Pathogens, Prejudice, and Politics: The Role of the Global Health Community in the European Refugee Crisis

In light of the fact that the number of displaced people reached a total of 60 million worldwide in 2015, this opinion piece explores contributions the global health community can make to help address infectious disease risks and global health inequalities, with a particular focus on the refugee crisis in Europe, where more than 1 million refugees crossed the Mediterranean Sea to enter in a 1-year period alone. These recommendations are offered in the framework of "exaggerated associations" that may be drawn between refugees, terrorism, and criminality due to terrorist attacks in Turkey, Lebanon, France, and Belgium and media reports of sexual and physical assaults in Europe. "As a result, policies and interventions in high-income countries taking in refugees will be increasingly framed mainly in relation to risks to national security rather than equity and global health security."

According to the authors, the global health community should consider the following:

1. Accurate communication of infectious disease risk assessments to both incoming refugees and host communities - the general public and policymakers - is key: "First, we propose to ensure that evidence is obtained about the true infectious disease risks from refugees and the burden they cause to health systems to prevent prejudicial concerns and unfounded stigmatisation....However, despite the commonly held view of an association between migration and spread of infectious diseases, no systematic association has been shown with many of the infectious diseases of concern."

    

   For example, the authors cite concerns about transmission of polio from Syrian refugees into Europe after the 2013-14 outbreak of polio, when both medical and lay press coverage extensively discussed the so-called polio threat in view of low vaccination rates in the United Kingdom (UK) and Germany. Yet no cases traceable to Syria were identified in asymptomatic toddlers screened in Germany. "What these reports did not consider was the ability of the global system to respond appropriately. The global response in that instance was measured, and risk communication on the whole was effective, with WHO's Emergency Committee's declaration of a Public Health Emergency of International Concern. The declaration brought WHO's Global Polio Eradication Initiative together with different organisations to complete several rounds of vaccinations in affected areas, and was effective at controlling the outbreak and minimising risk of spread."

    

   Based on this and other examples provided here, the authors suggest that "[a]ny misinformation reported in the press and on social media exaggerating the health and infectious disease risks associated with incoming refugees must be firmly countered with epidemiological data and a pragmatic approach to disease control. The evidence must be clearly provided and understood by politicians and the general public. To generate a strong evidence base, a coordinated approach to health needs assessments and surveillance should be developed, leveraging institutional networks such as the European Centre for Disease Prevention and Control and its links to reference laboratories and individual national public health agencies."

    

2. "Second, we strongly recommend that access to health care for all refugees and migrants is ensured through regular health checks for both communicable and non-communicable diseases (NCDs); hospital and high-quality health-care prevention and curative services are provided without discrimination on the basis of sex, age, religion, nationality, or ethnic origin; are cost-effective; and are culturally appropriate approaches, maintaining people's human rights and dignity....This aim can only be achieved if incoming refugees feel welcome and not the subject of stigmatisation or persecution."

    

   The authors assert that high-income countries have experience, knowledge, and resources to find solutions to health challenges that might arise from incoming refugees. For example, Sweden, where more than 100,000 refugees were taken in during 2015, is trialing creative approaches to integrate refugee communities, improve health literacy, and ensure adequate access to health services. Sweden has introduced fast-track schemes to integrate refugees (particularly from Syria), who are already medically trained, into the labour market, thus addressing many difficulties associated with staff shortages, language barriers, and cultural sensitivity. Information and communication technology (ICT)-based solutions to strengthen the control of infectious diseases in refugee populations could include mobile diagnostic and surveillance units similar to the Find and Treat service for tuberculosis for homeless and disadvantaged people in London, UK. These solutions could also include an integrated support function for psychosocial care and new public–private partnerships for health surveillance, delivery of messages about health promotion and phone-based incentives, and signposting of essential health services.

    

   The authors stress that, "for interventions to be effective, improved coordination and cooperation is needed by European countries. Additionally, there is a need for a more integrated and well managed role for humanitarian non-governmental organisations to provide services for refugees." They cite the 2015 publication of a joint statement by European countries, the European Commission, and WHO addressing the health needs of incoming refugees to Europe and the development of a patient health record that will be piloted at borders to evaluate refugees' medical needs and to reconstruct their medical history. They also point to WHO's Europe Public Health Aspects of Migration in Europe project, which has developed both evidence-based guidance and a series of tools.

3. "Finally, alongside protracted conflicts, widening of health and socioeconomic inequalities between high-income and lower-income countries should be acknowledged as major drivers for the global refugee crisis, and fully considered in planning long-term solutions." They note that, while a fundamental, long-term possible solution to the refugee crisis and the associated potential infectious disease challenges for the host countries is for more economically fortunate countries to increase efforts to reduce the health and socioeconomic inequalities driving populations to become refugees, a short-term is to better engage with those who have already arrived and with those who will continue to arrive. Yet the 2015 UK Department of Health's consultation on extending charges to visitors, refugees, and migrants and accessing primary and secondary care services in the UK was "done with little public or professional engagement".

In conclusion, while there is a refugee crisis, the authors note that many individuals and host communities have readily engaged with and are actively contributing to improve the lives of displaced populations. In doing so, they "reaffirm a shared humanity and demonstrate a commitment to a more equal world."