Abbas Omaar
Research Assistant, Centre on Global Health Security
Osman Dar
Project Director, One Health Project, Centre on Global Health Security
Professor Ali ZumlaProfessor of Infectious Diseases and International Health, University College London
The acute health risks associated with large movements of refugees are manageable. But the global health community also has the opportunity to address the broader issues of inequality that are driving the crisis.
Migrants attend a concert in a makeshift theatre on 25 November 2015 in the so-called 'Jungle' migrant camp in Calais. Photo by Getty Images.Migrants attend a concert in a makeshift theatre on 25 November 2015 in the so-called 'Jungle' migrant camp in Calais. Photo by Getty Images.

The overwhelming burden of hosting the now 60 million forcibly displaced people worldwide has for decades fallen on the developing world, with 86 per cent of the total being cared for in low- and middle-income countries. With the physical impacts of this growing global crisis now spilling into in the developed world, the issue – including aspects related to health − has rapidly ascended the global political agenda.

Significant to note from a health perspective is that there is no systematic association between refugee migration and the importation of infectious diseases. There is also no clear evidence of benefits of obligatory border screening for infectious diseases like tuberculosis. Nor have there been any significant outbreaks of infectious disease linked to the hundreds of thousands of refugees that have arrived in Europe since the start of the current crisis (over 850,000 have crossed the Mediterranean since January 2015). Mass movements of people do carry some health risks. But collective health security in relation to refugees is better understood as a danger of socioeconomic inequality.

Institutional strength

Freed from rhetoric, health risks among refugees are minimal in most cases, or significant but manageable in others. For example, strong vaccine surveillance systems in Germany quickly detected measles immunization uptake rates as below optimal among incoming refugees to Lower Saxony and measures are already in place to vaccinate arriving groups.

High-income countries have both the institutional strength and the innovative capacity to find cost and clinically effective solutions to health challenges that might arise from the inward migration and also the ability to harness its socioeconomic opportunities and benefits. For example, the use of social outreach models of care and of mobile screening units in East London showed them to be clinically- and cost- effective in finding and treating hard to reach cases of tuberculosis. Conceivably, given this is a crisis of large mobile populations across Europe, the role of mobile diagnostic units that have an integrated support function for psychosocial care (e.g. a psychiatric nurse) may provide a cost-effective option for monitoring and addressing health needs as the refugee crisis evolves.

It is critical not to ignore the potential long-term public health challenges that diseases such as tuberculosis pose – research in the UK shows that 77 per cent of cases among migrants are diagnosed two years after entry into the country. This has important implications in both large organized accommodation sites for refugees as well as irregular sites such as ‘the Jungle’ in Calais where there can be high concentrations of residents and poor living conditions. Reports from Calais already indicate wholly inadequate health service provision and a growing incidence of common respiratory, gastrointestinal and skin infections like scabies.

But it is important to remember that an orderly integration of refugees into health systems is best achieved by making them feel welcome and not the subject of stigmatization, or persecution. Routine health checks in a hospitable and culturally sensitive environment is strongly recommended by the World Health Organization and the results of any screening programmes should not be used as a justification for deportation. Refugees often suffer long and arduous journeys enduring cramped, unsanitary environments which take a toll on both mental and physical health and serve to compound existing chronic conditions. Working to alleviate not exacerbate these is in everyone’s best interests.

Alleviating inequality

More importantly, with an ethos committed to reducing health and socioeconomic inequalities now is the opportune time for public health authorities to demonstrate leadership and play an integral role in the design of policies and interventions that will help alleviate the crisis. Through sound research and evidence-based practice the risks associated with widening inequalities between the developed and developing world must be clearly articulated and the threats to collective health security framed accordingly. There seems to be a tacit, if not entirely conscious, recognition of this forming with the recent EU agreement to provide €1.8 billion in support to Africa to address the drivers of outward migration.

The sums being discussed to address the problem at source however are only a fraction of what is needed. Investment will need to be better directed and will be effective only if coupled to transparency, good governance and political stability in refugees’ countries of origin. Much of that spend could go to more equitable structuring of commercial and economic agreements between the developed and developing world that would generate employment and opportunity.

Fundamental to the success of policies and evidence-based interventions will be strengthened inter-country coordination across the region. Ensuring accessibility to appropriate and culturally acceptable health services and supporting integration into host communities would improve European health security by upholding the human rights values it espouses and to which it is legally committed.

The 1920 Aliens' Order barred entry into Britain of immigrants with a range of medical conditions. This was reversed during the World Refugee Year (1959-60), and allowed entry to refugees who had tuberculosis and other chronic illnesses. These refugees were successfully integrated into local systems and the policy change represented a step change in Britain’s own multicultural and social evolution. So while many people continue to suffer the direct consequences of the current crisis, it perhaps also provides an opportunity and impetus for meaningful socioeconomic reform − one based on a reaffirmed commitment to a more equitable world.

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