By: Brittany Troupe
Peer-reviewed by REAL members
The Problem
Vaccine-preventable diseases (VPDs) are communicable diseases that can be prevented through immunization. There are 17 VPDs that the United States and other countries target through policy measures.1 These diseases include measles, meningitis, cholera, and others that have a high incidence and prevalence in displaced populations.1,2 In this brief, displaced populations refer to groups that were forcibly removed from their homes. Refugees will be regarded as individuals who were legally recognized by the United Nations High Commissioner for Refugees (UNHCR) as having refugee status. 17% of all infectious disease outbreaks from 1996-2016 occurred in the Eastern Mediterranean region.3 Displaced populations in the Eastern Mediterranean region have a higher incidence and prevalence of VPDs than their non-displaced regional counterparts.4,5 Humanitarian crises cause an increase in malnutrition, a degradation of sanitation infrastructure, and a reduction in available health services.2 These risk factors directly increase the spread of communicable diseases. Civil conflicts cause humanitarian crises and increase the burden of VPDs on displaced persons, aid organizations, host countries, and non-displaced regional populations.2 Eastern Mediterranean displaced persons experience higher exposure to civil conflicts than any other regional group.6 The most recent estimates state that there are 82.4 million people currently displaced.7 Nearly 40% or about 20 million displaced persons are from the Eastern Mediterranean region.6 Policy solutions for reducing the burden of VPDs will be targeted at Syrian, Afghan, Libyan, and other large displaced ethnic groups that primarily speak Arabic.
The Social Determinants
Displaced persons in the Eastern Mediterranean region originate from countries, such as Afghanistan, Syria, and Libya, which have had decades-long civil conflicts and humanitarian crises.6 These persons have limited access to vaccines and health clinics within their countries of origin. The destruction of built environments in countries of origin and the insufficient infrastructure to address population influxes in host countries is a factor causing the increased burden of VPDs in displaced populations.2 Humanitarian crises increase political tensions within host countries leading to elevated levels of xenophobia. Xenophobia by host countries causes reductions in trust that displaced persons have in the host country’s health systems.8 The cultural implications of humanitarian crises cause barriers to care for displaced persons. Political perceptions of migrants in host countries increase individual prejudices and hinder social integration.2 Within xenophobic host countries, displaced persons are confined to groups with their cultural or displaced backgrounds. These groups most commonly exist in camp settings, formal or informal. Displaced persons are at an even higher level of risk for VPDs in camp settings due to overcrowding, poor sanitation, lack of infrastructure, and poor living conditions.2 Outbreaks of VPDs are more likely to occur in these populations because of their lower immunization rates.2,4 Host populations have higher immunization rates and a lower incidence of VPDs.2 Socially integrating displaced persons into host countries would decrease the burden of VPDs by invoking herd immunity.2 Integration requires political action and active efforts by policymakers to reduce xenophobia. Inaction will continue to put displaced persons and host populations at a higher risk of VPD outbreaks.
Other cultural determinants influence displaced persons’ willingness to receive vaccinations. Displaced persons can experience vaccine hesitancy because of general fears of side effects and doubts of vaccine efficacy.8 Vaccine hesitancy is more likely to be expressed when care is provided through host country health systems as opposed to international aid groups.8 Accessible health communication in Arabic, or a displaced person’s primary language, is a tool that needs to be integrated in all policy solutions. Displaced persons in the Eastern Mediterranean generally embrace medical care when it is available despite experiencing vaccine hesitancy at higher rates than non-migrants.8 Cultural competencies must be included into policy recommendations to develop inclusive solutions for reducing the burden of VPDs on displaced persons.
Key Actors
The social determinants of health that influence the burden of VPDs on displaced persons can be managed by host countries and international aid groups. The largest host countries in the Eastern Mediterranean are Turkey, Jordan, and Palestine.7,9 These three countries host a total of 6.4 million displaced persons.7,9 Turkey, alone, hosts 3.7 million displaced persons.7 Only 2% of the displaced population in Turkey live in camps.10 This is compared to the 81% of displaced persons living in camps in Jordan.9 Nearly 50% of displaced persons in Palestine reside in camps.11 The policy recommendations for these three host countries will differ slightly in their implementation.
Turkey, Jordan, and Palestine are accountable for integrating the World Health Organization’s (WHO) Expanded Program on Immunization (EPI). EPI programs are designed based on guidelines made by the WHO.12 Countries differ in the implementation of EPI programs based on social determinants of health. In Turkey, EPI programs must be developed for urban settings with local administrators and public health officials; considering that 98% of displaced persons are not encamped.10 EPI programs in Jordan should be chartered under national leadership to ensure that the 81% of displaced persons currently encamped have equitable vaccine access.9 Local resources may not be sufficient in developing EPIs for encamped populations. However, an extent of local implementation is required for all EPI programs. Palestine is currently in national conflict with Israel, EPI programs for displaced persons in Palestine would be implemented most effectively under international aid groups, such as the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). Each nation or implementing group must be held accountable by the UN and WHO for ensuring EPI programs are equitable. EPI programs developed for citizens of host countries may differ from EPI programs catered to displaced persons. This can raise the ethical concerns that displaced persons are being denied complete access to care due to political or cultural motivations.2 The ethical challenges of this are compounded by logistical challenges that hinder social integration.
Policy Recommendations
Turkey, Jordan, and other Eastern Mediterranean countries that support large numbers of displaced persons should expand the implementation of the EPI to specifically target services at border entry points. Establishing VPD reception centers at entry points can ensure the majority displaced persons in host countries receive screening for VPDs because they all cross through them.2 Reception centers intend to increase surveillance of VPDs. This surveillance would increase the efficacy of EPI programs because it establishes a documented medical history. Most countries facing conflict and humanitarian crises do not have reliable immunization records that displaced persons can access.13 These reception centers should provide treatment for VPDs to reduce the burden of VPDs on host countries. International aid groups should collaborate with host countries to establish reception centers at border points. Host countries can use the data from reception centers to establish EPI programs in camps and urban settings. EPI programs developed with surveillance data can target the most vulnerable people more precisely. This would decrease the burden of VPDs. The UNHCR, along with international aid groups, can collaborate with community leaders to provide resources for VPD treatment and EPI implementation.
The second policy recommendation in this brief is that host countries should disperse displaced populations throughout the country. Developing social integration and increased pathways to permanent residency can have a large effect on reducing the burden of VPDs on displaced persons and host countries. Social integration offers the benefits of increased trust from displaced persons and herd immunity. Current pathways to resettlement for displaced persons exist on the international and national scale. Displaced persons can currently apply for refugee status through the UNHCR and Palestinian displaced persons can apply for refugee status under the UNRWA. The demand for refugee status exceeds the capacity of the UNHCR, leaving millions of displaced persons without resettlement pathways. Turkey, Jordan, and other large host countries should work with their national governments to develop visas, resettlement, or naturalization pathways specific to displaced persons. Decreasing the burden of VPDs on displaced persons will require treatment, increased vaccination, and pathways to social integration.
All opinions are exclusively those of the author and not of George Washington University, the Graduate School of Education and Human Development, the Refugee Educational Advancement Laboratory or any of its members or other entities.
References
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