Health Systems and Policy Research

Keywords

Migrants; Refugees; Human rights; Adolescent girls; Public health; Global health; Health system

Introduction

Unrest and economic disparities in many parts of the world is causing mass exoduses of migrants and refugees. Migrants are people who choose to leave their home country in hopes of gaining a better future in another country [1]. If migrants desire, they can return home. On the other hand, refugees are displaced people, leaving home because of heinous human rights violations occurring in their country of origin [1]. Europe is experiencing a sharp increase in the number of migrants and refugees applying for asylum. The highest numbers of refugees arrive from Syria, followed by Afghanistan and Iraq [2]. In 2015 Germany accepted the highest number of asylum applications [3,4]. However, if the numbers of accepted asylum applications are counted according to the receiving country’s population size, then Sweden is the top receiving country of 2015 [5]. The United Nations Refugee Agency (UNHCR) reports a huge increase in the number of new arrivals as compared to last year. Since January 2016, the majority (55%) of the arriving migrants and refugees are women and children [2]. And 35% of these new arrivals are children. Of all the children who applied for asylum last year in 2015, it is estimated that 23.1% are unaccompanied [6]. And of this figure, 45% of unaccompanied children are girls [6]. This article addresses the human right to gender equality. We explain the extent to which gender inequality is a global problem. We highlight why migrant and refugee adolescent girls will alter their life history after they settle in Europe. The potential consequences of migrants and refugees moving to Europe are discussed.

The Position of Greece

Because of country geographical location, most economic migrants or refugees travel first to Greece, Italy or Hungary. This causes a huge burden to the health systems of entry point countries. Greece is one of the weakest countries in the European Union (EU). As compared to the entire EU, Greece has the highest unemployment rate [7]. The average yearly income is (USD 26,436) – a low figure as compared to Northern European countries [8].

For example, the average yearly income in the Netherlands is (USD 51,003) [8]. The Greek health system is in a poor state. Hospital resources are limited. Obtaining access to basic medical supplies is difficult. The number of physicians per capita is low [9]. The population health consequences of the recent financial crisis are problematic in Greece. The Greek government implemented a number of austerity measures. These changes to the system are causing economic hardship and increasing poor health outcomes [10]. Yet, Greece is the main entry point country – with boatloads of migrants and refugees arriving daily.

Even though a migrant or refugee manages to survive the journey, they are still at an increased risk of premature mortality during the first weeks of arrival to an entry point country [11]. Most are in need of immediate medical treatment – with death by malnutrition being extremely common, especially in small children. Mental health care is a major need for refugees [11]. In Greece, migrants and refugees in need of acute care are taken to hospitals to receive treatment. Many migrants and refugees arriving to Greece by boat are soaking wet. Sanitary facilities are not available during their journey. Outbreaks and cases of both communicable and non-communicable diseases are high [12]. The care for such a high number of people places an enormous constraint on an already weakened health system. Clearly, the mass arrival of migrants and refugees to the EU is an unexpected public health problem. But, a positive aspect of this new trend of displaced people fleeing to Europe is that adolescent girls allowed to stay in Europe will design a new future. Because of Europe placing high value on gender equality, an entire new world of possibilities will manifest for adolescent girls. The opportunities that might arise would probably never occur in their country of origin.

What is the Human Right to Gender Equality?

The Universal Declaration of Human Rights (UDHR) is not a geographical or cultural specific document. It is a universal treaty agreed upon by nearly all nations around the world [13]. Of course, the contents of human rights must remain open-ended, related to the ever-changing forms of inequality and injustice against which individuals and certain groups or countries might demand their rights. To make the contents of the UDHR into binding obligations of international law, various conventions have been formulated since 1948. Two important conventions are the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights, adopted in 1966.

The UDHR consists of 30 Articles [13]. The UDHR Articles define a number of rights that are granted to all people. Articles number 1, 2 and 7 pertain specifically to gender equality.

Article 1“ All human beings are born free and equal in dignity and rights.”

Article 3 “Everyone has the right to life, liberty and security of person.”

Article 7 “All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination.”

After the UDHR is introduced, other international treaties are created that specifically address the situation of women. Some include the Convention on the Political Rights of Women created in 1952 and the Convention on the Elimination of All Forms of Discrimination against Women adopted in 1979 [14]. These documents are important because they acknowledge that women are a marginalized and vulnerable group. The documents are used to advance the human right to gender equality.

Despite these conventions, gender inequality remains a global problem. Gender equality issues are apparent in both highincome and low-income countries. Gender inequality in Europe and the United States of America (USA) is particularly evident in the workplace [15]. Women are often not paid as much as men doing the same job. Working conditions seldom account for working mothers. And mothers, unlike fathers are often expected to find work that fits the family routine [15]. This is one of the reasons attributed to the lack of women in American politics [16]. America has never had a female president, whereas in Scandinavia women in government are the norm. Moreover, in Norway –the country with the smallest gender inequality in society- family duties are shared equally amongst men and women. It is common to see a woman on a construction site working as the engineer or overseeing the male construction workers. Women are also employed as television broadcasters for male sports.

Gender inequality manifests differently in different countries. For example, the Gender Gap Index (GGI) measures gender inequality on several domains (i.e. health, education, economics and politics) [17]. The US and the UK are ranked higher than India on the GGI. However, as Amartya Sen noted, a great disparity is evident between the number of tenured female professors in the US and UK as compared to in India [15].

Gender inequality negatively impacts the physical and mental health of girls and women [15,18]. Extreme cases are evident in the problem of selective abortions – many female babies never get the chance to start life [15]. In some societies girls are prevented from getting an education and this can detrimentally influence her health [19]. Women are often victims of gender based mental abuse and physical violence. For example, in some countries, women who have children and are not married might be verbally humiliated and outcast from the family. And are faced with criminal charges or possibly death [15,20], whereas men who have children out of wedlock are not subject to such abuse. These examples show why women, and lone mothers in particular, are a vulnerable group. Figure 1 describes what many women living in Mali experience [21].

Figure 1: Experience of Mali women.

In Syria the situation is different from the Mali experience. The Syrian constitution recognizes the human right to equality for all people [22]. Women are allowed to work and get an education. However, women must abide by normative social practices, meaning freedom is limited and women are not taken as seriously as men working in the same profession [22].

Female migrants and refugees, especially those who travel to Europe unaccompanied, are at a huge risk of being subjected to gender-based violence and harassment during their journey. Gender-based violence and harassment is also a big problem for women and girls living in the asylum reception center [23]. Female migrants and refugees who make the journey to Europe unaccompanied will benefit from a health perspective by being automatically classified as a vulnerable group that needs special protection. As of yet this is not done in Europe [23]. Lone mothers around the world are a vulnerable group and have poorer health as compared to couple mothers [24]. In the asylum reception centers, African lone mothers in particular are often singled out and shamed for being a lone mother [23]. The lack of automatic protection of women and adolescent girls who live alone in the asylum reception centers may cause an increase in poor health outcomes amongst this vulnerable group.

Transforming the Future by Reducing Gender Inequality

Once women and adolescent girls leave the asylum reception center the gender inequality gap narrows substantially. Women and adolescent girls will no longer be subjected to extreme forms of gender inequality as compared to what is common in their country of origin. For example, in Norway asylum seekers are taught about the value Norway places on gender equality [25]. The gender gap will narrow for all women, but for adolescent girls this is particularly special because a child’s life is not yet shaped. As these girls start to embrace their new position their choices in life will significantly shift. Adolescent girls settling in Europe will enjoy many new freedoms. These new freedoms will have a positive impact on their health. Female literary rate in this vulnerable group will increase. Programs should work with adolescent girls to facilitate adjustment to the next step in their lives. For example, Muslim girls will learn to navigate between family values and European norms. Europe does not have a law that requires girls to wear headscarves. As a result adolescent girls are free to choose whether or not they will wear headscarves. In most areas it will be safe to play outside alone. Adolescent girls will make European friends and adopt new habits. For girls from countries where arranged marriages are common, this type of marital union will no longer be the norm amongst her new peer group. Education is accessible and free. This means that poor adolescent girls who study hard can choose many professions. Thus, the poor girl from a rural community in her country of origin whose parents could not afford to send her to school or prohibited her from attending school can now become a police officer, doctor, university professor or a government official. This is a profound gain for global public health. Moving to Europe is a potential game changer with a paramount impact on an adolescent girl’s life.

Is Diversity the Answer to Europe’s Ageing Population?

Europe is undergoing changes. On the one hand, critics argue that the increasing number of migrants and refugees will overshadow the traditional European norms and values. Some Europeans view the influx of migrants and refugees as a security risk [26]. Boarders across Europe are restricted. Some countries have erected fences. Europe and Turkey made new agreements to reduce the flow of people to Europe. On the other hand, Europe has a high number of older people as compared to the number of young people [26]. To sustain the strong social system some governments increased retirement age and reduced many government social benefits. Europe is in need of an increased number of young people to sustain the system. It cannot be denied that an increase in diversity will change Europe. However, with the right government investments Europe can make this a positive change. If migrants and refugees are trained to become skilled workers and speak the language, then this influx of people might be useful additions to European society. Prior research shows that foreign-born residents living in the United States of America tend to have better outcomes as their US born counterparts [27]. In the Netherlands, migrants have a higher mortality rate as compared to the native Dutch population [28]. Although evidence is showing that some aspects of the American system might be positive for migrants, more research is needed to fully understand this dynamic.

A country significantly impacts population health [29]. Despite the sudden influx of migrants to Europe and the uncertainty of what to do with this new group of people, Europe must not forget that many of these people are children. Adolescent girls will need special attention to realize their full economic, physical and mental health potential. Investing in their education, economic inclusion and mental health should be a public health priority. Future research should examine the determinants that will result in empowerment and achievement for this vulnerable group. Comparative research should examine the differences in how this group thrives in different countries. Europe is a model world region in terms of the extent to which the government protects population health. If the European government arms migrant and refugee girls with the right tools, then these girls have the potential to succeed higher than they ever could imagine possible. Europe will substantially narrow the wide gender gap these girls are accustomed. Their success will benefit Europe. This is an unprecedented gain for global public health. And a significant human rights achievement.

References

1. (2016) Settlement Services International. What is the difference between a refugee and amigrant?
2. (2016) UNHCR The UN Refugee Agency. Refugees/Migrants Emergency Response-Mediterranean.
3. (2016) Asylum in Sweden Advisory. Advisory service for asylum seekers to Sweden
4. OECD (2015) "Average annual wages", OECD Employment and Labour MarketStatistics (database).
5. ChrisafisA (2015) Greek debt crisis: ‘Of all the damage, healthcare has been hit the worst.’
6. Kondilis E, Giannakopoulos S, Gavana M, Ierodiakonou I, Waitzkin H, et al. (2013) Economic crisis, restrictive policies, and the populations health and health care: the Greek case. American Journal of Public Health 103:973-979.
7. AzevedoSoares A, Tzafalias M (2015) Europe gears up to attend to refugees’ health. Bull World Health Organ 93: 822-823.
8. UN Women. Convention on the elimination of all forms of discrimination against women.
9. Sen A (2001) The Many Faces of Gender Inequality. The New Republic 225:35-40.
10. Slaughter AM (2012) Why some women still can’t have it all. The Atlantic.
11. United Nations Development Programme. Human development reports: Gender inequality index.
12. Van de Velde S, Huijts T, Bracke P, Bambra C (2012) Macro-level gender equality and depression in men and women in Europe. Sociology of Health and Illness 1-17.
13. (2003) United Nations. Education Health and Mortality. Population, Education and Development the Concise Report pp: 35-39.
14. Kolanda P (1993) Sibling relations and marriage practices. In: Nuckolls CW, editor. Siblings in South Asia: brothers and sisters in cultural concepts pp: 103-141.
15. Hawkins K, Newman K, Thomas D, Carlson C (2005) Developing a Human Rights-Based Approach to Addressing Maternal Mortality – Desk Review.
16. Bonewit A, Shreeves R (2016) Reception of female refugees and asylum seekers in the EU case study Germany
17. Witvliet MI, Arah OA, Stonks K, Kunst AE (2014) A Global Study on Lone Mothers: Exploring the Associations of Self-Assessed General Health with Motherhood Types and Gender Inequality in 32 Countries. Women’s Health Issues 24: e177-e185.
18. Higgins A (2015) Norway offers migrants a lesson in how to treat women. New York Times.
19. Horn H (2015) The staggering scale of Germany’s refugee Project. The Atlantic.
20. Bosdriesz JR, Lichthart N, Witvliet MI, Busschers WB, Stronks K, et al. (2013) Smoking prevalence among migrants in the US compared to the USborn and the population in countries of origin. PLoS ONE 8:e58654.
21. Stirbu I, Kunst AE, Bos V, Mackenbach JP (2006) Differences in avoidable mortality between migrants and the native Dutch in the Netherlands. BMC Public Health 6:78.
22. Witvliet MI (2013) Can your country make you sick? Multi-level explorations of population health and human rights in a global perspective. 's-Hertogenbosch: BOXPress.