WMH-Communique

A Communique on
refugees and migrants etc.*

Preamble

World leaders1 are agreed that there is a current global refugee and migration
crisis, caused largely by armed conflict, wars and violations of human rights. The
people of all countries are witnessing it, either in person or through their
television screens. This is placing unprecedented burdens on many countries
and needs coordinated efforts by all the worlds’ countries to produce a workable,
acceptable solution. The “crisis” emerges from the unwillingness or lack of
preparedness of states to properly and humanely respond to the needs of
current mass migration events.

Why is there a crisis?

Mass human migration events are common throughout history as they follow
wars, natural disasters for which countries are ill prepared, and other critical
events leading to difficulty with safely housing and feeding individuals and
families.

The current crisis has developed over a period of years and reflects a number of
world events. These include warfare, the consequences of major natural events
(including climate events such as drought), or continuing unrelenting poverty,
leading to mass migration events which we are responding to with a mixture of
panic and discrimination

To highlight the complexity of causation, and the interrelationship between
politics, natural events and human expectation that has caused this mass
movement of people it is worth considering just one such event. One such
exemplar event is the on-going war in Syria. This is a civil war, and the fighting
involves most of the country. Homes and workplaces have been and continue to

1 For the purposes of this communiqué the following definitions are assumed.
Refugees are people fleeing their country of citizenship and seeking safety and
security elsewhere. Migrants are leaving their country of origin, to seek a future
in another country, but without a proximal safety imperative to leave. Internally
displaced persons are people fleeing from their home, but staying within their
original country. They may flee the consequence of major natural events,
warfare, famine, or for other reasons. Asylum seekers are people who have
sought and been granted refuge in another country – their status will vary from
those seeking permission to stay and those for whom it has been granted either
for the present or permanently.
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be damaged and destroyed by bombardment; the number of places of safety for
families shrinks everyday. A number of towns and cities have been besieged by
different forces, national, local, regional and international, with media stories of
mass malnutrition and even deaths from starvation.

There are a large number of factions involved in the warfare in Syria, including
the current Assad government, various opposition groups, a number of other
international actors including other states and so-called Islamic State. There is
no real hope or expectation of a rapid solution being found to the conflict,
especially as a number of the non-state actors are not involved in any way in
such discussions as there are. Families have coped with huge difficulties over a
number of years but have now reached breaking point leading to mass
departures to seek a safer life elsewhere.

While Syria represents an acute crisis, as a source of refugees it sits alongside
many other countries with chronic problems leading to the departure of
individuals and families. These include severs on-going weather events
(droughts) and continuing and continuous conflict.

Conflict is very common around the world and waxes and wanes in different
countries at different times. In some cases the conflict is part of an international
or a civil war, in others it reflects generalized violence. The impact is the same; it
makes living conditions difficult, puts people in danger, and makes decisions to
depart the country easier.

Poverty remains a significant problem in many countries, especially in the so-
called developing world. Even in more developed countries opportunities for
individual self-development are not evenly distributed, and poverty including
poverty of expectation and of opportunity can lead people to seek alternatives. A
shortage of work opportunities leads to individuals and families seeking
opportunities to improve their living conditions by moving elsewhere.
Sometimes those lack of opportunities reflect a generalized deficiency,
sometimes it reflects local prejudices against a population subgroup. The impact
on total migration trends is the same albeit those who move might vary.

The crisis also reflects current media interest. The ability of mass media outlets,
supplemented by personal social media use, to transmit pictures worldwide in
seconds makes the scale of the issue immediately obvious to everyone; people
expect politicians to provide a solution. The outcry when photographs of a small
child, drowned while travelling with his family seeking to leave North Africa for
Europe, demonstrates that populations can be moved by these images; such
emotional responses do not necessarily develop to a welcome to more refugees
or to increased migration.

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What are the historical precedents?

There are a number of historical precedents involving mass migration. These
include the movement of millions at the time of partition of the Indian
subcontinent, and mass migrations at the end of World War 2. In both these
cases the event caused enormous disruption to individuals and to families and a
similarly enormous level of human suffering.

At the end of world war 2 there was some sympathy with displaced persons;
these were the results of fighting which had led to suffering for much of the
civilian population of the world and there was a short-lived common
understanding of the impact of war-caused homelessness and displacement.
Events in India and Pakistan, which arguably involved a still larger number of
people, were largely invisible outside the region.

Both historical events were, however, sufficiently long ago that they were not
immediately visible world-wide. Events occurring today are witnessed by the
global population on their TV screens, smart phones and the like. This means
there is a larger level of public interest and, therefore, of political concern.

Who are the refugees?

Refugees fall into a number of categories. They include those fleeing from war
zones, looking to live in places where they and their children will be safe from
bombs and bullets, and have a roof over their heads. Parents want to be able to
earn their living and give their children a safe place to live.

Other refugees are what are sometimes called economic migrants – they want to
improve their standard of living. They may come from countries devastated by
recent conflict or from countries where poverty is the norm. They have no
expectation of being able to improve their lives, or those of their families by
staying in their home country, so again the wish is for a better life for themselves
and their families.

A third category of refugee is those fleeing oppression. This might be
generalized oppression in a country with an oppressive regime, and restricted
freedom for all, or where the oppression is directed against a group – because of
their ethnicity, religion or gender. The wish here is to live in more freedom and
achieve a chance of social equality.

Refugees may be families, but can also be single people. Occasionally refugees
are children travelling alone.

The impact on the countries people leave can be considerable; some of these
migrants will be people with much needed skills already in scarce supply in the
country they are leaving. There can be a global loss of such skills as new
migrants may be unable to use their professional education, knowledge and
skills in their new country but only obtain work in relatively unskilled areas.
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What are their reasons for leaving their homes?

The reasons for leaving their homes are all variations on a theme – that of
improving their ability to live a free life with choices, chances and opportunities
not available in their country of origin. There is no difference in this from the
great migratory movements of the 19th and early 20th century to countries such
as the USA and Australia, where migration was based upon a lack of opportunity
at home and the presence of opportunity in the new country. Seeking to escape
political and religious oppression was a part of the reason during those mass
migrations, as was the will to improve the lot for self and family.

Catastrophic natural events such as earthquakes and tsunamis where there has
been inadequate prior planning or preparation can also lead to a mass exodus,
fleeing collapsed buildings, homes and workplaces, and seeking security and
safety. While natural events are not preventable, proper planning can
dramatically reduce their impact on individuals and on the infrastructure that
makes life possible.

The difference today is the presence of conflict in certain regions that has
become so long-lasting as to erase hope for a future for people who live in the
country of region. In addition, current warfare is fought alongside civilian
populations, with the destruction of living and working places. Historically, many
wars were relatively short lived and fought away from population centres,
disrupting the lives of civilians to a lesser extent.

Forced Migration

Besides these reasons military and other measures are occasionally used to force
people out of their homes for reasons including changing the ethnic composition
of an area. Houses, Schools, shops, workplaces and even cemeteries might be
bombed to aid achieving this purpose.

How are desired final countries chosen?

There has been relatively little research performed to discover the reasons for
choosing destination countries. In some cases it relates to language – are
migrants certain they can communicate with others in their destination country.
In other cases migrants will have family members, or others from their
community already in that country and feel that they will be helped and
welcomed. Some politicians feel that it is purely financial – that countries are
chosen which will offer access to state support upon arrival. It is also clear that
countries with an internationally seen profile offering stability, social inclusion
and peaceful streets are very desirable; their selection as a destination is a
marker of the external esteem in which they are held.

It is difficult to evaluate the impact of announcements by politicians, especially of
their willingness to accept refugees, asylum seekers and other potential
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migrants. Has a previously positive language about these groups helped to fuel
the mass movement of people?

What are the impacts on countries of transit during migration?

Mass migration, including problems for transit countries, is not just an issue for
rich countries.

Transit countries have to cope with, what can be, mass movements of people
through them. In some cases, especially in Southern Europe, and the Middle and
Far East, they may have to manage survivors of catastrophes, such as migrant
boats overturning, and rescue people from freezing seas.

Other countries find themselves holding large populations of people in transit,
who wish to pass through their country but where borders are closed to either
onward passage or to a final destination country. The mass migrant population
continues to build leading to the development of large numbers, often in camps,
placing a burden on the provision of services including basics such as shelter,
water, food and sewerage. Some of these camps can become sources of disease
outbreaks, especially where insufficient attention is paid to water and sanitation.
Others place burdens on countries with already overwhelming difficulty in
feeding and housing their populations.

Increasingly countries are, not only having to cope with these problems but also
to police the situation. Possible destination countries expect them to handle the
migrants and effectively restrict their onward movement. The migrants expect
to be able to transit quickly and resist attempts to limit their movement. This
places a burden on police and security forces that many countries struggle to
meet. Given the poor social status of the migrants and refugees this can lead to
serious abuses.

What are the social and economic impacts on destination countries?

The history of migration has been the foundation of many modern countries; it
has provided workers in all sectors, often skewed at times to cover specific
needs. Thus the building of the transcontinental railroads in the United States
led to the immigration of rail-road workers, who built the infrastructure. The
need for people with specific skills can also be seen in the migration of hundreds
of thousands of qualified nurses around the world, from countries such as Ghana
and the Philippines.

Current mass migration and refugee movements are less focused on one skill set.
But many migrants, in their overwhelming desire to provide a better life for their
families, will work in any sector, so that those with higher professional
qualifications do not use those skills but work in service industries where work
is plentiful. In some countries in Western Europe, eastern European migrant
labour carries out the jobs locally born people do not want – often very labour-
intensive, poorly paid work, such as fruit picking and other seasonal work.
Despite a relative unwillingness of country nationals to take these jobs, there is
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often resentment that jobs are occupied by recent immigrants, and the effect on
the general labour market is complex. Their access to jobs can be resented and
lead to civil unrest.

The reality of migrant work is that while some will have higher skills much
sought after in their destination country far more will take up poorly paid,
relatively unskilled, work, which is essential to the economy of their destination
country.

What are the health issues?

Migrants and refugees alike tend to come form the poorer sections of the
community – and often from the very poorest. They might have started as
professionals but events have impoverished them. Their transit to a destination
country may have taken many months, and produce health consequences
because of deprivation en-route, including lack of food and shelter. Given that
the migrant and refugee are likely to come from a poor background there is a
likelihood that they will already have some health problems, including untreated
and undertreated chronic diseases. This is especially true of all vulnerable
people, including the poor. Children are unlikely to have been vaccinated and
immunized and malnutrition (absolute or micronutrient) is common.

While some may be concerned about contagious diseases including tuberculosis,
the real problems will be of diseases of poverty including rickets, and other
malnutrition syndromes. Given the chronic exposure to risks within and outside
conflict PTSD and other stress related psychological disorders are also likely to
be common.

What is the political dialogue?

The political dialogue on mass migration and refugee movement is distressingly
one-sided. The only real concern appears to be limiting the movement of people,
and in particular their eventual arrival in possible destination countries.
An emerging thread is to look for the causes of this migration in an attempt to
turn it back; peace in countries of conflict may reduce migrant numbers, as might
improving the living and working conditions in the poorest populations of the
poorest countries. Peace must be sought as an end in itself, not simply as a
means of reducing the number of refugees. A short-sighted approach to peace is
unlikely to find a lasting solution.

The dialogue is rarely based upon the reasonable needs and expectations of the
migrating population, but on the integrity of national borders. There is little
demonstration of understanding of the desperation that leads someone to leave
their home for an uncertain future elsewhere.

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What can physicians add to this discussion?

Physicians understand the impact of social, economic, safety and other factors
which lead to migration, the urge to provide something better for the family, and
the effect of transit on family and individual physical and psycho-social health
and wellbeing. They can reassure the public about the lack of health risk from
the arrival of these people, as well as ensuring that those arranging their
reception provide the wherewithal for reasonably healthy living. Physicians can
also treat the diseases that need treatment, including the probable serious
psychosocial disorders, ensure children are immunized and vaccinated, and help
local planners consider housing and other needs.

The primary addition physicians can make relates to their understanding of the
broader issues around mass migration and people movement in terms of public
planning, while never losing sight of the individual at the centre and his/her
needs. This leads to a strong advocacy role, especially around social
determinants of health, illness prevention, the availability of health care and
other areas to prevent abuse, neglect and exploitation.

Recommendations

1. This meeting recognizes that there is a considerable overlap between all
mass migrations, with people moving from places of relative lack of safety
towards those of relative safety. They do this in order to improve their lot
in life and the opportunities for their children. In some cases real physical
danger, of death, injury, rape and other sexual violence, unfair
imprisonment, torture, forced labour and other very serious abuses are a
root cause, in others the slower onset but equally real dangers of poverty,
homelessness and starvation.

2. This meeting recognizes that mass migration will continue unless people
are content to stay in their birth countries because they see opportunities
to live their lives in relative peace and security and to offer themselves
and their families the ability to live lives with opportunities for fulfillment
of various sorts, including economic improvement. The global community
has a responsibility to seek to improve the lot of all populations, including
those in countries currently with the poorest economies and other key
factors. Sustainable development will give all populations improved
security, and economic options.

3. This meeting recognizes that warfare and other armed conflict, including
continuous civil strife, unrest and violence will inevitably lead to people
movement. The worse the conflict the higher the percentage of people
who will want to leave the conflict zone. There is a responsibility for the
global community, especially its political leaders, to seek to support peace
making and conflict resolution.

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4. This meeting recognizes and condemns the phenomenon of forced
migration, which is inhumane and must be stopped. Such cases should be
considered for referral to the International Criminal Court.

5. This meeting demands that civil, military and political authorities provide
safe transit routes for the victims of local, regional and national conflicts
and strife. This must include the provision of safe, secure facilities to
house migrants, whether they are in transit or have reached their final
destination country. It must also include treating migrants, including at
borders, with respect, ensuring that their dignity is not affected.
Adequate provision for potable water, food, sewerage and shelter must be
made. Those planning for these migrant populations must take adequate
public health advice in planning and delivering the facilities. Mass
detention of refugees is at best undesirable; if it is essential it must be
based upon the provision of excellent living facilities including
opportunities for safe play areas and education opportunities for children.

6. This meeting recognizes that mass casualty events occur during massive
natural events. The scale of casualties is directly proportional to the prior
planning; earthquake proofing houses and workplaces significantly
reduces the casualties of such natural events. It is unacceptable that such
infrastructure improvements are not available to the populations of many
countries prone to such natural events.

7. This meeting commends the welcome given to refugees, asylum seekers
and other migrants in some countries and deplores the reluctance to offer
help and support to these people in many other countries. The
development of barriers is not a solution; it condemns those moving
between countries to further hardship with an uncertain end. The
concept that treating migrants harshly will discourage future migrants is
both absurd and inhumane.

8. This meeting deplores the stigmatization, bigotry and bias in media
reporting of the refugee and migrant issue in some of the worlds’ media,
and demands that media outlets treat this issue with honesty and
integrity and properly reflect the human concerns faced by individual
migrants and refugees. We commend those media outlets that have
sought to treat the issue with fairness and humanity.

9. This meeting recognizes that migrants and refugees face considerable
health concerns, especially associated with the difficulties of the
migration process, the long periods of poor nutrition, appalling lack of
shelter, and the effects of the events that forced them to leave their
homes. We demand that destination countries ensure that migrants and
refugees get access to medical services on a par with their settled
population, free at the point of use or after adequate financial provision to
meet co-payment costs, and in particular that there are adequate mental
health services to deal with PTSD and other psychosocial disorders.
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Health care workers providing care must be enabled to do so without any
interference in their professional behavior, including ethical standards.

10. This meeting recognizes the pressures on local communities, including
their authorities, in seeking to manage the arrival and support of
significant numbers of migrants and refugees. We demand that national
and international governments recognize these pressures and provide
support, including finance as a priority.

11. Internally displaced persons (IDPs) also need care and consideration,
although they do not appear in the migration statistics. Some of the
countries facing considerable challenges in dealing with migrants will also
have many IDPs; this compounds the difficulty of providing safe living
conditions. This meeting believes that a consideration of the number of
IDPs needs to be performed alongside consideration of migrants, refugees
and asylum seekers.

12. The WMA recognizes the link of health consequences to poor living
conditions and invites medical and other health care worker associations
and organizations to join forces to ensure that governments understand
and respect the need to provide safe and healthy living conditions for all
types of migrants.

* This communique was adopted by participants of the Symposium. It does not
constitute an official policy document of the World Medical Association.