WH

COMMUNIQUE

A Communique on refugees and migrants etc. [1]

Preamble

World leaders [2] are agreed that there is a current global refugee and migration crisis, caused largely by armed conflict, wars and violations of human rights. The people of all countries are witnessing it, either in person or through their television screens. This is placing unprecedented burdens on many countries and needs coordinated efforts by all the worlds’ countries to produce a workable, acceptable solution. The “crisis” emerges from the unwillingness or lack of preparedness of states to properly and humanely respond to the needs of current mass migration events.

Why is there a crisis?

Mass human migration events are common throughout history as they follow wars, natural disasters for which countries are ill prepared, and other critical events leading to difficulty with safely housing and feeding individuals and families.

The current crisis has developed over a period of years and reflects a number of world events. These include warfare, the consequences of major natural events (including climate events such as drought), or continuing unrelenting poverty, leading to mass migration events which we are responding to with a mixture of panic and discrimination To highlight the complexity of causation, and the interrelationship between politics, natural events and human expectation that has caused this mass movement of people it is worth considering just one such event. One such exemplar event is the on-going war in Syria. This is a civil war, and the fighting involves most of the country. Homes and workplaces have been and continue to be damaged and destroyed by bombardment; the number of places of safety for families shrinks everyday. A number of towns and cities have been besieged by different forces, national, local, regional and international, with media stories of mass malnutrition and even deaths from starvation.

There are a large number of factions involved in the warfare in Syria, including the current Assad government, various opposition groups, a number of other international actors including other states and so-called Islamic State. There is no real hope or expectation of a rapid solution being found to the conflict, especially as a number of the non-state actors are not involved in any way in such discussions as there are. Families have coped with huge difficulties over a number of years but have now reached breaking point leading to mass departures to seek a safer life elsewhere.

While Syria represents an acute crisis, as a source of refugees it sits alongside many other countries with chronic problems leading to the departure of individuals and families. These include severs on-going weather events (droughts) and continuing and continuous conflict.

Conflict is very common around the world and waxes and wanes in different countries at different times. In some cases the conflict is part of an international or a civil war, in others it reflects generalized violence. The impact is the same; it makes living conditions difficult, puts people in danger, and makes decisions to depart the country easier.

Poverty remains a significant problem in many countries, especially in the socalled developing world. Even in more developed countries opportunities for individual self-development are not evenly distributed, and poverty including poverty of expectation and of opportunity can lead people to seek alternatives. A shortage of work opportunities leads to individuals and families seeking opportunities to improve their living conditions by moving elsewhere. Sometimes those lack of opportunities reflect a generalized deficiency, sometimes it reflects local prejudices against a population subgroup. The impact on total migration trends is the same albeit those who move might vary.

The crisis also reflects current media interest. The ability of mass media outlets, supplemented by personal social media use, to transmit pictures worldwide in seconds makes the scale of the issue immediately obvious to everyone; people expect politicians to provide a solution. The outcry when photographs of a small child, drowned while travelling with his family seeking to leave North Africa for Europe, demonstrates that populations can be moved by these images; such emotional responses do not necessarily develop to a welcome to more refugees or to increased migration.

What are the historical precedents?

There are a number of historical precedents involving mass migration. These include the movement of millions at the time of partition of the Indian subcontinent, and mass migrations at the end of World War 2. In both these cases the event caused enormous disruption to individuals and to families and a similarly enormous level of human suffering.

At the end of world war 2 there was some sympathy with displaced persons; these were the results of fighting which had led to suffering for much of the civilian population of the world and there was a short-lived common understanding of the impact of war-caused homelessness and displacement. Events in India and Pakistan, which arguably involved a still larger number of people, were largely invisible outside the region.

Both historical events were, however, sufficiently long ago that they were not immediately visible world-wide. Events occurring today are witnessed by the global population on their TV screens, smart phones and the like. This means there is a larger level of public interest and, therefore, of political concern.

Who are the refugees?

Refugees fall into a number of categories. They include those fleeing from war zones, looking to live in places where they and their children will be safe from bombs and bullets, and have a roof over their heads. Parents want to be able to earn their living and give their children a safe place to live.

Other refugees are what are sometimes called economic migrants – they want to improve their standard of living. They may come from countries devastated by recent conflict or from countries where poverty is the norm. They have no expectation of being able to improve their lives, or those of their families by staying in their home country, so again the wish is for a better life for themselves and their families.

A third category of refugee is those fleeing oppression. This might be generalized oppression in a country with an oppressive regime, and restricted freedom for all, or where the oppression is directed against a group – because of their ethnicity, religion or gender. The wish here is to live in more freedom and achieve a chance of social equality.

Refugees may be families, but can also be single people. Occasionally refugees are children travelling alone.

The impact on the countries people leave can be considerable; some of these migrants will be people with much needed skills already in scarce supply in the country they are leaving. There can be a global loss of such skills as new migrants may be unable to use their professional education, knowledge and skills in their new country but only obtain work in relatively unskilled areas.

What are their reasons for leaving their homes?

The reasons for leaving their homes are all variations on a theme – that of improving their ability to live a free life with choices, chances and opportunities not available in their country of origin. There is no difference in this from the great migratory movements of the 19th and early 20th century to countries such as the USA and Australia, where migration was based upon a lack of opportunity at home and the presence of opportunity in the new country. Seeking to escape political and religious oppression was a part of the reason during those mass migrations, as was the will to improve the lot for self and family.

Catastrophic natural events such as earthquakes and tsunamis where there has been inadequate prior planning or preparation can also lead to a mass exodus, fleeing collapsed buildings, homes and workplaces, and seeking security and safety. While natural events are not preventable, proper planning can dramatically reduce their impact on individuals and on the infrastructure that makes life possible.

The difference today is the presence of conflict in certain regions that has become so long-lasting as to erase hope for a future for people who live in the country of region. In addition, current warfare is fought alongside civilian populations, with the destruction of living and working places. Historically, many wars were relatively short lived and fought away from population centres, disrupting the lives of civilians to a lesser extent.

Forced Migration

Besides these reasons military and other measures are occasionally used to force people out of their homes for reasons including changing the ethnic composition of an area. Houses, Schools, shops, workplaces and even cemeteries might be bombed to aid achieving this purpose.

How are desired final countries chosen?

There has been relatively little research performed to discover the reasons for choosing destination countries. In some cases it relates to language – are migrants certain they can communicate with others in their destination country. In other cases migrants will have family members, or others from their community already in that country and feel that they will be helped and welcomed. Some politicians feel that it is purely financial – that countries are chosen which will offer access to state support upon arrival. It is also clear that countries with an internationally seen profile offering stability, social inclusion and peaceful streets are very desirable; their selection as a destination is a marker of the external esteem in which they are held.

It is difficult to evaluate the impact of announcements by politicians, especially of their willingness to accept refugees, asylum seekers and other potential

migrants. Has a previously positive language about these groups helped to fuel the mass movement of people?

What are the impacts on countries of transit during migration?

Mass migration, including problems for transit countries, is not just an issue for rich countries.

Transit countries have to cope with, what can be, mass movements of people through them. In some cases, especially in Southern Europe, and the Middle and Far East, they may have to manage survivors of catastrophes, such as migrant boats overturning, and rescue people from freezing seas. Other countries find themselves holding large populations of people in transit, who wish to pass through their country but where borders are closed to either onward passage or to a final destination country. The mass migrant population continues to build leading to the development of large numbers, often in camps, placing a burden on the provision of services including basics such as shelter, water, food and sewerage. Some of these camps can become sources of disease outbreaks, especially where insufficient attention is paid to water and sanitation. Others place burdens on countries with already overwhelming difficulty in feeding and housing their populations.

Increasingly countries are, not only having to cope with these problems but also to police the situation. Possible destination countries expect them to handle the migrants and effectively restrict their onward movement. The migrants expect to be able to transit quickly and resist attempts to limit their movement. This places a burden on police and security forces that many countries struggle to meet. Given the poor social status of the migrants and refugees this can lead to serious abuses.

What are the social and economic impacts on destination countries?

The history of migration has been the foundation of many modern countries; it has provided workers in all sectors, often skewed at times to cover specific needs. Thus the building of the transcontinental railroads in the United States led to the immigration of rail-road workers, who built the infrastructure. The need for people with specific skills can also be seen in the migration of hundreds of thousands of qualified nurses around the world, from countries such as Ghana and the Philippines.

Current mass migration and refugee movements are less focused on one skill set. But many migrants, in their overwhelming desire to provide a better life for their families, will work in any sector, so that those with higher professional qualifications do not use those skills but work in service industries where work is plentiful. In some countries in Western Europe, eastern European migrant labour carries out the jobs locally born people do not want – often very labourintensive, poorly paid work, such as fruit picking and other seasonal work. Despite a relative unwillingness of country nationals to take these jobs, there is

often resentment that jobs are occupied by recent immigrants, and the effect on the general labour market is complex. Their access to jobs can be resented and lead to civil unrest.

The reality of migrant work is that while some will have higher skills much sought after in their destination country far more will take up poorly paid, relatively unskilled, work, which is essential to the economy of their destination country.

What are the health issues?

Migrants and refugees alike tend to come form the poorer sections of the community – and often from the very poorest. They might have started as professionals but events have impoverished them. Their transit to a destination country may have taken many months, and produce health consequences because of deprivation en-route, including lack of food and shelter. Given that the migrant and refugee are likely to come from a poor background there is a likelihood that they will already have some health problems, including untreated and undertreated chronic diseases. This is especially true of all vulnerable people, including the poor. Children are unlikely to have been vaccinated and immunized and malnutrition (absolute or micronutrient) is common. While some may be concerned about contagious diseases including tuberculosis, the real problems will be of diseases of poverty including rickets, and other malnutrition syndromes. Given the chronic exposure to risks within and outside conflict PTSD and other stress related psychological disorders are also likely to be common.

What is the political dialogue?

The political dialogue on mass migration and refugee movement is distressingly one-sided. The only real concern appears to be limiting the movement of people, and in particular their eventual arrival in possible destination countries. An emerging thread is to look for the causes of this migration in an attempt to turn it back; peace in countries of conflict may reduce migrant numbers, as might improving the living and working conditions in the poorest populations of the poorest countries. Peace must be sought as an end in itself, not simply as a means of reducing the number of refugees. A short-sighted approach to peace is unlikely to find a lasting solution. The dialogue is rarely based upon the reasonable needs and expectations of the migrating population, but on the integrity of national borders. There is little demonstration of understanding of the desperation that leads someone to leave their home for an uncertain future elsewhere.

What can physicians add to this discussion?

Physicians understand the impact of social, economic, safety and other factors which lead to migration, the urge to provide something better for the family, and the effect of transit on family and individual physical and psycho-social health and wellbeing. They can reassure the public about the lack of health risk from the arrival of these people, as well as ensuring that those arranging their reception provide the wherewithal for reasonably healthy living. Physicians can also treat the diseases that need treatment, including the probable serious psychosocial disorders, ensure children are immunized and vaccinated, and help local planners consider housing and other needs.

The primary addition physicians can make relates to their understanding of the broader issues around mass migration and people movement in terms of public planning, while never losing sight of the individual at the centre and his/her needs. This leads to a strong advocacy role, especially around social determinants of health, illness prevention, the availability of health care and other areas to prevent abuse, neglect and exploitation.

Recommendations

1. This meeting recognizes that there is a considerable overlap between all mass migrations, with people moving from places of relative lack of safety towards those of relative safety. They do this in order to improve their lot in life and the opportunities for their children. In some cases real physical danger, of death, injury, rape and other sexual violence, unfair imprisonment, torture, forced labour and other very serious abuses are a root cause, in others the slower onset but equally real dangers of poverty, homelessness and starvation.

2. This meeting recognizes that mass migration will continue unless people are content to stay in their birth countries because they see opportunities to live their lives in relative peace and security and to offer themselves and their families the ability to live lives with opportunities for fulfillment of various sorts, including economic improvement. The global community has a responsibility to seek to improve the lot of all populations, including those in countries currently with the poorest economies and other key factors. Sustainable development will give all populations improved security, and economic options.

3. This meeting recognizes that warfare and other armed conflict, including continuous civil strife, unrest and violence will inevitably lead to people movement. The worse the conflict the higher the percentage of people who will want to leave the conflict zone. There is a responsibility for the global community, especially its political leaders, to seek to support peace making and conflict resolution.

4. This meeting recognizes and condemns the phenomenon of forced migration, which is inhumane and must be stopped. Such cases should be considered for referral to the International Criminal Court. 5. This meeting demands that civil, military and political authorities provide safe transit routes for the victims of local, regional and national conflicts and strife. This must include the provision of safe, secure facilities to house migrants, whether they are in transit or have reached their final destination country. It must also include treating migrants, including at borders, with respect, ensuring that their dignity is not affected. Adequate provision for potable water, food, sewerage and shelter must be made. Those planning for these migrant populations must take adequate public health advice in planning and delivering the facilities. Mass detention of refugees is at best undesirable; if it is essential it must be based upon the provision of excellent living facilities including opportunities for safe play areas and education opportunities for children. 6. This meeting recognizes that mass casualty events occur during massive natural events. The scale of casualties is directly proportional to the prior planning; earthquake proofing houses and workplaces significantly reduces the casualties of such natural events. It is unacceptable that such infrastructure improvements are not available to the populations of many countries prone to such natural events.

7. This meeting commends the welcome given to refugees, asylum seekers and other migrants in some countries and deplores the reluctance to offer help and support to these people in many other countries. The development of barriers is not a solution; it condemns those moving between countries to further hardship with an uncertain end. The concept that treating migrants harshly will discourage future migrants is both absurd and inhumane.

8. This meeting deplores the stigmatization, bigotry and bias in media reporting of the refugee and migrant issue in some of the worlds’ media, and demands that media outlets treat this issue with honesty and integrity and properly reflect the human concerns faced by individual migrants and refugees. We commend those media outlets that have sought to treat the issue with fairness and humanity. 9. This meeting recognizes that migrants and refugees face considerable health concerns, especially associated with the difficulties of the migration process, the long periods of poor nutrition, appalling lack of shelter, and the effects of the events that forced them to leave their homes. We demand that destination countries ensure that migrants and refugees get access to medical services on a par with their settled population, free at the point of use or after adequate financial provision to meet co-payment costs, and in particular that there are adequate mental health services to deal with PTSD and other psychosocial disorders.

Health care workers providing care must be enabled to do so without any interference in their professional behavior, including ethical standards. 10. This meeting recognizes the pressures on local communities, including their authorities, in seeking to manage the arrival and support of significant numbers of migrants and refugees. We demand that national and international governments recognize these pressures and provide support, including finance as a priority.

11. Internally displaced persons (IDPs) also need care and consideration, although they do not appear in the migration statistics. Some of the countries facing considerable challenges in dealing with migrants will also have many IDPs; this compounds the difficulty of providing safe living conditions. This meeting believes that a consideration of the number of IDPs needs to be performed alongside consideration of migrants, refugees and asylum seekers.

12. The WMA recognizes the link of health consequences to poor living conditions and invites medical and other health care worker associations and organizations to join forces to ensure that governments understand and respect the need to provide safe and healthy living conditions for all types of migrants.

 

[1] This communique was adopted by participants of the Symposium. It does not constitute an official policy document of the World Medical Association.

[2]  For the purposes of this communiqué the following definitions are assumed. Refugees are people fleeing their country of citizenship and seeking safety and security elsewhere. Migrants are leaving their country of origin, to seek a future in another country, but without a proximal safety imperative to leave. Internally displaced persons are people fleeing from their home, but staying within their original country. They may flee the consequence of major natural events, warfare, famine, or for other reasons. Asylum seekers are people who have sought and been granted refuge in another country – their status will vary from those seeking permission to stay and those for whom it has been granted either for the present or permanently.