an impact on mortality, and will need to be followed up as soon as possible with more widespread deployment of the vaccine in appropriate epidemiological situations if they show that the vaccine can be delivered, is effective, and is safe. RTS,S/AS01 should not be regarded as a replacement for other control measures, but rather as an additional method to be used in areas where malaria is proving difficult to control despite high levels of coverage with established control measures, and possibly in other specific circumstances, such as elimination programmes and control of malaria in areas where transmission is very seasonal. *Brian Greenwood, Ogobara K Doumbo Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK (BG); and Malaria Research and Training Centre, University of Bamako, Bamako, Mali (OKD) [email protected] BG declares that the London School of Hygiene & Tropical Medicine has received a grant from PATH to support work on the evaluation of RTS,S/AS01 candidate malaria vaccine in Ghana. OKD declares that the Malaria Research and Training Centre, Bamako, receives support from the National Institute for Allergy and Infectious Diseases, National Institutes of Health, for trials of malaria vaccine candidates in Mali.

Copyright © Greenwood et al. Open Access article distributed under the terms of CC BY. 1

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Cohen J, Nuessenzweig V, Nussenzweig R, Vekemans J, Leach A. From the circumsporozoite protein to the RTS,S/AS candidate vaccine. Hum Vaccin 2010; 6: 90–96. Casares S, Brumeanu TD, Richie TL. The RTS,S malaria vaccine. Vaccine 2010; 28: 4880–94. RTS,S Clinical Trials Partnership. Efficacy and safety of the RTS,S/AS01 malaria vaccine with or without a booster dose in infants and children in Africa: final results of a phase 3, individually randomised, controlled trial. Lancet 2015; 386: 31–45. Penny MA, Veity R, Bever CA, et al. Public health impact and cost-effectiveness of the RTS,S/AS01 malaria vaccine candidate: a systematic comparison of predictions from four mathematical models. Lancet 2015; published online Nov 5. Hamel MJ, Oneko M, Williamson J, et al. A marked reduction in mortality among participants in a clinical trial that removed barriers to care and implemented national case management guidelines. 63rd Annual Meeting of the American Society of Tropical Medicine and Hygiene; New Orleans, LA; Nov 2–6, 2014. 631 (abstr). Wilson AL, IPTc Taskforce. A systematic review and meta-analysis of the efficacy and safety of intermittent preventive treatment of malaria in children (IPTc). PLoS One 2011: 6: e16976 Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst Rev 2004; 2: CD000363 European Medicines Agency (EMA). First malaria vaccine receives positive scientific opinion from EMA. July 24, 2015. index.jsp?curl=pages/news_and_events/news/2015/07/news_ detail_002376.jsp&mid=WC0b01ac058004d5c1 (Oct 30, 2015). WHO. Pilot implementation of first malaria vaccine recommended by WHO advisory groups. Oct 23, 2015. releases/2015/sage/en/ (accessed Oct 30, 2015).

Refugees: towards better access to health-care services The migration crisis is one of the most pressing global challenges, as worldwide displacement is now at the highest level ever recorded. Latest global estimates by the UN Commissioner for Refugees (UNHCR) show that 59·5 million people are forcibly displaced as a result of persecution, conflict, generalised violence, or human rights violations.1 The estimated refugee population reached an unprecedented 19·6 million individuals worldwide in 2015—half of them being children—and the number is steadily increasing, with Syria as the leading country of origin of refugees.1,2 A lengthy drought preceded the Syrian crisis that led to a large movement of people into cities and contributed to instability; recent evidence suggests that risks of such droughts in the region are more than doubled as a result of climate change.3 More than a million refugees and migrants arrived in the European Union in 2015.4 The growing influx of vulnerable populations poses many challenges to host countries, not least with regard to preparedness and resilience of health systems and access to health-care services. Furthermore, increasing numbers of refugees are likely in future as a Vol 387 January 23, 2016

result of a complex combination of driving forces, such as faltering and unequal economic growth, population increases, conflicts, and environmental change. The need to develop more effective approaches that respond to the health needs of displaced populations and address the root causes of displacement is therefore imperative. A refugee is someone who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country”.5 Refugees experience conditions of vulnerability, marginalisation, and poverty, in addition to the high stress of displacement, which seriously affect the health of these populations, including women, children, and older people. Evidence suggests that refugees often have acute mental health problems and trauma symptoms, notably depression and post-traumatic stress disorder (PTSD), related to organised violence, torture, human

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Robert Geiss/picture-alliance/dpa/AP Images

rights violation, resettlement, and traumatic migration experience.6 Victims of torture and other forms of violence experience a range of physical problems and disabilities, including malunited fractures, soft tissue injuries, musculoskeletal symptoms, neuropathies, head injuries, and epilepsy.6 Refugees have a high burden of malnutrition and anaemia, treatable noncommunicable diseases, which are exacerbated by lack of access to regular medication, and infectious diseases, including hepatitis A and B and parasitic diseases.7,8 The threat of imported disease could contribute to public apprehension about refugees in receiving countries. It is important to emphasise that no systematic association exists between migration and importation of communicable diseases.9 In addition, refugees are particularly vulnerable to sexual and gender-based violence.10 Displacement also complicates the delivery of maternal and obstetric care increasing the risk of unsafe childbirth and maternal and neonatal morbidity and mortality.8 Despite this high burden of disease, access to health care for refugees is mostly restricted in host countries with great variation in entitlements.7,11 Although most welcoming countries offer in principle some kind of medical screening upon arrival, many refugees do not benefit from these services and the quality of screening programmes is questionable and often overlooks mental health problems.7 Legal restrictions also impede refugees’ access to health care. Asylum seekers are typically granted restricted access to health care, often limited to emergency medical care, pregnancy and childbirth care, and immunisation services.7,12 In many European and other countries in the Organisation for Economic Cooperation and Development (OECD), access to essential health-care services is conditional on confinement in detention facilities as part of processes to facilitate asylum claims and identify individuals.13 Yet, a recent systematic review showed an independent adverse effect of detention on the mental health of asylum seekers, including PTSD, depression, and anxiety.13 In addition, host countries often impose waiting periods before they grant refugees access to health-care services which delays care.14 Exclusion from health care is exacerbated by the undocumented status of many refugees and uncertainties about entitlements for failed asylum seekers. Practical barriers impede access to health-care services for refugees—eg, inadequate information and awareness 320

about the availability of services, insufficient financial means, restricted access to transport, culturally insensitive care, and inadequate provision of interpreters.7 Various OECD countries also charge migrants user fees for healthcare services, further restricting access to health care.12 Initial restriction of access to care for refugees leads to delayed care and increased per person health expenditures.15 Provision of preventive care, including primary and secondary prevention of cardiovascular disease and antenatal care, could generate savings for health-care systems by alleviating the burden of stroke, myocardial infarction, and adverse birth outcomes among refugees.16 Overall, robust evidence argues against claims that granting universal health coverage (UHC) to refugees increases health-care expenditure.15 Furthermore, poor access to health-care services interacts with discrimination and limited social rights thereby reinforcing exclusion as a root cause of ill health among refugees.11 Access to essential health services for refugees should be recognised as a fundamental human right.16 As such, host countries must address refugees’ exclusion from health-care services and their unmet health needs. Donor countries should support efforts to improve access to secure essential health-care services, including for those displaced within or close to their countries of origin who can be most vulnerable to ill health and violence. Greater efforts are needed to strengthen the resilience of health systems to foster equity and efficiency in refugee health. As the global community moves towards the ambitious goal of UHC in the post-2015 sustainable development era, serious consideration should be given to the right of refugees to access timely, appropriate, and quality healthcare services. *Etienne V Langlois, Andy Haines, Göran Tomson, Abdul Ghaffar Alliance for Health Policy and Systems Research, World Health Organization, Geneva 1211, Switzerland (EVL, AG); Departments of Social and Environmental Health Research and of Population Health, London School of Hygiene & Tropical Medicine, London, UK (AH); and Department of Learning, Informatics, Management, and Ethics, Karolinska Institutet, Stockholm, Sweden (GT) [email protected] We declare no competing interests. © 2016 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1

United Nations High Commissioner for Refugees. UNCHR global trends: forced displacement 2014. 70982.1419369449.1434622495 (accessed Jan 15, 2016). Vol 387 January 23, 2016






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United Nations Department of Economic and Social Affairs, Population Division. International migration flows to and from selected countries: the 2015 revision. New York: United Nations, 2016. Kelley CP, Mohtadi S, Cane MA, Seager R, Kushnir Y. Climate change in the Fertile Crescent and implications of the recent Syrian drought. Proc Natl Acad Sci USA 2015; 112: 3241–46. International Organization for Migration. Irregular migrant, refugee arrivals in Europe top one million in 2015. Dec 22, 2015. news/irregular-migrant-refugee-arrivals-europe-top-one-million-2015iom (accessed Jan 15, 2016). United Nations General Assembly. 1951 Convention relating to the Status of Refugees. (accessed Jan 15, 2016). Burnett A, Peel M. Asylum seekers and refugees in Britain: the health of survivors of torture and organised violence. BMJ 2001; 322: 606–09. Norredam M, Mygind A, Krasnik A. Access to health care for asylum seekers in the European Union—a comparative study of country policies. Eur J Public Health 2006; 16: 286–90. Gornall J. Healthcare for Syrian refugees. BMJ 2015; 351: h4150. Gulland A. Refugees pose little health risk, says WHO. BMJ 2015; 351: h4808. WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization, 2013.


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WHO Regional Office for Europe. How health systems can address health inequities linked to migration and ethnicity. Copenhagen: WHO Regional Office for Europe, 2010. Arie S. How Europe keeps migrants out of its health system. BMJ 2015; 350: h2216. Filges T, Montgomery E, Kastrup M, Klint Jørgensen AM. The impact of detention on the health of asylum seekers: a systematic review. Copenhagen: The Campbell Library, 2015. Rousseau C, Laurin-Lamothe A, Rummens JA, Meloni F, Steinmetz N, Alvarez F. Uninsured immigrant and refugee children presenting to Canadian paediatric emergency departments: disparities in help-seeking and service delivery. Paediatr Child Health 2013; 18: 465–69. Bozorgmehr K, Razum O. Effect of restricting access to health care on health expenditures among asylum-seekers and refugees: a quasi-experimental study in Germany, 1994–2013. PLoS One 2015; 10: e0131483. European Union Agency for Fundamental Rights. Cost of exclusion from healthcare: the case of migrants in an irregular situation. September, 2015. (accessed Jan 15, 2016).

The future leadership of WHO In about 3 months time, the Director-General of WHO will call for nominations from the Executive Board and Member States for her successor. The selection process will then be launched and a new Director-General elected in 2017. Over this coming year WHO has a huge amount of work to do. There are real and exciting opportunities, encapsulated in the Sustainable Development Goals and building on the progress made during the Millennium Development Goals before them. To take just one example, strong WHO leadership can help us all push ahead to achieve universal health coverage, leaving no one behind. Alongside such opportunities, the world also faces colossal challenges that WHO must help us all solve: the threat of antimicrobial resistance in humans and animals; the looming problem of ageing societies; the rise of noncommunicable diseases; and the effect of climate change on diseases and humanitarian disasters. It is only through tackling these issues that we can construct a global health architecture that can respond to health crises and support resilient and sustainable health systems. Meanwhile, west Africa is recovering from the worst ever Ebola outbreak. Although the international response to Ebola was vital, it could have been better. WHO’s action was also imperfect, but the organisation is working hard to reform the way in which it responds to emergencies and is accountable for them.1 This reform will be essential since other disasters, such as the Nepal earthquake and floods in Vol 387 January 23, 2016

Pakistan last year, have shown that WHO has an important role in response and recovery.2,3 We need one organisation with strong leadership and command that is able to respond quickly and coherently to health threats, including pandemics. That organisation is WHO. The myriad recent reports and commentators on WHO1,4,5 all agree that it is a vital institution—the preeminent international body within the UN system dealing with threats to international health and health security. As the Constitution of WHO states, its purpose is: “to act as the directing and coordinating authority on international health work…to establish and maintain effective collaboration with the United Nations, specialised agencies, governmental health administrations, professional groups and such other organisations as may be deemed appropriate. To assist governments, upon request, in strengthening health services and to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of governments”.6 WHO does all of this— and much more—as the leader of the Global Health Cluster, bringing together more than 40 international humanitarian health organisations. With all of this work, both routine and extraordinary, the appointment of the next WHO Director-General therefore seems a long way away. Member States should all agree that we must not waver from supporting the present Director-General Dr Margaret Chan and her

For Global Health Cluster see health_cluster/en/


Refugees: towards better access to health-care services.

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