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September 2019 (Volume 97)
Quarterly Article
Lawrence O. Gostin
March 2024
Mar 11, 2024
Feb 27, 2024
Back to The Milbank Quarterly
Since its founding in 1948, the World Health Organization has neglected the immense health impacts of migration. This is surprising because the agency was conceived as an integral part of the United Nations response to mass evacuation, forced displacement, expulsion, and deportation during World War II. Astonishingly, the United Nations Network on Migration created last year excluded WHO from its steering committee. WHO’s historical neglect may now be over. On May 27th, the World Health Assembly adopted a five-year Global Action Plan (GAP) to Promote the Health of Refugees and Migrants.
The world is now experiencing the greatest crisis of forced migration since WWII, with 1 billion people on the move, of which 258 million are crossing borders. Millions are stateless, lacking a nationality and being denied basic rights to education, health care, and freedom of movement. Forced migration—whether from persecution, climate change, or poverty—is undermining key global health goals, including universal health coverage (UHC) and health equity (“leaving no one behind”).
Migrants’ Health Endangered
Migrants face manifold assaults on their health, both during their journey and at their destination. The journey often involves brutal conditions, crossing desert expanses or open seas; nearly 14,000 migrants died crossing the Mediterranean from 2014 to 2018.1 Gangs and human traffickers pose lethal threats. The journey adds to the severe trauma of those fleeing violence, persecution, and disaster. And many migrants lack access to health care or medications for chronic conditions.
Once at their destination, migrants face added obstacles, and often are excluded from national health care systems. Poverty, discrimination, and inhumane policies force them to live in squalid housing and unsanitary conditions, fueling diseases like tuberculosis, which is 9 to 18 times higher among immigrants in OECD countries. Migrants are often unemployed or exploited in unsafe, unhealthy, and underpaid jobs. Migrants who are not legally entitled to remain in the country are under constant deportation threat, contributing to higher rates of anxiety, depression, and PTSD.2 All-cause mortality is higher among international migrants living in countries with restrictive policies.3 Ill health can be perpetuated down generations.
Migrants’ Health Under the Law
Human rights law guarantees nondiscrimination, notably under the right to health.4 Yet few human rights obligations are more widely disregarded than migrant health. The 1951 Refugee Convention and its 1967 Protocol guarantee refugees the same social security as nationals, including in event of sickness. The International Convention on the Protection of the Rights of All Migrant Workers also guarantees nondiscriminatory access to services. Migrants should have equal access to national health systems, but they don’t.5
National laws denying migrants equal rights are rife. Many countries deny equal access to health and education benefits. Only half of Refugee Convention states parties permit refugees to work.2 Worse still, national policies exacerbate physical and mental trauma. Consider President Trump’s policies separating children from their parents at the southern border, overcrowded migrant camps, and indefinite delays in hearing asylum claims. Six immigrant children recently died in US custody. Asylum-seekers must wait in Mexico for hearings, in violation of US and international law. The President threatened Mexico with punishing tariffs unless it cracked down on vulnerable migrants, mostly women and children.
Global Compacts on Migration and Refugees
Last year, the UN adopted two nonbinding global compacts: the Global Compact on Refugees (GCR) and the Global Compact for Safe, Regular and Orderly Migration (GCM). GCR’s guiding principles include equitable burden- and responsibility-sharing, reducing burdens on host countries and increasing migrants’ access to higher-income countries. The GCM emphasizes human rights, making migration safer and eradicating trafficking. The global compacts present a unique political opportunity, but cruelty toward migrants casts a shadow on hope for humane solutions.
WHO’s Global Action Plan
WHO’s Global Action Plan (GAP) expresses all the right values (human rights, non-discrimination, gender sensitivity); all the right goals (quality health care, occupational safety, and public health); and all the key tools (information systems, communication, and advocacy for migrant rights). Its overarching aim is to achieve UHC through full and equal inclusion of migrants in health systems.
Yet, the plan could stumble on two of WHO’s structural deficiencies: insufficient resources and weak political influence. The GAP promises WHO support to Member States, ranging from cross-border collaboration and strengthened data to improved continuity of care and culturally sensitive service delivery. But Member States offered no new resources to implement the plan. For decades now, the WHO budget has been wholly incommensurate with its global responsibilities. The agency’s total budget is lower than those of large hospitals in the United States and is one-quarter of the Centers for Disease Control and Prevention’s budget. And WHO has full control over only 25% of its budget, with most of the remainder earmarked for donor preferences.
To achieve its goals, WHO will have to persuade governments to treat migrants humanely, while affording them equal health and social benefits. But in a world of rising nationalistic populism, that is a hard sell. Governments view asylum-seekers as culturally and religiously incompatible with their country’s cultural values, or as a financial burden they don’t want.
Consider the European Union’s refusal to equitably share the burdens and responsibilities for migrants flowing from Syria and Africa; the United Kingdom’s determination to stem migration by leaving the Union; or the humanitarian crisis at the US/Mexico border, including family separations.
Most people don’t realize that low- and middle-income countries (LMICs) host 85% of the world’s refugees. Syrians cross the border to Jordan, Turkey, and Lebanon; Rohingya people flee from Myanmar to Bangladesh; and, amid “economic and humanitarian chaos,” 4 million have crossed from Venezuela to Columbia and Peru.6 Jordan alone hosts more than a million refugees, of whom 85% live below the poverty line, 48% are children, and 4% are elderly. LMICs simply cannot afford to humanely house, care for, and integrate massive populations.
Higher-income countries neither provide ample humanitarian assistance to LMICs nor take their fair share of refugees. Gripped by xenophobia, Europe and the United States have virtually shut their borders or made the asylum and resettlement process arduous or cruel. Despite signing the GAP, WHO has little influence to better ensure equitable burden-sharing.
Amidst antagonism to refugees, how is it possible to chart a different course? Appeals to humanitarian values have not worked. Nor have nations abided by their legal commitments. It may seem fanciful to propose international law reforms. Yet, the refugee crisis presents a classic collective action problem. Why would nations agree to settle foreign migrants when they can shift the burden? The answer to this “tragedy of the commons” dilemma is to legislate fair burden sharing. Refugee law should be reformed to protect asylum seekers, afford due process, and safeguard the rights and safety of all. International law should create accountability for equal rights to health, education, and social benefits. States should agree to a framework of assistance for LMICs experiencing a major influx of refugees.
The WHO GAP can be a starting point for negotiating binding commitments with strong compliance. Most of us understand the need for mutual solidarity on existential threats such as climate change or nuclear weapons. In its own way, mass migration poses a comparable threat. Some day—with rising oceans, searing heat, droughts, and cataclysmic weather—most of us will be on the move. When that day arrives, we will demand humane and equal treatment.Why not fulfill that promise of a healthier and fairer world now?
References
Published in 2019 Volume 97, Issue 3 (pages 631-635) DOI: 10.1111/1468-0009.12404
Lawrence O. Gostin is University Professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.”
