Health on the move: the impact of forced displacement on health
Good health depends on resources in the environment, control of disease threats and coordination of preventive and curative provision. Forced displacement represents a challenge to each of these elements that can last for years.
Ivorian refugees hosted in a village 10km away from the border. They left their village 2 weeks ago, walking 30 to 60km in order to flee the fighting in their country. Benoist Matsha-Carpentier / IFRC
After sudden-onset disasters, immediate health-issues typically concern food, water, sanitation and shelter. The March 2011 Japanese tsunami, the floods and landslides in the Philippines following Tropical Storm Washi in December 2011, and tornadoes in the US state of Kentucky in March 2012 all resulted in acute health challenges.
Problematic as these disruptions are, they are most threatening when combined with a population’s prevailing vulnerabilities. For example, the acute challenges presented by the Haiti earthquake, including a high number of crush injuries, were exacerbated by the chronic weakness of the health system. The crisis in Somalia reflects the interaction of acute health challenges related to shortages of food and water and chronic undernutrition, weak governance and political violence.
This combination of acute and chronic threats to health can lead to extraordinarily high mortality rates in refugee and displaced populations. By convention, a health emergency is defined by a mortality rate of more than three deaths per 1,000 of population per month – a rate exceeded in the 1990s among displaced populations in, for example, Angola, Bhutan, Bosnia, Burundi, Iraq, Mozambique, Rwanda, Somalia and Sudan.
For many forced migrants, displacement often leads to a life in organized refugee or internally displaced persons (IDP) camps. These facilitate monitoring of mortality and morbidity, surveillance, and rapid response to outbreaks of communicable disease. Such measures lead to as much as a 75 per cent decrease in deaths in six months.
However, camp conditions also present significant public health concerns. Crowded conditions enable rapid transmission of diseases such as cholera and hepatitis E, linked to limited access to water and sanitation.
Conflict and disaster in general contribute to an erosion of structures regarding sexual behaviour, and unsafe and transactional sex in such environments present health threats. Camp conditions further disrupt cultural norms, social conventions and community governance.
Management of risk for HIV and AIDS and other sexually transmitted diseases is a focus of concern in camps. But sexual and gender-based violence (GBV) also emerges, notably in terms of exposure to rape or other sexual abuse by armed groups.
Evidence of high levels of GBV is growing within camps. A study in IDP camps in northern Uganda found women facing up to ten times the risk of violent assault by their husband than by a stranger. The reason for this is unclear, but the loss of traditional male roles and authority has been frequently noted.
In camps or integrated settlements for IDPs or refugees, the health consequences of displacement are due less to the specific risks associated with migration than to the weaknesses of health systems. Other than in the immediate aftermath of a major disaster when there are specific health threats, most displaced populations face the same health problems as non-displaced populations, only in greater numbers. Even with conflict, mortality reflects inflated risk of existing patterns of disease more than deaths due to military action.
With forced migration, public health systems are chronically weak, and are weakened further by disruptions to logistics and drug supplies and loss of staff. Forced migrants are especially vulnerable to these disruptions and those affecting public health infrastructure and coordination. Maternal and reproductive health services are particularly vulnerable to disruption.
Continuity is another major challenge presented by the disruption of access to health systems for forced migrants. In the case of tuberculosis, for example, displacement can result in failure to complete the six months of DOTS or ‘directly-observed treatment short-course’. Similar challenges face IDPs who are receiving anti-retroviral therapy for HIV infection.
Another area where continuity of care among displaced populations is crucial is in relation to people with severe and enduring mental health problems.
These issues are of major significance after acute emergencies and major population displacement. But they continue to affect displaced populations in more protracted situations, including countries of asylum or resettlement. Here the concern is less disease risk or weakness in health systems, but more access to the health system as a result of legal, economic or cultural barriers.
These issues play out differently in the context of protracted displacement and permanent resettlement.
In the former case, for Iraqis in Jordan the UN refugee agency (UNHCR) is responsible for ensuring refugees’ access to health facilities through specialist clinics or supporting host government provision. Access is often severely restricted, however, with a minority of refugees receiving such support. In such contexts the work of the IFRC and National Societies may be crucial. In Jordan, the IFRC and the Jordanian Red Crescent have facilitated access to health care for unregistered refugees with a cash-transfer scheme engaging local health service providers.
By contrast, in countries of resettlement, barriers to health care for refugees may be more subtle. In the US, only refugees whose resettlement stems from a successful claim in a country of temporary settlement can register with a health-care provider within 60 days of arrival. Despite eligibility for Medicaid, refugees underutilize health provision, with major barriers to accessing health care often related to language and communication.
Health care in disasters and complex emergencies has advanced significantly in recent years. Surveillance and epidemiology have played a key role, documenting the risk of disease to displaced populations, the factors associated with this, and effective means of control. Measles, once a major threat to refugees, is well controlled now that children aged over six months are routinely immunized on arrival in a camp. The management of health for displaced populations is codified in the Sphere Handbook.
Professionalization requires not just evaluation and codification of effective interventions, but also harmonization of standards and principles, and it is also marked by improved coordination. The humanitarian field has witnessed significant investment in this area over the last decade. The cluster system has brought benefits to the health sector, with the global health cluster providing technical guidance, training and coordination. Practice on the ground appears varied, however, with recognition that the response to the 2010 Haiti earthquake was inadequate.
Camps may serve political and pragmatic ends, but much of camp life is toxic from a health perspective.
The mainstreaming of forced migrants’ health needs in national plans should apply not only to countries of temporary or protracted settlement but also to those of permanent settlement. There are frequently many barriers to effective service access in countries of resettlement, some rooted in socio-cultural practices.
This mainstreaming of health services is a crucial task for governments, but civil society plays an essential role. Access to health care is a key indicator of migrants’ integration into their countries of resettlement, and the role of civil society in advocating for and facilitating access to health care for displaced populations can be crucial. Perceived equity in health-care provision underpins stable governance.
Red Cross Red Crescent National Societies ensure the engagement of civil society with displaced populations. Kenya Red Cross youth volunteers have, for example, played a key role in work with displaced populations, including mediation with youth engaged in the post-election violence of 2010.
Consideration of migrants’ needs is an issue of equity, even though, as noted, they are often neglected in national exercises to prioritize health. Interventions are often made but are not accessible to all, such as reproductive, maternal and child health-services.
Maternal and child health services are a particular priority due to huge differentials in maternal and infant mortality between and within countries.
While communicable diseases remain a challenge, they centre more on logistics and political will than technical issues, but there is growing awareness of the incidences of non-communicable diseases in the lives of displaced communities.
Mental health and psychosocial support have become a major area of humanitarian programming. Although some criticize the prioritization of this area of work, the adoption of the Inter-Agency Standing Committee’s Guidelines on Mental Health and Psychosocial Support in Emergency Settings has put psychosocial interventions on a more rigorous footing.
Problematic as these disruptions are, they are most threatening when combined with a population’s prevailing vulnerabilities. For example, the acute challenges presented by the Haiti earthquake, including a high number of crush injuries, were exacerbated by the chronic weakness of the health system. The crisis in Somalia reflects the interaction of acute health challenges related to shortages of food and water and chronic undernutrition, weak governance and political violence.
This combination of acute and chronic threats to health can lead to extraordinarily high mortality rates in refugee and displaced populations. By convention, a health emergency is defined by a mortality rate of more than three deaths per 1,000 of population per month – a rate exceeded in the 1990s among displaced populations in, for example, Angola, Bhutan, Bosnia, Burundi, Iraq, Mozambique, Rwanda, Somalia and Sudan.
For many forced migrants, displacement often leads to a life in organized refugee or internally displaced persons (IDP) camps. These facilitate monitoring of mortality and morbidity, surveillance, and rapid response to outbreaks of communicable disease. Such measures lead to as much as a 75 per cent decrease in deaths in six months.
However, camp conditions also present significant public health concerns. Crowded conditions enable rapid transmission of diseases such as cholera and hepatitis E, linked to limited access to water and sanitation.
Conflict and disaster in general contribute to an erosion of structures regarding sexual behaviour, and unsafe and transactional sex in such environments present health threats. Camp conditions further disrupt cultural norms, social conventions and community governance.
Management of risk for HIV and AIDS and other sexually transmitted diseases is a focus of concern in camps. But sexual and gender-based violence (GBV) also emerges, notably in terms of exposure to rape or other sexual abuse by armed groups.
Evidence of high levels of GBV is growing within camps. A study in IDP camps in northern Uganda found women facing up to ten times the risk of violent assault by their husband than by a stranger. The reason for this is unclear, but the loss of traditional male roles and authority has been frequently noted.
In camps or integrated settlements for IDPs or refugees, the health consequences of displacement are due less to the specific risks associated with migration than to the weaknesses of health systems. Other than in the immediate aftermath of a major disaster when there are specific health threats, most displaced populations face the same health problems as non-displaced populations, only in greater numbers. Even with conflict, mortality reflects inflated risk of existing patterns of disease more than deaths due to military action.
With forced migration, public health systems are chronically weak, and are weakened further by disruptions to logistics and drug supplies and loss of staff. Forced migrants are especially vulnerable to these disruptions and those affecting public health infrastructure and coordination. Maternal and reproductive health services are particularly vulnerable to disruption.
Continuity is another major challenge presented by the disruption of access to health systems for forced migrants. In the case of tuberculosis, for example, displacement can result in failure to complete the six months of DOTS or ‘directly-observed treatment short-course’. Similar challenges face IDPs who are receiving anti-retroviral therapy for HIV infection.
Another area where continuity of care among displaced populations is crucial is in relation to people with severe and enduring mental health problems.
These issues are of major significance after acute emergencies and major population displacement. But they continue to affect displaced populations in more protracted situations, including countries of asylum or resettlement. Here the concern is less disease risk or weakness in health systems, but more access to the health system as a result of legal, economic or cultural barriers.
These issues play out differently in the context of protracted displacement and permanent resettlement.
In the former case, for Iraqis in Jordan the UN refugee agency (UNHCR) is responsible for ensuring refugees’ access to health facilities through specialist clinics or supporting host government provision. Access is often severely restricted, however, with a minority of refugees receiving such support. In such contexts the work of the IFRC and National Societies may be crucial. In Jordan, the IFRC and the Jordanian Red Crescent have facilitated access to health care for unregistered refugees with a cash-transfer scheme engaging local health service providers.
By contrast, in countries of resettlement, barriers to health care for refugees may be more subtle. In the US, only refugees whose resettlement stems from a successful claim in a country of temporary settlement can register with a health-care provider within 60 days of arrival. Despite eligibility for Medicaid, refugees underutilize health provision, with major barriers to accessing health care often related to language and communication.
Health care in disasters and complex emergencies has advanced significantly in recent years. Surveillance and epidemiology have played a key role, documenting the risk of disease to displaced populations, the factors associated with this, and effective means of control. Measles, once a major threat to refugees, is well controlled now that children aged over six months are routinely immunized on arrival in a camp. The management of health for displaced populations is codified in the Sphere Handbook.
Professionalization requires not just evaluation and codification of effective interventions, but also harmonization of standards and principles, and it is also marked by improved coordination. The humanitarian field has witnessed significant investment in this area over the last decade. The cluster system has brought benefits to the health sector, with the global health cluster providing technical guidance, training and coordination. Practice on the ground appears varied, however, with recognition that the response to the 2010 Haiti earthquake was inadequate.
Camps may serve political and pragmatic ends, but much of camp life is toxic from a health perspective.
The mainstreaming of forced migrants’ health needs in national plans should apply not only to countries of temporary or protracted settlement but also to those of permanent settlement. There are frequently many barriers to effective service access in countries of resettlement, some rooted in socio-cultural practices.
This mainstreaming of health services is a crucial task for governments, but civil society plays an essential role. Access to health care is a key indicator of migrants’ integration into their countries of resettlement, and the role of civil society in advocating for and facilitating access to health care for displaced populations can be crucial. Perceived equity in health-care provision underpins stable governance.
Red Cross Red Crescent National Societies ensure the engagement of civil society with displaced populations. Kenya Red Cross youth volunteers have, for example, played a key role in work with displaced populations, including mediation with youth engaged in the post-election violence of 2010.
Consideration of migrants’ needs is an issue of equity, even though, as noted, they are often neglected in national exercises to prioritize health. Interventions are often made but are not accessible to all, such as reproductive, maternal and child health-services.
Maternal and child health services are a particular priority due to huge differentials in maternal and infant mortality between and within countries.
While communicable diseases remain a challenge, they centre more on logistics and political will than technical issues, but there is growing awareness of the incidences of non-communicable diseases in the lives of displaced communities.
Mental health and psychosocial support have become a major area of humanitarian programming. Although some criticize the prioritization of this area of work, the adoption of the Inter-Agency Standing Committee’s Guidelines on Mental Health and Psychosocial Support in Emergency Settings has put psychosocial interventions on a more rigorous footing.
Persecution and forced migration in relation to sexual orientation and gender identity
In western Europe and North America, there have been important gains in LGBTI rights and recognition of the ‘pink’ dollar and vote, and the corresponding need to cater for this constituency in the domestic political arena. In sub-Saharan Africa, by contrast, persecution of sexual and gender minorities have, with support from religious and cultural conservatives, become an essential part of populist politics.
Sexual-orientation and gender-identity issues connect weaknesses in domestic political systems with tensions in international relations, as exemplified in recent threats by western governments like Sweden’s threat to make aid conditional on respect for LGBTI rights. These interconnections and the state-sponsored homophobia they produce generate new activism and asylum seekers.
Migration in areas that experience violent conflict or natural hazards often involves high risks and the consequences of displacement can be harmful. Risks may include repeated displacements of women and families undermining protective social networks, conflict over scarce resources, loss of ID papers, and return under less than optimal circumstances.
Support for community self-protection can take place on three levels of intervention, encapsulated by an ICRC model as:
• ‘Responsive action’ to prevent abuse or alleviate its effects
• ‘Remedial action’ to restore people’s dignity after a pattern of abuse
• ‘Environment-building’ to encourage authorities to respect the rights of individuals.
The ultimate protection measure in relation to forced migration is prevention, but it is also the most difficult. Supporting governments to protect their own people while at the same time diminishing a population’s exposure to risk is not easy. Success ultimately depends on the political will of the parties to conflict. Taking international action to prevent atrocities is very difficult. Often violent conflict escalates gradually but cannot be addressed until it reaches the level of large-scale atrocities.
A second question is whether to have a categorical approach. In other words, should the protection needs of the affected population as a whole be taken into account, or should the focus be on mitigating vulnerability for predetermined categories of persons? Should the approach be status-based, rights-based or needs-based?
Community protection strategies are not necessarily always without harmful effects: strategies developed during conflict may become liabilities during peace. Self-protection at times depends on engagement with the actors in a conflict.
This chapter concludes with three practical recommendations for governments, humanitarian organizations and donors.
Firstly, address shrinking protection space. Advocacy and action to address shrinking protection space are urgent as increasing numbers of people are trapped in chronic crisis, endless war, urban vulnerability or environmentally induced livelihood-problems.
Secondly, combine protection with livelihoods. It is possible to determine support based on assessment rather than designating different categories of vulnerable people. Some humanitarian organizations are already doing this, but recovering people’s access to institutions and livelihood options is one of the biggest challenges in protection work.
Thirdly, adapt the ICRC’s protection model and move environment-building beyond a national focus to one that addresses providers of protection at local, regional, national and international levels – from clan elders to host governments – in the light of shrinking protection space and increasing vulnerability of forced migrants.
Support for community self-protection can take place on three levels of intervention, encapsulated by an ICRC model as:
• ‘Responsive action’ to prevent abuse or alleviate its effects
• ‘Remedial action’ to restore people’s dignity after a pattern of abuse
• ‘Environment-building’ to encourage authorities to respect the rights of individuals.
The ultimate protection measure in relation to forced migration is prevention, but it is also the most difficult. Supporting governments to protect their own people while at the same time diminishing a population’s exposure to risk is not easy. Success ultimately depends on the political will of the parties to conflict. Taking international action to prevent atrocities is very difficult. Often violent conflict escalates gradually but cannot be addressed until it reaches the level of large-scale atrocities.
A second question is whether to have a categorical approach. In other words, should the protection needs of the affected population as a whole be taken into account, or should the focus be on mitigating vulnerability for predetermined categories of persons? Should the approach be status-based, rights-based or needs-based?
Community protection strategies are not necessarily always without harmful effects: strategies developed during conflict may become liabilities during peace. Self-protection at times depends on engagement with the actors in a conflict.
This chapter concludes with three practical recommendations for governments, humanitarian organizations and donors.
Firstly, address shrinking protection space. Advocacy and action to address shrinking protection space are urgent as increasing numbers of people are trapped in chronic crisis, endless war, urban vulnerability or environmentally induced livelihood-problems.
Secondly, combine protection with livelihoods. It is possible to determine support based on assessment rather than designating different categories of vulnerable people. Some humanitarian organizations are already doing this, but recovering people’s access to institutions and livelihood options is one of the biggest challenges in protection work.
Thirdly, adapt the ICRC’s protection model and move environment-building beyond a national focus to one that addresses providers of protection at local, regional, national and international levels – from clan elders to host governments – in the light of shrinking protection space and increasing vulnerability of forced migrants.
Health as a human right - does it apply to everyone?
One morning, Georgi waits to be attended at the Swedish Red Cross health-care centre in Stockholm. He has been here before and he knows that he will be taken care of safely. He has a prescription for medicine that he is unable to pay for, since he has no money.
Georgi and his wife Alina came from a former Soviet Republic some years ago. Alina had been persecuted for political reasons. They have not yet been granted asylum in Swe- den: they live without documents as irregular migrants and under very harsh circumstances. Alina is suffering from deep depression and the social authorities have placed their children in a foster home. Now the same authorities, according to Georgi, have refused to pay for the children’s medicine.
Georgi and his wife Alina came from a former Soviet Republic some years ago. Alina had been persecuted for political reasons. They have not yet been granted asylum in Swe- den: they live without documents as irregular migrants and under very harsh circumstances. Alina is suffering from deep depression and the social authorities have placed their children in a foster home. Now the same authorities, according to Georgi, have refused to pay for the children’s medicine.
Chapter 3 was written by Alastair Ager, Professor of Clinical Population & Family Health, Mailman School of Public Health, Columbia University, New York.
An IFRC project / www.ifrc.org
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