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Introduction

Before the escalation of conflict in Ukraine, the United Nations High Commissioner for Refugees (UNHCR) estimated that 82.4 million people were forcibly displaced around the globe, with refugees accounting for 26.4 million and 48 million internally displaced people. Moreover, 83% of refugees are hosted in developing countries and 73% are hosted in neighboring countries. The UNHCR estimates that as of March 22, 2022, there were 3,626,546 people globally being forced to flee their homes to seek safety and protection in neighboring countries.

The story of health and refugees is one of the ever-increasing inequalities; an antiquated system unfit to meet the realities of global population movements, and of a clash of principle and pragmatism with the overt politicization of an innate human right. It is a story that all too rarely has the dignity and rights of the individual at its core, and all too often focuses solely on clinical burden and cost. The clinical and healthcare challenges facing refugee populations are real, and while some of these health challenges are what is traditionally seen as 'refugee medicine,' the majority resonate from the collision of established health requirements recognizable in any society, with an international system inadequate and many times unwilling to meet those needs.  

On an individual or community level, these disparities and inadequacies are a stain on the global system in the 21st Century. Beyond that though, refugee healthcare challenges must be seen in a broader context. Consideration of healthcare as a contributor to the refugee movement, rather than simply a symptom of it, allows for a much broader discussion around the issues. Drawing the link between the erosion of accepted international norms on the protected status of healthcare, the weaponization of healthcare degradation, and drivers of the refugee crisis allows us to consider Refugee Healthcare in a context that considers healthcare as an independent determinant of national and global security. To treat the medical challenges of refugee healthcare without addressing the drivers of those challenges would be equivalent to addressing a patient's symptoms with no attempt to diagnose and manage the underlying cause, an approach that would garner a charge of negligence in any clinical setting. 



Rights and the Changing Face of Health


The UNHCR's 1951 Refugee Convention, along with its 1967 Protocol addressing the status of refugees, has health as a key and protected right, including 'equivocal healthcare standards' stating that refugees should have access to the same quality healthcare that those in the host country do. The political context within which the accepted norms and rights of the refugee were conceived have changed significantly, but that change is dwarfed by the change in healthcare over that same period. Healthcare inequalities globally have grown by almost all measures, with a significant portion of morbidity and mortality in low- and middle-income countries coming from medical conditions fully amenable to treatment or prevention with modern medicine. Infant and childhood mortality and morbidity remain stubbornly high across parts of the world that are net contributors to refugees. The cost and burden of healthcare globally have increased, with mounting economic pressures and rationing of services occurring.  As an indication of this, consider that in 1951, the year the UNHCR convention occurred, the only regularly used radiological investigation was plain film X-ray, only four antibiotics had been discovered, and only two were regularly used. There were no treatments for autoimmune conditions now considered mainstay, and no chemotherapy agents that had been trialed. The first antipsychotic medication, Chlorpromazine, would only be discovered later that year, a polio vaccine not for another four years, whilst treatments for chronic conditions such as hypertension, asthma, chronic obstructive pulmonary disease (COPD) and non-Insulin dependent diabetes would take decades. These medical advances come at a cost and are a challenge for many healthcare systems to meet with equity of access. This is amplified for the stateless migrant and presents a real challenge to host nations to meet increasing demand and needs whilst balancing their responsibility to their own citizens and health systems.



Refugee Health Inequalities

Refugees and migrants are often in good health, the arduous nature of being a refugee means those who are frail and sick often do not move. Despite this and particularly in the West, narratives exist that migrants are sources of communicable disease and a risk to a nation's public health.  This is mostly a political narrative based little on fact. Migrants' health status typically reflects the nation they are moving from, and whilst many are exposed to conditions that put them at risk from food and water-borne conditions due to lack of hygiene on the journey, the reality is that most diseases spread in a population occur AFTER arrival in the host nation.  Rates of HIV for example in migrants and refugees accessing Europe from the middle east increased post-arrival, not before. Refugees and migrants are not mass importers of disease, and the narrative around that serves nothing but a political agenda. There are, however, well-established needs for some refugee populations, and protocols and priorities exist for healthcare delivery in rapidly forming refugee populations, as outlined by the SPHERE standards. These are based predominantly around populations moving from areas with severe malnutrition and poor existing public health systems. The early immunization of measles is the often-quoted example, a programme to address this in unvaccinated populations due to its extreme transmissibility (R0 =12). To this could be added COVID-19, particularly due to the most recent variants. Key health determinants in refugee populations include:



Health as a Refugee Driver

Health is a societal enabler and a key tenet in any societal system, supporting cohesion, security, and safety.  As such healthcare is a mechanism of legitimating authority.  It fills a basic human need, and any organization or group that enables it is likewise legitimized.  It is for these exact reasons that healthcare systems have been supported by organizations such as Hezbollah, Boko Haram, and the Taliban, despite doing such whilst simultaneously disrupting or attacking established governmental or non-governmental healthcare efforts. The increasingly flagrant targeting of healthcare in conflict zones undermines the social fabric of communities and seeks to delegitimize the authorities they support.  In such a way, health is a determinant or driver of migration, as people seek safety and security.  It is not the only driver, but if those migrating do so in order to meet their basic human needs, then healthcare is often a major part of that.  Therefore, the rising attacks on healthcare contribute to the disruption of basic community infrastructure, leading to an increased humanitarian crisis.  More effort is needed to stop such attacks on healthcare personnel and facilities, not because they are protected under law - which they are, nor because attacks on healthcare are morally repugnant - which they are, but also because attacks on healthcare have implications beyond country borders, as it drives a migrant crisis.



Impact of Refugees on Healthcare Systems

There are ample examples in the medical literature demonstrating that the influx of refugees can overwhelm the host country's health systems. With the increased placement of refugees in host country communities rather than in camps, as seen recently in the Middle East and Europe, the immense burden placed on the health system can stress their ability to provide proper medical treatment for both the refugees as well as for the host country population.1 For example, throughout the Syrian crisis Jordan has been hosting over 673,000 registered refugees, with over 70% residing among host Jordanian communities and 30% residing in camps.2 Documented in a 2021 UNHCR report, ten percent of the refugees have a serious medical condition.3 Jordan is now facing a significant challenge as the healthcare system is dramatically strained due to excessive demand for its limited resources. Prior to late 2014, primary, secondary, and most tertiary public healthcare facilities were free for all refugees registered under UNHCR. Since late 2014, refugees have had to pay a co-payment equal to uninsured Jordanian citizens, because of the economic pressure on the host communities. The result has been that many refugees cannot afford basic healthcare.

In Greece, the impact of refugees on the health system has exacerbated the economic crisis the country was already facing. UNHCR reported that 2.28 million refugees arrived in Europe in 2015 and 2016 alone, from which 1,015,100 entered Greece.4 A total of 1,112,332 refugees have arrived in Greece by sea since 2014.5 Currently, 103,000 refugees live in Greece,6 leading to critical public health issues affecting emergency response and stretching health and social service, placing a burden on local hospital resources. Regional and international non-governmental organizations (NGOs) have been playing a crucial role in the primary healthcare of the immigrants, by some estimates providing half of their health requirements.7



Conclusion

With the Ukrainian war amplifying the global humanitarian and refugee crisis, the world is witnessing a catastrophic impact on both refugees and host country health systems. A fundamental change in the global approach toward refugees is needed to create sustainable solutions. Innovative approaches such as bolstering host country health systems to accommodate the influx of refugees, and consensus-driven unified global strategies to manage all aspects of refugee healthcare and minimize the duplication of efforts, are of paramount importance now more than they have ever been in recent history.



Footnotes

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