Refugee Health: A Moral Discussion

Dear Editor,

The world is currently witnessing the greatest refugee crisis of all times.¹ According to the United Nations Refugee Agency, the current number of forcibly displaced people is 65.6 million worldwide, including refugees, asylum seekers, internally displaced people and stateless persons [1]. These people live in a political limbo with very limited access to resources to meet their basic needs such as housing, healthcare, sanitation, education, and employment. Among all these problems, however, health has a special status. Literature shows that refugees have a higher rate of mortality and morbidity compared to the host community in country of asylum. They are faced with a greater risk of psychological problems, and communicable and chronic diseases. Many studies show that refugees have a higher rate of morbidity and mortality because of the situation in their country of origin and also conditions in their country of asylum, such as overcrowded refugee camps, poor sanitation and under-nourishment. In addition, they encounter barriers to access to healthcare services in host countries [2]. These barriers include language and cultural differences, discrimination from the public and from some health professionals, mistrust and financial constraints [3].

Recently the attention of the international community on refugees has increased significantly due to tragic instances such as the heart-breaking picture of a young boy drowned at the shores of the Aegean Sea or the devastating photos of women, children and elderly in inhumane conditions. However, this attention was not sufficient to solve the basic problems such as the limitations of international law to define the legal status of refugees. The governments of host countries continue not to include refugees in their national policies due to the fact that they do not reside in their country and consider them as temporary guests. The lack of formal citizenship and national bonds, still constitute the leading factors that limit the responsiveness of the national governments and international community to the problems of refugees. This urges us to probe the ethical grounds for the rights of refugees by asking the question: “do we have a moral obligation to ameliorate their health?”

The existing literature suggests that there is no consensus regarding the ethical basis for rights of refugees and responsibilities of the host countries and the international community. For example, the reflection of neglecting non-citizens or outsiders has grounds in moral theory. John Rawls, in his works on justice, defines a difference principle which allows inequalities insofar as it also works for the advancement of the worst-off groups’ conditions in the society [4]. In other words, a just society should be based upon the principle to compensate people for the disadvantages from which they are suffering. However, his justice theory refers to the national level, since it is based on a social contract between members of a society; outsiders are not subject to the justice structure of that society.

On the other hand, the account of primary goods in Rawls’ theory of justice provides a wider view. Rawls defines the things that every rational person would want because they are needed to carry out personal life plans as primary goods [4]. Primary goods are needed by every individual regardless of her nationality, and globalization has made every individual a member of the global community, who is subject to the effects of global policies. Public health in today’s globalized world is global health, and national governments have obligations to promote global public health, going beyond their territories. Peter Singer’s flowing account endorses this view: “the term globalization implies that the world is moving beyond the era of growing ties between nations and is beginning to contemplate something beyond the existing conception of nation state” [5].

Thomas Nagel, moreover, offers a global difference principle, a global original position and a global veil of ignorance [6]. So, behind the global veil of ignorance, we can think of a revision of national migration policies for the benefit of those who need protection and aid of others. Therefore, we can adopt a policy that aims to develop health of displaced people, keeping in mind the role of social determinants of health.

Cosmopolitanism also offers a plausible argument to ameliorate health of refugees. Peter Singer, who constructs a utilitarian account of cosmopolitanism, states that if it is in our power to prevent something bad happening without a morally significant sacrifice, then we are morally obliged to do so [7]. In his very influential article written in response to the famines that occurred in 1960s, he argues that we can, and we are obliged to, save people from suffering by donating an insignificant amount of our income. He emphasizes that the large number of other people who can also help does not weaken our obligation. We argue that in the case of the refugee crisis, we are faced with a situation similar to famines. Indeed, refugees, like people suffering from famines, are victims of the inability of their governments to provide their basic needs such as security, shelter, food, water, healthcare and education. Then the same arguments serve as grounds to justify our moral obligation to help refugees as well.

Another cosmopolitan argument focusing on the equal moral worth of every human being by Thomas Pogge also plausibly discusses our moral position with regard to medical conditions of foreigners [8]. He states that we have a stronger moral obligation to ameliorate health conditions of foreigners in which we play a causal role than to cure medical conditions of compatriots in which we did not play any role. In case of refugee health, this argument needs to be grounded on the causal factors that force people to migrate. Otherwise it would be applicable only in cases that involve individuals who are foreign to each other. Alex Sager, points out that our (affluent) countries played a pivotal role in the creation of the world economy which systematically deprives the least advantageous groups, and he adds that powerful states contribute to the existence of global inequalities by using border enforcement and adopting policies that keep foreigners out [9]. This idea requires further discussion which is beyond the scope of this letter. However, we feel the urgency to point out that all humanity plays a role in the situation of refugees, either by keeping them out of our territories with border enforcement, by developing and sustaining global economic structure, or by simply ignoring. So, we agree with this line of reasoning due to the fact that even doing nothing also plays a role. It is, therefore, clear that this moral reasoning also implies an obligation to deal with health problems of all displaced people.

The fact that the number of refugees is increasing faster than any time in the human history draws attention to the health of these people with the urgency to develop sustainable and affordable policies for their wellbeing. The existing migration policies of countries force refugees to stay in countries which have limited resources and capacity to meet their basic needs. Many studies show that refugees suffer from ill health. However, they live in a political limbo where they are away from their entitlements and suffer from incapacity or negligence of host countries and the international community. Therefore, we need to revisit moral arguments to question whether we are responsible to help refugees, in particular to ameliorate their health.

As discussed above, we reconsider Rawls’ theory of justice which urges a society to compensate disadvantages of worst-off groups [4]. The same argument works for refugees as the worst-off group of the global society. Cosmopolitanism also provides a plausible approach that can be adopted to the situation of refugees. Regarding Singer’s argument on preventing something bad happening [7], we can help refugees, at least in terms of health, if all members of the global society dedicates as much resources as possible to provide basic needs of refugees.

Pogge’s argument emphasizing that we have a stronger moral obligation to ameliorate the bad health of foreigners that we helped to cause is stronger than our moral obligation to cure the bad health of compatriots that we did not help to cause is also applicable to the refugee health. As members of the global society, we argue that all humanity is responsible for not meeting the basic needs of refugees through international migration policies of our governments or by ignoring. Therefore, we believe that health of refugees is of global concern and existing moral arguments on compensating the worst-off groups’ disadvantages and on our responsibilities to non-citizens obliges the global community to take action.

We should take action not only in international and national policies, but also in global health ethics. Global health ethics focuses on ethical issues such as health inequalities, health of worst-off groups and social determinants of health. However, its reaction to refugee health has been relatively slow. We should encourage more focus on refugee health in global health ethics.

Consequently, being healthy is the most precious thing in human life, hence it deserves a special attention in all our policies and disciplines with an inclusive approach that takes everyone into consideration including refugees. In the short-term we can give a priority to providing more health care and healthier conditions in humanitarian aid for refugees. But we need further solutions in the long-run.