A Silent Crisis

This Global Governance Working Paper is a feature of the Council of Councils (CoC), an initiative of the Council on Foreign Relations. Targeting critical global problems where new, creative thinking is needed, the working papers identify new principles, rules, or institutional arrangements that can improve international cooperation by addressing long-standing or emerging global problems. The views and recommendations are the opinion of the author only. They do not necessarily represent a consensus of the CoC members, and they are not the positions of the supporting institutions. The Council on Foreign Relations takes no institutional positions on policy issues and has no affiliation with the U.S. government.

The Challenge

Jude Alawa

Department of Public Health and Primary Care, University of Cambridge

Thomas J. Bollyky

Bloomberg Chair in Global Health; Senior Fellow for International Economics, Law, and Development; and Director of the Global Health Program

The world is facing the highest levels of displacement on record, and millions of refugees are suffering from chronic noncommunicable diseases (NCDs)—conditions such as diabetes, cancer, and cardiovascular disease that cannot pass from person to person, but can be life-threatening if left untreated.

According to the United Nations High Commissioner for Refugees (UNHCR), an unprecedented 70.8 million people around the world have been forced from their homes as of 2018. Roughly 25.9 million of those are refugees, defined under international law as persons living outside their countries of nationality who have a well-founded fear of being persecuted and are unable or unwilling to return to their home countries. Historically, the health needs of refugee populations were predominantly related to infectious diseases. Refugees generally came from impoverished, war-torn nations where tuberculosis and pediatric contagions were prevalent. Refugee health programs focused on treating and immunizing against infectious agents that refugees were thought to bring with them, as well as preventing the spread of new diseases like cholera and diphtheria that can arise when refugee camps crowd vulnerable individuals together.

While infectious diseases continue to be an urgent concern and health practices in humanitarian situations developed for camp settings remain important, most of the world’s refugees today primarily reside in non-camp, urban settings, and their health needs have increasingly shifted to cancer, diabetes, and other noncommunicable diseases. A 2014 study found that NCDs were prevalent in 9 percent to 50 percent of urban refugees in the Middle East. Refugees who endure prolonged exposure to violence or instability in their country of origin or another host country are also more likely to experience mental health problems associated with trauma, stress, or both.

This rise in noncommunicable diseases reflects the health needs in many refugees’ home nations (see figure 1). In 2018, NCDs accounted for three-quarters of all deaths in the Middle East and North Africa. A quarter of the world’s refugees (6.7 million) are from Syria, which was a middle-income country prior to its ongoing conflict. At the start of the civil war in 2011, NCDs represented nearly two-thirds of the burden of death and disability in that nation. Noncommunicable diseases also account for a significant share of the health burden in Afghanistan, Eritrea, and Sudan—countries that are similarly major sources of refugees. In Myanmar—which is the source of over one million Rohingya refugees—cancer, heart disease, and other NCDs now represent more than 60 percent of the country’s health burden.

NCDs are generally chronic and more expensive to treat than infectious diseases. Preventing and managing conditions like diabetes, hypertension, and chronic respiratory illnesses requires public health education, timely diagnosis, and consistent access to affordable, quality-assured prescription medicines. Delayed care results in more expensive, convoluted treatments and adverse health outcomes that would otherwise be preventable. Treating cancers and cardiovascular diseases could require inpatient surgeries, hospital beds, and specialist physicians.

Most nations that host the vast majority of the world’s refugees are signatories to the 1951 UN Refugee Convention and its 1967 Protocol, which mandate that refugees shall receive the same social security, including with respect to sickness, as nationals. Countries that are not signatories to the convention, such as Jordan and Lebanon, are signatories to regional agreements or frameworks that impose similar health-care obligations.

That said, many of the governments hosting the most refugees spend relatively little on health and are already struggling with a fast rise in NCDs in their native populations. The majority of Syrian refugees reside in Jordan, Lebanon, and Turkey, where NCDs already account for more than three-quarters of the deaths in each of these countries. Finding a method to care for refugee populations and nationals, however, is not the exclusive responsibility of Syria’s neighbors. Poorer countries shoulder most of the burden of the global refugee crisis (see figure 2). In 2018, developing regions hosted 84 percent of all refugees, with 6.7 million refugees in least-developed countries.

Further, host nations are required to provide care for the NCDs of refugees for many years. Most refugees worldwide (15.9 million) are now in “protracted situations,” which UNHCR defines as those in which twenty-five thousand or more refugees of the same nationality have been in exile for five consecutive years or more in a given host country.

Jordan, Lebanon, and Turkey have each responded to the influx of Syrian refugees with different approaches to the organization and financing of health services for NCDs. Until 2014, the Jordanian Ministry of Health provided access to primary and secondary care for Syrian refugees free of charge. Since then, the government has required refugees to register with the Ministry of the Interior and obtain an identification card to become eligible to pay a subsidized rate for care that is approximately 80 percent of what uninsured Jordanians pay. In August 2016, more than a quarter of the refugees in Jordan’s camps had not received identification cards. In Turkey, the host government bears the burden of providing free health services to only registered refugees; non-registered people have to pay out of pocket. With no national health insurance schemes to finance treatment costs, nearly all Syrian refugees—registered or unregistered—in Lebanon rely almost exclusively on humanitarian organizations for health care.

In Lebanon, refugees who have registered with UNHCR can access primary care services at public primary health-care centers at a subsidized cost and can be referred to a secondary or tertiary health center if they meet specific criteria established by UNHCR, which takes into account the necessity of the treatment, financial need, disease prognosis, and overall cost. UNHCR considers care for chronic illnesses, such as cancer, on a case-by-case basis. If a case is deemed life-threatening, then UNHCR covers 75 percent of treatment cost. The protracted nature of the Syrian crisis and limited funding from humanitarian organizations and donors have left UNHCR with an 83 percent deficit in overall funding for its budget.

Recommendations

In order to provide sustainable health care to displaced populations with NCDs, host governments and humanitarian organizations should pursue the following recommendations:

Governments, humanitarian organizations, and international institutions should invest more in preventive and primary care. Any improvement in refugee health will require increased attention and access to lower-cost approaches to support the prevention and management of chronic diseases in large populations of displaced individuals. Nearly every report of Syrian refugees in Jordan and Lebanon cites the cost of treatment as the most significant obstacle to accessing health care for NCDs. In Jordan, one study found that over half of urban Syrian refugees who had reported being diagnosed with arthritis, cardiovascular disease, chronic respiratory disease, diabetes mellitus, or hypertension did not seek care for their conditions because of the cost of treatment. In Lebanon, approximately 80 percent of urban Syrian refugee household members reported not being able to afford the cost of even seeking treatment; the average monthly income of Syrian refugees in Lebanon is about $200 per month per family. Nearly 71 percent of Syrian refugees in Lebanon and 59 percent of Syrian refugees in Jordan who were able to get treatment for chronic illnesses interrupted that treatment due to its costs. 

Little research or attention has been given to addressing NCDs and their prevention among refugee populations. Prevention is essential to any effort to improve and sustain affordable lifelong health and to avoid risk factors for chronic illnesses. By investing in increased access to preventive care as part of primary care, humanitarian organizations and host governments can decrease the need for chronic treatments and costly hospital services. For instance, community-based programs, outreach volunteers, and even emerging technologies can be used to increase early diagnosis of noncommunicable diseases before those conditions become advanced and more expensive to treat. Treatment in a primary-care setting offers opportunities to counsel refugees on the health hazards of tobacco use and alcohol abuse, to reduce the stigma around treatment of mental illnesses and trauma, and to encourage physical activity and healthy eating.

Host governments and humanitarian organizations should increase health promotion efforts and create more comprehensible health referral mechanisms. In order for individuals to effectively navigate a health system and seek out care for their conditions, they need adequate awareness of the symptoms they are experiencing and the means to seek health care. For newly arrived refugees, who could face discrimination and language barriers, understanding a new health system can be an immense challenge.

In Turkey, nearly half of the refugees living in an Istanbul neighborhood did not know about migrant health centers, which provide free primary health services. In Jordan, a population-based health assessment found that approximately 70 percent of refugees with at least one NCD and living in non-camp settings did not receive any health education about their condition while seeking medical attention. In many cases, the reasons for refugees’ lack of awareness do not stem from inaction on their part, but instead from a lack of action or clarity by host governments and humanitarian organizations. In 2014, Amnesty International found that the eligibility criteria for attaining subsidized health care for Syrian refugee patients remained unclear for three years after refugees began to migrate into Lebanon. Similarly, in 2016, nearly half of surveyed Syrian refugees in Jordan described difficulties in attaining the specialist care required to treat their chronic conditions as a result of a complex referral system.

Without health promotion and a widely comprehensible referral mechanism in place, refugees with chronic illness are often diagnosed late and cannot access the care they need to manage conditions that could become expensive and even deadly if not treated quickly. Thus, host governments and humanitarian organizations should make an effort to provide health services and to educate their constituents on how to access the care they require, the risk factors for the development of disease, and the symptoms of the most common illnesses. The push by the World Health Organization and the World Bank to advance quality universal health coverage could make it easier to extend and lower the cost of refugee health programs.

Host governments and humanitarian organizations should increase access to specialist health-care services and integrate refugee populations into national health systems. For the large population of refugees who have already been diagnosed with a noncommunicable disease, preventive and primary care will not suffice. Instead, specialized health-care services are necessary to provide more complex treatments and prevent compounding complications that often result from chronic illnesses. Nevertheless, countries and humanitarian responders facing an influx of displaced persons have sought to provide only primary care. Limited by funding constraints and the absence of an effective strategy to provide noncommunicable-disease care in protracted humanitarian settings, this approach has been inadequate to address refugees’ health-care needs.

Without access to specialists, refugees with noncommunicable diseases will not be able to find the care they require, which will adversely affect their health outcomes and ability to contribute to their surrounding communities. Though the provision of advanced health-care services remains an urgent concern among refugee populations in camp and non-camp settings, financing secondary and tertiary care for NCDs is expensive. To improve the availability of these services and to provide more sustainable access to health insurance, host governments should work to integrate refugee populations into their own national health systems. Nongovernmental organizations and humanitarian relief organizations should target gaps in the services that host governments provide. Doing so would allow those organizations to conserve resources and provide comprehensive, cost-effective health care for noncommunicable diseases.

Host governments and international humanitarian organizations should develop a new framework that accounts for today’s protracted urban refugee crises. The conception and strategy for addressing humanitarian situations is largely outdated given that most crises today are protracted and characterized by refugee populations with ongoing health challenges. As long as international humanitarian organizations and host governments remain entrenched in an antiquated strategy that does not account for these factors, they will be unable to address the health needs of refugees with chronic conditions. Ignoring the challenges presented by NCDs will only defer and increase the human and economic costs for refugees and host countries. International humanitarian organizations, in conjunction with host governments, should develop a framework that accounts for the realities of the health needs of this vulnerable population.

The development of such a strategy will be necessarily complex and will require the involvement of a diverse set of actors, including host governments, health providers, nongovernmental organizations, and international agencies. A meaningful strategy should identify the source of relevant resources to finance and provide comprehensive health services, hold actors accountable for the implementation and evaluation of their efforts, cultivate multi-sectoral partnerships, and include populations of all backgrounds. Given that the shifting health needs of refugees have been well documented, a formal strategy to address noncommunicable diseases among refugees should already be in place. Remedying the absence of such a framework should be at the top of the international refugee agenda on health. International organizations and governments across the world should prioritize the creation of a strategy to better account for protracted humanitarian crises and the rise of NCDs among those displaced.

Conclusion

The urgency of providing sustainable health care to displaced populations with chronic illnesses highlights the immense gaps and unmet needs in host countries’ health systems. Addressing this challenge will require both the development of a more representative humanitarian system and modifications in health-care delivery in host countries. Ultimately, an influx of a massive amount of additional resources will be required for displaced populations to gain adequate access to preventive care and specialist treatment services. Though the provision of these services could appear to be a burden to host countries, the reality is that a large proportion of refugee populations will not return to their country of origin. Thus, providing access to the resources that will enable refugees to take ownership of their health will decrease health-care costs for host countries and humanitarian organizations and help displaced persons contribute to the communities they could learn to call their own in the future.

This paper has benefited from numerous comments and suggestions from Council of Councils members, in particular Daniel Gulati (German Institute for International and Security Affairs), Anne Koch (German Institute for International and Security Affairs), Christophe Bertossi (French Institute of International Relations), Aimee-Noël Mbiyozo (Institute for Security Studies), and Carlos Javier Regazzoni (Argentine Council for International Relations).