Conflict, Climate Change, and Instability Drive Migration Worldwide. Health Care Organizations Adapt in Real Time.

The world is increasingly on the move, with growing numbers of people displaced from their homes or leaving their countries of origin. These shifts in population bring new health needs and challenges - and around the world, health systems and nonprofit groups employ on-the-ground expertise and growing insight to fill the gaps.

Even as Direct Relief reported this story, drawing on interviews with a humanitarian partner in Lebanon, rapidly escalating conflict in the Middle East caused displacement to increase exponentially, from about 100,000 people who'd left Lebanon's southern border to an estimated 1.3 million fleeing their homes in targeted areas across the country. Humanitarian workers - including Karim El Ferkh, an Anera health program manager based in Beirut, and many of his colleagues - have left Lebanon for safety in recent weeks.

"It's a phenomenon that's happening that's not going to stop," said Alondra Aragon, who coordinates migration health programs for the UN's International Organization for Migration in Mexico, of the rising migration rates. "We are developing these humanitarian responses to try to reduce this gap in access to basic services."

In a 2024 report, IOM estimates that 281 million migrants - about 3.6% of the world population - currently live outside their countries of origin. The same report calculates that about 117 million people - a group that includes refugees, asylum seekers, and internally displaced people, among others - were living in displacement at the end of 2022.

These numbers are expected to rise, and for disturbing reasons. Forced displacement from war, deadly violence, and other humanitarian crises is "the highest on record in the modern era," the report notes. Climate change and other environmental impacts may force more than 216 million people across six continents from their homes by 2050.

When providers around the world describe caring for migrant and displaced patients, whether in refugee camps, community-run shelters, or new homes, the same stories and issues are often repeated. Their patients have post-traumatic stress and other urgent mental health issues - and cultural stigma has made it shameful and difficult to seek care. Unable to access medicine or nutritious food either at home or on the move, they have serious, untreated health conditions. Many women have experienced sexual or intimate partner violence, and pregnancies are often a first point of contact with a medical provider.

At the same time, humanitarian budget cuts and shifting public focus, combined with newly emerging conflicts and growing numbers of natural disasters, make it hard for providers to secure support and keep long-term needs in the spotlight.

"We cannot just shut our door"

Dr. Iftikher Mahmood, a pediatric endocrinologist and professor, vividly remembers the urgency he felt in 2017, when more than 750,000 Rohingya, fleeing genocide in Myanmar, crossed the border into Bangladesh.

"It was obvious that a lot of them were severely traumatized" both physically and mentally, he said. Huge numbers had lost children or other relatives, survived brutal violence, and been separated from their families.

The NGO Dr. Mahmood founded, HOPE Foundation for Women and Children of Bangladesh, had provided medical care for underserved patients since 1999. In 2007, the organization opened a hospital in Cox's Bazar, where most of the Rohingya refugees settled and remained.

"It's a small area, already very dense," he said, explaining that the number of refugees in Cox's Bazar has grown over time to approximately 1.2 million. "That impacts hygiene, it impacts nutrition."

HOPE leaders established a field hospital and primary and women's health care clinics focused on refugees. Dr. Mahmood said linguistic and cultural similarities helped establish trust and connection. "They found us familiar," he recalled.

Mental health care was a high priority, so Dr. Mahmood recruited psychologists, psychiatrists, and social workers. Midwives working with pregnant patients screened for other health needs and issues like intimate partner violence, which more frequently affects forcibly displaced women.

Today, HOPE provides a wide range of services for both refugees and Bangladeshi patients, including care for non-communicable diseases like diabetes and hypertension, mobile health camps and telemedicine, oral health, and maternal and delivery services.

New and deadly violence against Rohingya communities in Myanmar this year has forced thousands more to flee the country. Refugees still living in camps in Bangladesh have died or lost their homes due to landslides, fires, and other disasters.

Dr. Mahmood's concern is that the situation will long outlast public awareness. "There's no solution that's going to happen anytime soon," he said. "We cannot just shut our door and move on."

Political upheaval and economic changes in Bangladesh complicate the picture. Support for Rohingya refugees relies on international humanitarian funding, but the pool is limited and need is widespread, Dr. Mahmood explained.

"I don't think many people talk about the Rohingya now," he said. "They are kind of forgotten."

"Common places"

Political discourse often overlooks the nuances of migration and displacement, but Aragon, at IOM in Mexico, describes a complex picture. Migrants and other people on the move in Mexico come from countries in Latin America, sub-Saharan Africa, and Asia. Many hope to settle in the U.S., but Mexico is increasingly an end destination. A number of Mexicans have been internally displaced by violence.

Migration is a fact of life, Aragon said. People need access to medicine and health care services, and instability and poverty increase those needs. The challenge is "to figure out how we're going to make all of this work."

Working with the government and other partners, IOM Mexico facilitates vaccination campaigns and offers access to primary health services, mental health and psychosocial support, and other medical services. They also provide "common places for people to interact and understand each other," helping to correct misconceptions and break down communication barriers.

Like Dr. Mahmood, Aragon said that post-traumatic stress, depression, and anxiety are common among displaced or newly arrived people. Many have experienced violence or natural disasters.

Although diabetes, hypertension, and other chronic diseases are common, Aragon said, many people were unable to access health care or medicine in their countries of origin. "It's more and more obvious that we have an underdiagnosis of these diseases in origin countries," she said. People displaced from their homes within Mexico may also struggle to manage chronic disease.

For many women, a maternal health provider is often their first encounter with the health system.

"When they are transiting, often the main focus is not to take care of their health. It's to reach their goal," Aragon explained.

"It escalated so fast"

Syria's civil war drove millions of refugees over the border into Lebanon in 2012. In the dozen years since, perhaps 1.5 million have remained, their health and circumstances fluctuating with the country's. For Karim El Ferkh, a health program manager at the NGO Anera - and formerly an epidemiologist - working closely with a refugee population has shown how much consistency matters, and how much can change in a moment.

Syrians newly arrived in Lebanon struggled to buy essential medications out of pocket, El Ferkh explained. Despite widespread trauma, mental health care was widely stigmatized - an attitude he describes as "just pull yourself together."

As Lebanon's health care system grew increasingly strong and sophisticated, medical care became easier to access - for a few years. But El Ferkh said the country's economic crisis, 2020's Beirut port explosion, the Covid-19 pandemic, and medical brain drain have all affected health and stability.

Most dramatically, Israeli strikes have escalated since October of last year as the regional conflict has spiraled. In September, when El Ferkh first spoke to Direct Relief, about 100,000 people, many of them Syrian refugees, had fled Lebanon's southern border. Hundreds had been killed, and government officials and other responders were working to connect displaced people to medicine and health services while strategically distributing clean water to prevent outbreaks of cholera and diarrheal disease.

A few weeks later, about 2,500 people in Lebanon had died in the strikes, and displacement had multiplied exponentially. El Ferkh described 1.3 people throughout the country, including his family and colleagues in Beirut, fleeing to safety. For him, the situation was "not political": He was focused on the danger to civilians, and horrified by the deaths of children. "It escalated so fast, so unexpectedly," he said.

He and his wife had taken their children first to Turkey, and then to the United Arab Emirates to stay with family, sleeping apart because there wasn't enough room in any one house. His colleagues were working virtually in crowded quarters to coordinate emergency response efforts, while children played in the background.

Anera has worked in the region since the 1970s, offering vocational training, education, infrastructure support, and other community-building measures. The organization also provides food, clean water, psychosocial support, and medications, along with other needed resources.

Health care access is an essential priority. Anera pre-positions medications in health care centers - aiming to provide a three-month supply to each patient - and supports the Lebanese government's mobile health care units, which provide regular care to communities in the country's south, including in conflict areas.

Their goal, El Ferkh said, is to provide long-term, consistent support that allows communities to build resilience over time.

War had changed that overnight. "For Anera, all of our [ongoing] programs have stopped and we have shifted to emergency response," El Ferkh said. People congregating in shelters across the country needed clean water and bedding. The approach of winter - an extremely cold season in Lebanon - demanded warm clothing and sleeping blankets.

And responders were reporting treating wounds and other physical trauma, patients in urgent need of chronic disease medicines, and a new and frightening outbreak of cholera. El Ferkh was worried about the disease spreading, and about new outbreaks as people crowded together and displacement interrupted vaccination campaigns.

When his family's 30-day visa expired, El Ferkh said, he wasn't sure they'd be able to stay in the UAE. He and his wife were considering taking their children to Kuwait, where his parents lived. While still devoted to his work at Anera, he said the "anxiety and stress" were taking a toll on humanitarian responders.

Still, he felt more fortunate than most. So many of those displaced by the conflict were in danger.

Many, he said, including Lebanese citizens and refugees originally from Syria, had fled across the Syrian border. Despite the country's ongoing civil war, it was still considered safer than Lebanon.

Direct Relief supports health care providers and emergency responders around the world who care for displaced patients, migrants, and other vulnerable communities.

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