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Forced Migration: The Human Face of a Health Crisis

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Addressing a joint session of Congress, Pope Francis said that migrants “travel for a better life.…Is that not what we want for our own children?”1 With that plea, the pontiff placed a human face on the modern migration crisis, with nearly 60 million refugees, asylum-seekers, and internally displaced persons (IDPs) fleeing predominantly from war-torn Syria, Afghanistan, and Somalia2; children comprise half the group. The global response is wholly incommensurate with the need: the European Union agreed to distribute only 120 000 asylum-seekers, and the United States will increase its annual refugee cap from 70 000 to 100 000 by 2017—neither of which will substantially affect the humanitarian crisis.

Lawrence O. Gostin, JD1; Anna E. Roberts, LLB, MIPH1


Each stage of the forced migration journey (predeparture, transit, arrival, and eventual return home) poses health risks. Individuals face armed conflict, famine, or both in their home countries causing physical illness, severe mental distress, and lifelong trauma. Hospitals are destroyed by conflict, and natural habitats are degraded (eg, water, soil, and air pollution). Family homes have been destroyed and communities have become uninhabitable.

Despite health hazards in home areas or countries, fleeing can be equally dangerous, with forced migrants facing high mortality rates.3 Of the nearly 500 000 asylum-seekers who have entered Europe this year, an estimated 3000 have died at sea.4Every asylum-seeker’s journey is different, but they share common risks, including exploitation by people smugglers; impoverishment; scarcity of food, water, and shelter; injuries and violence; separation from family; and decreased access to health and social services.3

Most forced migrants are hosted by neighboring low-income countries, which struggle to offer essential health and social services.2 Refugee and IDP camps can have epidemics of infectious diseases including typhoid, tuberculosis, measles, cholera, and dysentery3 caused by severe overcrowding, contaminated food or water, and disease vectors (eg, rats and mosquitos).3 International initiatives, such as the polio eradication campaign, are compromised. Girls and women often experience sexual abuse, with many contracting sexually transmitted infections. Health care barriers are not limited to low-income countries. Language and cultural differences can impede access, while fear of deportation may drive asylum-seekers underground.3 Forced migrants often do not know whether they are eligible for public benefits, and governments have been reluctant to extend entitlements to them.

Refugees have the right of return to their home countries, but it may be decades before it is safe to return. Rebuilding shattered infrastructures requires vast resources, including health and social systems, agriculture, education, roads, electricity, and housing. These factors make forced repatriation, especially for the sick, extremely hazardous, which is a clear violation of humanitarian law.


Given the health hazards, what duties do governments have to ensure basic protections for the rights and welfare of asylum-seekers? There are limited international legal obligations, the clearest of which apply to refugees, defined as individuals with well-founded fears of persecution.

The 1951 Refugee Convention (which has 145 States Parties) and its 1967 Protocol (the United States ratified only the protocol) obligates host countries to provide education, employment, and social security at levels equivalent to that provided to citizens, and health care for injuries, maternity, sickness, and disability. Asylum-seekers of undetermined status and IDPs, however, have few rights and remain vulnerable. The convention requires countries to process refugee claims, and governments are not permitted to discriminate against asylum-seekers. Countries, however, can process claims according to their national systems, which results in inconsistency and uncertainty. Moreover, if governments violate their legal obligations, there is no international legal mechanism to hold them to account.

Internally displaced persons (the most common form of forced migration) have the weakest claims to international protection. Ironically, the very governments that precipitated their displacement are responsible for their protection.2 The 1998 Guiding Principles on Internal Displacement urged countries to protect IDPs’ rights to life, dignity, protection, humanitarian assistance, and education and to food, water, shelter, clothing, sanitation, and essential medical services, including psychological services. However, the Guiding Principles are nonbinding. Rather than “respecting life and dignity,” countries routinely violate the Guiding Principles. Countries claim sovereignty to avoid international scrutiny of their treatment of IDPs, even if they have subjected them to state-sponsored violence, as in Syria. Many countries have even refused offers of international assistance, including food aid. Basic human rights, including the right to health, should be universally guaranteed even if countries refuse to cooperate.


Lower-income countries bear the disproportionate burden of the refugee crisis, with almost half the world’s refugees housed in countries in which the gross domestic product per capita is less than $5000. This sheer scale undermines national health systems, which diminishes access to health care for domestic, as well as migrant, populations. International assistance, moreover, offers only a fraction of the resources needed by fragile states to sustain essential services.

In contrast to the generosity and pragmatism of lower-income countries, European governments have erected border restrictions, police barricades, and detention centers, which strain the fundamental principle of a border-free Europe. The Schengen Agreement guarantees freedom of movement among the 26 European countries that comprise the Schengen Area.5 It permits temporary border restrictions only for national security reasons; although mass migration represents a political crisis, there are no immediate security threats that justifies impeding the right to travel.

Beyond the Schengen Agreement, European states have contravened multiple nonbinding policy directives. The Reception Conditions Directive requires countries to respect migrants’ “fundamental rights,” with detention a “last resort.” The Asylum Procedures Directive ensures consistency across the bloc for reception and processing of asylum claims. Yet the highly divergent national rules for entry of asylum-seekers, police barricades, detention centers, and the forced removal of asylum-seekers all place the European project at risk.


Glaring gaps in international protection and the enforceability of existing obligations imperil individuals and families, while impeding aid organizations. In the short term, high-income countries should ramp up international assistance and take in their fair share of asylum-seekers. International humanitarian organizations are chronically underfunded. The World Food Program, for example, reduced the frequency and portion sizes of rations to 4 million people in Syria due to funding shortfalls.6Voluntary organizations such as Médecins Sans Frontières have limited capacity and cannot always respond. Lower-income states continue to bear disproportionate burdens with a fraction of the resources needed to house, feed, and care for a flood of migrants.

For the longer term, the international community should buttress legal duties to protect forced migrants irrespective of their classification. This could entail, for example, responsibilities to protect asylum-seekers while their refugee status is being determined; enforcing existing rights under the Refugee Convention, including rapid processing of applications; and negotiating to turn the Guiding Principles into a binding, enforceable treaty.

Forced mass migration imperils human security. It undermines human dignity and poses risks that all nations share, including epidemics, political instability, and terrorism. In September, when a child drowned at sea and washed up on the shores of the Mediterranean, it shook the moral conscience of Europe and the world. It is within the power of the community of nations to safeguard the rights and health of forced migrants. It will require bringing armed conflicts to an end reducing the need to flee, while safeguarding the most vulnerable.

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