Downloaded from http://jme.bmj.com/ on June 5, 2015 - Published by group.bmj.com
JME Online First, published on August 18, 2014 as 10.1136/medethics-2014-102383 Viewpoint
Refugees, humanitarian aid and the right to decline vaccinations A L Caplan, David R Curry Population Health, Medical Ethics, New York University School of Medicine, New York, New York, USA Correspondence to Dr Arthur Caplan, Population Health, Medical Ethics, New York University School of Medicine, 227 East 30th St, New York, NY 10016, USA; [email protected] Received 21 July 2014 Accepted 23 July 2014
To cite: Caplan AL, Curry DR. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2014-102383
ABSTRACT Recent instances of governments and others refusing humanitarian assistance to refugees and IDPs (internallydisplaced persons) unless they agreed to polio immunization for their children raise difficult ethical challenges. The authors argue that states have the right and a responsibility to require such vaccinations in instances where the serious vaccine-preventable disease(s) at issue threaten others, including local populations, humanitarian workers, and others in camps or support settings. Recent news accounts of events at the Pakistan– Afghanistan border1 2 raise important ethical challenges to efforts aimed at dealing with the eradication of polio and the control of other infectious diseases. In a world full of deadly regional conflicts and poverty, which cause large numbers of persons to seek asylum or refuge in other parts of their nation or in other countries,3 very difficult ethical conflicts arise between the immediate needs of refugees for life sustenance and the drive to control the spread of deadly or disabling diseases through vaccination. The starkest form of this conflict is deciding whether people can be deprived of essential humanitarian commodities such as food, water and shelter unless they accept vaccinations. Can authorities require vaccination as a condition for access to basic sustenance in safe havens or prior to being allowed to cross a national or regional border? If the world’s goal is to move toward eradicating a disease such as polio,4 can food and water be withheld from would-be refugees unless and until they vaccinate? What if the refugees are potential vectors for polio coming from nations or regions with known outbreaks? What about conditionalisation of the provision of food, water and shelter in the face of the presence of deadly diseases that are vaccine-preventable which puts aid providers at immediate risk or huge numbers of residents in the region where refuge is being sought at risk? The challenge of immediately providing necessary life-saving aid while requiring vaccination against the risk of vaccine-preventable disease has arisen in the past year with respect to polio: first in Lebanon and, more recently, in Pakistan. In the border area between Pakistan and Afghanistan, refugee families were reportedly denied water, food and security until they agreed to have all children present vaccinated for polio. A similar vaccination incident arose at the Lebanese border as refugees fleeing from the vicious conflict in Syria, who had been in areas where polio had been reported, were refused entry to Lebanon without agreeing to polio vaccination.
Current international guidelines recommend that anyone leaving a country with endemic polio be vaccinated against the disease.5 6 But, they do not make clear how to weigh refugee rights to refuse vaccination against the duty to rapidly assist them by providing shelter, food and water. Also, recent WHO guidance7 8 has addressed approaches for decision-making on the use of vaccinations in humanitarian crises. Of course, polio is not the only transmissible disease that might trigger a vaccination requirement to keep refugees and internally displaced persons from becoming vectors or reservoirs of infectious disease. Polio may not even be the most pressing vaccination needed in a given situation. But, the recent incidents are useful illustrations of an ethical challenge created when the pressing needs of refugees who refuse vaccination are pitted against the protection of their longer-term health, the health of aid providers, the public health of those residing in altruistic nations and the worldwide goals of disease control and eradication. There are many regions of the world where vaccination is a matter of personal choice. This is true even in the face of outbreaks of measles, pertussis, mumps, influenza and other disabling and deadly maladies for which useful vaccines exist. Still, major campaigns to eradicate or control diseases such as polio have shown little interest in securing informed consent from or affording the right to refuse to all of those receiving vaccines. And many nations have made the acceptance of a broad array of vaccines, a precondition for anyone seeking status as a legal immigrant.9 It is against this backdrop of inconsistency with respect to the recognition of the right to refuse vaccination that the issue of how to handle displaced persons who refuse or will not disclose their vaccination status or who request that polio vaccination be delayed arises. In seeking a clear policy to guide governments, agencies, non-governmental organisations and other third parties in responding to vaccination refusals from those requesting immediate humanitarian assistance, it is important to carefully weigh both the facts and the deeper ethical issues involved. Those seeking refuge or temporary asylum in another state who are fleeing genocide, war, natural disasters, disease outbreaks or human induced catastrophes do have a moral claim to have their pressing dire circumstances recognised and addressed.10 States that can render help are under a moral duty to do so, if only on a temporary basis.11 Those nations rendering direct assistance should not stand alone in providing such support, merely due to their proximity to areas where large numbers of
AL, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102383 Copyright Article authorCaplan (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://jme.bmj.com/ on June 5, 2015 - Published by group.bmj.com
Viewpoint persons seek help and refuge. Other nations, especially wealthy ones, are obligated to assist in ways that are efficient and effective in relieving the misery of displaced persons. While granting that refugees have a right to humanitarian assistance, it is also true that states have the right and responsibility to control their borders in part to protect their own residents from harm. They do so regarding the inflow of migrants, temporary workers and tourists. This right is weakened but not voided in the face of a duty to assist those with pressing emergency needs. What balance is appropriate between the contending moral goods of aid and protection through vaccination? When a refugee population is fleeing or otherwise seeking to cross a border for protection, they are able to do so, ultimately, with the agreement of the potential welcoming state. Such a state may be under an obligation to provide safe haven, but it is each state’s right and responsibility to set conditions for the provision of that aid consistent with the protection of aid givers and the public health. Every nation should be aggressive in establishing immunisation requirements that protect the general public health of their citizens.4–6 For example, this is reflected in efforts to control the spread of disease when mass gatherings occur such as in Saudi Arabia during the Hajj. However, general disease prevention or eradication goals, even as important as that of permanently ending polio, do not morally trump the immediate life or death needs of refugees who may be vaccine refusers. However, during actual disease outbreaks of polio or other diseases such as sever acute respiratory syndrome (SARS), Ebola or pandemic influenza, immigration from impacted areas is and may justly be severely constrained and conditionalised on the grounds of public health protection. The duty to provide help presumes that this can be done without dire consequences to those giving assistance or to their own local or regional populations. In situations where highly infectious, vaccine-preventable diseases are known or suspected to be circulating, such as polio in Pakistan or Syria, those seeking assistance are and should be subject to the welcoming state’s immunisation requirements for the control of known disease threats. These requirements should be established in accordance with international standards and recommendations. Effective vaccination ought to be offered and can be mandated as a condition of aid in the face of actual disease outbreaks with the goal of protecting refugees, aidproviders and residents from imminent danger. In order to ensure the health of residents and encourage the provision of assistance to those in dire need, nations can invoke the right to impose vaccination and other health measures to control known disease outbreaks from harming their population. This is so even if in doing so they fail to follow their own internal ethical standards regarding the requirement of consent to vaccination. And it is so even in the face of explicit vaccine refusals by those in need of aid. Aid can morally be made contingent on vaccination when there is direct, imminent risk to aid givers and nations from whom aid is being sought. Housing and caring for large numbers of refugees or internally displaced persons can overwhelm even the most generous and altruistic of nations. And dealing with the needs of large numbers of unexpected refugees simply may not be an environment in which individual choice can be respected in the face of
2
serious disease risk. If there is knowledge that vaccinepreventable disease is present in the area of origin of refugees, then protection of the local population from serious harm by making aid contingent on vaccination even for those seeking immediate basic sustenance and shelter seems morally defensible. Vaccine refusers might be quarantined but this creates additional cost and work for those seeking to maintain a safe humanitarian protection infrastructure. Special camps or camp areas might be created for vaccine refusers but again this requires money, time and management which those willing to help may not have. It may also impose a level of risk on aid givers and their families that overwhelms their duty to help. A moral case can be made that, in the face of imminent serious disease risk, internally displaced persons and those seeking refugee status should be subject to the receiving aid givers’ prudent and medically valid immunisation demands. Using an emergency to justify routine immunisation for achieving abstract goals in the face of desperate need is difficult to justify. Insisting on vaccination as a condition of aid to control the danger of a vaccine-preventable serious disease outbreak is not. Despite the dire circumstances that the displaced face, their autonomy in seeking help, while creating a duty of assistance, does not require those providing assistance to put themselves or their own populations at immediate risk of vaccine-preventable lethal or severely disabling diseases. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2
3
4 5
6
7
8
9
10 11
Domínguez G. UNHCR: Pakistani offensive triggering humanitarian crisis. Deutsche Welle (DW), 26 Jun 2014. http://www.dw.de/unhcr-pakistani-offensivetriggering-humanitarian-crisis/a-17738335 Wasif S. Battling polio: IDPs turned back at Pak-Afghan border for refusing vaccine. The Express Tribune, 20 Jun 2014. http://tribune.com.pk/story/724374/battlingpolio-idps-turned-back-at-pak-afghan-border-for-refusing-vaccine/ Simmons AM. Flood of children across U.S. border reignites immigration debate. Los Angele Times, 1 Jul 2014. http://www.latimes.com/nation/nationnow/ la-nn-na-immigration-chat-20140701-story.html Polio vaccines: WHO position paper, January 2014. Weekly epidemiological record 2014;89:73-92. http://www.who.int/wer/2014/wer8909.pdf?ua=1 Meeting of the Strategic Advisory Group of Experts on immunization, November 2012 – conclusions and recommendations. Weekly epidemiological record 2013;88:1–16. http://www.who.int/wer/2013/wer8801.pdf?ua=1 WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. World Health Organization, 2014. http://www.who.int/mediacentre/news/statements/2014/ polio-20140505/en/ SAGE Working Group on Vaccination in Humanitarian Emergencies. Vaccination in acute humanitarian emergencies: a framework for decision-making. Revised Draft: 23 Oct 2012. http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd =1&cad=rja&uact=8&ved=0CCQQFjAA&url=http%3A%2F%2Fwww.who.int% 2Fimmunization%2Fsage%2Fmeetings%2F2012%2Fnovember%2FFinalFraft_ FrmwrkDocument_SWGVHE_23OctFullWEBVERSION.pdf&ei=EPDQU63sJofg8g HpzYGwBQ&usg=AFQjCNHcKdUSlahm9EOUThEnB7hnRtrk9g&bvm=bv.71667212, d.b2U Moodley K, Hardie K, Selgelid MJ, et al. Ethical considerations for vaccination programmes in acute humanitarian emergencies. Bulletin of the World Health Organization 2013;91:290–297. doi:http://dx.doi.org/10.2471/BLT.12.113480 Canadian Immunization Guide: Immunization of persons new to Canada. Public Health Agency of Canada, 2012. http://www.phac-aspc.gc.ca/publicat/cig-gci/ p03-11-eng.php Henkin L. Refugees and their human rights. Fordham Int Law J 1994;18:1077–90. Kritzman-Amir T, Spijkerboer T. On the morality and legality of borders: border policies and asylum seekers. Harv Hum Rights J 2013;25:1–38.
Caplan AL, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102383
Downloaded from http://jme.bmj.com/ on June 5, 2015 - Published by group.bmj.com
Refugees, humanitarian aid and the right to decline vaccinations A L Caplan and David R Curry J Med Ethics published online August 18, 2014
Updated information and services can be found at: http://jme.bmj.com/content/early/2014/08/18/medethics-2014-102383
These include:
References Email alerting service
This article cites 2 articles, 0 of which you can access for free at: http://jme.bmj.com/content/early/2014/08/18/medethics-2014-102383 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
JME Online First, published on August 18, 2014 as 10.1136/medethics-2014-102383 Viewpoint
Refugees, humanitarian aid and the right to decline vaccinations A L Caplan, David R Curry Population Health, Medical Ethics, New York University School of Medicine, New York, New York, USA Correspondence to Dr Arthur Caplan, Population Health, Medical Ethics, New York University School of Medicine, 227 East 30th St, New York, NY 10016, USA; [email protected] Received 21 July 2014 Accepted 23 July 2014
To cite: Caplan AL, Curry DR. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2014-102383
ABSTRACT Recent instances of governments and others refusing humanitarian assistance to refugees and IDPs (internallydisplaced persons) unless they agreed to polio immunization for their children raise difficult ethical challenges. The authors argue that states have the right and a responsibility to require such vaccinations in instances where the serious vaccine-preventable disease(s) at issue threaten others, including local populations, humanitarian workers, and others in camps or support settings. Recent news accounts of events at the Pakistan– Afghanistan border1 2 raise important ethical challenges to efforts aimed at dealing with the eradication of polio and the control of other infectious diseases. In a world full of deadly regional conflicts and poverty, which cause large numbers of persons to seek asylum or refuge in other parts of their nation or in other countries,3 very difficult ethical conflicts arise between the immediate needs of refugees for life sustenance and the drive to control the spread of deadly or disabling diseases through vaccination. The starkest form of this conflict is deciding whether people can be deprived of essential humanitarian commodities such as food, water and shelter unless they accept vaccinations. Can authorities require vaccination as a condition for access to basic sustenance in safe havens or prior to being allowed to cross a national or regional border? If the world’s goal is to move toward eradicating a disease such as polio,4 can food and water be withheld from would-be refugees unless and until they vaccinate? What if the refugees are potential vectors for polio coming from nations or regions with known outbreaks? What about conditionalisation of the provision of food, water and shelter in the face of the presence of deadly diseases that are vaccine-preventable which puts aid providers at immediate risk or huge numbers of residents in the region where refuge is being sought at risk? The challenge of immediately providing necessary life-saving aid while requiring vaccination against the risk of vaccine-preventable disease has arisen in the past year with respect to polio: first in Lebanon and, more recently, in Pakistan. In the border area between Pakistan and Afghanistan, refugee families were reportedly denied water, food and security until they agreed to have all children present vaccinated for polio. A similar vaccination incident arose at the Lebanese border as refugees fleeing from the vicious conflict in Syria, who had been in areas where polio had been reported, were refused entry to Lebanon without agreeing to polio vaccination.
Current international guidelines recommend that anyone leaving a country with endemic polio be vaccinated against the disease.5 6 But, they do not make clear how to weigh refugee rights to refuse vaccination against the duty to rapidly assist them by providing shelter, food and water. Also, recent WHO guidance7 8 has addressed approaches for decision-making on the use of vaccinations in humanitarian crises. Of course, polio is not the only transmissible disease that might trigger a vaccination requirement to keep refugees and internally displaced persons from becoming vectors or reservoirs of infectious disease. Polio may not even be the most pressing vaccination needed in a given situation. But, the recent incidents are useful illustrations of an ethical challenge created when the pressing needs of refugees who refuse vaccination are pitted against the protection of their longer-term health, the health of aid providers, the public health of those residing in altruistic nations and the worldwide goals of disease control and eradication. There are many regions of the world where vaccination is a matter of personal choice. This is true even in the face of outbreaks of measles, pertussis, mumps, influenza and other disabling and deadly maladies for which useful vaccines exist. Still, major campaigns to eradicate or control diseases such as polio have shown little interest in securing informed consent from or affording the right to refuse to all of those receiving vaccines. And many nations have made the acceptance of a broad array of vaccines, a precondition for anyone seeking status as a legal immigrant.9 It is against this backdrop of inconsistency with respect to the recognition of the right to refuse vaccination that the issue of how to handle displaced persons who refuse or will not disclose their vaccination status or who request that polio vaccination be delayed arises. In seeking a clear policy to guide governments, agencies, non-governmental organisations and other third parties in responding to vaccination refusals from those requesting immediate humanitarian assistance, it is important to carefully weigh both the facts and the deeper ethical issues involved. Those seeking refuge or temporary asylum in another state who are fleeing genocide, war, natural disasters, disease outbreaks or human induced catastrophes do have a moral claim to have their pressing dire circumstances recognised and addressed.10 States that can render help are under a moral duty to do so, if only on a temporary basis.11 Those nations rendering direct assistance should not stand alone in providing such support, merely due to their proximity to areas where large numbers of
AL, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102383 Copyright Article authorCaplan (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://jme.bmj.com/ on June 5, 2015 - Published by group.bmj.com
Viewpoint persons seek help and refuge. Other nations, especially wealthy ones, are obligated to assist in ways that are efficient and effective in relieving the misery of displaced persons. While granting that refugees have a right to humanitarian assistance, it is also true that states have the right and responsibility to control their borders in part to protect their own residents from harm. They do so regarding the inflow of migrants, temporary workers and tourists. This right is weakened but not voided in the face of a duty to assist those with pressing emergency needs. What balance is appropriate between the contending moral goods of aid and protection through vaccination? When a refugee population is fleeing or otherwise seeking to cross a border for protection, they are able to do so, ultimately, with the agreement of the potential welcoming state. Such a state may be under an obligation to provide safe haven, but it is each state’s right and responsibility to set conditions for the provision of that aid consistent with the protection of aid givers and the public health. Every nation should be aggressive in establishing immunisation requirements that protect the general public health of their citizens.4–6 For example, this is reflected in efforts to control the spread of disease when mass gatherings occur such as in Saudi Arabia during the Hajj. However, general disease prevention or eradication goals, even as important as that of permanently ending polio, do not morally trump the immediate life or death needs of refugees who may be vaccine refusers. However, during actual disease outbreaks of polio or other diseases such as sever acute respiratory syndrome (SARS), Ebola or pandemic influenza, immigration from impacted areas is and may justly be severely constrained and conditionalised on the grounds of public health protection. The duty to provide help presumes that this can be done without dire consequences to those giving assistance or to their own local or regional populations. In situations where highly infectious, vaccine-preventable diseases are known or suspected to be circulating, such as polio in Pakistan or Syria, those seeking assistance are and should be subject to the welcoming state’s immunisation requirements for the control of known disease threats. These requirements should be established in accordance with international standards and recommendations. Effective vaccination ought to be offered and can be mandated as a condition of aid in the face of actual disease outbreaks with the goal of protecting refugees, aidproviders and residents from imminent danger. In order to ensure the health of residents and encourage the provision of assistance to those in dire need, nations can invoke the right to impose vaccination and other health measures to control known disease outbreaks from harming their population. This is so even if in doing so they fail to follow their own internal ethical standards regarding the requirement of consent to vaccination. And it is so even in the face of explicit vaccine refusals by those in need of aid. Aid can morally be made contingent on vaccination when there is direct, imminent risk to aid givers and nations from whom aid is being sought. Housing and caring for large numbers of refugees or internally displaced persons can overwhelm even the most generous and altruistic of nations. And dealing with the needs of large numbers of unexpected refugees simply may not be an environment in which individual choice can be respected in the face of
2
serious disease risk. If there is knowledge that vaccinepreventable disease is present in the area of origin of refugees, then protection of the local population from serious harm by making aid contingent on vaccination even for those seeking immediate basic sustenance and shelter seems morally defensible. Vaccine refusers might be quarantined but this creates additional cost and work for those seeking to maintain a safe humanitarian protection infrastructure. Special camps or camp areas might be created for vaccine refusers but again this requires money, time and management which those willing to help may not have. It may also impose a level of risk on aid givers and their families that overwhelms their duty to help. A moral case can be made that, in the face of imminent serious disease risk, internally displaced persons and those seeking refugee status should be subject to the receiving aid givers’ prudent and medically valid immunisation demands. Using an emergency to justify routine immunisation for achieving abstract goals in the face of desperate need is difficult to justify. Insisting on vaccination as a condition of aid to control the danger of a vaccine-preventable serious disease outbreak is not. Despite the dire circumstances that the displaced face, their autonomy in seeking help, while creating a duty of assistance, does not require those providing assistance to put themselves or their own populations at immediate risk of vaccine-preventable lethal or severely disabling diseases. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2
3
4 5
6
7
8
9
10 11
Domínguez G. UNHCR: Pakistani offensive triggering humanitarian crisis. Deutsche Welle (DW), 26 Jun 2014. http://www.dw.de/unhcr-pakistani-offensivetriggering-humanitarian-crisis/a-17738335 Wasif S. Battling polio: IDPs turned back at Pak-Afghan border for refusing vaccine. The Express Tribune, 20 Jun 2014. http://tribune.com.pk/story/724374/battlingpolio-idps-turned-back-at-pak-afghan-border-for-refusing-vaccine/ Simmons AM. Flood of children across U.S. border reignites immigration debate. Los Angele Times, 1 Jul 2014. http://www.latimes.com/nation/nationnow/ la-nn-na-immigration-chat-20140701-story.html Polio vaccines: WHO position paper, January 2014. Weekly epidemiological record 2014;89:73-92. http://www.who.int/wer/2014/wer8909.pdf?ua=1 Meeting of the Strategic Advisory Group of Experts on immunization, November 2012 – conclusions and recommendations. Weekly epidemiological record 2013;88:1–16. http://www.who.int/wer/2013/wer8801.pdf?ua=1 WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. World Health Organization, 2014. http://www.who.int/mediacentre/news/statements/2014/ polio-20140505/en/ SAGE Working Group on Vaccination in Humanitarian Emergencies. Vaccination in acute humanitarian emergencies: a framework for decision-making. Revised Draft: 23 Oct 2012. http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd =1&cad=rja&uact=8&ved=0CCQQFjAA&url=http%3A%2F%2Fwww.who.int% 2Fimmunization%2Fsage%2Fmeetings%2F2012%2Fnovember%2FFinalFraft_ FrmwrkDocument_SWGVHE_23OctFullWEBVERSION.pdf&ei=EPDQU63sJofg8g HpzYGwBQ&usg=AFQjCNHcKdUSlahm9EOUThEnB7hnRtrk9g&bvm=bv.71667212, d.b2U Moodley K, Hardie K, Selgelid MJ, et al. Ethical considerations for vaccination programmes in acute humanitarian emergencies. Bulletin of the World Health Organization 2013;91:290–297. doi:http://dx.doi.org/10.2471/BLT.12.113480 Canadian Immunization Guide: Immunization of persons new to Canada. Public Health Agency of Canada, 2012. http://www.phac-aspc.gc.ca/publicat/cig-gci/ p03-11-eng.php Henkin L. Refugees and their human rights. Fordham Int Law J 1994;18:1077–90. Kritzman-Amir T, Spijkerboer T. On the morality and legality of borders: border policies and asylum seekers. Harv Hum Rights J 2013;25:1–38.
Caplan AL, et al. J Med Ethics 2014;0:1–2. doi:10.1136/medethics-2014-102383
Downloaded from http://jme.bmj.com/ on June 5, 2015 - Published by group.bmj.com
Refugees, humanitarian aid and the right to decline vaccinations A L Caplan and David R Curry J Med Ethics published online August 18, 2014
Updated information and services can be found at: http://jme.bmj.com/content/early/2014/08/18/medethics-2014-102383
These include:
References Email alerting service
This article cites 2 articles, 0 of which you can access for free at: http://jme.bmj.com/content/early/2014/08/18/medethics-2014-102383 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
