This Global Governance Working Paper is a feature of the Council of Councils (CoC), an initiative of the Council on Foreign Relations. Targeting critical global problems where new, creative thinking is needed, the working papers identify new principles, rules, or institutional arrangements that can improve international cooperation by addressing long-standing or emerging global problems. The views and recommendations are the opinion of the author only. They do not necessarily represent a consensus of the CoC members, and they are not the positions of the supporting institutions. The Council on Foreign Relations takes no institutional positions on policy issues and has no affiliation with the U.S. government.
Public opposition to refugees is widespread and often led by fear, insecurity, and mistrust. One prevalent fear, easily politicized and abused, is that refugees bring dangerous communicable diseases into their host countries.
Debunking this view is the first step in assuring that a communicable disease threat does not interfere with durable policy options for the continuing refugee crisis, such as supporting voluntary return in safety and dignity, making integration more sustainable, and realizing the potential for resettlement. The world has 26 million refugees and 4 million asylum seekers, 80 percent of them living in countries neighboring their country of origin. In contrast, there are as many as 1.4 billion international tourists, 258 million international documented immigrants, and 41 million internally displaced persons annually. The number of undocumented immigrants or temporary foreign workers is difficult to assess but is likely higher than that of refugees. The baseline risk of communicable disease is present in all these groups, and, because there are fewer refugees than other migrant groups, the risk from the refugee population is proportionally smaller. In addition, the World Health Organization (WHO) and the European Centre for Disease Prevention and Control have found no link between refugees and communicable diseases.
However, several factors could increase refugees’ vulnerability to communicable diseases. Refugees often come from unstable countries with health-care systems that do not provide simple preventive measures such as childhood vaccinations or information about sexually transmitted infections. They are often encumbered by multiple social determinants of poor health, such as poor nutrition and little health literacy or awareness. In addition, the journeys that refugees undertake to their host countries are often perilous, characterized by inadequate nutrition, exposure to the elements, cramped transport conditions, and sexual violence. In some situations, host countries deliberately withhold care from refugee populations, fearing that providing health-care services to refugees will generate social unrest among citizens, especially in countries where the health-care system is already overburdened.
These vulnerabilities have manifested in measles outbreaks in unvaccinated children, cholera from failed hygiene, sexually transmitted infections, tuberculosis, and typhus. Infections and outbreaks could cause stigmatization, increase refugee isolation, or incite violence toward refugees.
Countries struggle to address those vulnerabilities. This diversity of potential infections and the added risk that one or more could be resistant to antimicrobials prevent the creation of a one-size-fits-all disease control strategy. Recently, the rise of populism and ethnic nationalism has further complicated host-country responses for refugees. These political forces often use narratives that stoke the fear of refugees, making it difficult for national governments to dedicate funds and resources to care for refugees.
The UN Global Compact on Refugees provides a blueprint for more predictable and equitable responsibility-sharing between countries, but it is not legally binding and the United States is not a signatory. Donor fatigue and apathy are also prevalent. Despite international efforts, the humanitarian financing gap remains high. As a result, the tendency to use emergency humanitarian aid to address the refugee crisis, rather than enduring development aid and nation-building, remains.
Mitigating potential communicable disease in refugee populations is a subset of efforts for overall refugee health (general nutrition, noncommunicable diseases, and mental health), which is in turn a subset of efforts for refugees overall (sustainable financing, political rights, and durable economic livelihoods), which is in its turn a subset of efforts for all of humanity (human rights, equality, and dignity). Ideally conflict prevention, nation-building, and development aid could prevent refugees in the first place, but the continuing presence of refugees is realistically unavoidable.
The following recommendations focus on cross-border policy options and are not mutually exclusive. Efforts to strengthen health systems in countries of origin—such as monitoring disease outbreaks, providing vaccinations, or combining forces with communicable disease management—are all crucial and discussed elsewhere. These recommendations affirm the rights of refugees to health care and provide opportunities for refugees to assert their own dignity, agency, and choice. Issues of justice, human rights, proportionality, consent, and the law are embedded within the recommendations. They require both the hard power and legitimacy of the nation-state and the soft power and moral leadership of global powers and international institutions.
To mitigate potential risks of communicable diseases in refugee populations, countries, international institutions, and the private sector should work through the following nonpunitive and nondiscriminatory actions.
Europe and the United Nations should lead the architecture-building of a global refugee health partnership to ensure health care and preventive services for the steady flow of immigrants from the Global South to the Global North. Since health cannot be managed in isolation, this partnership should be embedded in all geopolitical, economic, and development aid, and in human rights partnerships and frameworks. It could be convened and coordinated by the United Nations, like the UN High Commissioner for Refugees (UNHCR) and the UN Office for the Coordination of Humanitarian Affairs (OCHA), but not directed or supervised by either agency. The Global North has the moral and geopolitical responsibility and the financial ability to shoulder the majority of the commitments. Given that the role of corporations is ill-defined beyond superficial statements of corporate social responsibility and the Business Action Pledge, this partnership could define a clearer role for corporations that builds on the stakeholder theory of capitalism. Although the flow of refugees from Africa and the Middle East commands significant global attention, countries should also consider that the line between migrants and refugees is thin, and situations with large numbers of migrants (such as the Venezuela-Colombia border) can quickly morph into large waves of refugees. These efforts can build on existing political tools such as the International Health Regulations signed by all 194 member countries of the WHO, which provides a legal framework for communicable disease outbreaks in any population, including refugees. These tools provide a decision tree against which communicable disease events can be assessed for their potential to spread across borders. They also mandate a global response when the WHO director general deems one necessary.
Global North governments should promote the idea that refugee health is an investment to their citizens. This recommendation is based on a humanitarian obligation; on the Global Compact on Refugees, which pledges international responsibility sharing; and on disease prevention principles. The economic case for preventing disease among noncitizen refugees is strong: to protect the host-country population, augment the labor market, and contribute to the tax base. Some countries need healthy refugees and immigrants to replace aging or shrinking populations. A good example is the Greek April 2016 law, which makes access to health care a right for refugees and asylum seekers. Additionally, persuasive public communication strategies using evidence and data could allay disproportionate public fears.
Governments and organizations should build screening, vaccination, and epidemiological surveillance systems at the first point of contact. The technology exists for point-of-care diagnosis of certain communicable diseases using noninvasive technologies. Pooled procurement and volume purchase of such test kits and vaccines could reduce the cost. Guidelines could be developed for a coherent and interoperable system to screen and vaccinate at first contact, anywhere along a refugee’s journey. Refugees could then be given a card to indicate that they have passed through the system. Public health officials could be embedded into refugee management, which is led mostly by law enforcement experts. The collaboration between the Centers for Disease Control and the U.S. military to manage refugees from the Vietnam War in the 1970s is one example of how integrating health and enforcement components could help improve the health security of a nation. These screening systems could coexist along a continuum of care and be integrated into the health systems of host countries, including epidemiological surveillance and the care for noncommunicable diseases. Additional resources should be provided for cultural mediators and interpreters and social integration for every phase of the refugee’s journey.
Humanitarian aid should improve living conditions in camps and build with health in mind, rather than rely on stopgap planning. The average refugee spends 10.3 years in exile, a number that could rise. Planners of temporary camps therefore need to consider that their designs could unintentionally become permanent camps. Although repatriation is ideal, it is not at present conceivable for refugees from Afghanistan, South Sudan, or Syria, for example. Planners should consider the minimum standards of living space, hygiene, ventilation, clean water, and adequate nutrition as ways to reduce communicable diseases. One risk is that any move toward a permanent camp could upset host countries that are themselves fragile and could struggle to convince their citizens that they have equal or more rights than the perceived rights of the refugees.
Qualified refugees can take on epidemiological surveillance. In Europe, up to 20 percent of refugees have tertiary education, compared to 27 percent of non-refugee migrants who enter after a rigorous screening process. Refugees with relevant formal training, such as doctors and paramedics, could receive accreditation to perform community surveillance of communicable diseases (as proposed by WHO) or become community health workers. This move would bring the added benefits of creating self-sufficiency and dignity among refugees, reducing the strain on host-country systems, creating a talent pipeline into the host country’s health system, and generating goodwill and trust, with some of these refugees becoming health ambassadors or ultimately citizens who contribute to a stronger national health system. Cultural mediators, social workers, community health groups, and interpreters would be crucial in this process, and additional resources should be allocated for data collection and intercultural medicine. Working hours would need to be organized around vulnerable populations, for example, adjusted to include refugees who work all day and can only see a doctor at night.
National governments, international institutions, and nongovernmental organizations should work toward gender empowerment in refugee populations. On top of its intrinsic value, gender empowerment has three additional benefits. First, as part of Sustainable Development Goal five, preventing sexual violence against and sexual exploitation of refugees would reduce their risk of sexually transmitted diseases. Second, because women are frequently the decision-makers for their families’ health, gender empowerment improves health outcomes. Third, gender empowerment also reduces the risk of women entering the sex trade, which further reduces the risk of communicable diseases. It is possible to imagine a virtuous circle emerging in which gender equality not only improves the lives of women but also leads to health benefits for them and their families.
Governments and organizations should collaborate to establish durable policy options for health financing for refugees in host countries. Currently, health financing is done on an ad hoc, temporary, and emergency basis. Sustainable financing is crucial, as is deciding the role of the United Nations, origin and host countries, private markets, nongovernmental organizations, and individuals. Discussions on innovative financing or health insurance for refugees could be conducted with all interested actors. Premiums or start-up capital costs could be paid by institutional or private donors. Health services could be integrated with existing national-level health-financing systems while being mindful of the risk of the public perceiving that refugees have more rights than citizens. Basic nutrition and vaccinations are low-hanging fruits to tackle.
In addition, countries and international organizations should consider the following bold options.
The European and American responses to refugees should be demilitarized. For example, Frontex, the European Border and Coast Guard Agency, had a massive 3,688 percent increase in funding between 2005 and 2015, much of which went to militaristic equipment and performance targets. Development aid and nation-building abroad will reduce the overall flow of refugees and increase the health of whoever is forced to seek refuge, which is not only more humane but also more effective and sustainable. Improving the social determinants of health is more valuable than quarantines in fighting communicable diseases.
UNHCR and OCHA should develop more and deeper partnerships with international health-care delivery organizations. They could start with organizations such as Médecins Sans Frontières and the International Federation of Red Cross and Red Crescent Societies and gradually expand to grassroots organizations through capacity development. UNHCR and OCHA would then not be directly delivering health care, but instead relying on more robust and clearly publicized partnerships to demonstrate mission clarity and avoid any gaps in responsibilities for health.
Refugees who prove that they have been vaccinated or are disease-free either before they arrive or after receiving treatment should have a smoother transition to citizenship or permanent residency pathways. This could motivate refugees to care for their own health. Examples include seeking vaccinations or completing the tuberculosis treatment regimen. To mitigate abuse and discrimination, such a policy should only be put in place after health-care services are made accessible to refugees and appropriate political, legislative, and human rights frameworks are established.
Any efforts to address communicable diseases should not be viewed in isolation but instead as one part of the entirety of policy options for refugees. The medical, logistical, technical, and financial hurdles can be overcome, but the political and geopolitical hurdles are more difficult. Nation-states need to enter into a new era of rational self-interest in dealing with refugee health given the powerful, albeit largely invisible, benefits.
These recommendations to manage perceived and potential communicable diseases in refugees today could provide the basic multilateral framework that future decision-makers can rely on to resolve even greater challenges. The final ingredient remains the same: political will. Ultimately, success will depend on the current power and legitimacy of nation-states and the neutrality and stature of the United Nations.
The authors thank the participants of the Council of Councils twelfth regional conference for valuable comments on this paper. In particular, we thank Christophe Bertossi (French Institute of International Relations), Daniel Gulati (German Institute for International and Security Affairs), Anne Koch (German Institute for International and Security Affairs), Aimée-Noël Mbiyozo (Institute for Security Studies), and Carlos Javier Regazzoni (Argentine Council for International Relations) for their detailed review and helpful suggestions on an earlier version.