Oral health in mobile populations: a focus on refugees.

Nazik M Nurelhuda¹, Herenia P Lawrence¹, Mark Keboa², Mary Ellen Macdonald²

¹ Faculty of Dentistry, University of Toronto

² Faculty of Dentistry, McGill University

Last year witnessed an advancement in the recognition of oral health as a neglected global health issue. This progress was crowned at the 74th UN General Assembly session, where the UN Political Declaration on Universal Health Coverage emphasized that integrating oral health into UHC will reduce inequities for local populations. However, what arrangements can be made for people who are on the move, such as refugees and people who need international protection?
Globally, the numbers of refugees are increasing each year. In 2018, UNHCR reported 70.8 million people had been forced to flee their homes, 25.9 million of whom were refugees and over half were under the age of 18. Most refugees (80%) spend time in their immediate region, resulting in poorer countries hosting most of the forcibly displaced. These countries’ capacities are already overstretched, with the refugee influx additionally affecting their social structure and economic development. Although ostensibly temporary, time in transit camps can be considerable, with many refugees spending years in an indeterminate state before they are settled in either a new country or return to their former homes.
Human migration is becoming a defining issue of our time, increasingly recognized as a global public health priority. The 2030 Agenda for Sustainable Development, the New York Declaration and WHO’s Global Action Plan “Promoting the health of refugees and migrants” (2019–2023) all emphasize that health is a human right. For refugees, the Convention Relating to the Status of Refugees and its Protocol warrants the right to “the same treatment with respect to public relief and assistance as is accorded their nationals” (Article 23), which means access to health care for refugees should be equivalent to that of their host populations.
Oral health is an integral part of overall health and well-being, is therefore a fundamental right for refugees. Refugee health is complicated and findings cannot be generalized because the effects of the migratory process, social determinants of health, risks and exposures in the origin, transit and destination environments. It is generally believed that mortality estimates are lower than European populations. They are vulnerable to infectious diseases and the risk for non-communicable diseases increases with duration of stay. They also have a high risk for mental disorders especially among children and young people. Refugee’s oral health needs are difficult to assess because of inadequate data, however, it has been reported that their oral health is worse than that of their general host populations.
This disparity is further complicated by challenges in the delivery of oral health care to migratory populations. The treatment of refugees is usually governed by legal frameworks, separate from those of host citizens. In most cases, refugees do not qualify for medical and dental subsidies. Financing universal oral health coverage through insurance and taxation mechanisms is not enough. Financing barriers are compounded by challenges in transportation, culture, employment, waiting times, poor oral health care delivery systems in host countries and poor knowledge of how to navigate the system. Research into innovative financing schemes and delivery models, especially in low and middle-income countries, would be helpful, particularly for refugees, and undocumented. Care may need to be mobile to reach vulnerable populations to ensure equal access. Oral health screenings could be part of any initial medical examination conducted for all refugees. Consequently, host countries will be able to address the identified specific oral health care needs of refugees as part of the basic healthcare package they deliver. Canada has set a good example in establishing specific guidelines for oral screenings for refugees.
Oral health care delivery for refugees is a shared responsibility. The private sector and civil society, including refugee and migrant organizations, through participating in multi-stakeholder alliances, can support efforts to deliver care to refugees. Investing in the oral health of refugees is of great benefit in the long term, as macroeconomic analysis on the impact of asylum seekers in Europe has concluded that refugees who have been granted asylum have a positive effect on host countries’ economies. Safeguarding the health of these newly-arrived populations will have positive effects on global wealth and population health in general.

We call on researchers, policymakers, and stakeholders to not leave the oral health of humanitarian migrants behind, and to invest in generating relevant evidence to influence oral health policy.