bangkok, Thailand. http://​urban-​refugees.org/​ bangkok/​(accessed 11 July 2017). Verghis, S. (2013). Access to Chin and Rohingya Refugee and Asylum Seekers to Maternal Health Services in the Klang Valley. PhD thesis, Monash University. Verghis, S. (2015). Why should we care about the health of non-​citizens? Malaysiakini, 29 October. https://​www.malaysiakini.com/​news/​317628 (accessed 11 July 2017). Verghis, S. and Pereira, X. (2009). Health concerns of refugees and asylum seekers. In Malaysia. Roundtable on Developing a Comprehensive Policy Framework for Refugees and Asylum Seekers, organized by the Bar Council, Malaysia, 23 June 2009. Kuala Lumpur. WHO. (2009). Health System Profile, Lebanon. Regional Health Systems Observatory, EMRO, World Health Organization. WHO. (2015). Regional Situation Report, April 2015. WHO response to the Syrian crisis. http://​www.emro.who.int/​syr/​syria-​infocus/​regional-​situation-​reports-​2015.html. WHO. (2016). WHO Treatment Guidelines for Drug-​Resistant Tuberculosis, 2016 Update. Geneva: World Health Organization. WHO. (2017). Regular vaccination of migrant population protects most vulnerable and helps Turkey maintain momentum towards measles elimination. http://​www.euro.who. int/​en/​health-​topics/​health-​determinants/​migration-​and-​health/​news/​news/​2017/​ 04/​regular-​vaccination-​of-​migrant-​population-​protects-​most-​vulnerable-​and-​helps-​ turkey-​maintain-​momentum-​towards-​measles-​elimination (accessed 11 July 2017). Women’s Refugee Commission. (2011). The Living Ain’t Easy. Urban Refugees in Kampala. New York, NY: WRC. Wong, W. C. W., Cheung, S., Miu, H. Y. H., et al. (2017). Mental health of African asylum seekers and refugees in Hong Kong: using the social determinants of health framework. BMC Public Health, 17, 153 doi:10.1186/​s12889-​016-​3953-​5. World Bank. (2017a). Jordan. Overview. http://​www.worldbank.org/​en/​country/​jordan/​ overview (accessed 11 June 2017). World Bank. (2017b). Lebanon. Overview. http://​www.worldbank.org/​en/​country/​lebanon/​ overview (accessed 11 June 2017). World Bank. (2017c). New country classifications by income level: 2017–​2018. https://​ blogs.worldbank.org/​opendata/​new-​country-​classifications-​income-​level-​2017-​2018 [Accessed 11 June 2017. Yıldız, A. and Uzgören, E. (2016). Limits to temporary protection: non-​camp Syrian refugees in İzmir, Turkey. Southeast Eur Black Sea Stud, 16, 195-​211 doi:10.1080/​ 14683857.2016.1165492.

Chapter 8

Addressing the rights of women in conflict and humanitarian settings Rajat Khosla, Sandra Krause, and Mihoko Tanabe

8.1 An unprecedented opportunity in challenging times The year 2015 presented an historic and unprecedented opportunity, bringing the countries and citizens of the world together to decide and embark on a new path to improve the lives of people everywhere. These decisions formulated the global course of action to end poverty, promote prosperity and well-​being for all, protect the environment, and address climate change. The centrality of human rights to sustainable development is recognized in the Sustainable Development Goals (SDGs) agenda. Agenda 2030 reaffirms that states must ‘respect, protect and promote human rights, without distinction of any kind as to race, colour, sex, language, religion, political or other opinions, national and social origin, property, birth, disability or other status’ (UNDESA, 2015). It emphasizes that the SDGs will not be achieved unless and until human rights and dignity are ensured for all individuals everywhere, leaving no one behind. However, the application of this approach has been met with challenges. The frequency and intensity of humanitarian crises around the world have increased over the last decade. Conflict, contagion, and disasters constitute the new normal for populations. The worst mortality and morbidity rates overall, and especially for women and children, occur in chaotic environments that are caused by and create breakdowns in governance, the rule of law, and support systems (WHO, 2015). They are characterized by destruction of public infrastructure including health facilities, massive population displacement, insecurity, and a collapse of the social contract. Hostilities may be actively directed at stigmatized populations, and governments may become hostile to displaced populations (Zeid et al., 2015).

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More than 80% of the 25 and 44 countries classified as making either ‘no progress’ or ‘insufficient progress’ towards achieving Millennium Development Goals 5 (to improve maternal health) and 4 (to reduce child mortality rates), respectively, have suffered a recent conflict, recurring natural disasters, or both (Zeid et al., 2015). According to UNOCHA majority of 134 million people across the world in need humanitarian assistance and protection are women and children. (UNOCHA, 2018). Disasters have a disproportionate impact on morbidity and mortality—​in fact, 95% of disaster fatalities occur in low-​and middle-​income countries (UNDP, 2014). Gender differences in disasters have been found to be closely linked to economic and social rights pre-​crisis. Studies show that in contexts where the socioeconomic status of women was high, men and women died in roughly equal numbers during and after disasters; whereas, where the socioeconomic status of women was low, more women died than men, or women died at a younger age (Neumayer and Plümper, 2007). Furthermore, certain risks associated with childbearing are compounded for girls who are exposed to forced or transactional sex (WRC/​SC/​UNHCR/​UNPF, 2012). Without access to emergency obstetric services, women and girls are at increased risk of dying during pregnancy or childbirth, or suffer preventable long-​term health consequences (PMNCH, 2014). Women and adolescent girls, especially those in fragile or hostile settings, face gender-​based exclusion, marginalization, and exploitation, including sexual and gender-​based violence (GBV). Gender inequality is a barrier to accessing essential services and contributes to harmful practices such as early and forced marriage. Risks can increase during emergencies, resulting in early pregnancies that further threaten girls’ lives (ICRW, n.d.). For instance, according to UN Women, the rate of child marriage among Syrian refugee girls in Jordan reached 51% in 2015, from 13–​17% in Syria before the current conflict (UN Women, 2015). Additional risks that women and girls face include rape, sexual assault, forced pregnancy and forced abortion, trafficking, forced marriage, and forced prostitution (Krug et al., 2002). Older women and women and girls with disabilities or HIV are additionally at heightened risk of sexual violence and GBV (Hutton, 2008; Atlas Alliance/​CBM, 2011; Tanabe et al., 2015b). In countries emerging from conflict, continued lack of access to health care, psychological and social support, and justice, coupled with ongoing sexual violence and GBV, impede recovery and development. Often, countries’ longer-​term development processes fail to include preparedness, response, and recovery. Globally, many SDG targets will not be reached without tailored attention to sustainable, inclusive development and

Unfinished agenda of women’s rights

participation for women and children in humanitarian settings (Save the Children, 2014). However, challenging as humanitarian settings are, they can present opportunities for reaching marginalized, remote, or otherwise underserved populations. Where humanitarian assistance is delivered in encamped spaces, this structure could facilitate the provision of services and information (Murshid, 2013). In camp settings specifically, the process of resettling displaced persons requires communication of health information (Morand, 2015), and openings exist for integrating family planning information and services, for example, into such processes (WHO, 2017c).

8.2 Unfinished agenda of women’s rights Progress has been slow, and disparities remain. The quinquennial MDG reviews highlighted that significant gaps remain to advance the health and human rights of women (UNPF, 2015). Persistent inequalities between women and men, adults and adolescents, and social and ethnic groups are reported across the world (Langer, 2006). Despite progress for some women in some areas, discrimination against women is arguably the most widespread human rights violation worldwide, with grave impacts on their health and well-​being (OHCHR, 2014). Discrimination and stigma in health-​care delivery are still widespread against women, especially those belonging to marginalized groups, preventing them from receiving essential health services (Vlassoff, 2007). Concerns remain about the use of punitive laws and sanctions in relation to accessing certain health services, including HIV and sexual and reproductive health services. These challenges are often further magnified within the context of humanitarian crises. In recent years, conflict, violence, and disaster have driven a dramatic rise in the number of displaced persons, both within and across national borders. According to the United Nations High Commissioner for Refugees (UNHCR), in 2016 there were over 68.5 million internally displaced persons (IDPs) and international migrants. The average time spent in displacement has reached 20  years (UNHCR, 2018). Evidence from recent emergencies demonstrates the intricate relationship among health, peace, and security, requiring countries to address these issues, not only in the aftermath of a disaster or conflict but also in efforts to build resilient health systems. Women, children, and adolescents are affected disproportionately in both sudden and slow-​onset emergencies and face multiple health and human rights violations (WHO, 2015).

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8.3 Why settings matter Crises expose significant weaknesses in health systems, differentially impacting subpopulations, especially women and adolescents (Tanabe, 2016). The proportion of women among refugees ranged between 47% and 49% from 2003 to 2015, while that of children ranged more widely, from 41% in 2009 to 51% in 2015 (UNHCR, 2016). Massive and long-​term displacement of women and children often result in their spending protracted time on the move or in otherwise fragile contexts. This has profound impacts on their life and well-​being, including their dignity and human rights in the intimate and often overlooked spheres of sexual and reproductive health (Zeid et al., 2015).

8.4 Humanitarian crises and sexual and reproductive

health as a human right 8.4.1 The rights context The appreciation of the disproportionate impact of conflict and disaster on women, children, and adolescents, and a lack of available services to address their needs, grew in the mid-​1990s (Schreck, 2000), with the release of a seminal report from the Women’s Commission for Refugee Women and Children, Refugee Women and Reproductive Health Care:  Reassessing Priorities (Wulf, 1994). The International Conference on Population and Development and Programme of Action identified reproductive health as a basic human right and affirmed the reproductive rights of displaced women as equal to those of all other women (UN, 1995a). The 1995 Fourth World Conference on Women in Beijing additionally reiterated these rights (UN, 1995b). Two networks formed thereafter, including the Inter-​Agency Working Group (IAWG) on Reproductive Health in Crises—​a collaboration of professional organizations dedicated to advancing the sexual and reproductive health of persons affected by conflict and natural disaster—​and the seven-​agency Reproductive Health Response in Crises Consortium. Both of these have since vigorously advocated for the realization of these rights for displaced women (Austin et al., 2008). The broader international human rights framework articulates the right to the enjoyment of the highest attainable standard of physical and mental health as a fundamental human right for all people in all settings, without distinction of race, religion, political belief, economic or social condition. As summarized by the Center for Reproductive Rights, people living in humanitarian settings have a right to equality and non-​discrimination; right to life; right to health; freedom from torture, cruel, inhuman, or degrading treatment (including from forced pregnancies); freedom from harmful traditional practices (including

Sexual and reproductive health

child, early and forced marriage, and female genital mutilation); freedom from sexual violence and GBV; and a right to an effective remedy for rights violations (cited in CRR, 2016). The committee that monitors the implementation of the Convention on the Elimination of all forms of Discrimination against Women (CEDAW) has additionally issued General Recommendation No. 30, which explicitly states that CEDAW remains in effect before, during, and in the aftermath of a conflict, and that states have a due diligence obligation to hold non-​state actors accountable for crimes perpetrated against women (CEDAW, 2013). In times of war where international humanitarian laws apply, Common Article 3 of the Geneva Conventions and the Rome Statute of the International Criminal Court stipulate that under certain conditions, acts of sexual violence can constitute war crimes or crimes against humanity (ICC, 1998). Hence, States Parties to international human rights treaties, the Geneva conventions, as well as the 1951 convention relating to the status of refugees, are required to ensure equal access to those affected by humanitarian crises the same treatment as accorded to their host-​country nationals with respect to public relief and social security, including access to health services (CRR, 2001).1

8.4.2 Operationalizing sexual and reproductive rights at the policy level The humanitarian response architecture has attempted to address the health needs of women and girls and realize their human rights through policy and guidance development. In 1995, the IAWG on Reproductive Health in Crises developed the Minimum Initial Service Package (MISP) for reproductive health to prevent excess morbidity a nd mortality in the initial days and weeks of an emergency, which it published as part of its guidelines, Reproductive Health for Refugees: An Inter-​agency Field Manual (UNHCR, 1995). The MISP is a coordinated set of priority activities aimed to prevent and respond to sexual violence; reduce HIV transmission; prevent excess maternal and newborn morbidity and mortality; and plan for the provision of more comprehensive reproductive health as the situation permits (IAWG, 2010). Since then, IAWG and its members have advocated for the inclusion of the MISP into the Sphere Handbook—​the most widely embraced humanitarian principles and standards—​and elevated it as a Sphere standard in the 2004 revision. The Sphere Handbook is now in its third edition (Sphere Project, 2011) and currently under revision. The MISP was further integrated into Inter-​agency Standing Committee (IASC) guidelines on GBV (IASC, 2005; IASC, 2015), gender (IASC, 2009), and HIV (IASC, 2010)  to provide operational guidance for programmatic interventions.

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In the broader policy sphere, with concerted IAWG advocacy, multiple global initiatives in the last few years have emphasized the importance of addressing women’s rights in humanitarian crises. In the context of disaster risk management for health, the Sendai Framework for Disaster Risk Reduction 2015–​2030 emphasizes the need to strengthen the design and implementation of inclusive policies and access to basic health services, including those related to sexual and reproductive health (UNISDR, 2015). The World Humanitarian Summit (2016) recognized the importance of comprehensive sexual and reproductive health care (UN, 2016). This was further reiterated in the outcome document of the UNHCR High-​level Meeting to Address Large Movements of Refugees and Migrants (2016), the new Global Strategy on Women’s, Children’s and Adolescents’ Health (2016–​30) and more recently, in a resolution adopted at the 140th Session of the World Health Organization Executive Board on Migration and Health (2017) (Every Woman Every Child, 2015; UNGA, 2016; WHO, 2017a). These landmark documents have not only helped highlight the importance of addressing sexual and reproductive health issues in humanitarian crises but have also underscored the fundamental gaps that persist. Low resilience in health systems and an absence of quality research and evidence in emergencies hinders the design and implementation of sustainable interventions (Askew et al., 2016). The 2016 High-​Level Meeting to Address the Movement of Refugees and Migrants, in particular, emphasized the importance of recognizing the vulnerabilities of women and children during the journey from the country of origin to country of arrival. This includes their potential exposure to discrimination and exploitation, as well as to sexual, physical, and psychological abuse, violence, human trafficking, and contemporary forms of slavery. It additionally emphasized the importance of combating such violence and the need to secure access to sexual and reproductive health services (UNGA, 2016). The World Health Assembly resolutions that govern the work of the World Health Organization (WHO) have further reinforced the need to ensure the health and human rights of populations in crises. The resolutions include 69.1 on ‘strengthening essential public health functions in support of the achievement of universal health coverage’ (2016); 69.11 on ‘health in the 2030 Agenda for Sustainable Development’ (2016); and 70.15 on ‘promoting the health of refugees and migrants’ (2017). Regarding sexual violence specifically, from 2000 to present, the United Nations Security Council has adopted resolutions 1325, 1820, 1888, 1889, 1960, 2106, 2122, 2242, 2272, and 2331 on Women, Peace and Security to establish the international policy framework to address the challenges women face in conflict and post-​conflict situations.2 Hence, the

Sexual and reproductive health

highest governing bodies have come to recognize the sexual and reproductive health needs in emergencies, as well as the rights of persons affected.

8.4.3 Progress and gaps for sexual and reproductive health as a human right The SDGs commit to an international development agenda based on the fundamental principle of leaving no one behind. Yet, the global convergence between conflict, crisis, migration, poverty, and young populations is driving grave health and human rights consequences for those living in humanitarian settings, especially for sexual and reproductive health and rights. An estimated 26 million women and girls of reproductive age live in emergency situations, all of whom need sexual and reproductive health and rights information and services (UNPF, 2015). Evidence shows that pregnant women may have increased medical risks such as gestational hypertension and anaemia, along with adverse pregnancy outcomes, including low birth weight or preterm birth (Masterson et al., 2014). Studies also show that humanitarian crises further increase the risk of pregnancy‐related death due to pre‐existing nutritional deficiencies, susceptibility to infectious diseases, lack of access to antenatal care, and lack of availability of assisted deliveries and emergency obstetric care (WHO, 2017b). Recent reviews highlight that mainstreaming of sexual and reproductive health into humanitarian health responses has grown. The 2012–​14 IAWG global evaluation found governmental and non-​governmental agencies self-​ reporting growth in institutional capacity to address sexual and reproductive health in crises, including through instituting organizational policy frameworks and accountability mechanisms, as well as increasing dedicated staff and financial resources to this issue (Tran et al., 2015). This growth in institutional capacity has also been reflected in responses to emergencies. The global evaluation further saw an increase in the number of emergency health and protection proposals that included sexual and reproductive health, for the 12 year period 2002–​13 (Tanabe et al., 2015a). Funding has also increased for sexual and reproductive health in humanitarian settings; an analysis of official development assistance (ODA) to 18 conflict-​affected countries found that from 2002 to 2011 overall ODA for sexual and reproductive health increased by 298% (Patel et al., 2016). Regarding service delivery, country studies from Jordan, Democratic Republic of the Congo, Burkina Faso, and South Sudan demonstrated increased awareness of the MISP standard of care and implementation of the MISP; expanded access to post-​abortion care; expanded HIV prevention, particularly regarding prevention of mother-​to-​child transmission and antiretroviral therapy; and increased attention to, and documentation of, GBV (Casey et al. 2015; Krause

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et al., 2015). Multiple other studies have further demonstrated the feasibility of providing long-​acting methods of contraception in humanitarian settings, as well as the creation of subsequent demand for this service from the community (Casey et al., 2013; Curry et al., 2015; Casey and Tshipamba, 2017). However, the global evaluation also found significant gaps remaining, largely due to a lack of equitable and adequate funding dedicated to sexual and reproductive health (SRH) services. Discrepancies exist in funding and programmatic attention towards the various components of SRH; over half (56.3%) of the 298% increase in total SRH-​related ODA disbursements was due to substantial increases in HIV/​AIDS funding (Patel et al., 2016). Programmatic gaps are further apparent, with gaps in the provision of SRH components, including emergency obstetric care, long-​term and permanent methods of family planning and emergency contraception, care for survivors of sexual violence, comprehensive abortion care, and cervical cancer screening and treatment (Casey et al., 2015). Availability, accessibility, and quality of care have further been impeded by logistics and supply chain gaps; lack of access for adolescents (Tanabe et al., 2017a); limited community involvement; and challenges in transitioning from the MISP to more comprehensive SRH services (Casey et al., 2015). As a result of these gaps, the full range of SRH services remains precarious in most settings (Chynoweth, 2015). This situation is compounded by a very weak evidence base and a lack of high-​quality evaluation studies and health systems and service delivery data for monitoring, programming and budgeting (Casey, 2015). An additional concern is an inequity between humanitarian and non-​ humanitarian settings. An ongoing funding gap additionally exists between stable development settings and conflict-​affected countries. The average annual per capita ODA for SRH activities to non-​conflict-​affected countries is 57% higher than to conflict-​affected countries, despite the latter having greater SRH needs (Patel et al., 2016).

8.5 Creating a common agenda for promoting and

protecting women’s rights in crises As enshrined in existing norms and agreements, the right to the enjoyment of the highest attainable standard of health should be exercised through non-​ discriminatory, comprehensive laws, and policies and practices that include social protection (CRR, 2016). From a public health perspective, this underscores the importance of equitable access to health services. International human rights norms and standards require equitable access to health promotion, disease prevention, and care. These should be provided to everyone, including those living in humanitarian settings, without discrimination based on gender,

Women’s rights in crises

age, religion, nationality, or race (WHO ROE, 2016); and in accordance with the international law for refugees (UNGA, 1951). The health of refugees and migrants should not be considered separately from the health of the overall population. Where appropriate, refugees and migrants should be integrated into existing national health systems, plans, and policies, with the aim of reducing health inequities and goal of achieving the SDGs. Human rights further prompt health systems to be responsive and resilient to crises by requiring them to be refugee-​, migrant-​, and gender-​sensitive and people-​centred. The aim should be to deliver culturally, linguistically, and gender-​and age-​responsive services (WHO, 2016). The legal status of populations in crises is often varied and complex,3 and their health needs may be similar to those of the host population or may vary greatly from them. What is important to emphasize is that women and girls in such settings may have been exposed to distress, torture, sexual violence, and GBV associated with conflict or displacement, and may have had limited access to preventive and curative services before their arrival in the host country. Health conditions experienced by refugees and other displaced persons should not be used as an excuse for imposing arbitrary restrictions on the freedom of movement, stigmatization, deportation, and other forms of discriminatory practices. International human rights law requires that protection measures and safeguards should be in place for health screenings for refugees to ensure non-​stigmatization, privacy, and dignity, and the screening procedure should be implemented on the basis of informed consent and to the benefit of both the individual and the public. It should also be linked to accessing risk assessment, treatment, care, and support. Addressing the complexity of humanitarian crises should, therefore, be based on international human rights norms and standards. While the health sector has a key role to play in ensuring the health and human rights of populations in crises, effective solutions require a coordinated approach that includes civil society, government, the private sector, and affected communities themselves. Ensuring participation and social inclusion of women, and specifically in planning and decision-​making related to health services, is imperative in this regard. Health policies, strategies, plans and interventions across the crisis cycle should be participatory, with women, girls and other at-​risk groups involved in relevant decision-​making processes. Box 8.1 lists a series of recommendations for realizing the sexual and reproductive rights of all. While much guidance on health and human rights in crises exists, it is not always well known or systematically distributed and implemented. ‘Cherry-​ picking’—​the offering of only selected services—​leads to fragmented services,

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Box 8.1.  Realizing sexual and reproductive rights for everyone 1. Promote a rights-​based approach that enhances participation, builds resilience, and empowers persons affected by humanitarian crises ◆ Engage crisis-​affected communities in programme design, monitoring, and evaluation to enhance acceptability and embed accountability. ◆ Support community resilience-​building and disaster risk management and preparedness activities (Tanabe, 2016). ◆ Foster participation and focus particular attention to the needs of adolescents and other marginalized groups, such as persons with disabilities; sex workers; elderly people; and lesbian, gay, bisexual, and transgender persons (IAWG, 2016).

2. Strengthen the evidence and guidance on SRH interventions in humanitarian settings ◆ Improve data collection and analysis by strengthening health management information systems and use innovative technologies to facilitate programme documentation. ◆ Promote task-​sharing and capacity development initiatives to empower the community-​level workforce and build the evidence base around alternative service delivery models to service hard-​to-​reach areas. ◆ Revise and adapt existing guidelines to incorporate the specific considerations related to humanitarian settings for implementation. Revisions to the IAWG field manual provide opportunities to draw normative change over time around expectations for service delivery in humanitarian settings.

3. Continue advocacy and leadership for advancing SRH in humanitarian settings ◆ Strategies to engage women as change agents in humanitarian contexts ◆ Equitable funding for SRH in humanitarian settings ◆ Integrated and comprehensive SRH services, regardless of political pressure (Askew et al., 2016).

Creating a new vision for the future

with exclusion, in particular, of critical services for women, such as comprehensive abortion care and family planning services. Multiple reviews point towards substantial evidence gaps because of a historical lack of investment in systematic, robust research and research capacity on SRH in humanitarian settings (Warren et al., 2015). Challenges with research methodologies continue to plague progress in this regard. While conducting rigorous research in humanitarian settings is often difficult, organizations have successfully used innovative, ethical, and participatory approaches (Tanabe et al., 2017b). Quasi-​experimental designs remain an underused option. Many research designs exist: a methodology should be used that best suits the research question. Country case studies provide a snapshot of what is occurring in a country, but different methodologies are needed to identify interventions that work and assess generalizability across settings.

8.6 Creating a new vision for the future To respond to these challenges, and to realize the SDGs’ vision of leaving no one behind, the global strategy sets out a vision for an integrated, multisectoral action agenda whose ambition extends to the creation of ‘enabling environments’ and transformational change (Zeid et al., 2015). To ensure this vision delivers its promise of more rights-​based approaches requires leadership. It requires integrating human rights into health and public health programming and enhancing accountability for these rights. Addressing the gaps and inequities in implementation is essential to ensure that current and new generations of women and girls everywhere can claim and realize their health and human rights. When the right to health is upheld for women and girls, their access to other human rights is also enhanced, triggering a cascade of transformative change. Given that preventable death, ill-​health, and impairment are firmly rooted in the failure to protect human rights, this requires leadership to realize rights to health and through health. In many settings, the international community can play an important role, but given the primary duty of states to respect, protect, and fulfil human rights, national and local leadership are vital. Even when resources are restricted, committed leadership can make a major difference to the lives of women and girls. A transformative leadership agenda is vital if women and girls everywhere are to realize their health and well-​being. World leaders must form their efforts in pursuit of this agenda on the human rights principles of equality, inclusiveness, non-​discrimination, participation, and accountability. Evidence shows that this can create the transformation necessary to secure more peaceful, more equitable, and more inclusive societies.

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Notes 1. See document A70/​24 (WHO 2017a), paragraphs 11–​13. 2. See United Nations Security Council, Resolution 1325 on Women and Peace and Security, U.N. Doc. S/​RES/​1325 (2000); Resolution 1820, U.N. Doc. S/​RES/​1820 (2008); Resolution 1888, U.N. Doc. S/​RES/​1888 (2009); Resolution 1889, U.N. Doc. S/​RES/​1889 (2009); Resolution 1960, U.N. Doc. S/​RES/​1960 (2010); Resolution 2106, U.N. Doc. S/​RES/​2106 (2013); Resolution 2122, U.N. Doc. S/​RES/​2122 (2013); Resolution 2242, U.N. Doc. S/​ RES/​2242 (2015); Resolution 2272, U.N. Doc. S/​RES/​2272 (2016); and Resolution 2331, U.N. Doc. S/​RES/​2331 (2016). 3. The international legal framework applicable to refugees includes the 1951 convention relating to the status of refugees and its 1967 protocol, and relevant resolutions and conclusions of international bodies relating to the rights of refugees in respect of health, including the conclusions adopted by the Executive Committee of UNHCR. At the international level, there is also no universally accepted definition of the term ‘migrant’.

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Murshid, N. (2013). The Politics of Refugees in South Asia: Identity, Resistance, Manipulation. New York: Routledge. Neumayer, E. and Plümper, T. (2007). The gendered nature of natural disasters: the impact of catastrophic events on the gender gap in life expectancy, 1981–​2002. Ann Assoc Am Geographers, 97, 3. OHCHR. (2014). Women’s Rights and Human Rights. Geneva: Office for the High Commissioner for Human Rights Patel, P., Dahab, M., Tanabe, M., et al. (2016). Tracking official development assistance for reproductive health in conflict-​affected countries: 2002–​2011. BJOG, 123(10), 1693–​ 1704. doi:10.1111/​1471-​0528.13851. PMNCH. (2014). Protecting Women’s and Children’s Health from a Changing Climate. PMNCH Knowledge Summary #32. Partnership for Maternal, Newborn, and Child Health/​World Health Organization. http://​www.who.int/​pmnch/​knowledge/​ publications/​summaries/​ks32/​en/​index1.html. Reese Masterson, A., Usta, J., Gupta, J., and Ettinger, A. S. (2014). Assessment of reproductive health and violence against women among displaced Syrians in Lebanon. BMC Womens Health, 14, 25. doi:10.1186/​1472-​6874-​14-​25. Save the Children. (2014). State of the World’s Mothers 2014. Saving Mothers and Children in Humanitarian Crises. http://​www.savethechildren.org/​atf/​cf/​%7B9def2ebe-​10ae-​432c-​ 9bd0-​df91d2eba74a%7D/​SOWM_​2014.PDF. Schreck, L. (2000). Turning point: a special report on the refugee reproductive health field. Int Family Planning Perspect, 26(4),  162–​8. Sphere Project. (2011). Humanitarian Charter and Minimum Standards in Humanitarian Response, 3rd edition. Geneva: Sphere Association. Tanabe, M. (2016). Building National Resilience for Sexual and Reproductive Health: Learning from Current Experiences. New York: Women’s Refugee Commission. Tanabe, M., Meyers, A., Bhandari, P., et al. (2017a). Family planning in refugee settings: findings and actions from a multi-​country study. Confl Health, 11, 9. doi: 10.1186/​s13031-​017-​0112-​2. Tanabe, M., Nagujjah, Y., Rimal, N., et al. (2015b). Intersecting sexual and reproductive health and disability in humanitarian settings: risks, needs, and capacities of refugees with disabilities in Kenya, Nepal, and Uganda. Sex Disabil, 33(4), 411–​27. doi:10.1007/​ s11195-​015-​9419-​3. Tanabe, M., Pearce, E., and Krause, S. (2017b). ‘Nothing about us, without us’: conducting participatory action research among and with persons with disabilities in humanitarian settings. Action Res J, doi:10.1177/​1476750316685878. Tanabe, M., Schaus, K., Patel, P., et al. (2015a). Tracking humanitarian funding for reproductive health: a systematic analysis of health and protection proposals from 2002–​2013. Confl Health, 9(Suppl 1), S2. doi:10.1186/​1752-​1505-​9-​S1-​S2. Tran, N.-​T., Dawson, A., Meyers, J., et al. (2015). Developing institutional capacity for reproductive health in humanitarian settings: a descriptive study. PLoS ONE, 10(9), e0137412. doi:10.1371/​journal.pone.0137412. UN. (1995a). Programme of Action, International Conference on Population and Development. Cairo, 5–​13 September 1994. New York: United Nations.

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Chapter 9

The health challenges facing children on the move Susan Bissell and Jacqueline Bhabha

9.1 Introduction In 2015, over 400,000 children applied for asylum in Europe, including nearly 100,000 unaccompanied minors (UNICEF, 2016). With reports of large-​scale disappearance of migrant children, gang recruitment, and other forms of exploitation on the rise, there could not be a more timely moment to be writing about children (defined by international law as persons under 18) who are ‘on the move’ in the world today. An unprecedented number of these young people are indeed crossing borders; many more are internally displaced. Climate change, escaping conflict, crisis, and other violence can be added to more traditional economic drivers of mobility. Against background of current political trends, a ‘rights’ approach to children on the move becomes ever more urgent. This chapter explores the vulnerability and resilience of refugee children and adolescents. It examines standards and policies designed to protect and enable these young people to survive and thrive. Given the growth in its importance, the matter of minors being returned to their countries of origin is also examined. This is followed by an analysis of some real-​life situations in which existing standards and policies are applicable. What is ultimately clear is that for a range of reasons—​including the political and the practical—​there are growing challenges to the safety of children and youth who are on the move.

9.2 Health, protection, and survival It has long been known that children affected by conflict, displacement, or other emergencies, particularly those who are separated from parents or traditional caregivers, face heightened risks of poor health, including long-​term threats to both their physical and mental well-​being. Children who were of school age during World War II in Germany exhibited poor health outcomes and self-​reported health satisfaction decades later, in their mature adult years

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(Akbulut-​Yuksel, 2009). The same patterns of negative health impacts from conflict have continued to manifest themselves. A study on the consequences of the Ethiopian–​Eritrean conflict and its impact on child health outcomes indicates that malnutrition and lack of access to health facilities due to the conflict have a statistically significant impact on height, which is also potentially correlated with other forms of development (Akresh, Lucchetti, and Thirumurthy, 2011). Chronic malnutrition and low levels of age-​adequate immunization were also reported in children affected by the Angolan civil war, with significantly poorer health outcomes reported for children identified as living among supporters of opposition movements (Agadjanian and Prata, 2003). These health detriments are the product not only of the harsh political and economic circumstances associated with war, but also of the social breakdown and crises of law and order that follow on from such situations. As a result, in most emergency and conflict situations, children face an increased risk of sexual abuse and violence. Forced displacement and relocation present risks to the safety and security of children, as well as a potential source of psychological distress. Children affected by war and conflict are also faced with interruption to family life, schooling, routines, and rituals; the loss of their home; and for some the death of parents, family, and friends. According to UNESCO, war, conflict, and natural disasters can have a profound negative impact on the mental health of children, a large proportion of whom exhibit symptoms of post-​traumatic stress disorder (PTSD) (Tamashiro, 2010). Studies of child survivors of the Holocaust and children who had been interned in Japanese concentration camps also demonstrated that PTSD symptoms lasted for up to 50 years after exposure, while a study in Cambodia showed that not only children exposed to conflict but also their own subsequent children were affected by conflict-​related trauma (World Bank, 2003). Cognitive impairments have also been documented among children affected by conflict and war, and this has been posited to be a consequence of malnutrition, stunting, and the potential long-​term effects of shocks on the sensitive neurological systems of children in adverse conditions (World Bank, 2003). In a number of conflict settings, children as young as seven may have been abducted and forced into being child soldiers (Toole and Waldman, 1997). A  study in Uganda demonstrates that child abductees exhibit significantly higher levels of psychological distress symptoms than those who had not been abducted or forced into being child soldiers. However, it also found that resilience among former child soldiers was more robust than in the general population (Blattman and Annan, 2010). In Nepal, significant differences were found between the mental health status of children who had been conscripted as part of an armed group and those who had not (Kohrt et al., 2008).

International standards

State failures compound these serious health impacts on children on the move. These failures are not confined to refugee camps or transit spaces in the resource-​strapped countries of the global south. They are also evident in the deficient response to the needs of child refugees and migrants transiting to or arriving in the global north, including the European Union. A 2017 study noted that 91% of refugee children studied in Greece did not have the recommended vaccinations, leaving them vulnerable to contracting disease before and during migration (Pavlopoulou et al., 2017). The UNICEF report ‘Danger Every Step of the Way’ (UNICEF, 2016) documents the numerous challenges and vulnerabilities that migrant children were exposed to en route to Europe. Exposure to violence and sexual assault along the smuggling routes in North Africa and the Middle East was reported to be common, with children being forced into slave labour, including prostitution (UNICEF, 2016). Amnesty International noted that Syrian refugees en route to Europe through Turkey, many of whom were children, were denied access to health care and social protections. In addition, it reported that unaccompanied children were forcibly returned to Syria by Turkish authorities, placing them in clear and, at times, immediate danger (Amnesty International, 2016). Similarly, a report by Save the Children entitled ‘Protecting Syrian Children en route to Europe’ (Save the Children, 2017) documented the presence of ‘mental health risks’ and the need for psychosocial support for children on the move, noting particularly that facilities and protections for adolescents were sorely lacking.

9.3 International standards, norms, and policy—​some

key principles More widely and swiftly ratified than any other human rights treaty, the Convention on the Rights of the Child (CRC) serves as the critical reference point for what ought to be done for and with the world’s children. The only Member State yet to ratify the CRC is the United States of America, but US officials have ratified two of the three Optional Protocols to the CRC. One of these addresses the sale of children, child prostitution, and child pornography; the other the involvement of children in armed conflict. As widely ratified as it is, even for non-​ratifying Member States, the CRC is considered the common international law. Four general principles of the CRC are particularly relevant to the issues this chapter addresses:  survival, best interests, non-​ discrimination, and participation. In June 2016, a group of agencies collaboratively drafted a common set of principles to influence stakeholders responsible for implementing measures

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that affect the rights and needs of migration-​affected children (Bhabha and Dotteridge, 2016). 1. Children on the move and other children affected by migration shall be considered children first and foremost and their best interests shall be a primary consideration in all actions concerning them. 2. All children have the right to life, survival, and development. 3. Children have the right to liberty of movement within their State, and to leave their State and any other. 4. The detention of children because of their or their parents’ migration status constitutes a child rights violation and always contravenes the principle of the best interests of the child. 5. Children during all phases of migration shall not be separated from their parents or primary caregivers (unless this is in their best interests). 6. No child is illegal—​children should be protected against all forms of discrimination. 7. Child protection systems shall protect all children, including children on the move and children affected by migration. 8. Migration management measures shall not adversely affect children’s human rights. 9. Children have a right to express their views freely in all matters affecting them and to have their views taken into consideration in accordance with their age, maturity, and understanding of the options available. Just as they apply to children on the move, so international norms also define what is meant by ‘health’ and how current understandings of this term apply to children. The World Health Organization (WHO) defines health holistically, to include a much broader set of circumstances than the mere absence of disease. According to the WHO’s constitution, ‘Health is a state of complete physical, mental and social well-​being and not merely the absence of disease or infirmity’. This broad understanding is reflected in the child-​specific provisions about health set out in the CRC. Expanding on the conception of the right to health set out in previous human rights instruments, CRC Article 24 describes States Parties’ obligations with respect to child health as follows: States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.

Several aspects of this set of obligations merit brief comment. One is that states ratifying the CRC have an obligation to establish facilities that promote

The concept of ‘return’

not only treatment of illness but rehabilitation—​a critical service in the case of children on the move, many of whom experience the grave and lingering effects of trauma, displacement, loss, and separation, with serious physical and psychological consequences. A second important point is the explicit obligation to facilitate universal access to health care, irrespective of legal or citizenship status. This also has considerable relevance for migrant and refugee children, many of whom are in situations of precarious or irregular legal status. The human rights obligation articulated by the CRC requires states to establish firewalls between health service providers and vulnerable communities on the one hand and law enforcement and immigration control agencies on the other, to ensure that access is real and not illusory. Finally, because the CRC articulates a right to health that is ‘the highest attainable’ given the contextual circumstances, a one-​size-​fits-​all approach to child migrant health rights is no more appropriate to this group than to any other group of children. Instead, the CRC requires States Parties, to the best of their capacity and in line with their fiscal and economic resources, to gear their services and interventions to the target populations. In the case of child migrants, this means paying attention not only to the health needs that apply to all children at certain developmental stages (vaccination, sexual and reproductive health care) but also to specific needs linked to the migration context. The basic health principles set out in the CRC are relevant to all children on the move, not only because of the disruption inherent in their lives and its ensuing health consequences but also because the abnormal circumstances they experience compound the health needs that all children have and to which states have to respond.

9.4 The concept of ‘return’ for children and adolescents A key issue when considering the health and well-​being of children on the move is to ensure that measures taken by governments enhance rather than detract from their current state. In particular, where children have migrated abroad, either as forced migrants fleeing conflict or other disasters or for other reasons, careful and holistic consideration of the impact of permitting or prohibiting their continuing residence in the destination country is imperative from a child rights perspective. It follows that prevailing international standards and guidelines ought to guide the practice of returning children and adolescents to their countries of origin. Unsurprisingly, these are not dramatically different from the above-​mentioned principles. However, there are some important details to note, following the European Commission’s March 2017 presentation of new measures to safeguard the interests of migrants being returned.1

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First, determination of best interests for any and all children being considered for return should be based on a set of very specific procedures. This is a deliberate effort to systematize the process, reducing as much as possible the extent to which subjectivity informs the decision. The best interests determination has to be made before any consideration of return and must be undertaken by a trained professional, in consultation with parents, caregivers, guardians, and others involved in the life of the child. Reuniting a child with family is not in and of itself a sufficient reason for return. Considering the views of the child on this matter is imperative, alongside his or her safety, long-​term prospects after return, and other factors. This marks an important and positive development for at least two reasons—​a recognition of the agency and opinion of the child; and an acknowledgement that a best interests determination is not a short-​term matter, but rather with enduring effects on the child’s future health and well-​ being. Best interests must not equate with institutionalizing children on return, a practice that has not been uncommon historically. Best interests should also take into account differences in gender. This could, in our opinion, go further to address considerations of ‘gender identity’, not only gender, as well as special consideration for children living with disabilities and other discriminated and marginalized groups. Finally, whatever the outcome of this well-​documented process, the child has a right to counsel, and to appeal the decision. Second, in the case of voluntary return, some provisions have been introduced that are designed to safeguard and protect children and their families. The consequences of an unsolicited willingness to return must be based on a full understanding of what the consequences are likely to be. These need to be explained in such a way that the child truly understands them, in a language and manner adjusted to the evolving capacity of the child. Where the impact of voluntary return may carry with it stress and trauma, children and family members should have access to counselling and support as required. The notion of ‘safeguards’ is introduced. Third, there is a provision that takes on board the long-​term nature of ‘returns’, calling for careful planning and discussion between and among family, the child, and concerned authorities. A specific reference to placing children in institutions is noted, and children are not to be returned if an institution is the only option for their accommodation. The provision speaks of the issue of health specifically, as well as other basic needs, including eventual enrolment in school. The need for adequate planning and funding is emphasized, including provision for necessary social and other forms of support. All of these are to be considered and documented prior to the return of a child. A fourth provision insists that while forced return always contravenes the best interests of a child, where this must nevertheless take place safeguards are

In reality

again necessary. This is presented as doing the least harm possible, and taking measures that will protect the child to the maximum extent possible. No use of detention or restraint is mentioned, likewise no use of force. The provision emphasizes humane approaches: escorts for the child in plain clothes, medical and other professionals providing support as needed, and children remaining with family members in the process if they are present. Where possible even forced return should be done in a manner that is sensitive, for example, to a child completing a school year or term, receiving his or her leaving certificate, and other such measures of civility and common sense. Fifth, there are strong references to the collection, storage, and use of data that are specific to children. While the provisions, as written, are specific to migration in Europe, their underlying principles are clear. Data on children must be collected in a sensitive manner appropriate to children. It must be stored in a confidential, safe place. Data on children must not be shared with law enforcement and is to be used solely in the best interests of the child in question. Given the subjectivity of this, regulations are to be drawn up regarding data, children, and migration. These should include procedures regarding child-​ friendly fingerprinting. Sixth and finally, this set of provisions on the return of children and adolescents speaks to the matter of a child turning 18, the age of maturity under most legal systems. States should consider allowing children to remain, for education and employment. Consideration should also be given to the fate of the young adult if he or she must leave.

9.5 In reality The principles and provisions discussed in section 9.4 are laudable. They are an advance on thinking and practice to date, building on important human rights and child protection advocacy over the last two decades. Most recently the recommendations have been informed by the current European migration situation and the lived experience of an unprecedented number of young people on the move. What is prescribed is grounded in international human rights broadly, and in the human rights of children specifically. Unfortunately, the experience of children on the move—​from those in transit and destination countries to those returned, forcibly or otherwise—​falls alarmingly short of the well-​intentioned provisions and principles just summarized. As noted earlier, there are sociopolitical forces driving this lacuna in rights recognition and the operationalization of that recognition. Turning all of the recommended approaches into real programmes will be challenging, and costly. However, on the part of host communities and officials there has been

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a much-​needed shift in perceptions of child and adolescent migrants and attitudes towards them. There is no doubt that the challenges arising in current migration situations are having a significant physical and emotional health impact on the lives of thousands of children. Digidiki and Bhabha, in their recent work with child migrants in Greece, demonstrate that there is a real crisis of protection embedded in the broader migration crisis (Bhabha and Digidiki, 2017). They document sexual exploitation and abuse of children, not unusual in humanitarian settings, amplified by the fact that these children have already suffered en route to Greece. In addition, the authors link children’s vulnerability to violence to a number of structural and procedural issues: Specifically we draw attention to the lengthy asylum process, long wait times, inadequate accommodation facilities for vulnerable children, inhumane living conditions, lack of security, and ineffective humanitarian and child protection services. (p. 36)

It is clear in both the conclusions and recommendations of this sobering report that there is an enormous gap in even the basic infrastructure that would keep migrant children safe. A logical step forwards in addressing what is an increasing global crisis is the development of ‘agreements’ on how to proceed and who should do what among authorities, international actors, local civil society organizations, and others. Bhabha and Dottridge (2017) document this in their work on child rights and global compacts. Their work was supported by 27 organizations, all concerned with the current and seemingly worsening plight of children on the move. The authors address, among other things, best interests, child protection, non-​discrimination, immigration detention of children, access to services, and sustainable solutions. One unique feature of this work is the linkage to the Sustainable Development Goal Agenda, or Agenda 2030. In that new agenda, there is clear recognition of the importance of the safety and security of all the world’s children, wherever they are. There is explicit recognition of the imperative to end violence, exploitation, abuse, neglect, trafficking, torture, child labour, child marriage, and female genital mutilation/​cutting. All of these, as demonstrated by recent research in Greece (Bhabha and Digidiki, 2017), are entirely relevant to the health and well-​being of children and adolescents in the context of migration. The global compacts document (Bhabha and Dotteridge, 2017)  illustrates with examples the implications of implementing the principles and provisions outlined earlier in this chapter. Goals and targets are included, thus attaching measurability as an indicator of the success or failure of processes, and

In reality

of outcomes, for children. The document stresses the importance of collecting disaggregated data on migrant children and adolescents. The discussion in the previous paragraphs illustrates both the opportunities for reform and the serious challenges still outstanding in addressing the health and well-​being of children on the move. With vaccination rates dangerously low for refugee children, even those who have made it to the European Union, with malnutrition, physical morbidity, mental illness, sexual violence, and other forms of exploitation demonstrably on the rise for children on the move in regions as different as South East Asia, Central America, and North Africa, the time has come to galvanize an alerted international community into action. We have referred to several useful and promising policy innovations, and to some recent tools that provide positive instruments for future concerted action and political engagement in both the migration and development arenas. An additional promising occurrence is the growing evidence of self-​mobilization, active participation, and engagement among current and former child migrants themselves—​stories of academic success, political leadership, and creative contributions. The haunting image of young Alan Kurdi, the three-​year-​old Syrian boy who drowned off the coast of Turkey, should encourage us to promote more accessible, safe, and legal routes to protection for refugee children fleeing for their lives, as recommended in the policy briefings quoted earlier. In addition, the resilience of child migrants themselves provides powerful incentives to promote their best interests as vigorously as possible. A growing body of literature provides evidence of the remarkable endurance and courage of thousands of young people on the move as they navigate situations of exclusion, stigma, and extreme vulnerability. The situation of Ali, a 17-​year-​old unaccompanied child from Somalia, living alone in a shelter for unaccompanied young asylum seekers in Istanbul, is emblematic of the optimistic determination and enterprise that fuels many child migrant survival stories. His past was riddled with conflict, loss, separation, and deprivation—​his father killed by Al-​Shabaab and his mother forced to sell their ancestral lands to pay smugglers to ensure the escape of her two young teenage sons, Ali and his brother (forever separated from their mother and sisters). The experience of deracination could have been devastating, leading to lifelong trauma as the literature so often documents. Consider part of his first-​person narrative: Can a tree ever give up on his roots? If it does, it can’t drink water anymore; it will die. I wonder sometimes, why did my mother send us away? Why did not all of us live in another village? I could have built a hut from wood for all of us, next to the sea. I could have made a boat and fished for all my family; we could even open a restaurant. Maybe

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we wouldn’t earn that much, but we wouldn’t go hungry, I  am sure about that. But perhaps the rebels would have found us there too, and we would have had to leave everything behind once again, and we would have to live running away all the time, like a fugitive, so I suppose my mother must have known something that we did not understand at that time. Otherwise, why would she send us so far away? I ask this question all the time to myself, and sometimes I just cannot sleep, thinking all about the ifs; what if we stayed? What if we never migrated? How would have life been, back there? (Tibet, 2018)

Despite these dark reflections and a series of other traumatic incidents, including six months detention in a smuggler-​controlled transit house in the United Arab Emirates, Ali managed to build a resilient and optimistic outlook for himself, finding a way to reach Istanbul from Syria (‘we found ourselves once again in the middle of war’), to enrol in high school and doggedly nurture his aspiration of acquiring skills to promote future earning prospects to support his family. Asked to sketch his dream he says: Far away there is an island. I have a small boat, a small house, and I have a beautiful tree. I have some vegetables, and then there is a flag that will bring peace to my island. The world is truly an annoying place. Therefore this is the picture of someone who wants to stay on his own, someone who wants to be left alone. (Tibet, 2018)

No clearer evidence of the resilience and self-​reliance of young migrants in the face of uncertainty and discrimination exists than the case of the ‘Dreamers’; the young undocumented migrants brought to the United States by their parents as children. This large cohort of adolescents and young adults has persisted in claiming a future in their adoptive home despite threats of deportation, highly exploitative working environments that levy a grave physical and mental toll, public attacks, and legal uncertainties—​all stressors with the potential to be psychologically devastating. The United We Dream national youth-​led advocacy network consists of more than 50 affiliated organizations who have consistently pressed for legal status for this population. Challenges, risks, and hardships have abounded for them; some have been arrested, others live with acute poverty, social isolation, depression, insomnia, crippling anxiety, and other health-​related challenges (Gonzales, 2016; Terrio, 2018). And yet they have persisted, a testimony to the force of youthful spirit given opportunity and the prospects of nurture and acceptance.

Note 1. Much of this is drawn from the European Commission renewed EU Action Plan on Return announced on 2 March 2017, see http://​europa.eu/​rapid/​press-​release_​IP-​17-​350_​en.htm

References

References Agadjanian, V. and Prata, N. (2003). Civil war and child health: regional and ethnic dimensions of child immunization and malnutrition in Angola. Soc Sci Med, 56(12), 2515–​2527. Akbulut-​Yuksel, M. (2009). Children of war: the long-​run effects of large-​scale physical destruction and warfare on children. IZA Discussion Paper 4407. http://​ftp.iza.org/​ dp4407.pdf (accessed 28 February 2018). Akresh, R., Lucchetti, L., and Thirumurthy, H. (2011). Wars and child health: evidence from the Eritrean-​Ethiopian conflict. IZA Discussion Paper 5558. http://​ftp.iza.org/​ dp5558.pdf (accessed 28 February 2018). Amnesty International. (2016). Turkey: illegal mass returns of Syrian refugees expose fatal flaws in EU-​Turkey deal. https://​www.amnesty.org/​en/​press-​releases/​2016/​04/​turkey-​ illegal-​mass-​returns-​of-​syrian-​refugees-​expose-​fatal-​flaws-​in-​eu-​turkey-​deal/​ (accessed 28 February 2018). Bhabha, J. and Digidiki, V. (2017). Emergency within an Emergency: The Growing Epidemic of Sexual Exploitation and Abuse of Migrant Children in Greece. Boston: Harvard FXB Center. Bhabha, J. and Dotteridge, M. (2016). Recommended principles for children on the move and other children affected by migration. http://​principlesforcom.jimdo.com/​ (accessed 28 February 2018). Bhabha, J. and Dotteridge, M. (2017). Children’s Rights in the Global Compacts: Recommendations for Protecting, Promoting and Implementing the Human Rights of Children on the Move in the Proposed Global Compacts. Geneva and the UK: Oak Foundation, Terre des Hommes, and Save the Children. Blattman, C. and Annan, J. (2010). The consequences of child soldiering. Rev Econ Statist, 92(4), 882–​898. Gonzales, R. (2016). Lives in Limbo. Undocumented and Coming of Age in America. Oakland, CA: University of California Press. Kohrt, B. A., Jordans, M. J. D., Tol, W. A., et al. (2008). Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal. JAMA, 300(6), 691–​702. Pavlopoulou, I. D., Tanaka, M., Dikalioti, S., et al. (2017). Clinical and laboratory evaluation of new immigrant and refugee children arriving in Greece. BMC Pediatr, 17, 132–​142. Save the Children. (2017). Protecting Syrian children en route to Europe. https://​ resourcecentre.savethechildren.net/​node/​12177/​pdf/​protecting_​syrian_​children_​en_​ route_​to_​europe_​feb_​2017.pdf (accessed 28 February 2018). Tamashiro, T. (2010). Impact of conflict on children’s health and disability. Background paper for UNESCO/​Education for All Global Monitoring Report 2011. http://​unesdoc.unesco.org/​images/​0019/​001907/​190712e.pdf (accessed 28 February 2018). Terrio, S. (2018). Undocumented Central American children in the United States. In J. Bhabha, J. Kanics, and D. Senovilla Hernandez (eds.), Research Handbook on Child Migration. London: Edward Elgar.

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Tibet, E. (2018). Learning as agency: strategies of survival among the Somali unaccompanied asylum seeking youth in Turkey. In J. Bhabha, J. Kanics, and D. Senovilla Hernandez (eds.), Research Handbook on Child Migration. London: Edward Elgar. Toole, M. J. and Waldman, R. J. (1997). The public health aspects of complex emergencies and refugee situations. Annu Rev PublHealth 18, 283–​312. UNICEF. (2016). Danger every step of the way: a harrowing journey to Europe for refugee and migrant children. p. 7. https://​www.unicef.org/​emergencies/​childrenonthemove/​ files/​Child_​Alert_​Final_​PDF.pdf (accessed 28 February 2018). World Bank. (2003). Mental Health and Conflict. Washington: World Bank Group.

Chapter 10

The health impacts of displacement due to conflict on adolescents Anushka Ataullahjan, Michelle F. Gaffey, Paul B. Spiegel, and Zulfiqar A. Bhutta

10.1 Epidemiology Conflict causes the forcible displacement of populations, generating refugees and internally displaced persons (IDPs). A  refugee, according to the 1951 Geneva Convention, is an individual who is forced to flee their country of origin out of fear of persecution (UNHCR, 1951). An IDP flees their home for reasons similar to a refugee but remains within their country of origin (Lee, 1996). Without the crossing of an international border, the Geneva Convention does not afford IDPs the same protections as refugees (Lee, 1996). Consequently, IDPs are particularly vulnerable (Lee, 1996). Adolescence is the period between the ages of 10 and 19 years. It is a period of rapid cognitive, physical, and psychosocial change (UNFPA/​SC-​USA, 2009). Estimates of the number of refugee and displaced adolescents worldwide are limited. Where data are available, UNHCR publishes estimates of the number of persons of concern which includes refugees, asylum-​seekers, IDPs, stateless persons, and returnees, in specific geographies disaggregated by particular age groups; based on these data, approximately 15% of persons of concern are between the ages of 12 and 17 (Figure 10.1) (UNHCR, 2017). Current estimates are that there are approximately 22.5 million refugees and 65.6 million people displaced worldwide. If similar demographic patterns hold, then one can estimate that globally there are a minimum of 3.4 million refugees and 9.8 million displaced individuals between the ages of 12 and 17 (UNHCR, 2017). The number of displaced adolescents is far higher as these figures exclude individuals between the ages of 10–​11 and 18–​19 years. Forcibly displaced adolescents face difficulties obtaining health services with conflict disrupting care, aggravating existing health concerns, and introducing new health issues.

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Persons of Concern1 Disaggregated by Age

Country of Origin 0–4 years

18+ 16% 5–11 years

47%

22% 15% 12–17 years

1 Persons of concern is defined by the UNHCR as refugees, asylum seekers, IDPs, returned refugees, returned IDPs, stateless persons, and others of concern

Number of Outgoing Refugees

Syria

5,524,333

Afghanistan

2,501,410

South Sudan

1,436,667

Somalia

1,012,277

Sudan

650,588

Dem. Rep. Congo

537,429

Central African Rep.

490,869

Myanmar

490,265

Eritrea

459,390

Burundi

408,036

Table 1: Top 10 countries with the highest number of outgoing refugees in 2016

U.S.A. at least 712,731 Germany, at least 1,256,691

Turkey, at least 3,115,275

Iran, at least 979,526

Lebanon, at least 1,026,663 United States

Jordan, at least 720,748

Pakistan, at least 1,357,399

Uganda, at least 982,672

Ethiopia, at least 793,564 Kenya, at least 494,822 Total 5

311527S

Figure 2 Major countries of asylum for refugees in 2016

Figure 10.1  Age distribution of persons of concern (defined by UNHCR as refugees, asylum seekers, IDPs, returned refugees, stateless persons, and others of concern). Data from UNHCR.

Access to health services and commodities varies for displaced adolescents depending on the income level and the level of functioning of the health-​care system in their country of asylum. Many displaced populations are located in resource-​scarce environments; it is estimated that 84% of refugees are in lower-​ and middle-​income countries (UNHCR, 2017). Health services and commodities can be easier to access in refugee camps, where they are often provided free of charge. Individuals living outside camps face increased economic pressure and difficulties when accessing health care (UNHCR, 2015). Urban or rural locations also play a role in the availability of health services and commodities. Forcibly displaced adolescents have specific needs and require focused programming (UNFPA/​SC-​USA, 2009). Until recently there has been limited

Pathways to ill health

focus on the health and needs of adolescents. Several adolescent subgroups are considered high-​risk. These include adolescents who are female, very young (10–​14), orphaned/​unaccompanied, pregnant, or a member of a marginalized group (e.g. LGBTQ+, HIV+, disabled) (UNFPA/​SC-​USA, 2009). The needs of adolescent girls are often overlooked because of the lower social status constructed by their gender and age (Falb et  al., 2016). Very young adolescents, particularly girls, are at an increased risk of sexual abuse as the result of their limited power and autonomy (UNFPA/​SC-​USA, 2009). Orphaned and unaccompanied adolescents are particularly vulnerable to abduction and trafficking and face difficulty navigating the refugee application system (Lustig et al., 2004). The scope of this issue is significant, as there are approximately 75,000 unaccompanied children worldwide (UNHCR, 2017). Pregnant adolescents have an increased risk of maternal mortality and face risks associated with obstructed labour and obstetric fistulas (UNFPA/​ SC-​USA, 2009). They also face additional burdens related to family rejection and disownment. As a result, many seek unsafe abortions to avoid this stigmatization (UNHCR/​STC-​UK, 2002). Lastly, marginalized groups such as individuals who are LGTBQ+, HIV+, or have a disability may have increased difficulty accessing services, and face stigmatization and exclusion from community networks in their host and displaced populations (UNFPA/​ SC-​USA,  2009).

10.2 Adolescent burden of ill health It is estimated there are 1.3 million adolescent deaths a year worldwide (WHO, 2014), with the majority of these deaths occurring due to preventable causes (Sawyer et al., 2012). Despite the regional variability, the top five leading causes of death for girls aged 10–​14 are HIV, intestinal infectious disease, lower respiratory infections, road injuries, and diarrheal disease (Global Burden of Disease and Adolescent Health Collaboration, 2017). Similar patterns are seen in girls aged 15–​19, where the top five leading causes of death are road injuries, self-​harm, HIV, malaria, and lower respiratory infections (Global Burden of Disease and Adolescent Health Collaboration, 2017). For boys aged 10–​14 the top five causes of death are HIV, road injuries, drowning, intestinal infections, and lower respiratory infections, and for boys aged 15–​19 they are road injuries, interpersonal violence, self-​harm, drowning, and collective violence and legal intervention (Global Burden of Disease and Adolescent Health Collaboration, 2017).

10.3 Pathways to ill health Conflict has both direct and indirect effects on the health of adolescents (Devkota and van Teijlingen, 2010). Injury and death increase as a direct result

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Impacts of displacement on adolescents

of armed conflict (Garfield, 2008). The indirect health effects of conflict have significant long-​term implications for adolescent health. Displaced adolescents experience increased psychological trauma, nutrition deficiencies, and physical and sexual violence (Campbell, 2003; d’Harcourt and Purdin, 2009; Mowafi, 2011). Several factors exacerbate these health risks including poor access to care, disruption of family and community links, marginalization, economic pressure, and disruption of education. This section describes the negative effects of conflict on health and several of the pathways that increase the health risks of displaced adolescents.

10.3.1 Health impacts 10.3.1.1  Direct impacts of conflict During conflict, physical violence executed by armed militia increases adolescent injury and death. Children and adolescents are often targeted in an effort to quell future resistance (Barbara, 2008). They can experience serious injuries such as the loss of hearing, vision, limbs, or neurological functions (Barbara, 2008). Limited access to rehabilitation services means these injuries are debilitating and lifelong; survival is also lower among injured children and adolescents (Barbara, 2008). Sexual violence is a systematic aspect of some military offensives. The sexual assault of women during conflict is often framed as a way to humiliate and torture not only the individual women but also the men who are responsible for their protection and to whom they ‘belong’ (Campbell, 2003). The term genocidal rape describes the use of rape as a means to sexually ‘contaminate’ women. Genocidal rape has been used in ethnic conflicts such as with Tutsi women in Rwanda and Muslim women in the former Yugoslavia (Hynes, 2004). Rape during conflict is under-​reported due to stigma and other social factors. Available figures are therefore likely to be underestimated, masking the gravity. Although the direct impacts of conflict on adolescents are appalling, they represent only a portion of the impact of conflict on the health of adolescents (Garfield, 2008; d’Harcourt and Purdin, 2009). 10.3.1.2  Nutrition problems Impaired food availability during conflict and displacement worsens health outcomes for adolescents. Food insecurity is a key aspect of conflict (Banatvala and Zwi, 2000). In communities where agricultural self-​sufficiency is the primary food source, displacement can have large impacts on food consumption (d’Harcourt and Purdin, 2009; Urdal and Che, 2013). Children and adolescents often display reduced nutrition indicators prior to the conflict, which

Pathways to ill health

only worsens with ensuing conflict (d’Harcourt and Purdin, 2009). Anaemia is a pressing concern within refugee populations, particularly among adolescent girls (UNHCR, 2008). Conflict also reduces trade and supplies, and looting by soldiers can further decrease food availability (d’Harcourt and Purdin, 2009). Malnutrition experienced in conflict can have long-​term effects on populations. For instance, a study in Peru found women who were in utero during the civil war displayed decreased height in adulthood (Grimard and Laszlo, 2014). 10.3.1.3  Sexual and physical violence During conflicts, rates of opportunistic crime and murder increase (Ghobarah et  al., 2004). Children are trafficked and used as sexual slaves, combatants, porters, and domestic help (d’Harcourt and Purdin, 2009). Displaced adolescent girls are at an increased risk for sexual violence including trafficking and kidnapping (Mowafi, 2011). During the recent Iraq conflict, women and girls were afraid to leave their homes because of kidnappings (WRC, 2007). These kidnappings were often used as a means to coerce their male relatives (WRC, 2007). Many of these women were repeatedly raped, subsequently suffering miscarriages and long-​term mental health issues (WRC, 2007). Sexual and gender-​based violence is common during conflict. Alarmingly high rates of sexual violence have been seen in the eastern Democratic Republic of the Congo where increased sexual violence by armed combatants has normalized sexual violence against women, in turn leading to increased rapes by civilians (Bartels et al., 2011). Survivors of rape are often ostracized and rejected by their families; consequently, many avoid or delay accessing medical care out of fear of social exclusion (Steiner et al., 2009). Intimate partner violence is a serious concern during conflict and displacement; often it continues to persist even after refugees are resettled in their country of asylum (Hyder et al., 2007). Displacement decreases safety and increases exposure to violence as adolescents travel through harsh and dangerous terrain for weeks or months on end (Fazel et al., 2012). In the course of the journey, they are exposed to violence, extreme temperatures, disease, malnutrition, and physical exhaustion (d’Harcourt and Purdin, 2009). The ‘lost boys’ of Sudan are an incredible example of the hardships faced by children and adolescents as they travel to safety. This group travelled thousands of miles with many losing their lives to wild animals, armed militia, malnutrition, and exposure to the elements (d’Harcourt and Purdin, 2009). Once arriving at refugee camps, children and adolescents are still vulnerable to abuse, rape, extortion, and violence (Ashford, 2008; d’Harcourt and Purdin, 2009).

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10.3.1.4  Psychological trauma including child soldiers During conflict exposure to violence, displacement can worsen existing mental health issues and cause psychological trauma (Gasseer et al., 2004; d’Harcourt and Purdin, 2009; Mowafi, 2011). Adolescent refugees present with a variety of mental health issues including depression, anxiety, and post-​traumatic stress disorder (PTSD). PTSD is the most common war-​induced mental health issue (Al-​Jawadi and Abdul-​Rhman, 2007; Neuner and Elbert, 2007) with rates of 25–​70% among war-​exposed refugee children (Dyregrov and Yule, 2006). Mental health issues that are not addressed continue to persist, leading to compromised social functioning which can diminish the ability of refugee children and adolescents to be successful in school (Beers and De Bellis, 2002; Neuner and Elbert, 2007). Untreated mental health issues also have long-​term implications for economic development and the continuation of conflict (Neuner and Elbert, 2007). Recruitment of child soldiers is a common feature of many conflicts. Children and adolescents are easier to train, condition, and recruit since they are impressionable and defenceless. Armed militias prefer child soldiers as their lives are considered expendable (d’Harcourt and Purdin, 2009; Kelly et al., 2016). Child soldiering is highly gendered, with young girls forced into domestic roles and sexually abused, and young boys forced to participate in armed conflict (Kelly et al., 2016). Child soldiers are indoctrinated through a process of isolation, stripping of identity, intimidation, and control (Kelly et al., 2016). As frontline combatants, child soldiers are at increased risk of rape, torture, injury, anxiety, depression, suicidal ideation, and substance abuse (Lustig et al., 2004). Once child soldiers are free their mental health issues persist, with many believing they are unable to live a normal life (Kelly et al., 2016). Their ability to adjust to normal life after conflict is influenced by the length of time they spent as a child soldier (Lustig et al., 2004). Some child soldiers display dysfunctional attachment, others violent and exploitive behaviour (Barbara, 2008). Addiction is also a serious issue as many child soldiers are forced to consume drugs and alcohol to calm fears and lower their inhibitions (Barbara, 2008). In some conflicts, fears related to recruitment of child soldiers cause mass displacements of children and adolescents. To avoid abduction into the Lord’s Resistance Army in the Gulu area in northern Uganda, thousands of children and adolescents travelled to distant towns where they would live in makeshift shelters. To minimize the possibility of abduction, these individuals would only leave their homes at night and return before sunrise (Barbara, 2008).

Pathways to ill health

10.3.2 Factors exacerbating ill health 10.3.2.1  Excess health risks due to poor access to care Conflict disrupts access to preventive and curative health services. As conflict increases, government spending shifts from health services to weapons and munitions (Ghobarah et  al., 2004; d’Harcourt and Purdin, 2009; Urdal and Che, 2013). Health infrastructure, such as hospitals, is physically destroyed by artillery, weakening the provision of preventive services (Ghobarah et al., 2004; Iqbal, 2006; d’Harcourt and Purdin, 2009, Urdal and Che, 2013). Immunization programmes suffer greatly (Urdal and Che, 2013) and the unavailability of contraceptives increases the risk of unintended pregnancies (Gardam and Charlesworth, 2000). Qualified workers such as nurses, doctors, and other health personnel flee the conflict epicentre (d’Harcourt and Purdin, 2009). Limited personnel and an exhausted medical supply cause inflation of the costs of health care, and transport costs also increase as health services become sparse (Price and Bohara, 2013). Any remaining health personnel must adapt to working with limited supplies; for instance, conflict forced physicians in Iraq and Bosnia to perform Caesarean sections with no anaesthesia (Ashford, 2008). Insecurity can also disrupt physical access to services, as safety concerns prohibit travel. Displaced adolescents often arrive with compromised health due to long-​ term disruption of care. Many adolescents from conflict areas are missing routine immunizations, and thus have increased susceptibility to infectious diseases (Barbara, 2008). Measles epidemics are of particular concern in conflict-​affected and displaced populations. As a result of disrupted immunization schedules, adolescents can be at high risk for measles (Grais et al., 2011). Displacement exposes displaced populations and host populations to new infections to which they are increasingly susceptible, while exacerbating existing conditions (Banatvala and Zwi, 2000). Displaced adolescents may also face difficulties accessing health services in their new setting due to financial constraints. Orphaned and unaccompanied adolescents or families with limited means cannot afford health services. Adolescents are forced to find a way to obtain health commodities and services. In some contexts, adolescent girls resort to exchanging sex for money to purchase sanitary products (Sommer, 2012). Adolescents may also encounter several barriers to contraceptive access such as cost and cultural norms. As one study described, female Iraqi refugees in Jordan reported several providers refusing to sell contraceptives to adolescent girls (WRC, 2007).

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10.3.2.2  Disruption of family and community networks Forced displacement isolates adolescents from their community networks which provide safety and care (d’Harcourt and Purdin, 2009). Adolescence is a period of change and growth and those navigating through it require support:  however, with the disruption of community networks, adolescents are isolated (Campbell, 2003). These young people lose sources of information, assistance, and protection and are forced to navigate adulthood without role models (Campbell, 2003). The disruption of these networks has mental health implications; for instance, there is evidence that the presence of at least one positive adult or nurturing family member acts as a protective factor (UNFPA/​ SC-​USA,  2009). Orphaned and unaccompanied children are at an increased risk of violence, trafficking, abduction, and death (d’Harcourt and Purdin, 2009). They must support themselves financially, often resorting to behaviours that put them at risk, such as transactional sex. Orphaned and unaccompanied children and adolescents must also navigate the refugee process without assistance (Lustig et al., 2004). Many are unaware of their legal rights and do not seek hearings. It is estimated that less than half of refugee children have any legal representation (Lustig et al., 2004). 10.3.2.3 Marginalization Refugees and IDPs may face issues in their new communities. Ethnic, religious, and cultural differences between the displaced population and host population can lead to social marginalization. Accounts from Bosnian refugees in Sweden describe incidents of racial discrimination, bullying, and encounters with armed skinheads (Goldin et al., 2001). Many government policies exacerbate the social marginalization of refugees, such as policies that resettle different ethnic groups together that have animosity for one another, or place refugees in impoverished and disadvantaged areas (Goldin et al., 2001). Individuals who are LGBTQ+, HIV+, disabled, or a member of another vulnerable group experience further social marginalization. Adjusting to a new cultural context can be particularly difficult for displaced children and adolescents, especially those who are unaccompanied or orphaned. Cultural bereavement is common as this group attempts to adjust to their life in a new environment without the support of their community and social networks while missing their homeland (Lustig et al., 2004). 10.3.2.4  Increased economic pressure Armed conflict disrupts economic activity, increasing financial pressure on families (Fazel et al., 2012). Loss of income decreases the affordability of health

Interventions

care (d’Harcourt and Purdin, 2009). Conflict and displacement can separate families from male breadwinners, placing economic pressure on women and children (Gardam and Charlesworth, 2000). Many women have limited financial opportunities and must resort to transactional sex for food, shelter, and protection (Gasseer et al., 2004; Hynes, 2004; WRC, 2007). A UNHCR study found that in Guinea and Liberia, male aid workers were forcing girls between the ages of 13 and 18 to trade sexual favours for commodities (UNHCR/​SC-​UK, 2002). Some of these girls had unintended pregnancies, and their male sexual partners often refused to provide financial support for their offspring. Subsequently, these adolescent mothers faced increased financial pressure (UNHCR/​SC-​UK, 2002). They were highly reliant on aid, and in turn, more vulnerable to further sexual exploitation by aid workers (UNHCR/​SC-​UK, 2002). Early marriage, particularly of adolescent girls, increases during conflict in response to economic pressure (Charles and Denman, 2013). Some families marry off young girls to alleviate financial pressure, while some hope that their daughters will enjoy a higher quality of life in their marital home (Charles and Denman, 2013). Young girls who are out of school are more likely to be married at an early age (Campbell, 2003). Recently, increased early marriage has been seen among Syrian and Palestinian refugees in Lebanon (Charles and Denman, 2013). One study found that among Syrian refugees in Jordan, the marriage of girls younger than 18 had doubled since the beginning of the conflict in Syria (CARE, 2015). Early marriage increases the risk of adolescent pregnancy with the associated risks of maternal mortality and other pregnancy-​related complications (CARE, 2015). Financial constraints and displacement cause individuals to live in makeshift shelters. They are forced to live in inadequate conditions which exposes them to accident, disease, and injury (Gardam and Charlesworth, 2000; d’Harcourt and Purdin, 2009). These shelters are overcrowded, with limited fresh access to water, heating, and sanitation facilities (Banatvala and Zwi, 2000; Gasseer et al., 2004; Ghobarah et  al., 2004; Iqbal, 2006; Urdal and Che, 2013). Inadequate living conditions also increase disease transmission of HIV infection, cholera, tuberculosis, and malaria (Urdal and Che, 2013).

10.4 Interventions 10.4.1 Preventive and promotive interventions Adolescent refugees and IDPs rely on the provision of several interventions that are essential for the whole population including the provision of protection, food, shelter, water, and sanitation (Table 10.1). They also receive a variety of

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Global evidence of the effectiveness of interventions (pooled estimates)

Reduction of gender-​based violence

Interventions to prevent female genital mutilation (FGM)

Sexual reproductive health interventions

Distribution of firewood in Dadaab refugee camp to prevent gender-​based violence among women and girls5 ◆ reduction in incidence of reported rape at the camp

No evaluations found through literature scoping

Use of community-​based health workers to access female IDPs (15–​45 years) in eastern Burma3 ◆ increase in prevalence of contraceptive use of 23.9% to 45.0% (prevalence rate ratio (PRR) = 1.88 [1.63, 2.17]) Use of community based health workers to increase in the use of modern contraception among women (10–​49 years) in Afghanistan4 ◆ increase in modern contraceptive use (OR = 1.61 [1.12, 2.15])

Condom use (23 studies; RR = 1.11 [1.04, 1.20])1

Prevalence of FGM (3 studies; RR = 0.63 [0.49, 0.82])1 Knowledge of harmful consequences of FGM (3 studies; SMD = 1.53 [1.08, 2.16])1

Use of mobile outreach and public health strengthening in conflict affected populations (15–​49 years) in northern Uganda2 ◆ use of any FP method increased (adjusted odds ratio [OR] = 3.34 [2.27, 4.92) ◆ use of long-​acting and permanent methods increased from 1.2% to 9.8% (adjusted OR = 9.45 [3.99, 22.39]) ◆ the proportion of women with unmet need for FP decreased from 52.1% to 35.7%

Examples of the evidence on the effectiveness of interventions in conflict-​ affected populations

Mean knowledge of family planning (FP) score (13 studies; SMD = 2.04 [95% CI: 1.31, 2.78])1

Sexual and reproductive health

Interventions

Table 10.1  Evidence on the effectiveness of interventions for adolescents

Mean birthweight (8 studies; RR = 0.25 [0.08, 0.41]) 6 Low birthweight (9 studies; RR = 0.70 [0.57,0.84]) 6

Nutrition in pregnant adolescents

Mumps incidence (1 study; RR = 0.96 [0.42, 2.21])9 Measles incidence (1 study; RR = 0.12 [0.03, 0.38]) 9 Rubella susceptibility (1 study; RR = 0.27 [0.15,0.46]) 9

Varicella deaths (1 study; RR = 0.74 [0.56, 0.98]) 9

MMR

Varicella

( continued )

Use of general vaccination strategy to control varicella outbreaks among asylum seekers (15–​39 years) in Switzerland11 ◆ attack rate in rapid response strategy following case detection was 2.8% compared to 0% in general vaccination strategy

Use of expanded vaccination strategy to include adults over 15 years to address measles epidemic in Dadaab, Kenya, and Dollo-​Ado, Ethiopia10 ◆ no statistical analysis of impact

HPV prevalence (2 studies; RR = 0.56 [0.38, No evaluations found through literature scoping 0.82]) 9 Incidence of genital warts (3 studies; RR = 0.66 [0.52, 0.84]) 9

HPV

Infectious disease including immunizations

Maize fortification in refugees (10–​19 years) in Zambia7 ◆ increase in serum retinol of 0.16 µmol/​L (p