Vaccines and Global Health: The Week in Review has expanded its coverage of new reports, books, research and analysis published independent of the journal channel covered in Journal Watch below. Our interests span immunization and vaccines, as well as global public health, health governance, and associated themes. If you would like to suggest content to be included in this service, please contact David Curry at: firstname.lastname@example.org
An unhealthy state to be in
by Seth Berkley | Gavi, The Vaccine Alliance
Thomson Reuters Foundation | 20 March 2018
Most refugees are living in low- and middle-income countries which are usually in no great position to support a huge influx of people
For the millions of people living in conflict zones, often the biggest killer isn’t bullets or bombs, but infectious disease. This was true of the First World War, where Spanish flu claimed four times more lives than conflict, and it is true of modern wars, even particularly brutal ones, like in Darfur. There, non-violent deaths, mainly due to infectious disease compounded by nutritional issues, were responsible for a ten-fold increase in mortality. Yet, for refugees it’s a very different story. There are always exceptions, but generally those people fleeing conflict or persecution who make it across national borders are on average no more likely to die than the residents of their new host country.
What this highlights is the vital role that aid agencies and host countries play in providing refugees with critical health interventions, such as vaccines, which may not have been available in their home country due to a breakdown of health services. As U.N. officials meet in Geneva this month to discuss a new draft global agreement on refugees, it’s also a role that is now likely to come under increasing pressure in the face of growing fragility, as the number of conflicts continues to rise, displacing more and more people.
With a record high of more than 65 million people across the world now displaced from their homes, conflict is only one driving force. Climate change, in the form of land degradation, desertification, rising sea levels and extreme weather events, is also now a contributing factor, as is the poverty that often comes with it. And in the coming decades this is expected to get worse.
All this points to two worrying challenges. The first is the question of how we continue to make immunisation and other vital preventive health interventions a priority for refugees. This can be challenging at the best times, as the ongoing diphtheria outbreak among the 650,000 Rohingya refugees in Cox’s Bazar demonstrates. But as the number of refugees continues to rise, this continuity of healthcare is likely to become less sustainable, raising difficult questions about who is responsible for providing for these essentially “stateless” people.
Indeed, given that refugee crises are rarely resolved quickly, and that it can take years before people can be safely repatriated, there is also the long-term pressure placed on host countries to consider. While headlines about the global refugee crisis mainly focus on the burden placed on wealthy nations, most refugees are living in low- and middle-income countries which are usually in no great position to support a huge influx of people. Countries like Jordan, Kenya, Ethiopia and Uganda currently have millions of Syrian, Somali and Sudanese refugees in vast camp cities. Should countries like these be expected to use their limited resources or take out additional borrowing and incur sovereign debt in order to fund the needs of millions of people who are not their citizens, but are nevertheless on their territory?
The second arguably even greater challenge will be finding better ways to reach those tens of millions of people who are displaced but remain in their home country, which is the vast majority of the global total. These people are in so many ways more vulnerable, and yet harder to reach, with their health and safety often at the mercy of the same forces that drove them from their homes in the first place.
Continued fighting and a lack of basic infrastructure can make it extremely difficult for aid agencies to reach these displaced civilians populations, who are often sheltering in over-crowded situations, with limited access to food, water and sanitation, conditions that are ripe for outbreaks of disease and the vectors that spread them. If the children within that population miss out on vaccinations, such outbreaks become almost inevitable.
This is precisely what triggered the diphtheria outbreak among the Rohingya in Cox’s Bazar and this is what is now unfolding in Yemen. The only difference is that while aid agencies were able to get vaccines to the Rohingya refugees when they crossed over into Bangladesh, in Yemen access to the 22 million people in need of humanitarian assistance is limited. With around 1,300 suspected cases of diphtheria and 73 deaths, there are now 7.2 million doses of the diphtheria vaccine on their way. It remains to be seen whether they make it to each and every person at risk.
Ensuring that health remains a priority in the new global agreement on refugees is one solution. In seeking to create a global public good that eases pressure on host countries and delivers services, as well supporting self-reliance of refugees and making it easier for them to either resettle in third countries or voluntarily repatriate, should be a positive step for all parties. However, we also need to find solutions to help people on the other side of the border, those millions of internally displaced people who are ultimately more at risk. By supporting their human right to lead healthy lives through the prevention of vaccine preventable disease, we can not only reduce the risk of outbreaks, but also end the tragedy of people fleeing violence only to be struck down by disease.