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Rayhan Ahmed Topader:
Health care access for refugees and migrants
Legal status is one of the most important determinants of the access of migrants to health services in a country. Each refugee and migrant must have full, uninterrupted access to a hospitable environment and, when needed, to high-quality health care, without discrimination on the basis of gender, age, religion, nationality or race. WHO supports policies to provide health care services irrespective of migrants’ legal status. As rapid access to health care can result in cure, it can avoid the spread of diseases; it is therefore in the interests of both migrants and the receiving country to ensure that the resident population is not unnecessarily exposed to the importation of infectious agents. Likewise, diagnosis and treatment of NCDs such as diabetes and hypertension can prevent these conditions from worsening and becoming life-threatening.Migrants’ risk for being infected or developing TB depends on: the TB incidence in their country of origin; the living and working conditions in the country of immigration, including access to health services and social protection; whether they have been in contact with an infectious case (including the level of infectiousness and how long they breathed the same air); and the way they travelled to Europe (the risk for infection is higher in poorly ventilated spaces). People with severe forms of infectious TB are often not fit to travel.
The incidence of TB in the countries of origin varies from as low as 17 new cases per 100 000 population in the Syrian Arab Republic to 338 in Nigeria. The average TB rate in the European Region is 39 per 100 000 population. TB is not easily transmissible, and active disease occurs in only a proportion of those infected (from 10% lifetime risk to 10% per year in HIV-positive people) and within a few months or a few years after infection. TB is not often transmitted from migrants to the resident population because of limited contact. In spite of the common perception of an association between migration and the importation of infectious diseases, there is no systematic association. Communicable diseases are associated primarily with poverty. Migrants often come from communities affected by war, conflict or economic crisis and undertake long, exhausting journeys that increase their risks for diseases that include communicable diseases, particularly measles, and food- and waterborne diseases. The European Region has a long experience of communicable diseases such as tuberculosis (TB), HIV/AIDS, hepatitis, measles and rubella and has significantly reduced their burden during economic development, through better housing conditions, access to safe water, adequate sanitation, efficient health systems and access to vaccines and antibiotics.These diseases have not, however, been eliminated and still exist in the European Region, independently of migration.
This is also true of vector-borne diseases in the Mediterranean area,such as leishmaniasis, with outbreaks recently reported in the Syrian Arab Republic. Leishmaniasis is not transmitted from person to person and can be effectively treated. Typhoid and paratyphoid fever are also registered in the European region. In the European Union, the vast majority of cases are related to travelling outside the EU. The risk for importation of exotic and rare infectious agents into Europe, such as Ebola, Marburg and Lassa viruses or Middle East respiratory syndrome (MERS),is extremely low. Experience has shown that, when importation occurs, it involves regular travellers, tourists or health care workers rather than refugees or migrants. The health problems of refugees and migrants are similar to those of the rest of the population, although some groups may have a higher prevalence. The most frequent health problems of newly arrived refugees and migrants include accidental injuries, hypothermia, burns, gastrointestinal illnesses, cardiovascular events, pregnancy-and delivery-related complications, diabetes and hypertension. Female refugees and migrants frequently face specific challenges, particularly in maternal, newborn and child health, sexual and reproductive health, and violence. The exposure of refugees and migrants to the risks associated with population movements psychosocial disorders, reproductive health problems, higher newborn mortality, drug abuse, nutrition disorders, alcoholism and exposure to violence increase their vulnerability to noncommunicable diseases (NCDs).
The key issue with regard to NCDs is the interruption of care, due either to lack of access or to the decimation of health care systems and providers; displacement results in interruption of the continuous treatment that is crucial for chronic conditions. Vulnerable individuals, especially children, are prone to respiratory infections and gastrointestinal illnesses because of poor living conditions, suboptimal hygiene and deprivation during migration, and they require access to proper health care. Poor hygienic conditions can also lead to skin infections. Furthermore, the number of casualties and deaths among refugees and migrants crossing the Mediterranean Sea has increased rapidly, with over 3100 people estimated to have died or gone missing at sea in the first 10 months of 2015, according to the United Nations High Commissioner for Refugees (UNHCR). Conflict and emergencies can disrupt HIV services; however, the prevalence of HIV infection is generally low among people from the Middle East and North Africa. Hence, there is a low risk that HIV will be brought to Europe by migrants from these countries. The proportion of migrants among people living with HIV varies widely in European countries, from below 10% in eastern and central Europe to 40% in most northern European countries; in western Europe, the proportion is 20–40%. Despite a decline during the past decade, migrants still constitute 35% of new HIV cases in the European Union and the European Economic Area; however, there is increasing evidence that some migrants acquire HIV after their arrival.
As many developing countries have a high burden of viral hepatitis, the increasing influx of refugees from highly endemic counties is changing the disease burden in Europe. Refugees and migrants do not pose an increased threat for further spread of respiratory infections from, for example, influenza viruses, respiratory syncytial virus, adenovirus, parainfluenza virus to the populations of the receiving countries, where these are common infections that circulate widely. However, physical and mental stress and deprivation due to lack of housing, food and clean water increase refugees’ risk for respiratory infections. Influenza can cause severe disease in known risk groups (pregnant women, children under the age of 5 years, people with chronic underlying conditions and the elderly). Who supports policies to provide seasonal influenza vaccine to risk groups, irrespective of their legal status. In line with WHO recommendations, most countries of the WHO European Region recommend seasonal influenza vaccination for health care workers.
When people are on the move and reach geographical areas different from those of their home country, they are more likely to experience disrupted or uncertain supplies of safe food and water, especially under difficult and sometimes desperate circumstances. In addition, basic public services such as electricity and transport can break down. In these conditions, people may be more prone to use inedible or contaminated food ingredients, cook food improperly or eat spoilt food.
Health issues associated with the movement of peoples have been on the agenda of the WHO European Region for many years. The WHO European health policy framework Health 2020 has drawn particular attention to migration and health, population vulnerability and human rights. Following the political, economic and humanitarian crises in the north of Africa and the Middle East, the WHO Regional Office for Europe, in collaboration with the Italian Ministry of Health, established the Public Health Aspects of Migration in Europe project in April 2012. Its aims are to strengthen the capacity of health systems to meet the health needs of mixed inflows of refugees, migrants and host populations; promote immediate essential health interventions; ensure refugee- and migrant-sensitive health policies; improve the quality of the health services delivered; and optimize use of health structures and resources in countries receiving these populations. Up to October 2015, the Regional Office had conducted joint assessment missions with the ministries of health of Albania, Bulgaria, Cyprus, Greece, Hungary, Italy, Malta, Portugal, Serbia and Spain, with the new Toolkit for assessing health system capacity to manage large influxes of migrants in the acute phase, to respond to and address the complex, resource-intensive, multisectoral, politically sensitive issues in health and migration.
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