“Mental health, mass people displacement and ethnic minorities” 10th ISHHR Conference

Preparatory worshop

“Health implications of the transnational mass movement of people” Thursday, November 24th, 2016

Health implications in mass migration in Central and South East Europe: challenges and possible solutions

Gian Matteo Apuzzo, PhD

Senior expert, Focal Point on Migrations, Central European Initiatives

Health implications in mass migration in Central and South East Europe: challenges and possible solutions

OVERVIEW

- Health as a human right - Health-related issues - Health risk assessment - Mental Health

Health implications in mass migration in Central and South East Europe: challenges and possible solutions

Health as a human right

Migrations and the right to health

Migrations and the right to health

International human rights law provides that all persons, without discrimination, must have access to all fundamental human

rights provided in the international bill of human rights.

Therefore, migrants, regardless of their status, are protected by international human rights law.

Migrations and the right to health

International migration – that is, the entry into and exit from a sovereign territory – is intimately related to legal and sociological notions of nationality and sovereignty.

However, the Committee on Economic, Social and Cultural Rights (CESCR), which is the UN treaty body monitoring the implementation of the International Covenant on Economic, Social and Cultural Rights (ICESCR), has articulated that nationality must not be used as a ground for discrimination in relation to health care and other rights in the Covenant.

Migrations and the right to health

The right to health obligates governments to ensure that “health facilities, goods and services are accessible to all, especially the most vulnerable or marginalized sections of the population, in law and in fact, without discrimination”

With regard to the right to health Article 12 of the ICESCR provides the most comprehensive articulation by recognizing “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” A key aspect of the right to health is that it contains both ‘freedoms’ and ‘entiltements.’

States must make sure that health facilities, goods and services are available, accessible, acceptable, of good quality and applicable to all sectors of the population, including migrants.

The components of the right to health

1. Availability. Functioning public health and health-care facilities, goods and services must be available in sufficient quantity.

The availability component obligates states to ensure general supplies, as well as to avoid stock shortage.

Specific essential medicines and vaccinations, for example, should be ordered in sufficient quantities to cover the needs of all, including migrants and their families.

Further, the principle requires states to enlist and cater for specific essential medicines and goods that are particularly relevant to migrant populations.

2. Accessibility. The concept of accessibility includes several aspects that are related to the principle of non - discrimination: physical accessibility, economic accessibility (affordability), information accessibility

The components of the right to health

3. Acceptability. Health facilities, goods and services must be acceptable, meaning gender- and age-sensitive, culturally appropriate and respectful of medical ethics.

Migrant-sensitive health services may include interpretation, translated written materials and ‘cultural mediation’ in hospitals and health centres. Introducing these services can assist in tackling language and cultural barriers

4. Quality: quality of services, quality of care, quality of premises and facilities.

Scientifically and medically appropriate

Health implications in mass migration in Central and South East Europe: challenges and possible solutions

Health-related issues

Elements of health-related issues

The stage of migration process

Differencies in health vulnerability among migrants (gender, education, legal status,…)

Living in conditions of marginalisation and social

disadvantage

Linguistic barriers to access to health services

Cultural barriers to health service access (migrant-sensitive health professional workforce)

Conditions of migrants: data on asylum claims and illegal immigrants

Emergency on the WESTERN BALKANS ROUTE (on 2015*)

By the end of October 2015 nearly 700,000 people had travelled along the Western Balkans route from

Greece to Central Europe.

*by the European Commission

Needs of the addressed populations*

- Reception centres/systems for newly arrived migrants in order to assure health assessments immediately upon arrival

- Adequate shelter to avoid crowding and ensuring good sanitation and hygienic conditions

- Health education and health promotion emphasising the benefits of screening, immunisation and other measures

- Screening for communicable diseases according to their country of origin and countries transited during migration

*Expert Opinion on the public health needs of irregular migrants, refugees or asylum seekers across the EU's southern and south-eastern borders*European Centre for Disease Prevention and Control. September 2015

Public health measures to be considered*

Disease screening. According to a recent survey in EU/EEA countries, screening for

communicable diseases among migrants is currently directed predominantly towards tuberculosis (TB). Other diseases include hepatitis B, hepatitis C, HIV, sexually transmitted diseases, vaccine-preventable diseases, cholera, malaria, helminths, intestinal protozoa and Chagas disease. Any screening should be connected to a process of diagnosis and treatment.

Syndromic surveillance. According to EU Member State experience, syndromes to

consider include: respiratory tract disease, suspected pulmonary tuberculosis, bloody diarrhoea, watery diarrhoea, fever and rash, meningitis/encephalitis or encephalopathy/delirium, lymphadenitis with fever, botulism-like illness, sepsis or unexplained shock, haemorrhagic illness, acute jaundice, parasite skin infection, unexplained death.

Public health follow-up. A system to track migrants for health purposes including

vaccinations, treatment outcome monitoring, access to medication, and chronic disease management.

*Expert Opinion on the public health needs of irregular migrants, refugees or asylum seekers across the EU's southern and south-eastern borders, European Centre for Disease Prevention and Control. September 2015

Public health measures to be considered* - II

- Vaccination. Vaccinations to consider among migrants include: measles (mass immunisation,

prioritising children up to 15 years old); poliomyelitis (vaccination should be considered for children and adults coming from countries currently exporting poliovirus, such as Afghanistan and Pakistan, infected countries, such as Nigeria and Somalia, or countries which remain vulnerable to international spread, including Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel, and Syria); meningococcal disease and diphtheria.

- General hygiene measures and preventing or minimising overcrowding in reception centres

for migrants. These measures are particularly important to prevent occurrence of louse-borne relapsing fever (LBRF), trench fever, epidemic and endemic typhus, scabies, and other vector-, air-(meningococcal disease), and food-borne diseases.

- Health education and health promotion.

- Access to healthcare, free of charge, for the diagnosis and treatment of communicable

diseases including primary and emergency healthcare.

*European Centre for Disease Prevention and Control. September 2015

Health status and services - A MSF report on migrants and displaced persons along the Balkan route

Syrians, Afghan Hazarans, and Iraqis are the main nationalities attending our consultations.

Young male adults represent the largest group requiring our medical services (40%), followed by children younger than 5 years (25%), women (20%), and patients older than 60 years (5%).

The highest number of consultations has been provided to adults with lower limbs injuries (30%; this was mostly severe feet blisters, and muscular problems)

Upper respiratory tract infection is the main diagnosis in the overall adult and child groups (25%)

Lack of proper follow-up of non-communicable diseases (NCD), poor mother and child health, and the high number of children with unknown vaccination status show the absence of general access to basic primary health services.

Health implications in mass migration in Central and South East Europe: challenges and possible solutions

Health risk assessment

Methodological problems

Statistics are based on data collected in clinical settings. Clinical data are useful as an indication of the kind of problem that services can expect to deal with, but the information that they can give us about the prevalence of these problems outside the clinic is limited

Given this methodological limitation, epidemiological knowledge is extremely inadequate

A lot of data is availbale from NGOs, need to match them

Social determinants as the main risk factors (great impact on health conditions)

There is hardly any reliable evidence about state of health of migrants and the differencies among migrants and between migrants and national population in destination countries

Risk factors

environmental: poor housing, overcrowding, slums (less care services, widespread criminality)

Social exclusion: higher poverty, higher unemployment, lower wages

individual factors, especially legal status, money, etc.

physical and/or organization obstacles (accessible information, number of operators, language obstacles etc.).

General health impacts reported

Compared with general population, people with a former migration experience share:

lower life expectancy

major infant mortality

higher incidence of diseases/ill-health

major inappropriate access to healthcare services (both overruns and

under runs)

Main problems reported are mental health, infectious diseases, sexually transmitted diseases and HIV, reproductive health, dental health.

Health implications in mass migration in Central and South East Europe: challenges and possible solutions

Mental Health

Mental Health - A MSF report on migrants and displaced persons along the Balkan route

The mental health status cannot be assessed easily because of the extreme mobility of the people. However, the high number of patients looking for a secure space to be listened to shows the important need for psychosocial services.

Walking and waiting long hours under adverse weather conditions, difficulties of access to food, water, shelter, and basic medical services at the borders and along the route are behind most of the causes of our consultations.

The hard conditions of the journey by sea and land, the restrictions and barriers, and the lack of general information has a negative effect on the mental health of the displaced population often exposed to violence, including sexual and gender-based violence.

The combination of all these factors increases the risk of complications related to sexual and reproductive health, NCDs, and communicable diseases (particularly vaccine-preventable diseases since in some of the countries of origin high immunisation coverage is not maintained).

Mental health issues among migrants (from literature)

Challenges to mental health and psychosocial wellbeing of migrants

Refugees and migrants often faced war, persecution and extreme hardships in their countries of origin

Many experienced displacement and hardship in transit countries and embarked on dangerous travels

Lack of information, uncertainty about immigration status, potential hostility, changing policies, undignified and protracted detention in countries of destination

Forced migration erodes pre-migration protective supports – like those provided by extended family - and may challenge cultural, religious and gender identities.

Forced migration requires multiple adaptations in short periods of time.

Challenges to mental health and psychosocial wellbeing of migrants

• Especially, but not only, women and children become more vulnerable to abuse

• Pre-existing social and mental health problems can be exacerbated.

• Importantly, the way people are received and how protection and assistance is provided may induce or aggravate problems, for example by undermining human dignity, discouraging mutual support and creating dependency.

• An acute sense of urgency among the people on the move may prompt them to take extreme medical and psychosocial risks and their fast-paced mobility through several countries, leaves only very little time for service provision.

Common mental health and psychosocial responses

Refugees and migrants may feel overwhelmed or confused and distressed, and experience extreme fear and worries, outbursts of strong emotions such as anger and sadness, nightmares and other sleep problems.

Initially, on immediate arrival in Europe, some may be elated.

Many are affected by multiple losses and are grieving for people, places and life left behind.

They may feel fearful or anxious, or numb and detached.

Some people may have reactions that affect their functioning and thinking capacities and therefore undermine their ability to care for themselves and their families and cope with dangers and risks on their path.

Common mental health and psychosocial responses

The effects of stress can be buffered by basic services, safety, and social support.

Rates of disorders related to extreme stress, such as post-traumatic stress disorder (PTSD), are higher in refugees than in people who are not forcibly displaced. However, for most refugees and migrants potentially traumatic events from the past are not the only, or even most important, source of psychological distress.

Most emotional suffering is directly related to current stresses and worries and uncertainty about the future.

Being a refugee or a migrant does not, therefore, by itself, make individuals significantly more vulnerable for mental disorders, but refugees and migrants can be exposed to various stress factors that influence their mental wellbeing

Key Principles for promoting mental health and psychosocial well being*

There is no single way or model to provide mental health and psychosocial support to refugees and migrants , but the following good practice principles have been agreed upon by organizations working in this field to guide the response and to prevent inadvertently doing harm:

1. Treat all people with dignity and respect and support self-reliance

2. Respond to people in distress in a humane and supportive way

3. Provide information about services, supports and legal rights and obligations

4. Provide relevant psycho-education and use appropriate language

5. Prioritize protection and psychosocial support for children, in particular children

who are separated, unaccompanied and with special needs

6. Strengthen family support

*Mental Health and Psychosocial Support for Refugees, Asylum Seekers and Migrants on the Move in Europe A MULTI-AGENCY GUIDANCE NOTE, DECEMBER 2015 - by UNHCR, IOM and MHPSS.net

Key Principles for promoting mental health and psychosocial well being*

7. Identify and protect persons with specific needs

8. Make interventions culturally relevant and ensure adequate interpretation

9. Provide treatment for people with severe mental disorders

10. Do not start psychotherapeutic treatments that need follow up when follow up is unlikely to be possible

11. Monitoring and managing wellbeing of staff and volunteers

12. Do not work in isolation: coordinate and cooperate with others

*Mental Health and Psychosocial Support for Refugees, Asylum Seekers and Migrants on the Move in Europe A MULTI-AGENCY GUIDANCE NOTE, DECEMBER 2015 - by UNHCR, IOM and MHPSS.net

Costs of exclusion from health care*

• The main argument for improving access to health care for marginalised groups has always been based on human rights and principles of equity.

However, in recent years more attention has been paid to the economic costs of limiting coverage for these groups. Policies of exclusion are often defended on economic grounds, but they may increase rather than decreasing health system costs.

• The additional costs of indadequate care may be direct (incurred by

the patient and/or the health system) or indirect (incurred by the patient or the wider society as a result of the disabilities and burdens resulting from illness).

*Study carried out by the Center for Health and Migration (www.c-hm.com ) within the Equi-Health project (http://equi-health.eea.iom.int ).

Infographic on costs of exclusion from healthcare (Equi-Health project)

THANK YOU!