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The Right to Flee – looking after the wellbeing of people who are forcibly displaced

By guest contributors Sylvia Garry, Clare Shortall, Rita Issa, Aula Abbara, Sarah Walpole

Every day, people choose to move within countries and across borders for many reasons: to follow careers, to adventure, or for a new start. However, millions are also forcibly displaced from their homes to escape risks of persecution, conflict and violence, food insecurity and humanitarian disasters. They leave their country, environment, and family and friends in pursuit of safety, often to a place previously unknown to them.

Forced displacement is on the increase[1]. While recent high profile acute conflicts such as those in Ukraine[2] and Afghanistan[3] have brought discussions of displacement to the fore, we must not forget those forcibly displaced from protracted conflicts such as in Syria, Myanmar, Ethiopia and South Sudan[4]. These chronic and complex settings have caused entire generations to grow up in instability, not knowing the security of peaceful times. The UNHCR estimates that at the end of 2021, 89.3 million people were forced to leave their homes, of whom 2 in 5 are children[5].

Although we live in an increasingly interconnected world, achieving global health remains a huge challenge. The COVID-19 pandemic demonstrated again the need for equitable access to health promotion, vaccination, healthcare and therapeutics to protect public health. There is a strong public health case – as well as an ethical one – for ensuring access to care of refugees and migrants to safeguard the whole population of any country. However, significant inequalities remain both within and between countries, often driven by politics and economics and underpinned by neo-colonial histories and practices; this adversely affects access to diagnostics, treatments and care and health outcomes for individuals and populations. Through addressing the needs of those who are forcefully displaced, we are offered opportunities to reduce health inequalities and support state and international commitments to universal health coverage (UHC).[6]

With the events of recent years, several important principles around the care of refugees and those who are forcibly displaced have become even more evident.

Firstly, it is often simple interventions, adaptations, and approaches which make the biggest differences to the lives of those who are displaced[7]. People’s needs differ hugely according to their pre-existing health status, their experiences along their journey, the socio-political context in which they live and travel, and availability of local resources. Supporting displaced populations means keeping them at the heart of the conversation – listening to them, hearing what they value most, and ensuring culture, religion, mental health and wellbeing is considered at all times. They must be involved in decisions which affect their everyday lives; autonomy, dignity and control over their own lives is an essential aspect of wellbeing; hard to measure but infinitely important.

Secondly, the framework for understanding health in forced migration means taking a socioeconomic approach as the factors impacting health are complex, diverse and often interconnected. It is important to break out of the health silo to identify population needs in a comprehensive way. Poverty, unemployment, xenophobia and discrimination have impacts on families and wider communities, and compound each other. Providing support for these populations is an opportunity to change health, educational and wider impacts from equitable health outcomes and wellbeing[8].

Thirdly, the impacts of displacement resonate beyond the acute setting, and can impact both an individual’s life course and future generations. Pregnant women, children and newborns are often most affected by displacement[9],[10]  due to their vulnerability and what they might be exposed to during their displacement and journey. A pregnant person’s health has repercussions for the health of the child at birth and into adulthood[11]. Providing support is an opportunity to reduce inequality now, and into future generations.

Finally, it is essential for those working with forcibly displaced populations to speak out, in order to support greater understanding and development of policies, approaches and interventions that recognise and meet the needs of forcibly displaced populations. The geopolitical, socioeconomic, and environmental landscape suggests that the number of refugees and asylum seekers is set to increase[12] . Adequately mitigating and addressing the health impacts of forced migration requires collaboration, sharing of resources and lessons learnt, and advocacy to highlight and protect the health and wellbeing of those who are experiencing forced migration.

Providing the best care and support for individuals requires working effectively with colleagues from different professions, and particularly those with good understanding both of the history, preferences and priorities of those who have been forced to migrate and of the local landscape, available resources and challenges. The Handbook of Refugee Health is a free online resource[13]. It won the British Medical Association medical book award for 2022[14], and aims to support frontline workers and policy makers in the context of forced migration. Divided into three sections, it outlines the public health background (migration trends and global health context), applied public health skills (humanitarian coordination systems, working with vulnerable groups, ethical and personal considerations) and the clinical skills and approaches to working with forcibly displaced populations when on the move, in refugee camps, and upon settling in a destination country. ​​The Handbook outlines clinical guidelines across different specialties and areas of health and healthcare, and how these may be applied given the particularities of providing care to those who have experienced forced displacement and in unstable, and sometimes precarious and under-resourced, situations.

All authors are writing in their personal capacity.

Dr Sylvia Garry is a Public Health Consultant working in London.

Dr Clare Shortal is a Health and Nutrition Operational Adviser for Action contre la faim (ACF)

Dr Aula Abbara is an Infection and Acute Medicine Consultant at Imperial NHS Healthcare Trust, and honorary clinical senior lecturer at Imperial College

Dr Rita Issa is a General Practitioner and humanitarian doctor, and research fellow in climate change, migration and health for the Lancet Migration

Dr Sarah Walpole is an Infectious diseases and General Medicine Specialist Registrar in the North East of England

[1] Schwerdtle P, Bowen K, McMichael C et al, Human mobility and health in a warming world, Journal of Travel Medicine, Volume 26, Issue 1, 2019, tay160, https://doi.org/10.1093/jtm/tay160

[2] World Health Organization, 2022, Ukraine emergency, https://www.who.int/emergencies/situations/ukraine-emergency, (29 Oct 2022, date last accessed)

[3] World Health Organization, Oct 2022, Afghanistan crisis, https://www.who.int/emergencies/situations/afghanistan-crisis, (29 Oct 2022, date last accessed)

[4] OCHA, 2022, The Global Humanitarian Overview 2022, https://gho.unocha.org, (29 Oct 2022, date last accessed)

[5] UNHCR, 2022, Figures at a Glance, https://www.unhcr.org/uk/figures-at-a-glance.html (29 Oct 2022, date last accessed)

[6] World Health Organization, 2021, COP26 – Direct linkages between climate change, health and migration must be tackled urgently – IOM, WHO, Lancet Migration, https://www.who.int/news/item/09-11-2021-cop26—direct-linkages-between-climate-change-health-and-migration-must-be-tackled-urgently-iom-who-lancet-migration, (29 Oct 2022, date last accessed)

[7] Culver A, Rochat R, Cookson ST. Public health implications of complex emergencies and natural disasters. Conflict and Health 2017;11:32.

[8] World Health Organization, 2022, Refugee and migrant healt,hhttps://www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health, (29 Oct 2022, date last accessed)

[9] Jolof L, Rocca P, Mazaheri M, et al. Experiences of armed conflicts and forced migration among women from countries in the Middle East, Balkans, and Africa: a systematic review of qualitative studies. Confl Health. 2022 Sep 7;16(1):46.

[10] Moss WJ, Ramakrishnan M, Storms D, Henderson Siegle A. et al.  Child health in complex emergencies. Bulletin of the World Health Organization 2006;84

[11] Garry S,  Checchi F, Armed conflict and public health: into the 21st century, Journal of Public Health, Volume 42, Issue 3, September 2020, Pages e287–e298, https://doi.org/10.1093/pubmed/fdz095

[12] UNHCR, 2022, Global displacement hits another record, capping decade-long rising trend, https://www.unhcr.org/uk/news/press/2022/6/62a9d2b04/unhcr-global-displacement-hits-record-capping-decade-long-rising-trend.html (29 Oct 2022, date last accessed)

[13] Orcutt M, Shorthall C, Walpole S, Abbara A, Garry S, Issa R et al, 2022, Handbook of Refugee Health, Taylor and Francis Group, Oxon, https://insights.taylorandfrancis.com/ukraine#group-section-Refugee-health-resources-eZqrREoYdX

[14] British Medical Association, 2022, Handbook of Refugee Health wins BMA Medical Book Awards, https://www.bma.org.uk/news-and-opinion/handbook-of-refugee-health-wins-bma-medical-book-awards#:~:text=This%20year%2C%20more%20than%20300,of%20the%20BMA%20international%20committee, (29 Oct 2022, date last accessed)

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