Lancet: Refugees - Refuge for the selected few

This article first appeared in: The Lancet Volume 357, Number 9266, 05 May 2001 Mass population movements were a major feature of the 20th century, provoking some of the starkest examples of the interaction between human rights and health. Armed conflicts have increasingly targeted civilians and led to enforced migration. No area of the world has been spared - from Indonesia to Sierra Leone, Bosnia to Nicaragua - the direct and indirect human toll of war remains a global public-health priority. Although real progress has been made in defining the health needs of refugees, through more focused and effective programmes and accelerated conflict resolution efforts, population displacement remains a major global concern. The needs of 40 million displaced Europeans at the end of the Second World War stimulated the formation of the Office of the United Nations High Commissioner for Refugees (UNHCR) and the adoption of the UN Refugee Convention in 1951. In the following two decades, international relations were marked by Cold War tensions, with the Berlin Blockade, the communist party victory in China, the war in Korea, and the Hungarian uprising. In 1971, the flight of ten million people from East Pakistan (now Bangladesh) into India provided UNHCR with the largest case-load in its history. Before 1968, the focus of attention was on those people who met the international definition of a refugee ("... persons who flee their own country because of ... a well-founded fear or persecution ..."). However, during the Indochina wars, millions of internally displaced persons (IDPs) remained beyond the reach of UNHCR and other international agencies. In the 1970s and 1980s, ideological conflicts in Indochina, the Horn of Africa, Afghanistan, Central America, Mozambique, and Angola, generated millions of refugees. Western countries generously supported aid programmes for refugees from socialist states, while neglecting IDPs trapped in zones of conflict. The Soviet bloc neither supported nor funded UNHCR or other relief efforts. It was not until the 1980s that the number of IDPs began to escalate rapidly, and by the early 1990s their global number surpassed the refugee total. Footnote 1 This development was largely caused by an increase in internal conflicts in Africa, the Middle East, and Eastern Europe. When Turkey denied asylum to hundreds of thousands of Kurds in 1991, the UN Security Council created a safe zone to allow international agencies access to a population essentially displaced within northern Iraq. The deployment of armed peace-keeping forces to ensure the passage of aid convoys in the midst of the Bosnian conflict did nothing to halt the appalling human rights abuses which continued unimpeded despite a widespread UN presence. In 1994, when millions of Rwandans were subjected to genocidal violence and internal displacement, the world did nothing; however, when more than a million refugees fled into surrounding countries, there was a massive (but not very effective) international response. Extremely high death rates have been documented among refugees and IDPs; in camps in less-developed countries, most deaths have been due to preventable conditions such as measles, diarrhoeal disease, malnutrition, pneumonia, and malaria, especially among women and young children. In the industrialised countries of Eastern Europe, the combination of conflict and economic collapse has led to the elderly being prone to food scarcity, people with chronic diseases going untreated, and preventive services such as antenatal care and child immunisation collapsing. Tuberculosis has been inadequately diagnosed and treated resulting in widespread multidrug resistance. The impact of extensive sexual violence documented in the former Yugoslavia, Somalia, Sierra Leone, and Rwanda has been compounded by the rapid spread of HIV and AIDS. Meanwhile, more than three million Palestinians remain stateless in the Middle East, 50 years after the events that forced them to flee their homeland. Footnote: 2 Because peace remains elusive, they are neither able to return home nor permanently resettle in neighbouring countries. More than 100 000 Tibetan refugees have remained in India for more than 40 years and half a million people have been displaced by lengthy internal conflicts in Burma. These people are powerless pawns in chronic political disputes. When the Soviet Union collapsed, millions were displaced as people returned to their ethnic homelands - sometimes centuries after their ancestors were forcibly removed. Refugees who flee their countries through fear of persecution are part of a much larger body of migrants searching for better work and education possibilities. In 2000, an estimated 150 million people were living outside the country of their birth; of these, only about 10% were refugees. Footnote 3 Prosperous industrialised nations have tightened their controls on people seeking entry, including the interdiction of boats carrying, for example, Albanians into Italy, Haitians and Chinese into the USA, and Iraqis and Afghans into Australia. These restrictions inevitably affect the chances of genuine asylum seekers to gain refuge. The trend towards reducing social services in western countries has also meant that the particular health needs of asylum seekers, many of them survivors of torture and other human rights abuses, are not addressed by public-health systems. Since 1998, there have been humanitarian crises in Central and West Africa, the Horn of Africa, Sri Lanka, Kosovo, East Timor, and a number of Indonesian provinces. The response to these emergencies has depended on the perceived self-interests of western nations. Given the changed nature of conflicts, the post World War II focus on refugees is no longer adequate; for example, in 2000, of the 22.3 million people "of concern" to UNHCR, only 52% were refugees. Footnote 3 And with a plethora of actors now involved - UN agencies, governments, military forces, and a diverse array of non-governmental aid and advocacy organisations - the need for a consistent and well-coordinated international approach to protecting refugees and IDPs is greater than ever. In every corner of the world, individuals, families, and entire communities seeking refuge for various reasons find that barriers to their movement are more intimidating than ever. The root causes remain lack of basic freedoms, poverty, inequality, armed conflict, and rapid environmental degradation. Old definitions of refugees are no longer sufficient and leave millions of people vulnerable and unprotected. The international response to the issue of forced migration must address root causes, be more consistent, less reactive, and take proactive prevention more seriously. References 1 Norwegian Refugee Council. Internally displaced persons: a global survey. London: Earthscan, 1998. 2 US Committee for Refugees. World Refugee Survey, 1999. Washington DC: US Committee for Refugees, 2000. 3 United Nations High Commissioner for Refugees. The state of the world's refugees, 2000. Geneva: