Refugee Health in Europe: Who is Responsible?

~Written by Victoria Stanford (Contact: vstanford@hotmail.co.uk)

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Tents below a motorway pass, Piraeus Port, Greece. Photo credit: Victoria Stanford

The number of refugees arriving in Europe continues to rise, despite the EU-Turkey deal struck in March 2016 aimed at halting the numbers of new arrivals. This deal represented one of the first consensual decisions made by the 28 member states of how to respond to the unprecedented refugee crisis in Europe seen over recent years. However, across Europe there remains an overwhelming lack of political effectiveness, or indeed will, to co-ordinate the care of those arriving on the continent. Supranational institutions, European governance bodies, NGOs and humanitarian partners have scrambled in varying degrees of commitment to offer their services to refugees and the impression for many is that they are not achieving enough, quickly enough. But how have the various actors responded to the health needs of the refugees, and who is held accountable for this most basic human necessity?

Arrival versus Settlement

There is a significant difference between the immediate and long-term healthcare needs seen among refugee populations. This protracted crisis must be able to respond to both the immediate and often-life saving measures needed on Greek islands where refugees are still arriving by boat, and the long-term needs of refugees who have settled in host countries, in many cases for months or even years. Understanding this transition between the emergency and post-emergency phase, is essential for planning an effective healthcare response. The needs of those new arrivals mostly consists of sanitation, nutrition, shelter and basic safety provision, whilst those further along the asylum process must be integrated into long-term health systems that provide them with more complex and comprehensive services such as chronic disease management.

 As it stands, the initial needs of refugees arriving to European shores are often provided by humanitarian agencies who are equipped to launch an emergency response, and gradually they hand over this responsibility to the local health care structures. An excellent example of this was seen in Bulgaria when Doctors without Borders provided medical care to over 1500 refugees, allowing the national authorities who have now taken over healthcare service provision in this area, to build capacity and prepare (1). In many places this handover scenario has not been achieved so clearly and in fact often it is best for organisations and local partners to share the healthcare responsibilities. For example in Piraeus port in Athens (now dissolved), NGOs such as Praxis and the Red Cross were stationed within the camp itself and acted as primary care providers to the population on the ground, referring patients who required more specialised care on to state-run and funded hospitals or clinics in Athens. A similar system is currently established between the residents of the Jungle camp in Calais and the PASS clinic (Permanence d'Accès aux Soins de Santé)-provided by the government for refugees and others without social security insurance in France. However the extent to which this collaborative effort is effective depends much on the nature of the healthcare needs required; patients with mental health issues requiring long-term psychological treatment or those with post-surgery rehabilitation needs are often prematurely discharged or simply not offered longstanding care. Logistical difficulties are also often neglected as many appointments and consultations are arranged in neighbouring cities and patients are required to arrange their own transport which for many is an impossibility.  Achieving adequate provision and access in healthcare for refugees is complex and is largely dependent on context, their status in the asylum process and capacities of local health organisations.

The ‘Unofficial’ Refugee

Much complexity has been added to this crisis by the lack of clarity in defining those who are arriving in Europe- undocumented migrants, labour migrants, refugees and asylum seekers are terms often confused and used interchangeably and this has an impact on how these people can interact with official services. As refugees and others spread across Europe, the way in which they settle varies dramatically-there are families living in air-conditioned containers in official UN-led refugee camps, whilst others squat in abandoned buildings in the suburbs of Athens. This undoubtedly leads to much heterogeneity in terms of both their access to and quality of healthcare. Much of the healthcare that refugees living in official camps receive is provided by large, international NGOs such as Doctors without Borders (MSF) or the Red Cross. These organisations provide high-standard medical and nursing care, including psychological support in many cases, and also organise public health services such as child immunisations. As priority for official camp accommodation is usually given to families with children or vulnerable people with either chronic diseases or disabilities, providing comprehensive healthcare services to these populations is even more imperative. What this means however, is that resources are stretched thin and those refugees who are either in transit or living in unofficial areas often receive a lower quality or even a complete lack of healthcare.

The legal status of a refugee can also be a barrier to seeking healthcare, particularly in the few chaotic months after arrival in Europe. Many do not fully understand their legal rights or how to access healthcare in host countries; this is particularly problematic for those who are not settled immediately into official camps, instead attempting to cross international borders or avoid registration for fear of the barriers this may pose to freedom of movement (2). This means many do not receive their healthcare entitlements and depend on the ad-hoc and inconsistent presence of healthcare-providing groups often from outside any official aid delivery process.

The ‘unofficial’ refugee population is in fact where the grassroots organisations have trumped more established humanitarian groups. Countless groups have been set up in recent years by concerned citizens across Europe and have provided the in-the-field manpower that many official partners have failed to do. Groups such as Drop in the Ocean, Care 4 Calais, Help Refugees and many others have integrated into the ‘official’ aid delivery system and have in many cases outpaced those organisations who are often restricted by mandates or internal bureaucracy.  These groups offer assistance that is not always recorded on health surveillance statistics or official reports but in fact they are in many cases acting as primary carers. As healthcare itself is not the only way of keeping refugees healthy, these groups who attend to other needs such as shelter and food provision, hygiene, childcare and education may actually be having a significant impact on the refugee population’s health (3).

What about the Supranationals?

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Red Cross Measles Vaccination Campaign, Scaramangas Camp, Athens. Photo credit: Victoria Stanford

Under the 1951 Refugee Convention, refugees should enjoy access to health services equivalent to the host population, and institutions such as the World Health Organisation (WHO) and the Office of the United Nations High Commissioner for Refugees (UNHCR) are tasked with upholding these rights under the UN Charter (4). It is increasingly clear that Europe is struggling to deal with the crisis and the UN has put pressure on European governance bodies to establish a comprehensive, mutually-agreed response plan to address the health needs of the refugee populations. This has achieved some success particularly in communicable disease control with large-scale vaccination programmes used in camps and non-camp settings alike (5) (see photo).

 However, the long-term nature of this crisis will require more of a focus on capacity-building of existing healthcare structures in host countries. For this reason, the WHO has performed a number of Assessment missions in countries receiving the most footfall of refugee movement including Cyprus, Greece, Italy and others, providing countries with context-specific information and guidance on responding to the health needs of refugees either temporarily or permanently settling in these countries (6). These analyses of the current preparedness of national health structures have helped to pinpoint where increased funding or skills are needed to boost local response; the European Commission have subsequently invested over 5 million euros on projects with the aim of “supporting member states under particular migratory pressure in their response to health-related challenges” (7). Crucially, these projects integrate NGOs with national structures, bridging the gap between short and long-term response, and focus on fostering comprehensive access to all aspects of the health system, not only emergency care. One of these projects also places a particular focus on the health needs of pregnant women, unaccompanied minors and young children, highlighting a concern for the most vulnerable populations in this crisis (7). However, whilst these projects are theoretical problem-solvers, there is a gap between plan and action. Many projects will take years to see results and whilst they do, countries such as Greece are reliant on existing health care systems, which have been struggling for years to cope with both the steady influx of refugees over many years and domestic austerity policies (8).

The bottom line is that funded and elected institutions such as the UN are mandated to protect the rights of refugees and these include access to healthcare. This situation sees the heavily bureaucratised system overloaded and rendered flimsy by the sheer volume of refugees depending on it, not only in Europe. This has meant that other humanitarian partners and grassroots movements have stepped in and provided invaluable assistance on the ground. The provision of healthcare to refugees in Europe largely depends on capacity and it is clear that there must be far-reaching plans made to build on both national and international health system structures. Whether these plans will materialise into effective action that both prevents ill health and treats disease remains to be seen as the crisis, without long-term solutions, inevitably continues. 

References:

(1)   MSF (2016) Bulgaria: providing healthcare to Syrian refugees [Online] Available at: http://www.msf.org.uk/article/bulgaria-providing-healthcare-syrian-refugees [Accessed August 2016)

(2)   Global Health Watch (2015) Migrants and asylum seekers; the healthcare sector, London, Page 63.

(3)   Kuepper, M (2016) Does Germany need to rethink its policies on refugees? Researchgate.net [Online] Available at: https://www.researchgate.net/blog/post/does-germany-need-to-rethink-its-policies-on-healthcare-for-refugees [Accessed August 2016]

(4)   UNHCR; Health (2016) [Online] Available at: http://www.unhcr.org/uk/health.html [Accessed August 2016]

(5)   UN News Centre (2015) UN seeks common European strategy on healthcare for refugee and migrant influx [Online] Available at: http://www.un.org/apps/news/story.asp?NewsID=52630#.V7DT6_krK01 [Accessed August 2016]

(6)   WHO (2015) Stepping up action on migrant and refugee health [Online] Available at: http://www.euro.who.int/en/countries/greece/news/news/2015/06/stepping-up-action-on-migrant-and-refugee-health [Accessed August 2016]

(7)   European Commission Health Programme (2015) Health projects to support member states, Geneva.

(8)   Chrisafis, A (2015) Greek debt crisis: of all the damage, healthcare has been hit the worst, The Guardian, 9 July 2015 [Online] Available at: https://www.theguardian.com/world/2015/jul/09/greek-debt-crisis-damage-healthcare-hospital-austerity [Accessed August 2016]

Humanitarian Congress: A Workforce Self-Evaluates

~Written by Victoria Stanford (Contact: vstanford@hotmail.co.uk)

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Humanitarian Congress, Berlin. Photo Credit: Victoria Stanford

The 17th Humanitarian Congress - ‘Understanding Failure, Adjusting Practice’ - took place in early October this year. The stimulating two-day event in Berlin, Germany could not have occurred at a more appropriate moment for the international humanitarian movement, its workers and its supporters. Just six days previously on October 3rd, an MSF (Doctors without Borders) trauma centre in Kunduz, Afghanistan was bombed, killing over 30 people including 10 patients and 13 staff, and injuring over 30 (more are missing and/or unidentifiable; MSF).  The Conference began with a poignant moment of silence for the victims of this tragedy. Inevitably however, the agenda was overwhelmingly full of lectures and seminars shedding light on numerous serious, devastating, and urgent crises that call upon the attention of the humanitarian community; the ongoing instability in the Central African Republic and protracted crisis in the Democratic Republic of Congo, the war in Syria and its subsequent refugee crisis, to name a few.

The demand on the humanitarian system is ever-growing and events such as the Congress facilitate a reflection of its principles, priorities, objectives and effectiveness. The focus on ‘failure’, albeit with its negative connotations, helpfully directed discussions towards ideas for improvement. Importantly, this approach avoided blame and finger-pointing and instead flagged problems that applied to many agencies, in many situations. For example, speakers from the Treatment Action Campaign suggested that international agencies often use local agencies as subcontractors, outsourcing risk to those whose protection is less internationally observed. It was argued that this can often mean that the local workforce, and those directly involved in the crisis are not placed at the centre of decision-making processes. Instead, beneficiaries or those workers who are part of the vulnerable community are treated as “victims” without autonomy, who blindly receive assistance rather than self-remediate. This idea of working with communities rather than for them, expanded to a conference-wide discussion of responsibility. Questions like, whose role is it to alleviate suffering, who should provide the funding and resources, and who should decide policy and provide care for vulnerable people in crisis situations were discussed.

 Whilst the conference facilitated stimulating intellectual discussion on the ideas and concepts of today’s humanitarianism, it also showed the reality of human need. An engineer from Syria who came to Germany as a refugee, risking his safety along the highly publicised journey across the Mediterranean, spoke about his experiences. He spoke of the boat that took him across the sea slowly sinking while other passengers panicked, treading water for hours until an eventual coastguard rescue. A story such as his reminded all at the Conference that the jargonised political discussions about the refugee crisis create a rhetoric that often overlooks the human experience. Speakers from the Democratic Republic of Congo and Somalia also provided the weekend’s event with a more individualised, personalised view of the concepts and themes we were discussing; reminding us of the human aspect of an increasingly intellectualised and politicised field. 

The Congress also served as a pre-dialogue to the Humanitarian Summit, a novel event announced by the UN Secretary-General to be held in Istanbul in early 2016. The purpose is to discuss current challenges and decide on an agenda for future humanitarian action (ICVA, 2015). Many of the regional consultations which will contribute to the Summit have already taken place, and many of the speakers in Berlin commented on the predictability of the points which have been brought up thus far. For example, it was mentioned by many that staff security and safety in the field is likely to ignite serious discussion and debate, as is the issue of agency co-ordination and leadership. The example of the Ebola Crisis in West Africa provided an astute example of this need for a decision on establishing leadership and accountability in humanitarian action; the general rhetoric was that the WHO did not do enough, early enough, and NGOs such as MSF found themselves to be the principal driving force behind the response efforts.  

Increasingly complex humanitarian crises which involve both more agencies and beneficiaries than ever before, must be met with an efficient workforce that can respond to the challenges the humanitarian sector faces. The Conference seemed to bring about an understanding of the fact that the extent to which the sector can be successful may depend on how far the actors are willing to innovate and adapt, introduce creativity, and collaborate with non-traditional allies.  Humanitarianism is no longer a subjective theory with ad-hoc projects run by the adventurous few, it is a rapidly-expanding multidisciplinary system which should be based on rigorous evidence and carried out by legitimate actors who show consistent adherence to mutual humanitarian principles. If and how this will come about will rely on the humanitarian sector continuing to self-evaluate, a feat which will be facilitated by the upcoming Summit in 2016, which we all eagerly anticipate.

References:

MSF (2015) Afghanistan: Death toll from the MSF hospital attack in Kunduz still rising, www.msf.org, 23rd October 2015 [Online] Available at: http://www.msf.org/article/aghanistan-death-toll-msf-hospital-attack-kunduz-still-rising [Accessed 24 October 2015]

ICVA (International Council of Voluntary Agencies) (2015) World Humanitarian Summit 2016 [Online] Available at: https://icvanetwork.org/world-humanitarian-summit-0 [Accessed 09 November 2015]