The purpose of the paper is to offer a summarised report of the current knowledge specific to the health conditions of the displaced refugees, migrants and the degree to which the issues are being solved. The timeline between 2014 to 2015 has the largest number of rapid escalations of individuals being compelled to leave their homes. Millions were left homeless and had to flee from the conflict in Afghanistan, Syria, Ukraine, along with the persecution regions of sub-Saharan Africa and Southeast Asia (Matlin et al., 2018). The period witnessed the highest number of displacements following the Second World War. The events were influenced partly by a global phenomenon that has led to a huge number of displacements worldwide and are not isolated. The neighbouring nations of those countries act as hosts to refugees or merely transition points between the war-torn countries and the high-income countries. Turkey hosted 2.8 million refugees in 2016, the highest among any country. The sub-Saharan African regions hosted 4.5 million, and Europe gave refuge to 2.1 million people (Stroud, Jones & Brien, 2018). Italy, Greece, France, and Germany received the highest number of refuge seekers among the European countries in 2016. Global humanitarian assistance increased to 27.3 billion USD the same year. With the rise in migrants and refugees seeking shelter in host countries, the responsibility of health onus lies with these countries to respond to the emerging health crisis among the refugees and assist them in their health needs during their stay in these countries or the transit regions. In September 2016, 193 Member States at the UN Summit signed the New York Declaration mainly focussing on public health crisis (paragraphs 5c, 7b, 13b and paragraphs 30 to 33, 59, 80, 83 of the 'Comprehensive Refugee Response Framework) (Gammeltoft-Hansen et al., 2017). However, there seems to be a lag in support and solidarity among the global community regarding the commitments offered in the New York Declaration.
Identification of Displacement Crisis as a Public Health Challenge
Extreme public health repercussions have been observed and documented after armed conflict emergencies, mostly in developing nations. Around 130 armed conflicts have been documented globally since 1980, 32 of which have created approximately 1000 battlefield casualties. In Africa alone, civil conflicts have caused around 750,000 deaths, 800,000 in the Middle East regions, and 3,400,000 in Asia between 1975 and 1989. The direct and indirect effects of public health from these conflicts are the displacement of population, food shortage, higher mortality rates and the crumbling of fundamental healthcare services (Garry & Checchi, 2020). Mass migration, internal and external displacement and food shortages are accountable for most casualties in armed strifes in Asia and Africa. Displaced persons or refugees are described by most international conventions as people who are forced to leave their own country, governed by the fear of persecution due to factors like religion, race, political ideologies, and social class (Shacknove, 2017). Between 1980 and 1994, the quantity of independent refugees that sought security from the United Nations High Commissioner for Refugees (UNHCR) exponentially grew from 5 million to 20 million (Glover, 2018). A number of large migrations in recent times have occurred in Afghanistan, Syria and Nigeria. Internal conflicts in Nigeria displaced 3,300,000 in 2013 and 2,730,000 in 2020. As of December 31, 2020, a total of 3,547,000 people has been displaced due to internal violence and armed conflicts. Syria witnessed 6,568,000 displacements in the year 2020. The reason for most displacements is usually the same: civil unrest, war, search for stability and security, and escaping persecution. Additionally, along with people who are internationally designated as 'refugees', an approximate 25 million individuals in the late 1990s have been forced to flee their homes for similar reasons but continue to remain 'internally displaced' in their home country.
Public Health Challenges of Population Displacement
The major risks of public health issues of internally displaced people and refugees are the same. Although, the status of health on the internally displaced individuals have been historically worse since accessing these groups of people by relief agencies and humanitarian agencies pose a difficult endeavour (Blanchet et al., 2017). The internally displaced people suffer more trauma and physical injuries since they are often left homeless, without shelter, and in conflict zones.
Mortality- The Crude Mortality Rate (CMR) precisely represents the public health of people impacted due to civil war and emergency conditions. Mortality rates are calculated from the evidence of burial records, hospital records, site surveillance, population census and community-based reporting. The challenges in estimating mortality rates in times of conflict and unrest are:
- poor representation of population surveys
- families not reporting deaths fearing loss of entitlement to food rations
- inaccuracy in estimating affected groups to calculate the mortality rates
- negligence in standard reporting systems.
However, it is often noted that mortality rates have been severely underreported due to underreporting and inaccuracy in counting. The reliable source of mortality rate estimation comes from the refugee camps where the camp organisations and humanitarian agencies are responsible for gathering data. The difficult situations are mainly when the internally displaced people get scattered in the regions of conflict since surveys can only be conducted in a relatively safe area. In an emergency, due to the peak time of mortality rates, it is important to note the CMR as deaths per 10,000 population every day (Reed, Sheftel & Behazin, 2018). In developing countries, the CMR baseline recorded annually in non-displaced groups is observed to e 12 to 20 per 1000, corroborating a per-day rate of 0.3 to 0.6 per 10,000 population. An emergency is characterised by an elevated CMR having a threshold of 1 death per 10,000 population each day. The median Crude Death Rate (CDR) in these countries is 9 deaths for every 1000 population. Refugees are at the biggest risk of death during the time following their displacement and arrival in the host country, witnessing long spans of inadequate medical care and food before or during their escape. For example, about half the total Syrian population has fled the country that began in 2011, and among them, over 5 million have received asylum in the neighbouring nations (Akgündüz, Van den Berg & Hassink,2015). The civil unrest, armed conflict, scarcity of food, breakdown of health service, insufficient medical care, scarcity of vaccination and dearth of professional medical personnel and medical supplies have led to an increase in mortality and morbidity rate among the internally displaced people in Northern Syria since the beginning of the conflict. Mortality can also be due to famine or communicable diseases that are most often impacted due to civil wars. Such crises include Sudan, Somalia and Ethiopia in the 1980s and 199s, and Biafra in Nigeria in 1968.
Demographic Risks- Most deaths occur among children below the age of 5 due to chronic malnutrition and the risk of immune deficiency. In 1992, among the Mozambican refugees who arrived in Malawi, the mortality rate for children below 5 years of age was more than 4 to 5 times the crude mortality rate, which signifies that most deaths among the refugees belonged to this age group. In many emergencies, it has been observed that gender-specific data of mortality were not collected. However, there were more deaths among girls and women than boys in many conflict regions. In spite of the lack of women's mortality data in health emergencies, many researchers have noted the increased threats for mortality and morbidity among the females in internally displaced populations and the refugees.
Factors affecting Mortality and Morbidity
The highest occurring causes of death reported among displaced populations during the beginning of the influx stage are measles, diarrheal disease, infections, acute respiratory diseases, infections and malaria (Lam, McCarthy & Brennan, 2015). These diseases account for the most critical factors behind morbidity and are at the centre of many public health mediations. The most impactful consequences for the refugees and internally displaced people occur during the emergency stage when relief and humanitarian efforts are in their early phase. During this time, the mortality rates are 60 times higher than the CMR among the non-refuge seeking population in civil unrest and war places. However, the international emergency response quality has improved over the last decade, the cost of coerced migration remains huge. Most deaths occur during armed combats and due to sustained battle injuries, landmines blast, communicable diseases or collateral damage connected with the impacts of war. Acute protein deficiency and malnutrition is also leading cause of elevated fatality rates for comorbidities and altogether mortality rates. Epidemics of acute diarrhoea is another increasing cause of mortality and is common to refugees and displaced populations. Cholera epidemics are a common occurrence in refugee camps of Afghanistan, Nigeria, Zimbabwe, Nepal, Swaziland, Turkey, Burundi, Bangladesh, Malawi and Zaire.
In Nigeria, the Boko Haram group have been causing insurgency since 2009 (Abbani, 2021), and the Kuchigoro Camo is one of many refugee camps for the internally displaced populations of the country. A makeshift township to house the internally displaced have been created under the government's nose, and reports show marasmus and kwashiorkor evident among the children, lack of basic facilities and hygiene, no clean running water and no proof of the government's suppor (Taylor-Robinson & Oleribe, 2016). The federal government and the local authorities have done very less to upgrade the lives of the displaced individuals other than allowing them to live on the land. Despite the Kuchigoro camp being near government offices and posh residential areas, the site is riddled with diseases and neglected by the authorities. The prevalent disease in the refugee camp is tuberculosis, measles, malaria, sexually transmitted diseases (STDs), HIV and diarrheal diseases (Olanrewaju et al., 2019). To earn money, the camp residents take up illegal ways like selling drugs setting up brothels for prostitution that directly caused implicit risks of STDs like Hepatitis B, HIV and others. To eradicate the problem, the Nigerian government improved the five fundamental public health organisations such as the National Agency for the Control of AIDS (NACA), Nigerian Centre for Disease Control (NCDC), the Nigerian Institute of Medical Research (NIMR), the National Primary Health Care Development Agency (NPHCDA), and the National Health Insurance Scheme (NHIS) (Taylor-Robinson & Oleribe, 2016). These are important government institutions and agencies of the health sector of Nigeria. However, the NIMR, which is responsible for overseeing the aspects of health research, has not yielded well over the years and, when compared with the organisations of the other countries of Africa, lags behind. With the repositioning and new improvements, it can be expected that the organisation will show some great improvements in the health sector. In recent years, the National Agency for the Control of AIDS has been under controversy for their poor management of international funds that were granted to Nigeria. The agency has been newly improved to regain the trust of the people and to administer proper and comprehensive HIV facilities for the residents of the refugee camps. An NGO called the Excellence and Friends Management Care Centre (EFMC), headquartered in Abuja, is an active agent committed to disease containment, human development and system re-engineering are highly active in the area. The NGO works to enhance the lives of the people using efficient, effective and regionally generated solutions. EFMC works hard to help the displaced people, especially the marginalised sections, through integration, commonization, rationalisation, and decentralisation of the services of public health. They have diverse expertise in management and leadership, training, education, nutrition, human and child rights and other health facilities.
According to UNHCR, with the rapid increase of civil war and fight in Afghanistan, the effect will impact the females as 80% of the approximate 250,000 Afghans who were forced to displace by May of 2021 were all females and children (P?ívara & P?ívarová, 2019). The Afghan who escaped the country and fled to the United States of America had to endure the tardy process of getting immigration status and some even way today. Many of them who had assisted America in the war efforts as reporters, translators and others have received special immigration visas (SIV), which makes them automatically become holders of green cards and permanent residents. Every refugee migrant with SIV status has the eligibility for state and federal health and public benefits, along with all other refugees (Fix, Hooper & Zong, 2017). These benefits include Medicaid and Refugee Medical Assistance, Temporary Assistance for Needy Families (TANF), Supplement Nutrition Assistance Program (SNAP), and other Refugee Resettlement Program benefits. The emergency scenario of the evacuation process was rapid and disorganised, which led to most refuge seeking Afghans who had pending SIVs receiving authorisation to enter the USA via a temporary system called Humanitarian Parole. The USA grants this status to people affected by urgent humanitarian conditions or war emergencies. The changes made in the Continuing Resolution have made it easier for the humanitarian paroles to receive the same benefits as the documented refugees, including placement support, food assistance, and Medicaid. This designation only permits them to work and live in the USA temporarily and has no direct link to permanent residency. Humanitarian paroles must apply to SIV status and asylum to receive permanent citizen recognition.
In Afghanistan, there had been an exponential increase in child deaths during the recent insurgency of the Taliban, as stated by the UN News France. One among two children below the age of five endure severe and chronic malnutrition and face extreme hunger. The camps are riddled with cholera and diarrhoea due to a lack of clean running water and basic hygiene. Along with that, the recent insurgency collided with the COVID-19 situation that was taking more than 100 lives a day. Each day 2000 cases were reported to be COVID-19 positive, and these numbers were only the ones that could get documented. There were numerous other cases that went unreported or uncounted. The Afghans who sought refuge in Pakistan had a similar fate, and most people who died were males. The principal factor for higher mortality rates in the male refugees in Pakistan was that men are more subjected to external stresses than females. The mortality rate among Afghan men was reported to be 0.09 every 1000 refugees, and for females, it was 0.07. The children under 5 years of age suffered the most deaths, with a mortality rate of 0.24 for every 1000 (Malik et al., 2019). The causes of death among the Afghan asylum seekers in Pakistan were mainly respiratory diseases (14.22%) and cardiovascular disorders (23.53%). The other causes were diarrhoea (1.61%), hepatitis (2.75%), typhoid (0.74%), dysentery (1.30%), tuberculosis (0.12%) and measles (0.17%). More than 49% of the refugees in the camps of Pakistan suffered from respiratory tract diseases. The incidence rate for upper respiratory tract infections (URTI) of 12.74/1000 was higher than lower respiratory tract infections (LRTI) of 3.49/1000. Other diseases that affected the Afghan refugees were skin infections with an incidence rate of 3.59 per 1000 refugees, reproductive tract infections with an incidence rate of 0.94 per 1000 refugees and psychological disorders. 42.02% of the total refugees experiencing psychological issues were men and 71.42% women, signifying a greater impact on women than men (Schmeidl & Bose, 2016).
The civil unrest of Syria is a prime example of a humanitarian and health crisis evident from the latest chemical attacks over the Damascus region that have affected millions of lives in Syria. This has led to mass displacement, and after 7 years of civil wars, the estimated number of people who were internally displaced were 6 million (Aburas et al., 2018). This claimed to be the biggest displacement crisis in the world (Ostrand, 2015). More than an estimated 5 million Syrians sought asylum in the neighbouring countries. The situation can be equated to six in ten people who have been coerced to leave their homes. In spite of the humanitarian actions of international organisations and NGOs to improve the conditions, healthcare coverage and access to medical facilities for the refuge seeking Syrians have become worse as the conflict persists in continuing. Even though Syria had an efficient public health structure and had been enjoying improved health outcomes before the crisis, the ongoing civil conflict, violence, disruption of daily lives, and political instability have steered it to collapse (Vernier et al., 2019). The dire situation has left millions of Syrians vulnerable without proper medical facilities and services. According to United Nations Population Fund (2016) report, it was estimated that 360,000 internally displaced women were pregnant and had not received any postnatal and antenatal care. The previous year's report stated that 70,000 women would have to be forced to give natural birth in unhygienic and dangerous conditions if access to medical services was impossible.
In every case discussed above, the main concerns of public health remained focused on women and children. In most cases, the children below the age of five are the population who suffers the most. In the case of Syria, it can be understood that the collapse of the basic public health structure had been the major problem and restoring the system in an ongoing war have been difficult. This resulted in neglect of the women, especially the pregnant ones, who had to be forced to endure the birthing process without any medical access and in unhygienic, unsafe conditions. In the case of Nigeria, the case is different from Syria since the Nigerian government were doing the bare minimum for the internally displaced people. The situation started to turn around only when the government-appointed new officials in the five public health institutions tackled the health issues of the refugees affected by the Boko Haram insurgency. Nigeria already had a public health system running, but it neglected to focus on the situation of the refugee camps. Whereas Syria suffered as a country, and their entire public health system had collapsed under the impact of attacks and wars (Akbarzada & Mackey, 2018). Based on that, it can be said that lessons absorbed from these situations in refugee camps should be kept in mind during future civil unrest emergencies. The governments and international bodies should guide their policies and decisions in such a way that these morbidities and mortalities can be avoided.
It can be therefore concluded that although the ongoing crisis in many countries around the world surrounding wars and displacement of people is a major issue in the world forum, efforts should be made by the international humanitarian bodies to improve the efforts so that in future emergencies, similar conditions can be avoided. Improving networking and working with various governments are also necessary to develop relationships that can help get foreign aid from those countries.
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