Migrant and minority health in Europe: the way forward

Migrant and minority health has always been an issue of special concern in public health. While migration is not a new phenomenon, the number of refugees and migrants across the globe grew rapidly in 2015, with large numbers from the Middle East and Africa. Furthermore, the recent migrant crisis in Europe—sparked by civil wars in Syria and Libya and continuing conflict in Iraq and Afghanistan—has escalated to the level of a humanitarian emergency requiring immediate action. We conducted an international workshop on migrant and minority health in Salzburg from 3 to 9 April 2016 to examine migrant and minority health issues in greater depth, sponsored by the American Austrian Foundation and in cooperation with the Association of Schools of Public Health in the European Region (ASPHER) and Public Health Reviews (PHR). To continue this discussion within the academic literature, PHR’s special issue on migrant and minority health includes articles from conference participants and other experts in medicine and public health from the European region and beyond. Informed by the contribution of senior representatives of the European Union, the International Organization for Migration (IOM), Médecins Sans Frontières (MSF), and public health practitioners and investigators from over 30 countries, this editorial summarizes recommendations of the conference participants for improving migrant and minority health in Europe. They include (i) developing a conceptual framework for health care intervention for migrants, (ii) oversight and coordination of migrant and minority health activities, (iii) reaching a consensus on implementation practices, and (iv) mobilizing sufficient resources for addressing the health needs of migrants.


Introduction
The American Austrian Foundation and PHR-ASPHER conducted an international workshop on migrant and minority health in Salzburg from 3 to 9 April 2016. 1 Public Health Reviews (PHR) is now publishing a special issue on migrant and minority health, and the conference participants included both authors of articles for this special issue and representatives of the Association of Schools of Public Health in the European Region (ASPHER) member schools across the European region.
Migrant and minority health has always been an issue of special concern in public health. The recent migrant crisis in Europe-sparked by civil wars in Syria and Libya and continuing conflict in Iraq and Afghanistan-has escalated to the level of a humanitarian emergency requiring immediate action [1,2]. While migration is not a new phenomenon, the number of refugees and migrants has grown rapidly in the past year, with large numbers originating from the Middle East and Africa. As of January 2015, the Office of the United Nations High Commissioner for Refugees (UNHCR) counts a total of 13,685,607 refugees worldwide and lists the total population of concern at 54,945,467 [3]. In Europe, UNHCR and the International Organization for Migration (IOM) estimate that over one million men, women, and children arrived in 2015 [4]; nearly 190,000 additional migrants have arrived as of May 2016, with many more continuing to make the arduous journey [5].
To examine migrant and minority health issues in greater depth, the Salzburg Workshop included presentations from senior representatives of the European Union, IOM, Médecins Sans Frontières (MSF), as well as public health practitioners and investigators from over 30 countries in Europe and beyond. Presentations were given on international organizations and also on national experiences with migrant and minority health issues. Workshop participants contributed to one of three working groups examining (i) the political aspects of the crisis, (ii) the public health effects, and (iii) their social implications.

Principles
From the outset, the Workshop participants recognized the following internationally sanctioned UN declarations and conventions as the foundation for understanding the current migration crisis: the 1948 Universal Declaration of Human Rights [6], the 1948 Convention on Prevention and Punishment for the Crime of Genocide [7], and the 1951 Convention Relating to the Status of Refugees-including the 1967 Protocol Relating to the Status of Refugees and Resolution 2198 (XXI) [8]. These documents establish the international norms of human rights, protection from genocide, and the rights of refugees. Despite these standards-many of which emerged in response to the bitter and tragic experience of World War II and the Holocaust, including the refugee crisis in its aftermath-genocide and forced migration continue. The current migration crisis in Europe has led to a renewed global commitment and a re-doubling of efforts to substantiate the rights of individuals seeking refuge from conflicts in the Middle East, Africa, the Balkans, and other parts of the world.

Key issues
Four key issues were identified to address migrant and minority health: (1) development of a conceptual framework for health care intervention, (2) oversight and coordination of migrant and minority health activities, (3) consensus on implementation practices, and (4) mobilization of sufficient resources. Figure 1 illustrates how attention to these key issues contributes to the coordination of migrant health policy.
A conceptual framework for addressing migrant health care interventions must consider and harmonize both health care and public health policies and practices. International organizations have a fundamental role to play in the oversight and coordination of migrant and minority health. Effective leadership from international organizations is critical, particularly for monitoring health and for coordinating health responses across borders. Achieving a consensus on implementation practices, such as a standard set of international health guidelines, could better facilitate communication between health professionals and ensure that theoretical principles are translated into clinical practice in a way that is both consistent and evidence-based. Finally, sufficient resources must be dedicated to providing public health protection and medical care to those in need. This includes educating policy makers, supervisory and health service staff, and community health workers on the unique health needs of migrants and minorities, which can be informed and facilitated by health care professionals with international experience.
Migrant and minority health includes not only physical health but also mental and emotional health. While the physical and material needs of refugees-shelter, safety, warmth, nutrition, sanitation, and health care-often take priority, the mental and emotional health needs of migrants are just as integral to their well-being. This includes encouraging self-actualization, supporting avenues for self-help, providing opportunities for gainful employment, and fostering a sense of belonging and self-esteem [9]. Help in adapting to a new cultural environment and lifestyle, such as learning the local language, norms, and customs, is vital to successful assimilation and integration of migrants and minorities in a way that preserves their dignity, independence, and selfrespect as well as commitment to absorption and inclusion in their host country.

Discussion and recommendations
Facilitated by the three working groups, the Workshop participants prepared a summary and draft recommendations related to the political, social, and public health aspects of the migrant crisis. Problem areas identified in migrant and minority health, along with examples and possible interventions, are listed in Table 1.
Public health and its representatives have a duty to ensure the ethical guardianship of global health standards for all vulnerable groups-including migrants-through the use of their many professional competencies across sectors. Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole [10]. The WHO states that health is a state of complete physical, mental, and social well-being-not merely the absence of disease or infirmity

People with disabilities
Increased vulnerabilities along the migrant journey, including exposure to violence Improve health monitoring of migrants with disabilities through improved record keeping Promote access to health, education, and employment services for those with disabilities [11]. Furthermore, health is a human right, based on the principles of justice, equity, and social solidarity. By transcending state boundaries to respond to public health challenges (such as the current migrant crisis in Europe), public health professionals and organizations can promote health for all and advancing well-being on a global scale. History will judge how this crisis is addressed. The European community must draw from its collective memory of the massive displaced person experience following World War II and the Holocaust and from more recent recollections of the Balkan wars of the 1990s. Europe should be generous in giving humanitarian help for those who respect commonly accepted "European values" based on the principle of solidarity.
Sovereign states have concurrent concerns regarding the massive inflow of refugees, which may include security threats. In response, countries may introduce screening practices and may prefer legitimately documented refugees and survivors of genocidal action in their home countries to other migrants. Many countries will limit total migration to a number that can be managed and absorbed into the society while adhering to international law. We must work collectively (i) to avoid inconsistent practices and the introduction of new border restrictions and (ii) to ensure that international laws, ethical standards, and the rights of migrants and minorities are respected.
Solving the complex problems of migrant and minority health requires us to think through the interests and motivations of a number of actors, including governments, humanitarian agencies and their workers, academics, and the media. The organizational, financial, and human resource allocation needed to meet the health challenges of the current crisis will require high-level coordination at political, professional, and technical levels. Governments must work together with international governmental and nongovernmental organizations to achieve consensus and share responsibilities and best practices on how to address migrant and minority health issues.
Addressing the health aspects of the migrant crisis is important because protecting and promoting migrant health is inextricably linked to public health. National governments have already demonstrated an ability to reach agreement on a number of areas concerning the current migrant crisis in Europe. The steps outlined in Table 1 for protection, basic needs, and health promoting activities are critical for addressing the health aspects of the migrant crisis facing Europe today.  LGBT health Increased vulnerability to depression, substance abuse, and acquiring HIV and other sexually transmitted infections Eliminate discrimination and promote equal access to health services regardless of sexual orientation Provide education of risks and preventative interventions, both along the migrant journey and within the host country