Escape from threats in your home country, survive a journey that little can imagine, and then, finally, if you’re lucky, arrive in a country that you hope will welcome you. This is the reality for many refugees. But what then? A recent World Health Organization report has concluded that many migrants and refugees face worse health outcomes than the local population. We examine why health systems need to change to meet the needs of a changing world.
War in Ukraine, civil war in Syria, turmoil and hardship in Afghanistan – these are just some of the situations that lead people to leave their country.
According to the World Health Organization (WHO), worldwide, more people are moving than ever before.
But what happens when they arrive in the country where they hope to be safe? For some, asylum will be granted and they will be accepted, as evidenced by the efforts of Ukrainian asylum seekers in the United States and Europe.
For others, uncertainty and long battles to prove refugee status and obtain asylum will follow. During this time, they may struggle to access healthcare, leading to “worse health outcomes” described in the WHO report.
Some people are willing to leave their country of origin, but the situation sometimes makes it impossible to stay there. War, natural disasters, discrimination, and persecution are some of the reasons people have to leave, all of which can cause mental and physical scars.
To be able to undertake what will almost certainly be a difficult journey, most migrants, according to the WHO report, are healthy by nature. Indeed, many will begin their journey healthier than the host population in their destination country.
However, the WHO report found that:
“Refugees and migrants often experience poor living and working conditions when leaving, transiting or arriving in the host country and, therefore, face additional barriers to receiving appropriate diagnosis, care and treatment, which can increase the prevalence of diseases among them.”
If they survive the long land journey and perilous sea crossing, many migrants then spend long periods in transit camps or container centers en route to safe destinations.
Conditions in these centers can be dire, and many are unable to provide adequate healthcare for all who live there. This, inevitably, causes the deterioration of health for many.
Charities such as Médecins Sans Frontières (MSF) and other non-governmental organizations provide healthcare for some, but they cannot do so for all migrants.
A recent report from MSF on the situation in the container centers in the Greek islands identified “significant systemic and structural gaps in the provision of essential and urgent health services to asylum seekers, refugees, and migrants.”
For women, the situation can be especially challenging.
About 25% of female migrants are of reproductive age, so reproductive health is a major concern. The WHO report identified several problems in this region, including lack of antenatal care, malnutrition, and anemia in mothers and children during migration.
Facing menstruation during transit also carries a huge burden, especially for women from cultures where menstruation is a taboo topic.
The Oxfam 2020 report identified the shortage of menstrual hygiene materials (MHM) and “the lack of adequate, accessible, safe and private spaces” to change and remove MHM as the main problems for Syrian refugee women in camps in the Bekaa valley in Lebanon.
Another problem with the lack of privacy is that women may be reluctant to use the facilities because of the risk of experiencing sexual harassment and violence.
And this fear is unfounded – a 2015 study found that up to 69.3% of female migrants experienced some form of sexual violence since arriving in Europe.
The risk is greatest for women and children who migrate without family or social networks to protect them.
Those lucky enough to reach their destination country may arrive in good health, but that health does not always last. Dr. Luz Garcini, assistant professor at Rice University, Texas, spoke to Medical News Today about the situation of migrants coming to the US.
“Immigrants – who can endure such a difficult journey – they are healthier than US-born citizens. Eventually, the longer they spend in the US, the worse their health becomes. I think it’s because of stress […] we break it down.
So to maintain that health, they should try to access health care. According to the Refugee Council, access to healthcare is a fundamental right, but many migrants find that accessing healthcare at their destination is far from straightforward.
In the UK, refugees and asylum seekers are fully entitled to National Health Service (NHS) care. Refused asylum seekers, however, only have access to some aspects of NHS care, such as emergency care. Complicated rules create uncertainty and distress.
Helen Kidan, volunteer coordinator at BHN, a charity that works with asylum seekers in Bristol, England, told MNT about some of the problems that asylum seekers there face.
“The impact of the hostile environment in the UK [has] meant that many asylum seekers and refugees are worried about registering with [primary care] GP surgeries because of their immigration status and concerns about paying for medical assistance,” he said.
“GP surgeries also refuse registration to refuse asylum seekers in the [wrong] belief that they are not allowed to be registered,” Kidan added.
The situation in the US is similar. Many migrants, especially the undocumented, can only access minimal healthcare. Dr. Garcini explained that while emergency health care is available to immigrants, illegal immigrants do not have the right to care for chronic conditions.
“Say they have chronic kidney disease that needs some dialysis treatment – they can’t get access to it. […] So they have to choose to go back to their home country they left years ago, where they have nothing left with the health system destroyed. […] And they are not in a condition to travel,” he told us.
“We definitely have a broken immigration system. […] The healthcare system is definitely not ready for that. In many ways. In terms of accessibility but also in terms of providers being prepared to meet the needs.
“The COVID-19 pandemic has once again shown that the health of refugees and migrants and their host communities cannot be protected and promoted if refugees and migrants are not included in national public health strategies, including preparedness and response.”
Refugees and migrants have faced a disproportionate burden of disease due to COVID-19. Vaccine hesitancy among some groups is also a problem.
Some countries, such as Portugal, provide vaccinations to refugees and migrants regardless of their status. But many fear that coming forward with vaccinations could inform immigration services.
“No they don’t want it [vaccination], but they fear the consequences, […] being separated from their families. Even from being returned. […] Surviving beats the risk of disease.”
For those lucky enough to avoid physical ailments as a result of migration, there will be unimaginable mental stresses to those who have not undergone this experience.
The UCL-Lancet Commission on Migration and Health said:
“Even in the best of circumstances, migration is stressful and most people move in a way that is far from ideal; the stress of migration, the conditions of travel, and the causes that lead to migration in the first place, can all affect mental health.
Traumatic events in their homeland often lead to migration. Add to this the traumas of a, often prolonged, journey to their destination, and many migrants will show symptoms of mental health problems.
According to a WHO report, depression and post-traumatic stress disorder (PTSD) are common, and these conditions, along with anxiety, are particularly prevalent among young migrants.
Dr. Garcini has seen this in the US.
“A lot of kids have a lot of trauma and grief, but when you talk to kids, they’ll deny anything – ‘I’m strong, I can do it.’ […] Immigrants hide their difficulties […] seem strong enough not to be a burden. […] [T]hat adds to the complications,” he told us.
And access to mental health services, like all health services, is difficult for those who do not have settled status in a country. Kidan commented that “[m]any asylum seekers suffer from varying degrees of PTSD, and this affects their lives, but many go undiagnosed because they don’t seek medical help.”
“Mental health issues also remain stigmatized in many asylum-seeking communities and this creates barriers, so health practitioners also need to understand cultural barriers,” he added.
Even if they have mental health services, accessing them in many countries can be difficult, as explained by Dr. Garcini: “There is a public mental health crisis in the US. […] This is creating a hostile anti-immigrant environment.
The WHO report states that migrants are often unwilling to access, much-needed, health services due to anti-migrant discourse and fear of deportation, especially irregular migrants and asylum seekers who lack official documents.
Anti-migrant discourse has increased in many countries. The KFF 2022 report states that “changes to immigration policy implemented during the Trump administration contributed to increased fears among immigrant families about participating in programs and seeking services, including coverage and health care.”
All over the world, health services are under enormous pressure, partly as a result of the COVID-19 pandemic. In the UK, a recent BMA analysis found that nearly 39,000 nursing homes are underfilled, and to reach the OECD EU average, the UK would need to recruit the equivalent of 46,300 full-time doctors.
When resources are scarce, people don’t want to share them with “outsiders”.
“The anti-immigrant rhetoric has to stop. It has caused so much damage to this community. They have been portrayed as a burden on the system, as a threat to the community, as terrorists coming into the country, as a health risk, as carriers of disease. You can imagine what made for one person.”
“Fundamentally, collective action requires greater political dedication and the necessary resources to ensure that policies for health systems and services include refugees and migrants, regardless of their legal status. In the long term, the ‘othering’ of refugees and migrants must be reduced and eventually removed to avoid ‘us versus them’ discussions in policy making and society in general.
The number of migrants is increasing worldwide and, with increasing instability in many countries, is likely to continue to increase. Currently, there is a lack of good quality data, meaning refugees are largely invisible. If they are unseen, they cannot be taken care of.
Failure to reorient the health system to include migrants and refugees denies the basic right to health care for many.
While some countries, such as Costa Rica, Thailand, and Spain, are moving toward comprehensive policies, many are not. These countries show that a health care system that caters to all requires political will.
As many countries charge their immigration policies, we must remember that, as the 2018 Lancet commission stated: “Migrants generally contribute more to the wealth of the host society than they are worth.”
