Dr Waheed Araian spent the first five years of his life hiding with his family in a cellar in Kabul from rockets and bombs.

“I came to the UK as a 15-year-old child refugee with no family support, hardly any education and about $100 in my pocket,” said Arian, now an emergency doctor in the UK’s National Health Service. “And that is just one story out of 1 billion.”

One billion people worldwide are refugees. And many of them are invisible to health systems lacking access to basic health services as well as to decent work, housing and food essential to good health, according to a first-ever WHO World Report on the Health of Refugees and Migrants, published Wednesday.

Speaking at a WHO press briefing, Arian, who was born in Kabul in the 1980s, during the Afghan civil war and Soviet invasion, vividly described the hunger, cold and illness that marked his childhood. 

“We didn’t have much food, and many children, including ourselves, suffered from whooping cough. We didn’t have enough clothes,” he recalled. His parents finally decided to risk the dangerous, covert journey to Pakistan, traveling through rugged mountains astride horses and donkeys. They came under attack three times along the way. In a tented refugee camp  in Pakistan, he survived bouts of malaria and nearly died from tuberculosis. His family moved back to Kabul when there was relative calm again. But when war flared up again in the 1990s, his family sent him to the United Kingdom – where he vowed to study medicine. 

“My parents sent me away to the UK as a refugee. But I also came with hope to be able to life safely, to be able to study, to contribute,” he observed, “And that’s how it is with so many other refugees and immigrants across the globe.”

One in 8 people are migrants or refugees – only 1 in 3 countries offer full access to health services 

As many as 1-in-8 people worldwide are refugees or migrants. Despite the astonishing numbers, only about one-third of the countries surveyed by WHO offer refugees access to universal health coverage and primary health care services, according to the new report. 

“While many countries hosting refugees have policies allowing refugees to access health and social protection services, that access may be partial, entail prohibitive out-of-pocket expenditures and involve additional barriers, including distance to facilities, language and discrimination by providers,” the report says.

A multi-country survey of some 30,000 migrants and refugees conducted by WHO as part of the research found that some 37% of those people questioned said fear of deportation was a barrier to accessing health services, while close to 30% said they couldn’t pay the out-of pocket costs,” said Dr Santino Severoni, director of WHO’s Health and Migration Programme, at the briefing.

“The difficulty of navigating the health systems.. to identify where to go to receive suport, and access the service needed,” were other barriers identified along with a limited capacity of health care workers to respond to the special problems that refugees and migrants might present, Severoni said.

Along with those barriers, the report finds many countries have “policies and programmes that separate families, limit access to medical or social services, or condone or promote violence, discrimination, prolonged detention or illicit trafficking yield poor health.”

Working conditions – dirty, dangerous and demanding

Migrants and refugees also tend to occupy jobs at the lowest economic rungs of their host countries. WHO’s Director General Tedros Adhanom Ghebreyesus, speaking at the press launch, called them “3D jobs” which put migrants and refugees at a higher risk of occupational injuries. 

“Many migrant workers are engaged in the so-called ‘3D jobs – dirty, dangerous and demanding’ without adequate social and health protection or sufficient occupational health measures,” he said.

As a result, rates of work injuries are high even among migrants and refugees that manage to resettle, added Severoni, referring to WHO’s multi-country survey: “About 40% of the population which was surveyed and sampled, reported at least one injury related to their own conditions of employment.”

Mental health distress and self-harm rates also run high

Some 22% of refugees who are directly touched by conflict also suffer from mental health distress. Not surprisingly, self-harm rates also are high.

Many refugees and migrants suffer from fear and abuse by traffickers during their migration, only to be subjected to forced confinement or legal limbo upon arriving at their destination. They also tend to suffer from being apart from family and friends, and from a lack of regular education or employment. 

“Often it’s due to many levels of traumas over many years,” Arian said of the risk factors he experienced first-hand and saw in others. “You are going through trauma by displacement, abandoning family members or loved ones, the social protective factors which are enhancing their mental well-being.”

Arian said many suffer “extensively” but receive no mental health screening or compassionate care, due to language and social factors. 

“In many cases they are put in detention centers or they go into hiding,” he said, citing additional political factors. “They live in extremely unkempt conditions. So it’s an accumulation of many factors.”

Environmental factors pose added health risks 

The report details how many migrants and refugees face high out-of-pocket expenses to access health services that legal residents and citizens of their host country may get for free, even in some high-income countries. Those range from treatments for chronic diseases to sexual and reproductive health services. At the same time, a wide range of environmental factors also put them at greater risk.

That is particularly true when it comes to a lack of adequate housing or water and sanitation facilities, food insecurity, and poor air quality in neighborhoods with a preponderance of refugees and migrants. The report notes those factors are particularly prevalent in migrant settings across low-income Africa, the Middle East, and the Americas, though they also are present in higher-income Europe and Eurasia.

Housing for migrant workers, for example, often is inadequate even in high-income Asia, according to the report.

“In the WHO Western Pacific Region,” it says, “thousands of low-skilled migrant workers employed in the construction and marine industries, and in various other low-wage sectors in Singapore, live in dormitories – the largest of which have common and shared areas (e.g. recreational facilities, grocery stores and other services).

And these kinds of conditions have made migrant workers more vulnerable to infectious diseases, particularly COVID-19, the report notes from among many examples.

But the report also points to some favorable practices for refugees and migrants, such as public housing policies in Germany and Poland that allow some to qualify for below-market rental accommodations and other forms of support.

The report cites widespread issues with food insecurity among migrants, particularly in parts of Africa and WHO’s Eastern Mediterranean Region. It cites studies of refugees and migrants in Iran, Egypt, Libya South Africa, as well as Syrian, Sudanese, Somali and Yemeni refugees who have fled to Syria, Jordan, Lebanon and often may have to forego meals or reduce their food intake.  

“In the WHO Eastern Mediterranean Region, one fifth of refugees in Egypt could not meet their basic food needs, citing unemployment as a major barrier to food security,” the report notes. “And one-in-three migrants living in Libya reported inadequate food consumption.”

‘Almost invisible’ to health systems 

The report highlights a “fundamental knowledge gap” about migrant and refugee health, Dr Tedros said, insofar as these groups are often not tracked by national health systems or global health surveys. 

“Refugees and migrants are virtually absent from global surveys and health data, making these vulnerable groups almost invisible in the design of health systems and services,” he said, adding this makes “these vulnerable groups almost invisible in the design of health systems and services.”

Appeal to politicians and advocates 

Dr Tedros appealed to policymakers and civil society to both close the data gaps and begin considering refugees and migrants more holistically in health services planning. 

“We hope government will use this report to develop evidence employment policies and actions and we hope advocates will use it in their efforts to call for inclusive health systems,” he said.

WHO is calling on governments and organizations that work with refugees and migrants to work together and to evolve, through participatory governance, to a point where the data includes them, Dr Tedros said. WHO also wants to prioritize them in research, he said, and to include them in social and financial protections that allow them to gain better access to health systems worldwide.

“It’s a matter for the political leaders in every country to make a decision to show political commitment to address the barriers that refugees and migrants are facing,” said Tedros. “This is a political issue and the political leaders should address it. If that’s addressed.”

Today’s host could be tomorrow’s refugee  

But addressing migrant and refugee health issues also are human and moral obligations in all societies, most of which are built upon previous generations of migration and refugee waves, Tedros added.

“Movement is tradition or it’s in our DNA. We have been moving  for millennia,” he said. “And even countries who prided themselves of not having any refugees because of conflict or other problems, are now becoming major contributors of refugees and migrants.”

Image Credits: WHO / Ploy Phutpheng, WHO / Kasia Strek, WHO, WHO / PAHO / Karen Gonzalez, WHO / Lindsay Mackenzie.