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]

Uncovering the Realities of Human Trafficking

~Written by Sarah Weber (Contact: sarahkweber@gmail.com)

There is a hidden business of slavery that is tucked away from the untrained eye but alive and thriving today. The word "slavery" most likely conjures up images of African slaves in the United States (US) or Great Britain, a practice that was abolished in the nineteenth century. Although every country in the world now has laws banning slavery (the last being Mauritania in 2007), slavery still exists today in almost every country. Modern day slavery, also known as human trafficking, affects tens of millions of women, men and children around the world in the form of forced labor, domestic servitude, and sex trade [1]. In fact, there are more slaves now than at any other time in human history [1]. While the exact number of people trafficked globally is unknown, research efforts to better understand the magnitude of the issue have estimated that 21 to 36 million people are trafficked worldwide [1]. Human trafficking is the second largest criminal industry in the world after drug trafficking. Yet, the public is often not aware that it is such a significant global issue, affecting people not only in far away countries, but also in the countries, and possibly even the communities in which they reside.

What is human trafficking?

The terms “human trafficking,” “trafficking in persons,” and “modern day slavery” all refer to, "The act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through the use of force, fraud, or coercion" [2]. A common definition was adopted by the United Nations (UN)'s Protocol to Prevent, Suppress and Punish Trafficking in Persons as:

"Trafficking in persons" shall mean the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power, or of a position of vulnerability, or of the giving or receiving of payments or benefits, to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation or the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs [3].

There are many different types of modern day slavery, including: debt bondage, contract slavery, sex trafficking, forced or servile marriage, domestic servitude, child labor and child soldiers.  According to Free the Slaves, a nonprofit focused on advocating against modern day slavery and liberating slaves, approximately 78% of slavery victims are in forced labor, 22% are in sex slavery, and 26% are children under age 18[1]. Learn more about the types of slavery and global statistics in this Free the Slaves factsheet here.

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Source: freetheslaves.net

A key component of human trafficking is the use of force, fraud or coercion to lure victims into positions of exploitation. Traffickers generally prey on people who appear vulnerable, including those who are experiencing psychological or emotional vulnerability, economic hardship, lack of a social safety net, natural disasters or political instability. Women and girls who have been victims of sexual, physical or emotional abuse, and runaway children are particularly at risk. Refugees and/or people living in areas of war or political instability are also at increased risk [2].

Human Trafficking and Health

In addition to human trafficking blatantly violating human rights, it results in devastating long-lasting health consequences for the victims. Since victims are often dependent on their traffickers for their livelihood, receive limited food and are often malnourished. This is especially problematic for the estimated 5.5 million children in slavery today [4]. Women in forced prostitution and child soldiers, are often given drugs by their traffickers to ensure compliance, thus drug addiction is sadly all too common. Women forced into the sex industry are at risk of sexually transmitted infections and unwanted pregnancy and often don't have the agency to negotiate safer sex practices. [7]. In addition to the physical health effects, victims of human trafficking suffer from impaired emotional and psychological health [7]. Traffickers control through fear, physical, emotional and sexual assault, and manipulation [8]. This has negative impacts on victims and often leaves them ashamed, psychologically traumatized, emotionally attached, and afraid to leave their trafficker [8].

Raising Awareness Globally

Although human trafficking still does not receive an adequate amount of global attention or recognition, efforts in the last decade have elevated awareness of the problem. In 2010 the UN General Assembly adopted the Global Plan of Action to Combat Trafficking in Persons and urged countries to take coordinated efforts to combat and eliminate human trafficking [3]. In 2013 the UN General Assembly adopted a resolution, designating July 30 as the World Day against Trafficking in Persons. The resolution was made to, “Raise awareness of the situation of victims of human trafficking and for the promotion and protection of their rights” [5]. In December 2014, the president of the US, Barack Obama, established January as National Slavery and Human Trafficking Prevention Month in the US and January 11th as Human Trafficking Awareness Day, in recognition that modern day slavery or human trafficking still exists in communities across the US and the globe [6].

It is important to remember that human trafficking happens across the globe. It isn't something that just happens across international borders and/or in low- or middle-income countries. The US has an estimated 60,000 victims of slavery and the United Kingdom (UK) has an estimated 13,000 [1]. While a majority of these victims come from overseas, an alarming number of people are trafficked domestically within both the US and the UK, with the Federal Bureau of Investigation estimating that 293,000 American youth are at risk for sex trafficking within the US each year [9]. Given the rise of social media and the Internet, traffickers now use the Internet as a primary mechanism for recruiting victims both internationally and domestically.

Stopping Demand

Efforts to educate the public are an important step in combating the issue. Human trafficking is an industry because there is demand. Traffickers are motivated by high profits, with an estimated $150 billion USD generated by traffickers each year [1]. Therefore, decreasing/stopping the demand is key to eliminating human trafficking. "Sex tourism"- travel planned for the specific purpose of sex, generally to a country where prostitution is legal - fuels the demand for human trafficking, as does large events which bring in crowds of people [10]. In fact, the US Super Bowl is one of the largest magnets for sex trafficking globally [10]. Efforts to hold accountable both the traffickers and those purchasing the services are needed to stop the demand. Global efforts such as the UN's Protocol to Prevent, Suppress and Punish Trafficking in Persons, tougher sentencing for traffickers and purchasers in many countries, and local efforts to raise awareness in communities are helping to combat the issue. However, vigilance and awareness from all people and continued united global efforts are needed to end human trafficking.

References:

1. Free the Slaves. http://www.freetheslaves.net/about-slavery/  

2. United States Trafficking in Humans report, July 2015. http://www.state.gov/documents/organization/243557.pdf 

3. United Nations Office of Drugs and Crime. https://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html?ref=menuside

4. Anti-Slavery International. http://www.antislavery.org/english/slavery_today/child_slavery/default.aspx

5. United Nations World Day Against Human Trafficking in Persons. http://www.un.org/en/events/humantrafficking/

6. United States Department of Homeland Security. http://www.dhs.gov/blog/2015/01/20/national-slavery-and-human-trafficking-prevention-month

7. Center for Disease Control and Protection. http://wwwnc.cdc.gov/travel/page/sex-tourism

8. Polaris Project. https://polarisproject.org/victims-traffickers

9. Federal Bureau of Investigation, Law Enforcement Bulletin. https://leb.fbi.gov/2011/march/human-sex-trafficking

10. Federal Bureau of Investigation. https://www.fbi.gov/phoenix/press-releases/2015/super-bowl-sex-trafficking-operation 

The Environmental Cost that Living in this World Puts on Our Health

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

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Source: Environmental Health, World Health Organization (WHO)

As revolting as it sounds, there are places in the world where the chances of consuming one’s neighbours’ faeces are quite high if one is not vigilant regarding sanitation and hygiene. That being the condition of many areas in low and lower-middle income countries does not mean that high and higher-middle income countries are exempt from any environmental conditions that are harmful to health.

But, what is environment health? The World Health Organization (WHO) defines the term as, “All the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours”. It, however, excludes genetics and the social and cultural environment.

In low-income settings, concerns for environmental health may arise in the context of sanitation and hygiene, as well as indoor and outdoor pollution. In high-income countries, many chronic diseases like diabetes and cardiovascular disease, are associated with sedentary lifestyles. While these might be attributed to behaviour, one must consider that such behaviours can arise from changes in the environment. Over 80% of communicable and non-communicable diseases can be attributed to environmental hazards.  Overall, conservative estimates indicate that about one quarter of the total global burden of disease is owing to this cause (WHO, 2011). Furthermore, the biggest killers of children under 5 years are all environmental-related diseases, including diarrhoea, respiratory infections, and malaria.

Other diseases of concern are helminthic infections, trachoma (a bacterial eye infection), Chagas disease, leishmaniosis, onchocerciasis, and dengue fever. All of which are associated with impoverished conditions and can be mitigated by improving sanitation, hygiene, and housing. Although conflicts and natural disasters might be catastrophic for any country, struggling economies tend to suffer more because disasters worsen the poor conditions which directly affect sanitation and hygiene practices, creating conducive conditions for various infectious diseases, and ultimately feeding into the vicious cycle of poverty.

Many interventions are underway to address these conditions, including Water, Sanitation and Hygiene (WASH) initiatives, Integrated Vector Management, Programme on Household Air Pollution, International Programme on Chemical Safety, Health and Environment Linkages Initiative, and Intersun Programme for the effects of UV radiation. The acknowledgement of the effects of the environment has grown. One of the Millennium Development Goals (MDGs) was, “To ensure environmental sustainability.” The Sustainable Development Goals (SDGs) are more extensive and thorough in placing focus on the environment. Goal 1 is to end poverty, goal 6 is to make provision of clean water and sanitation possible, and goal 13 is to stop climatic change resulting in floods and drought (United Nations, 2014).

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The Sustainable Development Goals. Source: United Nations System Staff College

It is encouraging to see steps being taken to control environmental hazards; however, the journey to measuring and eradicating such conditions still remains a challenge, which will hopefully be overcome through future endeavours.

References:

United Nations (2014). Sustainable Development Goals. doi:10.1017/CBO9781107415324.004

World Health Organization (2011). WHO Public Health & Environment Global Strategy Overview

Motor Vehicle Accidents - A Growing Public Health Burden

~ Written by Mike Emmerich, Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za

https://twitter.com/MikeEmmerich

“Road Traffic Crashes do not just happen! They are caused by Fatal Moves (actions) by a driver. The message is simple - DON'T DO FATAL MOVES!”@FatalMoves https://twitter.com/FatalMoves* 1990 to 2010: Deaths from road traffic injuries increased by almost half.*

The largest category of fatal events are transport related. In 1990, according to Global Burden figures, these were the 10^th leading global killer. By 2013, they were fifth! Ahead of malaria, diabetes, chronic obstructive pulmonary disease, cirrhosis or any kind of cancer. In part, this is because of progress against these diseases. But it also because as incomes have risen worldwide, more people are buying, and crashing, motorbikes and cars.

Most global road traffic deaths occur in low and middle-income countries and are rapidly increasing because of the growth in motorisation. Mortality rates caused by traffic related injuries are increasing in low and middle-income countries and they account for 48 percent of the world’s vehicles but more than 90 percent of the world’s road traffic fatalities. Pedestrians are most often affected, followed by car occupants and motorcyclists. Alcohol plays a key factor in the drivers and pedestrians, notably in South Africa, where as many as 65% of all pedestrians have increased blood alcohol levels. Conversely, traffic deaths are decreasing in high-income countries, Sweden is an excellent case study that we will review further on in this article.

10 countries are responsible for 600,000 road traffic deaths annually (see this link to see if your country is on the list). Each year, 1.3 million people die in car accidents, so these 10 countries are responsible for nearly half of all road deaths! India tops the list for the highest overall number of road deaths, followed by China and the U.S. If public health leaders are to catch up on accident prevention, the Global Burden of Disease study (Lancet links below) findings can help them see where and how. “Now that somebody’s done the work and we recognize that there’s a difference we may not have seen before, we can go to work and ask why,” said Dr. Schauben

Besides the rapidly rising fatalities we must also take cognisance of the rising number of injured persons and their cost on the (Global) health burden. Road-traffic crashes were the number one killer of young people and accounted for nearly a third of the world injury burden, a total of 76 million DALYs (Disability Adjusted Life Years) in 2010, up from 57 million in 1990. Most of the victims were young, and many had families that depended on them, who know have to rely on other sources of support, in most instances, the state.

What does the current research then tell us about this rapidly rising burden on global public health; transport injury prevention shows that collective action is as important as individual efforts. Motorcycle helmets, car seatbelts and sober drivers are important, but so are safe vehicles, consistent law enforcement and a reliable infrastructure. Thanks to a combination of insufficient, nonexistent or poorly enforced safety laws, poor infrastructure and a lack of enforcement and corrupt enforcers, the bulk of the countries globally keep aiding and abetting in the deaths of over 1.3 million persons annually! Only 28 countries, representing 449 million people (7% of the world’s population), have adequate laws that address all five risk factors (speed, drunk driving, helmets, seat-belts and child restraints). Over a third of road traffic deaths in low and middle-income countries are among pedestrians and cyclists. However, less than 35% of these countries have policies in place to protect their road users.

India has the dubious distinction of registering the highest number of road fatalities in the world (250,000), despite the fact that its population is much smaller than neighboring China and there are more vehicles on the roads in the USA than in India. "A large proportion of these deaths can be prevented by simple measures. The most important of these is strict enforcement of traffic rules, which is conspicuous by its absence in our cities as well as on highways," says the Times of India, and this would be true of the top 10, and also of the country where I reside, South Africa, where 47 persons die each day!

Further compounding the cost of the traffic fatalities is the actual real cost impacting on the affected countries economies; many who cannot afford to have the extra burden on their already strained public health budgets. The economic cost of road collisions to low and middle income countries is at least $100 billion a year! The risk of dying as a result of a road traffic injury is highest in the African Region (24.1 per 100 000 population) It's such a big problem, in fact, that the U.N. feels it needs an entire decade to fix it. In 2011, the U.N. launched a "Decade of Action" that aims to “stabilize and then reduce” global road traffic fatalities by 2020.

Is there any good news? Sweden is one success story, in 2013 only 264 people died in road crashes, a record low. How have they done this? Planning has played the biggest part in reducing accidents. Roads in Sweden are built with safety prioritised over speed or convenience. Low urban speed-limits, pedestrian zones and barriers that separate cars from bikes and oncoming traffic have helped. Globally we need to reduce human error, or eliminate the opportunity for drivers to make fatal moves; human error can even further be reduced, for instance through cars that warn against drunk drivers via built-in breathalysers and making the implementation of safety systems, such as warning alerts for speeding or unbuckled seatbelts/child-seats, compulsory on all new vehicles, built in any factories across the globe.

Individually we need to be aggressive in safe and sober driving habits and not allow our friends and family to place themselves, their passengers and fellow pedestrians at risk by not looking kindly on their unsafe driving practises. Bad and drunk driving should become as unpopular as using a cellphone while driving.

References:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961682-2/fulltext http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2962037-6/fulltext http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2962037-6/fulltext

http://www.worldlifeexpectancy.com/cause-of-death/road-traffic-accidents/by-country/ http://apps.who.int/gho/data/node.main.A997 http://apps.who.int/gho/data/node.main.A998 http://mikebloomberg.com/BloombergPhilanthropiesLeadingtheWorldwideMovementtoImproveRoad_Safety.pdf

Corporate Responsibility and Duty of Care - Health Insurance and Assistance

-Written by Mike Emmerich, Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za) 

https://twitter.com/MikeEmmerich

"Between one in two and one in three expatriates has no international health insurance" International Private Medical Insurance Magazine REPORT: International And Expatriate Healthcare And Insurance 2014

I believe this to be a very accurate statement notably, with regard to the African continent (where I spend most of my time), this figure might even be flattering to some companies employing expat staff in Africa.

The globally mobile population has grown dramatically. There are over 50 million expatriates, and by 2020 this will be 60 million. 232 million people now live away from their country of birth. Between one in two and one in three expatriates has no international health insurance, although a minority is covered by domestic health insurance. Several countries seek to get expatriates and migrants to pay for healthcare or have compulsory health insurance.

This is a disturbing issue, as too many companies are happy to send their staff abroad, or to remote work sites, without any or inadequate medical cover; be it insurance or assistance. This shows very poor duty of care. In discussions with some of these companies, when trying to assist them with advice on even basic assistance packages or client managed services, their responses are troubling; when viewed against the light of corporate responsibility and duty of care. To defer the responsibility to the employee and abdicate corporate responsibility, should be cause for concern.

The duty of care of the employer, is a term that is often thrown about and The UN Global Compact, is one way that companies are being encouraged to show a greater duty of care, although some would cynically say that Corporate Social Responsibility is a box-ticking exercise, companies are just paying lip service, but do no more than is necessary to avoid affecting the bottom line. The UN Global Compact, is engaging over 8,000 companies in more than 145 countries on human rights, labour standards, environment and anti-corruption, hopefully at the same time pushing to commit to a sustainable workforce, via duty of care and corporate social responsibility.

The level of care offered by companies, will depend where the company is registered, as to what laws could be enforceable, hence most companies register an off-shore shell for hiring, staffing and contracts. (this is in itself a topic for another day – relating to contracts, taxes etc.)

Possibly other avenues should be explored, with respect to medical assistance/insurance; by pushing that investors use their muscle, ensuring that their investment capital is being well managed. Staff that cannot be properly cared for (ex-pat and local), via medical cover that is in place, place a further drain on company resources, shifting capital away from its intended purpose. A well managed corporate health care plan, ensures ongoing confidence in the company.

Till now I have only been speaking about expat staff, but the issue of medical care for local staff would also need to be addressed, in fact poor care for expat staff, could be viewed as an indicator of poor care for local staff. The ever growing impact of business on society means that staff, investors and consumers expect corporate power to be exerted responsibly, the corporate community will have to step up its game and build greater trust with respect to duty of care. Business are being expected to do more in areas that used to be the exclusive domain of the public sector – ranging from health, education and to community investment.

Having insurance/assistance programs from reputable companies, linked to well managed onsite managed health care programs, which is in place for ALL staff, makes good business sense. This then empowers staff to work safely in environments that might be deemed risky, allowing them to work with confidence and be fully focused on their daily tasks.

References:

http://www.researchandmarkets.com/reports/2788557/internationalandexpatriatehealthcareand 

https://www.unglobalcompact.org/abouttheGC/thetenprinciples/index.html 

Inequality within those who Call for it the Loudest

~Written by  Mikael Ashorn (Contact: mikael.ashorn@gmail.com)

Last March I had the chance to be part of a team representing our graduate program in the annual Emory Global Health Case Competition in Atlanta. We were given the not-so-easy task of transforming the World Health Organization (WHO) to the 21st century (http://www.globalhealth.emory.edu/what/student_programs/case_competitions/pdfs/2014_international_cc_case.pdf).

As we pondered this thrilling case among our group there was a lot of discussion around the fundamental core structure of the WHO and about the politics surrounding it. How could it serve better those in need – and as equally as possible? Among other things the WHO, as well as other United Nations (UN) branches, try to promote equity among the world's population. Health is listed as a fundamental human right, which everyone should have equal access to, already in the Universal Declaration of Human Rights in 1948. But do these large organizations promote equity also within their own system?

A Swiss newspaper writes (http://lenews.ch/2014/11/20/the-united-nations-more-consultants-fewer-rights/) on how the UN has started to save by using short-term consultants on a long-term basis. The Joint Inspection Unit (JIU) has already noted this negative trend. According to the JIU this trend creates inequality and a two-tier structure among the workers: consultants with next-to-none social benefits and full-time employees.

About half a year later I was attending Youth & Student UN-days in Finland. The theme was human rights. No one seemed to be talking about the equal rights of the employees within the UN. Among other presentations, I heard a former intern give a talk on how much she had learnt during her internship in the UN. However, in the same breath she spoke about how hard it was to make it through this unpaid internship financially.

Yes – you heard me right. Unpaid.

The UN does not pay any of its interns, nor does it help them financially in any other way. Does this provide equal opportunities for everyone to participate? Brilliant students from developing countries already struggle with tuition fees more than students coming from more prosperous countries. However in this field of work a good education is usually not sufficient to land a job. All employers expect work experience, which is usually gained through internships.

Some organizations, like the International Federation of Red Cross and Red Crescent Societies (IFRC), seem to have noticed this. For instance the IFRC claims to be “an equal opportunity employer”. With almost identical competences required as for internships for the UN, they pay all the interns expenses as well as a nominal salary.

A Washington Post article claims, that poor kids who do everything right are still worse off than rich kids who do everything wrong (http://www.washingtonpost.com/blogs/wonkblog/wp/2014/10/18/poor-kids-who-do-everything-right-dont-do-better-than-rich-kids-who-do-everything-wrong/). They claim that this is because of the different opportunities they get in life. These are the kinds of differences the UN promotes with non-paid internships. My fellows and I from developed countries are fortunate enough to have social-networks that we can rely on during the internship without a salary. However others are not so fortunate.

When the JIU published its report, the UN responded that changing the systems is very much in their interest, as they “need to have the best people possible”. By continuing these unpaid internships, the UN not only creates inequality between candidates but also might rule out some very competent prospective employees, whom are not fortunate enough to be able to work unpaid.

As an employer, the UN seems to pay rather high salaries (https://careers.un.org/lbw/home.aspx?viewtype=SAL). Could these be scaled back so that at the very least, interns' living expenses can be paid? This way, the UN would also be promoting equity within the organization. It would give more people the opportunity to get their careers kick-started through an internship, which future employers would appreciate.