Richard Smith: Migrant health—political hysteria but insufficient attention to an issue that will increase substantially

richard_smith_2014Although there is political hysteria about migrants in Europe, the health of migrants receives insufficient attention. That was the main message to emerge from Imperial College’s Institute of Global Health Innovation’s forum on migrant health in December.

Definitions are a besetting problem in studying migrant health. A migrant is anybody who moves across borders away from their home. A refugee is a person with a special legal status who has fled their home and is frightened to return for fear of harm. Refugees have rights, which explains why countries may be reluctant to agree to call migrants refugees—as in the case of the Rohingya people in Bangladesh. An asylum seeker is somebody who is applying for refugee status, but has not received it.

There are some 244 million migrants, about 2-3% of the global population. This proportion has been remarkably constant over the years, but the proportion of migrants who are refugees is increasing. UNHCR (United Nations Refugee Agency) records that there are 65.6 million people who are “forcibly displaced” by war—up from 37.5 million in 2005. Of the 65.6 million, 22.5 million are refugees, half of whom are under 18. UNHCR is responsible for 17.2 million refugees, but the 5.3 million Palestinian refugees are the responsibility of UNRWA (United Nations Relief and Works Agency for Palestine). There are also 10 million stateless people, who lack basic rights like education, health care, employment, and freedom of movement.

The number of migrants is likely to increase, particularly because of climate change. Rising sea levels are likely to mean that about 1.4 billion people will be displaced by 2060. The rise in sea level is having an impact now, and Stephen Matlin, former Executive Director of the Global Forum for Health Research, illustrated this by showing a series of pictures of how the sea has progressively drowned areas of Cotonou on the coast of Benin.

Britain, pointed out Matlin, is the 10th largest supplier of migrants. But more than half of UNHCR refugees (55%) come from three countries: Syria (5.5 million). Afghanistan (2.5 million), and South Sudan (1.4 million). Most of the refugees stay close to the homes they are forced to leave, meaning that most are in low and middle income countries. Three-quarters of refugees are in 10 countries, including 2.9 million in Turkey (which, as people at the forum pointed out has been “bribed” by the European Union to keep the refugees), 1.4 million in Pakistan, and 1 million in Lebanon, which has a base population of only 3.5 million.

Mohammed Jawad, a PhD candidate at the Public Health Policy and Evaluation Unit at Imperial, described how the Middle East hosts about 40% of the world’s displaced people. Despite the “refugee crisis” in Europe only about 3-4% of the people displaced in the Middle East are in Europe, and zero are in the Gulf States, the richest countries in the region. Jordan, in contrast, has 659 000 refugees, of whom 436 000 are children.

Ban Ki-Moon, the former UN director general, has said that the refugee crisis is not a crisis of numbers but a crisis of solidarity. All the speakers at the forum said how an increasing number of refugees has to be recognised as normal and suitable policies adopted. Sadly Britain has one of the worst records on both receiving refugees and supporting them once they are here. There has, said Sally Hargreaves of the Department of Medicine at Imperial been a “massive failure” in Europe.

NHS Digital, which stores information on all NHS patients, has given the Home Office easier access to information on migrant patients, meaning that immigration officers can track down and deport undocumented migrants. This scares patients, including pregnant women, away from the health services they need, and turns health workers into “border guards.” The #StopSharing campaign being run by Doctors of the World is trying to stop patient data from being shared. 

Refugees, said Matlin, may suffer harm to their health before they are forced to flee, while they are fleeing, and once they arrive. Before fleeing they may suffer from war, torture, poverty, a disrupted environment, and inadequate health systems. While fleeing they might drown, starve, or be assaulted. The famous picture of the drowned baby momentarily shook Europeans out their indifference and hostility to refugees. Once they’ve arrived in a host country refugees might bring diseases like TB with them but may have difficulty with, or be fearful of, accessing health services. Jawad paints a vivid and personal account of the health of refugees in a blog describing what he sees on his walk to work in Beirut. Refugees in Lebanon must pledge not to work, meaning that they are likely to fall into poverty.

There is, of course, a “healthy migrant effect” among those who self-select to migrate. They are usually young and resourceful. The healthy migrant effect is seen less among refugees, although, as students of positive psychology point out, overcoming dreadful experiences may give refugees capabilities that can never be achieved by those who have never had such experiences.

The classic pattern for migrants once they arrive in countries is that mental health improves, infections and injuries fall, but non-communicable disease steadily increases as migrants adopt the unhealthy lifestyles of their new countries.

Funding for the much needed research into migrant health is hard to come by and is usually small and short term, said Jon Friedland, Head of Infectious Diseases and Immunity at Imperial College London. He illustrated why research is needed by describing studies he and others have conducted of screening migrants for TB. Before he described the research, he said how a migrant with severe TB had spent six weeks in an intensive care unit and then two and half months on the ordinary wards. His admission could have been avoided if he had been screened at an earlier stage.

About three quarters of the TB in Britain occurs in migrants, usually about four years after they enter the country; and migrants have three times the risk of locals of having multiple drug resistant (MDR) TB. There is a lack of an evidence base on the best way to screen, but Friedland and others tried screening in a general practice with a high number of immigrants. They screened 1235 patients, but in the end treated only one. Screening in general practice does not seem to be a good method.

They then tried screening in St Mary’s Accident and Emergency Department. Screening is hard, said Friedland, in the pandemonium of A&E, but they screened 96 people from 43 countries—and identified 14 cases. But for various reasons, including patients failing to return, they treated only four. This was huge amount of work for the yield and, said Friedland, is “not going to work.”

There is also a “productive migrant effect” because migrants are usually industrious and enterprising. The true picture of migrants is the opposite of that depicted in tabloid newspapers: migrants contribute to the economy, use public services less and are less likely to be unemployed than the local population, and often do jobs that natives don’t want to do.

But because of headlines like one in the Daily Express—“Migrant hordes hell-bent on reaching soft-touch Britain”—barriers for refugees have increased exponentially since 2005, across the world not just in Britain.

What is needed, everybody at the forum agreed, is a humanitarian, ethical, rights-based approach to migrants and refugees. We need, said Matlin, to normalise migration, collaborate more, address the root causes, pay attention earlier, provide more training to those working with migrants and refugees, and voice the true facts about migrants and refugees.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS is an unpaid Adjunct Professor in the Imperial College Institute of Global Health Innovation.