Team:Thessaly/Healthcare Model
HEALTHCARE MODEL.
Abstract
Population movement is one of the defining phenomena of our time. Globally, in 2017, 258 million people (approximately one in every 30) lived outside their country of origin. According to UNHCR’S statistical yearbook, the number of forcibly displaced people by the end of 2018 remained high and reached 74.7 million worldwide. Conflict, persecution, generalized violence, and violations of human rights have caused people to leave their homes and livelihoods seeking a more secure living situation for themselves and their families [1]. The public health challenges and humanitarian needs associated with large influxes of refugees, asylum- seekers, and migrants have led us to propose a healthcare model with the aim to communicate it to policymakers. Our model proposes an inclusive, intersectoral and multidisciplinary approach to migration with strong collaboration, going beyond the identification of disease patterns of arriving refugees and also monitoring access to quality health care.
Refugee: The primary and universal definition of a refugee that applies to states is contained in Article 1(A)(2) of the 1951 Convention, as amended by its 1967 Protocol, defining a refugee as someone who:
"owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence, is unable or, owing to such fear, is unwilling to return to it [2].
Asylum- seeker: refers to a person asking for international protection under international refugee law, but whose claim has not yet been finally decided on by the country in which he or she has submitted it. Not every asylum-seeker will ultimately be recognized as a refugee, but every refugee is initially an asylum-seeker [3].
Active Tuberculosis: Active tuberculosis (TB) refers to a disease that occurs in someone infected with Mycobacterium tuberculosis. It is characterized by signs or symptoms of active disease, or both, and is distinct from latent TB infection, which occurs without signs or symptoms of active disease. It typically affects the lungs (pulmonary TB), but can also affect other sites (extrapulmonary TB) [4].
Introduction
Refugee and migrant trends
Over the past decade, the global population of forcibly displaced people grew substantially from 43.3 million in 2009 to 70.8 million in 2018, reaching a record high [5].
This steady increase in the global number of refugees and migrants includes the WHO European Region. The 53 countries of the WHO European Region have a population of almost 920 million, representing nearly a seventh of the world’s population; international migrants make up almost 10% (90.7 million) in the Region and account for 35% of the global international migrant population (258 million) [6].
Τhe geographical position of the Mediterranean basin, including our country, has attracted and continues to attract a large number of influxes. According to the International Organization of Migration’s (IOM) Flow Monitoring, there were 144,166 arrivals to Europe in 2018 with about 50,215 refugees and migrants entering Greece. These trends look set to continue in 2019 as a number of 41, 615 migrants have already reached Greece, with the root causes of displacement and migratory movements remaining unresolved. This journey to Europe often has numerous health and safety risks.
Health Aspect
The journey to Europe is often long and treacherous for migrants and refugees. Traveling in large numbers, these vulnerable groups face health risks affected by the country of origin, their experiences during the journey as well as the living conditions on the country of arrival. Combined with the poor conditions in refugee camps, the possibility of disease outbreaks increases. Tuberculosis is a leading health threat for populations affected by crises, and more than 85% of refugees flee from and stay in countries with a high burden of ΤΒ. An untreated case of active tuberculosis has a case-fatality ratio (CFR) of about 50% and will transmit the infection to 10 to 15 contacts annually until death or recovery [7]. The disease is spread when people who are sick with pulmonary TB expel bacteria into the air, for example by coughing. Active TB is distinct from latent TB infection, which occurs without signs or symptoms of active disease. Individuals that belong to the large influxes are at higher risk of falling ill with TB due to limited access to health care and treatment for the disease which further compounds its negative effects.
Refugee Supporting Stakeholders
The events of recent years have demonstrated the speed with which migration crises can evolve, and the impact they can have in term of both the numbers of people affected and the rapidity with which people can move from one part of the world to another. These events highlight how sociopolitical circumstances in one part of the world can challenge the border control policies, procedures and preparedness of host countries.
In times of crisis, the principal responsibility for assisting and protecting migrants rests with States. To face the challenges posed by large influxes of refugees, asylum- seekers, and migrants to health systems, States need to call upon the assistance and support of the international community. This international support is delivered through organizations with mandates and experience in this field, most notably UNHCR and IOM. International, regional, national, and local nongovernmental organizations have important roles to play in addressing the protection and assistance of migrants.
On 3 December 1949, the United Nations General Assembly decided to establish a High Commissioner’s Office for Refugees as of 1 January 1951.
UNHCR focuses broadly on:
• Seeking to ensure that migration-management policies, practices and debates take into account the particular protection needs of asylum-seekers, refugees and stateless people, and acknowledge the legal framework that exists to meet those needs;
• Assisting States and partners to meet asylum and migration-management challenges in a manner that is sensitive to protection concerns;
• Identifying migration, trafficking and related developments impacting on persons under UNHCR’s mandate, and
• Supporting stronger governance and closer observance of the universal character of human rights, including the rights of all persons on the move, regardless of their legal status, in ways that reinforce the principles and practice of international refugee protection.
To support these aims, UNHCR collects and analyses data and trends, develops policy and guidance, implements programmes and provides operational support to governments and other stakeholders on mixed movements and related issues such as trafficking in persons and protection at sea [8].
The International Organization for Migration was founded in December 1951, operating as the Intergovernmental Committee for European Migration (ICEM).
IOM Greece, as a founding member of IOM, has a long cooperation experience with the Greek Government and the civil society, aiming at helping and supporting migrants. As the leading international organization for migration, IOM always acts with safety and dignity among its partners in the international community in order to:
• Assist in meeting the growing operational challenges of migration management.
• Advance understanding of migration issues.
• Encourage social and economic development through migration.
• Uphold the human dignity and well-being of migrants [9].
Frontex was established in 2005 as the European Agency for the Management of Operational Cooperation at the External Borders and is primarily responsible for coordinating border control efforts. In response to the European migrant crisis of 2015–2016, the European Commission proposed on 15 December 2015, to extend Frontex's mandate and to transform it into a fully-fledged European Border and Coast Guard Agency.
Countries that have an external border have sole responsibility for border control. But Frontex can provide additional technical support for EU countries facing severe migratory pressure. It does this by coordinating the deployment of additional technical equipment and specially-trained border staff.
Frontex’s areas of responsibility include:
• Risk analysis
• Joint operations
• Rapid response
• Research Training
• Joint returns
• Information-sharing [10]
The European Asylum Support Office (EASO) is an agency created by European Union Regulation 439/2010 to strengthen the cooperation of EU Member States on asylum, enhance the implementation of the Common European Asylum System, and support Member States under particular pressure.
EASO’s task:
• organising support and assistance for the general or specific needs of the Member States’ asylum systems;
• coordinating and stimulating operational cooperation between Member States and enhancing quality;
• acting as an independent centre of expertise on asylum;
• organising EU-wide analyses and assessments of asylum data;
• facilitating and stimulating joint action and ensuring consistency within the asylum field;
• engaging with the full commitment of Member States;
• respecting the responsibility of Member States and their asylum decisions;
• cooperating with the European Commission, the European Parliament and the Council of the European Union, as well as other EU institutions, agencies and bodies;
• involving international organisations and civil society; and
• performing its duties as a service-oriented, impartial and transparent organisation within the EU legal, policy and institutional framework [11], [12], [3].
Doctors of the world is an international Non – Governmental, independent, humanitarian organization, which was founded in 1980 by 15 French doctors that believed in bearing witness and providing direct access to medical care for the world’s most vulnerable populations.
The first and foremost mission of Doctors of the World is to provide medical care. Actions though are not limited to medical treatment: Always based on the medical experience, the organization is vocal against the obstruction of access to healthcare, against violation of human rights and dignity. MDM is aiming to ensure access to healthcare and promote it as a universal human right [13].
Médecins Sans Frontières (MSF) is an international, independent, medical humanitarian organization that delivers emergency aid to people affected by armed conflict, epidemics, natural disasters and exclusion from healthcare.
Today, it is a worldwide movement of 21 sections, 24 associations and various other offices, bound together by MSF International which provides coordination, information and support to the MSF Movement [14].
Current policies
These barriers to care, coupled with the magnitude and persistence of the global TB burden, argue for a redoubling of efforts to ensure early identification of and treatment for all people with TB. All Member States of WHO and the UN have committed to this goal, initially through their unanimous endorsement of WHO’s End TB Strategy at the World Health Assembly in May 2014 and then their adoption of the UN Sustainable Development Goals (SDGs) in September 2015. Specific targets for 2030 set in the End TB Strategy are a 90% reduction in the absolute number of TB deaths and an 80% reduction in TB incidence (new cases per 100 000 population per year), compared with levels in 2015 (WHO tuberculosis report 2018).
The EU Approach was launched as part of the EU Agenda on Migration to assist Member States facing disproportionate migratory pressure at the EU’s external borders. Located at key arrival points, hotspots are designed to provide operational support by the EU agencies to Member States, with a focus on assisting in the identification, registration, fingerprinting and processing of asylum seekers.
The policy measures translate into different practices depending on national contexts, available resources and capacities as well as political imperatives and arrangements- such as the EU-Turkey Statement- and have different implications for procedural safeguards and for access to the asylum procedure, as reflected below [15]:
• When refugees and migrants arrive on the Eastern Aegean islands by boat, they are transported to hotspots facilities, which are legally defined as Reception and Identification Centres (RIC), and managed by the Greek authorities in the Reception and Identification Service (RIS). The Hellenic police, Frontex, the Greek Asylum Service, and EASO as well as National Public Health Organization (NPHO) are also present in the hotspots.
• The initial step in the hotspot procedures is the identification and registration of new arrivals by the police with the assistance of Frontex.
• New arrivals are detained for purposes of identification and registration as to return irregular migrants or asylum seekers whose application for asylum has been found inadmissible.
• In Greece, the authorities at the RIC register all new arrivals, who ask for asylum, with the Greek Asylum Service.
• Asylum seekers in the Eastern Aegean islands can be subjected to a geographical restriction during their asylum procedure. Asylum seekers from certain nationality groups with recognition rates below 25% are placed in detention in pre- removal centers the so- called “low- profile scheme”, and an admissibility procedure is applied to asylum seekers of nationalities with recognition rates above 25% such as Syrian nationals [16], [17].
The most frequently screened diseases among newly arrived migrants are communicable diseases and TB in particular. The WHO has published guidelines that set out the principles for screening for active TB and provide recommendations on prioritizing risk groups and choosing a screening approach [4].
Humanitarian responses to crises have traditionally focused finite resources on acute diseases perceived as the main crisis-emergent threats (eg, measles, cholera, and other diarrheal diseases), leaving more chronic disorders such as tuberculosis for the later stages of humanitarian action.104 Existing WHO/UNHCR recommendations for establishing tuberculosis programs in crises list essential criteria, including that (1) data from the population shows that tuberculosis is an important problem; (2) basic human needs (water, food, shelter, sanitation) have been met; (3) the acute phase of the emergency is over (as defined by population death rates); (4) essential services and drugs for common illnesses are available; and (5) basic health services are accessible to a large part of the conflict-affected population [18].
Like all case-finding strategies, systematic screening for TB has three primary goals:
1. to ensure the early detection and initiation of appropriate treatment for those with active TB;
2. to reduce the risk of poor treatment outcomes, health sequelae and the adverse social and economic consequences of TB; and
3. to reduce transmission of TB, with the ultimate goal of reducing future incidence.
One of the key principles set out in the guidelines is that screening for TB needs to be properly targeted to high-risk groups and tailored to each specific situation, depending on the epidemiological, social and health-systems contexts [19].
Supporting universal and sustainable health systems
As iGEM Thessaly, we were inspired by the large population movement that characterizes our time; a phenomenon that affects the whole world, but also our country, Greece. Therefore, we decided to develop “ODYSSEE” a modular platform for field diagnosis of Tuberculosis aimed at being applied in refugee camps in our country as well as worldwide.
The competition was the opportunity that allowed us to incorporate Synthetic Biology’s principles in the design of our test and revolutionize TB diagnostics, making a step towards global health coverage.
In our effort to better integrate our test in the community it is addressed to, and also considering the public health challenges and humanitarian needs that these vulnerable groups face, we wanted to provide this health care model. It includes a holistic implementation of our diagnostic test and connects doctors, psychologists, translators and social workers from both governmental and non-governmental organizations.
In our effort to identify and deeply understand the real problems that need solving as well as to gather all the information about the current situation, frameworks and policies applied in refugee camps we interacted with the stakeholders involved and experts.
As part of our project development, we adjusted its design according to the feedback we got from these interviews. Our test is customized to the specific requirements for Tuberculosis screening in Reception Identification Centres (RIC). Besides the basic test design though, we have specific propositions we developed after coming in touch with experts directed to policy makers and Greece’s refugee health coordinator, The National Public Health Organization (NPHO).
It soon also became our goal to turn ODYSSEE into a universal tool able to detect several diseases. Despite TB being the most commonly screened disease among newly arrived refugees, Hepatitis B is high on the list as well [6]. We successfully proved that our system is able to detect this pathogenic agent as well, by only adjusting the primer set.
Data collection
One of the main obstacles that reception personnel faces, together with the significantly large number of migrant arrivals, is the difficulty in collecting medical data regarding the limited time and the clarity with which the information is made available [1].
There is a lack of reliable, comparable and nationally representative data on refugee and migrant health and one reason for this is that refugee and migrant health-related variables are not commonly included in national datasets: only 20 of the 40 Member States responding to the survey included these variables in their national datasets [4].
A strong health information system would enable the needed healthcare to be provided to the newly arrived. For this reason, we designed an electronic platform basically presenting the migrants’ health profile, to be used by all partners.
It mainly contains factors that affect health risks at all stages and shape a person’s health status. Specifically, it contains 7 tabs that include personal data, medical history, clinical exams, vaccinations, and current treatments along with information around Tuberculosis specifically, and comments that the treating doctor finds important to mention. In terms of human rights protection, of course, access to the platform will be strictly limited. Only the Ministry of Health, through the treating doctors, will be able to enter and edit the data included.
The purpose of our platform is to contribute to preparedness and response to the arrival of large groups and provide reliable and timely information on health determinants that will improve the capacity of addressing health-related issues of migrants as well as possible communicable diseases.
To achieve that, it is important to analyze the health risks that migrants face in their country of origin as well as during their journey. This would require the collaboration between partners and countries, so that information on potential exposure to public health threats, as well as health profile and statistics in both the countries of origin and transit, would be available.
Workforce education
A successful response and temporary settlement of migrants depends significantly on rescue teams, health personnel and local people who get involved in the care of migrants. The task of protecting and improving the health of a population especially under the specific circumstances in refugee camps is multilaterally demanding [1].
A basic ODYSSEE property is that it can be conducted without the need for specialized personnel and equipment. For this reason, the product we aim to provide contains a guide explaining the simple steps that need to be taken.
We propose that public authorities together with the private health sector should collaboratively schedule education sessions to train personnel and civilians engaged with migrant care on our test and to provide information on epidemiologic statistics and procedures.
Apart from medical training, educational programs should take three important aspects into consideration; the different cultural and linguistic backgrounds of the people arriving, as well as their unique psychological condition. Social workers, psychologists, and interpreters could train the engaging personnel to provide health services with sensitivity and multilateral awareness of refugee needs.
Psychological Support
The ways in which refugees experience and respond to loss, pain, disruption and violence vary significantly and may in various ways affect their mental health and psychosocial wellbeing or increase their vulnerability to develop mental health problems [1].
A first step in achieving complete mental health support is to monitor which groups access services and which do not. In refugee settings, groups or individuals with specific needs may be intentionally or unintentionally ignored or excluded. For groups such as unaccompanied children, pregnant women as well as minorities, community and partners should act on any discriminatory patterns and improve access to mental health and psychological support.
It is also important to minimise any interventions that may cause stigma and discrimination. This could be achieved by using designated consultation rooms, thus ensuring confidentiality and also by using non stigmatizing language. To this end, the involvement of people with mental disorders could prove useful and send a positive message.
Another important aspect concerns the communication of available services and supports for mental health and psychosocial problems to the target population. Trained personnel including medical staff, social workers and volunteers should inform the population about the availability and location of these services and support.
Conclusion
War, social inequalities, and violence are taking place for over a decade now and are likely to continue causing the forced displacement of a large number of people who flee from their countries, seeking a more secure situation in Europe. Thus, the European Union faces migration challenges concerning health services access and protection of human rights. This phenomenon inspired us to develop ODYSSEE, a modular platform for field diagnosis of tuberculosis, which is a leading health threat for populations affected by crises that lack access to innovative diagnostic tools. ODYSSEE is aimed to be conducted in Reception Identification Centres. Taking all aspects into consideration, though, we also created a healthcare model to better integrate our project addressed to policy makers. Countries of arrival must be prepared to deal with the needs that arise from large influxes and able to improve the health system aiming for better healthcare of migrants as well as the host communities.
References
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