Health of refugees
Author: Karim Moutchou
Institution: Medical Student, Fez Faculty of Medicine and Pharmacy
Editors: Akihiko Ozaki M.D., Yasuhiro Kotera., Yuki Senoo
Geographically, Morocco is the closest African country to Europe. In fact, two Spanish cities—Ceuta and Melilla—are in Africa, in the northern region of Morocco, yet they are a part of European Union territory. Heavily guarded walls separate the 2 cities from Morocco. Additionally, the distance between the mainland and the far south of Spain is only 14 km through the Mediterranean Sea.
This proximity has made Spain one of the largest receivers of refugees from African countries or Arab regions suffering from humanitarian crises, like Syria and Yemen.
It is hard to go a few hundred meters in the streets of Morocco without seeing a refugee, if not more, begging for money in the street. Morocco has historically been a country of a passage from the sub-Saharan countries to Europe. However, the hard anti-immigration techniques and laws imposed by the European Union have made Morocco a destination and not just a quick stop like it used to be.
This situation poses great challenges to the healthcare systems of the European Union countries and Morocco, as they must adapt to the continuous flow of immigrants from a large region with different challenges than what is usual in the North African and European countries. Yet, it also puts the lives of the refugees and illegal immigrants in great danger because they do not present themselves to hospitals, from fear of being arrested or deported.
Unknown Situation with No Numbers
No reliable numbers exist of how many refugees are in Morocco, especially because most of them never officially apply to get official documents affirming their status, due to the fear of deportation. Additionally, their eventual goal is to cross the wall or the sea to Spain, so they are worried about having their movement limited if the Moroccan government tracks them.
The United Nations Agency in Charge of Refugees (UNHCR) said through its representative Jean-Paul Cavaliéri that Morocco’s Immigration and Asylum Strategy1 enables refugees to recover their dignity and contribute to wealth creation.
The government put a goal of giving 100% of refugees access to primary healthcare centers throughout the country.2However, this considers only the thousands of refugees who have already registered as refugees and were granted that status. They are only the tip of the iceberg, in comparison to those who have never applied.
NGOs and Governmental Projects: Good Intention but Little Effect
While all parties involved have a real interest in giving access to healthcare to refugees, discovering how to do it is still very challenging. The main questions that are hard to answer are where, how, through what processes, and who would pay.
The Moroccan healthcare system is already overloaded. Less than 70% of the population has health coverage.3 The numbers of hospital beds, doctors, and nurses are far below the international recommended standards. Adding more people to the equation would not be efficient without careful consideration and help from international partners.
Nongovernmental organizations have been doing many good deeds in this area. For example, medical interns in the capital’s Faculty of Medicine created the association Action Urgence,4 whose goal is to offer free consultations and medications to patients in need who lack access to healthcare facilities, including refugees and illegal immigrants. The NGO’s headquarters have been a destination for refugees for almost 2 decades now.
Many other local and international NGOs have organized free, open-door medical events for immigrants. They offer consultations, distribute medications, and screen for people with serious deadly diseases like cancer or HIV.
Doctors and NGOs try to put these patients in special programs, get them legal exemptions to be treated in public hospitals for free, or orient them towards Doctors Without Borders. However, in the absence of a clear circuit for the patients to follow and the constant fear of being deported, most of the screened patients end up being lost or dead before receiving treatment.
Being Sick: A Problem for Everyone
Understandably, the main concern of the receiving parties—the European Union and Morocco—is to limit the transmission of infectious diseases that have been eradicated or limited. Tuberculosis, HIV, malaria, and leishmaniosis are on the top of the list, along with hepatitis B and C. Airborne diseases can spread quickly. Insects and rats can cause outbreaks. In addition, difficult economic situations push many refugees toward prostitution as their only source of income, putting them and others at risk of sexually transmitted diseases.
That is why most prevention and treatment programs implemented by the government and its partners focus on limiting outbreaks, which could put millions in danger. For example, the UNHCR, with the government, organizes regular information sessions on STIs/HIV/AIDS prevention . In addition, all primary healthcare centers offer free and anonymous screening.
Nevertheless, refugees still get many noninfectious diseases, and with the lack of programs focused on them, their health can deteriorate badly and quickly from the simplest treatable diseases. Without access to insulin, hypertension medication, hormones, or any other treatment, chronic disease can have deadly consequences. We can say the same thing about prenatal care and children’s delivery.
As such, in the absence of free access to healthcare, most refugees act in desperate ways to raise money. Prostitution is the most common method, after begging in the street for handouts, and it puts the immigrants and their clients in more danger. According to testimony gathered by journalists and investigators, most refugees end up in a vicious circle between being sick with no money, working in prostitution, and becoming sicker. Many of them become pregnant in a country that does not allow abortion in public hospitals, and they cannot afford to do it under the radar in private clinics. This adds more people to the crisis, with babies born in the street, already infected with deadly viruses, from unknown fathers and very poor and sick mothers.
Investigators have reported the following quotations from refugees6:
“I had back pain. I went to the hospital. . . . The doctor just gave me some medicine and asked me to do more tests. I could not pay, so I did not go back” (Laura, Meknes).
“This is no life, I have no work. . . . sometimes, I just cannot get up in the morning to do it again and again. . . . I left to support my family, and now, I sometimes ask them for money just to survive or to eat. . . . It is humiliating” (Martin, Nador).
‘I am sick and often tired, but I keep myself going for the children. Because when I don’t go to the FOO, I don’t have money to eat. I am sick, but I really make an effort. When I am really sick, I leave my children with the neighbor and take myself to the clinic”.75
COVID-19 Has Made the Crisis Deeper and More Complex
The COVID-19 crisis and the lockdown put in place in Morocco hit illegal immigrants and refugees harder than it did almost everyone else in the country. Although the government has offered COVID-19-related diagnosis tests and treatments for free to everyone, including illegal immigrants, the fear of deportation and the communication barriers have slowed down their access to the healthcare system immensely. Moreover, the curfew and closing of the borders halted all kinds of financial and food aid that they usually got.
Another complex aspect of this situation is that immigrants are now vectors of transportation for the disease as they travel from one city to another or from Morocco to Spain. This has been particularly challenging for authorities on both sides of the Mediterranean Sea, as they discover an outbreak every few days among immigrants crossing illegally to Spain or living in collectivity in Morocco.7
While the United Nations and many NGOs have helped with the Moroccan government’s efforts to help refugees, the country’s healthcare system is still struggling to guarantee access for them. This has only been worsened by the COVID-19 pandemic.
The continuous flow of people coming from epidemic regions is overloading the system, governments, and partners. The system, governments and partners are still far behind in solving the problem. This situation puts all countries involved in great danger, and many souls are being lost in the process.
 Govt. Morocco. Immigration and asylum: Moroccan strategy ensures dignity, socio-economic Integration for Refugees. https://reliefweb.int/report/morocco/immigration-and-asylum-moroccan-strategy-ensures-dignity-socio-economic-integration. Published Jun 21, 2018. Accessed Oct 25, 2020.
Sebastian Bonknight. Learning between the lines: protecting immigrant children’s right to education In Morocco. Published Oct 21, 2018. Inside Arabia. https://insidearabia.com/protecting-immigrant-childrens-right-education-morocco/#:~:text=While%20Moroccan%20legislation%20guarantees%20education,whom%20were%20school%2Dage%20children. Accessed Oct 25, 2020.
 CNSS. CNSS en chiffres. https://www.cnss.ma/fr/content/chiffres-cl%C3%A9s-1. Updated 21 Jun 2018. Accessed Oct 25, 2020.
 Association Action Urgence. Facebook page. https://www.facebook.com/actionurgencerabat/.Accessed Oct 25, 2020.
 United Nations High Commissioner for Refugees. Rapport UNHCR. https://www.unhcr.org/4a8e9aa39.pdf. Published Jan, 2008. Accessed Oct 25, 2020.
 Medicins Sans Frotieres. Violences, Vulnérabilité et Migration : Bloqués aux Portes de l’Europe Un Rapport sur les Migrants Subsahariens en Situation Irrégulière au Maroc.https://tbinternet.ohchr.org/Treaties/CMW/Shared%20Documents/MAR/INT_CMW_NGO_MAR_14800_F.pdf. Published Mars, 2013. Accessed Oct 25, 2020.
 Jacqueline Skalaski-Fouts. The forgotten victims of COVID-19 amid migration crisis. InDepthNews. Published July 14, 2020. https://www.indepthnews.net/index.php/sustainability/reduced-inequalities/3692-the-forgotten-victims-of-covid-19-amid-migration-crisis. Accessed Oct 25, 2020.