One Health approaches to improve refugee health
Authors: Indorica Sutradhar, Muhammad H Zaman
Journal: The Lancet Global Health (2021)

By estimates from 2020, there are approximately 26·4 million refugees worldwide today and the refugee population has been increasing over the past decade.1United Nations High Commissioner for RefugeesRefugee Data Finder.https://www.unhcr.org/refugee-statisticsDate: 2021Date accessed: September 9, 2021Google Scholar The unfolding situation in Afghanistan following the US withdrawal is likely to further increase the number of individuals who are forcibly displaced. The process of migration can expose refugees to risk factors for disease and hinder access to basic health care. Additionally, refugees often face continued disadvantage compared with host populations due to xenophobia and shortage of cohesive support in their host country.2Bempong N-E Sheath D Seybold J Flahault A Depoux A Saso L Critical reflections, challenges and solutions for migrant and refugee health: 2nd M8 Alliance Expert Meeting.Public Health Rev. 2019; 40: 3Crossref PubMed Scopus (14) Google Scholar Infectious disease is of particular concern in refugee camps. Increased occurrence, severity, and case fatality for infectious diseases can occur in refugee camps due to factors including exposure during migration, poor sanitation conditions, shortage of vaccinations, and overcrowding.2Bempong N-E Sheath D Seybold J Flahault A Depoux A Saso L Critical reflections, challenges and solutions for migrant and refugee health: 2nd M8 Alliance Expert Meeting.Public Health Rev. 2019; 40: 3Crossref PubMed Scopus (14) Google Scholar, 3Altare C Kahi V Ngwa M et al.Infectious disease epidemics in refugee camps: a retrospective analysis of UNHCR data (2009–2017).J Glob Health Rep. 2019; 3e2019064Crossref Google Scholar In fact, indirect causes, particularly infectious disease, account for the majority of deaths in conflict and displacement.3Altare C Kahi V Ngwa M et al.Infectious disease epidemics in refugee camps: a retrospective analysis of UNHCR data (2009–2017).J Glob Health Rep. 2019; 3e2019064Crossref Google Scholar Furthermore, refugees can also face treatment interruption, which can increase the risk of developing a drug resistant infection.2Bempong N-E Sheath D Seybold J Flahault A Depoux A Saso L Critical reflections, challenges and solutions for migrant and refugee health: 2nd M8 Alliance Expert Meeting.Public Health Rev. 2019; 40: 3Crossref PubMed Scopus (14) Google Scholar However, interventions aimed at improving refugee health, such as vaccinations, are often only focused on human health factors. To fully address the challenges of refugee health, a broader scope when planning interventions could be necessary. Although the effects of refugee camps on their environment have been the subject of several studies, the effects of environment on refugee communities, such as environmental contamination in sewage and wastewater, have received less attention. This shortage of research is troubling as sewage and wastewater can host dangerous pathogens, leading to disease in surrounding communities. Furthermore, it has been shown that wastewater is a reservoir for antimicrobial resistance due to the collection of antibiotic waste from humans and animals.4Sutradhar I Ching C Desai D et al.Computational model to quantify the growth of antibiotic resistant bacteria in wastewater.mSystems. 2021; 3E00360Google Scholar Refugee camps often have open sewer systems and little access to wastewater treatment, putting people at particular risk of deadly drug-resistant outbreaks. Other environmental threats such as overcrowding and poor housing conditions have also been associated with illness in refugee camps.5Habib RR Basma SH Yeretzian JS Harboring illnesses: on the association between disease and living conditions in a Palestinian refugee camp in Lebanon.Int J Environ Health Res. 2006; 16: 99-111Crossref PubMed Scopus (20) Google Scholar For instance, poor ventilation, moulds, and crowding were shown to be directly related to the incidence of upper respiratory tract disease in the al-Amar'ri refugee camp in the West Bank of Palestine.6Al-Khatib I Ju'ba A Kamal N Hamed N Hmeidan N Massad S Impact of housing conditions on the health of the people at al-Ama'ri refugee camp in the West Bank of Palestine.Int J Environ Health Res. 2003; 13: 315-326Crossref PubMed Scopus (22) Google Scholar Another source of infection is contaminated drinking water as observed with rotavirus in a camp in Jordan.7Nimri LF Hijazi S Rotavirus-associated diarrhoea in children in a refugee camp in Jordan.J Diarrhoeal Dis Res. 1996; 14: 1-4PubMed Google Scholar Conflict and weapons of war also affect the environment and enable the development and proliferation of drug resistant pathogens.8Bazzi W Abou Fayad AG Nasser A et al.Heavy metal toxicity in armed conflicts potentiates AMR in A. baumannii by selecting for antibiotic and heavy metal co-resistance mechanisms.Front Microbiol. 2020; 11: 68Crossref PubMed Scopus (32) Google Scholar Interactions between humans and animals are often ignored in the discussion of health of refugees, but animal populations are often closely tied with refugee communities. Many refugee communities rely on livestock to aid in self-sufficiency in food acquisition. For example, the Sahrawis in Western Sahara depend on a large population of goats, sheep, and camels.9Forced Migration ReviewAnimal and human health in the Sahrawi refugee camps.https://www.fmreview.org/economies/angeloni-carrDate: 2018Date accessed: August 31, 2021Google Scholar However, livestock zoonoses are widely occurring in low-income and middle-income countries (LMICs), which often host these refugee populations.10Cleaveland S Sharp J Abela-Ridder B et al.One Health contributions towards more effective and equitable approaches to health in low- and middle-income countries.Philos Trans R Soc Lond B Biol Sci. 2017; 37220160168Crossref PubMed Scopus (65) Google Scholar Animals that migrate with refugee communities can contract new infections that they do not have immunity towards. Pests can also spread infection in refugee camps, in which they are often drawn to inappropriately disposed of waste.5Habib RR Basma SH Yeretzian JS Harboring illnesses: on the association between disease and living conditions in a Palestinian refugee camp in Lebanon.Int J Environ Health Res. 2006; 16: 99-111Crossref PubMed Scopus (20) Google Scholar The risks presented by zoonoses are particularly of concern as they occur frequently but are understudied, and mismanagement of related cases can lead to a cycle of poor health in these communities. These often neglected environmental and veterinary risk factors show the importance of taking a One Health approach to the challenges in refugee health. One Health is defined as approaching issues of global health by looking at the areas of human, animal, and environmental health, and their intersections (appendix). This approach can allow for the development of more effective interventions and preventive measures. These One Health approaches have been used successfully in LMICs; for example, in Latin America mass dog vaccination for rabies has been shown to be effective in preventing deaths in humans caused by rabies.10Cleaveland S Sharp J Abela-Ridder B et al.One Health contributions towards more effective and equitable approaches to health in low- and middle-income countries.Philos Trans R Soc Lond B Biol Sci. 2017; 37220160168Crossref PubMed Scopus (65) Google Scholar Preventive measures such as these described can extend beyond rabies and apply to other zoonoses in which vaccines are available. Developments in Afghanistan will increase the global refugee population and many will be forced to live in camps or poorly structured urban settlements. The threats to refugee health from animal and environmental sources cannot be ignored. Addressing these issues can allow society to address challenges in refugee health and prevent future crises. One Health offers potential systematic-level approaches for the health of forcibly displaced communities. Initial approaches could include previously successful interventions including animal vaccinations and wastewater management. Other interventions can be developed through further research, rooted in improved surveillance, data analytics, bioinformatics, and meta-genomics, which can provide insights into disease dynamics and ethical and evidence-based interventions. Taken together, we believe that One Health approaches could provide an opportunity to address challenges of refugee health by considering not only the human variables, but also the animal and environment considerations in these communities. We declare no completing interests Download .pdf (.2 MB) Help with pdf files Supplementary appendix