Migration – WMA – The World Medical Association

Adopted by the 70^th WMA General Assembly, Tbilisi, Georgia, October 2019

PREAMBLE

Population displacement resulting from war, violence or persecution has wide-ranging implications for the entire global community. Refugees – that is, individuals who have been forced to flee their respective countries of origin for these reasons – generally must undergo rigorous procedures for determining their legal status according to the national legislation of the country in which they are seeking asylum.

An increasing number of refugees fall under the category of unaccompanied minors, which are defined as people under the age of 18 who have been separated from or who have fled their countries of origin without their families. In light of their unique vulnerability, unaccompanied minor refugees are eligible for special protections, as outlined in the United Nations’ Convention on the Rights of the Child, which states that the best interests of the child must be the primary consideration in all stages of the displacement cycle.

Given the differences in how adults and unaccompanied minors are processed and protected when seeking asylum, recipient countries have an interest in verifying the age of applicants outside the context of criminal proceedings. However, some asylum seekers either do not have access to documentation confirming their age or originate from countries in which there is no central birth registry. In cases where there is doubt as to whether an asylum seeker is a child or an adult, e.g. if the authenticity of available documentation is called into question or if there is reason to believe the applicant’s physical appearance suggests a discrepancy between the reported age and the actual age, the competent authorities may resort to medical and/or non-medical methods for assessing the applicant’s age.

Medical age assessments carried out by medical professionals may take the form of X-ray scans of the jaw, hand or wrist; CT scans of the collarbone; MRI scans of the knee; or the examination of secondary sex characteristics to determine the applicant’s stage of puberty. However, ethical concerns have been raised about these and other forms of examination, as they can potentially endanger the health of those being examined and violate the privacy and dignity of young people who may already be severely traumatized [1]. Furthermore, there is conflicting evidence about the accuracy and reliability of the available methods of medical age assessment, which may generate significant margins of error [2]. For example, some available studies do not appear to take into account potential delays in skeletal maturation caused by malnutrition, which is just one factor that could translate into a risk of age misclassification among asylum seekers [3]. Comparative assessments are further impeded by a lack of standard images from certain world regions and limited representation in age assessment reference data, much of which was compiled on the basis of European and North American populations [4]. An imprecise assessment of an individual’s age can have far-reaching administrative, ethical, psychological and other significant consequences, including potential breaches of children’s rights.

The following recommendations apply explicitly and exclusively to cases outside the context of the criminal justice system.

RECOMMENDATIONS

The WMA recognizes that there is sometimes a need to assess the age of asylum seekers to ensure that all unaccompanied minors receive the protections afforded them under international and national law.
The WMA recommends that medical age assessments only be carried out in exceptional cases and only after all non-medical methods have been exhausted. The WMA recognizes that non-medical methods, e.g. questioning children about traumatic events, may also have a negative impact and must therefore be carried out with great care. Each case must be evaluated carefully based on the totality of circumstances and the preponderance of available evidence.
The WMA asserts that, in cases where medical age assessment is unavoidable, the health and safety and dignity of the young asylum seeker must be the highest priority. Physical examinations must be carried out by a qualified physician with appropriate pediatric examination experience in accordance with the highest medical and ethical standards, in observance of the principles of proportionality, in adherence to the standards of prior informed consent and with consideration of cultural and religious sensitivities and potential language barriers. The asylum seeker must always be made aware that the examination is carried out as part of the age assessment procedure and not to provide healthcare.
The WMA underscores that any medical methods that could involve a health risk for the applicant, e.g. radiological examinations without medical indication, or that infringe upon the dignity or privacy of an already potentially traumatized asylum seeker, e.g. genital examinations, must be avoided.
The WMA stresses that medical certificates indicating the results of medical age assessment examinations should include information concerning the accuracy and reliability of the methods used and the relevant margins of error.
The WMA urges constituent members to develop or promote the development of internationally accepted interdisciplinary guidelines which outline the scientific basis, as well as ethical and legal or regulatory principles of medical age assessment of asylum seekers, including the potential health risks and psychological impact of specific procedures.
The WMA emphasizes that, in cases where doubts regarding the age of an asylum seeker cannot be resolved or confirmed with absolute certainty, any remaining uncertainty should be interpreted in favor of the asylum seeker.

References:

[1] Zentrale Ethikkommission der Bundesärztekammer (2016): Stellungnahme “Medizinische Altersschätzung bei unbegleiteten jungen Flüchtlingen. Deutsches Ärzteblatt 2016; A1-A6. / German Medical Association’s Central Ethics Committee: Statement on Medical Age Assessment of Unaccompanied Minor Refugees.

[2] Separated Children in Europe Programme (2012): Position Paper on Age Assessment in the Context of Separated Children in Europe. Online http://www.separated-children-europe-programme.org/separated_children/good_practice/index.html. Last accessed 03.07.2018.

[3] Sauer PJJ, Nicholson A, Neubauer D, On behalf of the Advocacy and Ethics Group of the European Academy of Paediatrics (2016): Age determination in asylum seekers: physicians should not be implicated. European Journal of Pediatrics 175, (3): 299-303.

[4] Aynsley-Green et al. (2012): Medical, statistical, ethical and human rights considerations in the assessment of age in children and young people subject to immigration control. British Medical Bulletin 2012; 102: 39.

Adopted by the 69^th WMA General Assembly, Reykjavik, Iceland, October 2018
and rescinded and archived by the 72^nd WMA General Assembly (online), London, United Kingdom, October 2021

Nowadays, we are facing increased migration trends globally. This situation, far from being resolved, has worsened over the last months, exacerbated by political, social and economic events, with serious impacts on the population deteriorating the quality of life and in some cases putting people in mortal danger. This violates their fundamental right to health and in many cases forces them to abandon their countries to search for a better life.

International migration is a global phenomenon, caused by multiple factors, including demographic and economic inequalities among countries, in addition to war, hunger and natural disasters. Migration policies adopted by the majority of receiving countries are becoming more and more restrictive towards economic migrants.

The World Medical Association (WMA) considers that health is a basic need, a human right and one of the essential drivers of economic and social development. Increased migration is a phenomenon linked to progress and to the trends of the 21^st century.

The WMA reaffirms its Resolution on Refugees and Migrants adopted in October 2016.

The WMA, its constituent members and the international health community should advocate for:

Strong continued engagement of physicians in the defense of human rights and dignity of all people worldwide, as well as combatting suffering, pain and illness;
The prioritization of the care of human beings above any other consideration or interest;
Providing the necessary healthcare, through international cooperation, directed to countries that welcome and receive large number of migrants.
Governments to reach political agreements to obtain the necessary health resources to deliver care in an adequate and coordinated manner to the migrant population.

The WMA emphasizes the role of physicians to actively support and promote the rights of all people to medical care based solely on clinical necessity, and protest against legislation and practices contrary to this fundamental right.

Adopted as a Council Resolution by the 203^rd WMA Council Session, Buenos Aires, April 2016,
adopted by the 67^th World Medical Assembly, Taipei, Taiwan, October 2016,
and rescinded and archived by the 72^nd WMA General Assembly (online), London, United Kingdom, October 2021

PREAMBLE

Currently, a very large number of people are seeking refuge and/or asylum; some are fleeing war zones or other conflicts, others are fleeing from desperate poverty, violence, and other injustices and abuses with potentially very harmful effects to mental and physical health.

The global community has been ill prepared for handling the refugee crisis, including addressing the health needs of those seeking refuge.

The WMA recognizes that mass migration will continue unless people are content to stay in their birth countries because they see opportunities to live their lives in relative peace and security and to offer themselves and their families the ability to live lives with opportunities for fulfilment of various sorts, including economic improvement. The global community has a responsibility to seek to improve the lot of all populations, including those in countries currently with the poorest economies and other key factors. Sustainable development will give all populations improved security, and economic options.

The WMA recognizes that warfare and other armed conflict, including continuous civil strife, unrest and violence, will inevitably lead to people movement. The worse the conflict the higher the percentage of people who will want to leave the conflict zone. There is a responsibility for the global community, especially its political leaders, to seek to support peace making and conflict resolution.

The WMA recognizes and condemns the phenomenon of forced migration, which is inhumane and must be stopped. Such cases should be considered for referral to the International Criminal Court.

PRINCIPLES

1. The WMA reiterates the WMA Statement on Medical Care for Refugees originally adopted in Ottawa, Canada in 1998 which states:

Physicians have a duty to provide appropriate medical care regardless of the civil or political status of the patient, and governments should not deny patients the right to receive such care, nor should they interfere with physicians’ obligation to administer treatment on the basis of clinical need alone.

Physicians cannot be compelled to participate in any punitive or judicial action involving refugees, including asylum seekers, refused asylum seekers and undocumented migrants, or Internally Displaced Persons or to administer any non-medically justified diagnostic measure or treatment, such as sedatives to facilitate easy deportation from the country or relocation.

Physicians must be allowed adequate time and sufficient resources to assess the physical and psychological condition of refugees who are seeking asylum.

National Medical Associations and physicians should actively support and promote the right of all people to receive medical care on the basis of clinical need alone and speak out against legislation and practices that are in opposition to this fundamental right.

2. WMA urges governments and local authorities to ensure access to adequate healthcare as well as safe and adequate living conditions for all regardless of their legal status.

Adopted by the 66^th General Assembly, Moscow, Russia, October 2015
and rescinded and archived by the 72^nd WMA General Assembly (online), London, United Kingdom, October 2021

The WMA recognises that mass movement of people often follows disasters that flow from armed conflict or natural phenomena as populations seek to escape danger and deprivation. The current mass movement of the populations, to escape the effects of armed conflict including bombing, lack of access to utilities, clean water, and the destruction of homes, schools and hospitals, has been numerically larger than any mass movement of populations in over 70 years.

While the WMA recognises that countries may have concerns about their ability to absorb significant numbers of new migrants, we recognise that people fleeing warfare, or natural phenomena are doing so because they are desperate and often face life-threatening conditions. They are afraid for their health, safety and welfare, and that of the family members who accompany them.

Most countries have signed international treaties giving them binding obligations to offer aid and assistance to refugees and asylum seekers. The WMA believes that, when there are events, including on-going events such as conflict, which generate refugee crises, governments must increase their efforts to provide assistance to those in need.

This should include ensuring safe passage for refugees, and appropriate support after they enter countries offering refuge. Recognising that the disaster from which they have fled, and the vicissitudes of the journey, may have led to health problems it is essential that receiving countries establish systems to provide health care to refugees.

Governments should seek to ensure that refugees and asylum seekers are able to live in dignity within their country of refuge and make all efforts to enable their integration into their new society. The international community should seek to obtain a peaceful solution in Syria under which the population can either stay at home safely or, if they have already left, safely return home.

The WMA recognises that mass population movement cause significant stress on existing populations of countries as well on those who become refugees. We believe that governments and international agencies including the United Nations must make more concerted efforts to reduce the pressures that lead to such movements, including rapidly providing extensive relief after natural phenomena, and making more efforts to avert or stop armed conflict. Re-establishing security of food, water, housing, sewerage, education and health care, and improving public safety, should make a significant impact and reduce the numbers of refugees.

The WMA:

Recognises that the process of becoming a refugee is damaging to physical and mental health;
Commends those countries that have welcomed and cared for refugees, especially those currently fleeing Syria;
Calls on other countries to improve their willingness to receive refugees and asylum seekers;
Calls on national governments to ensure that refugees and asylum seekers are enabled to live in dignity by providing access to essential services;
Calls on all governments to work together to seek to end local, regional, and international conflicts, and to protect the health, safety and welfare of populations;
Calls on all governments to cooperate in providing immediate help to countries facing the effects of natural phenomena, remembering that those already the most socio-economically disadvantaged will face the most challenges;
Calls upon global media to report on the refugee crisis in a manner that respects the dignity of refugees and displaced persons, and to avoid bigotry and racial or other bias in reporting.

Adopted by the 54^thWMA General Assembly, Helsinki, Finland, September 2003
and revised by the 65^th WMA General Assembly, Durban, South Africa, October 2014

PREAMBLE

The WMA acknowledges that temporary stays of physicians in other countries help both the receiving and the sending countries to exchange medical knowledge, skills and attitudes. The exchange of medical professionals is therefore beneficial for the development of medicine and healthcare systems and in general deserves the support of national medical associations as well as governments.

The WMA Statement on Medical Manpower – 1 (1983, 1986) called upon all National Medical Associations to work with their governments towards solutions to the emerging problems related to the medical workforce.

The WMA Resolution on the Medical Workforce (1998) identified the major components of the medical workforce situation that need to be taken into account when developing a national workforce policy.

For several decades many governments, employers and medical associations have misinterpreted demographical data regarding the number of physicians that are required. Young people seeing employment as physicians have often been seriously affected by poor medical workforce planning.

In many countries, including the wealthiest ones, there is a shortage of physicians. A major reason for the shortage is a failure to educate enough physicians to meet the needs of the country. Other reasons for the net loss of physicians are the recruitment of physicians to other professions, early retirement and emigration, and the problems of combining professional and family responsibilities, all of which are often due to poor working conditions for physicians.

Some countries have traditionally solved their need for physicians by recruiting medical graduates from other countries. This practice continues today.

The flow of international migration of physicians is generally from poorer to wealthier countries. The poorer countries bear the expense of educating the migrating physicians and receive no recompense when they enter other countries. The receiving countries gain a valuable resource without paying for it, and in the process they save the cost of educating their own physicians.

Physicians do have valid reasons for migrating, for example, to seek better career opportunities and to escape poor working and living conditions, which may include the pursuit of more political and personal freedoms and other benefits.

RECOMMENDATIONS

National medical associations, governments and employers should exercise utmost care in utilizing demographic data to make projections about future requirements for physicians and in communicating these projections to young people contemplating a medical career.
Every country should do its utmost to educate an adequate number of physicians, taking into account its needs and resources. A country should not rely on immigration from other countries to meet its need for physicians.
Every country should do its utmost to retain its physicians in the profession as well as in the country by providing them with the support they need to meet their personal and professional goals, taking into account the country’s needs and resources.
Countries that wish to recruit physicians from another country should only do so in terms of and in accordance with the provisions of a Memorandum of Understanding entered into between the countries.
Physicians should not be prevented from leaving their home or adopted country to pursue career opportunities in another country.
Countries that recruit physicians from other countries should ensure that recruiters provide full and accurate information to potential recruits on the nature and requirements of the position to be filled, on immigration, administrative and contractual requirements, and on the legal and regulatory conditions for the practice of medicine in the recruiting country, including language skills.
Physicians who are working, either permanently or temporarily, in a country other than their home country should be treated fairly in relation to other physicians in that country (for example, equal opportunity career options and equal payment for the same work).
Nothing should prevent countries from entering into bilateral agreements and agreements of understanding, as provided for in international law and with due cognizance of international human rights law, so as to effect meaningful co-operation on health care delivery, including the exchange of physicians.
The WHO Global Code of Practice on the International Recruitment of Health Personnel (May 2010) was established to promote voluntary principles and practices for the ethical international recruitment of health professionals and to facilitate the strengthening of health systems. The Code takes into account the rights, obligations and expectations of source countries and migrant health professionals. The WMA was involved in the drafting of the Code and supports its implementation.
The WHO Code states that international recruitment should be “conducted in accordance with the principles of transparency, fairness and promotion of sustainability of health systems in developing countries.”
The monitoring and information-sharing system established by the WHO should be robustly supported with the goal of international cooperation. Stakeholders should regularly collate and share data, which should be monitored and anlaysed by the WHO. The WHO should provide substantive critical feedback to governments. Information should be shared about how to overcome challenges encountered.

Adopted by the 174^th WMA Council Session, Pilanesberg, South Africa, October 2006
and rescinded at the 67^th WMA General Assembly, Taipei, Taiwan, October 2016

There are credible reports that arrangements between the Cuban government and the Bolivian government to supply Cuban physicians to Bolivia are bypassing systems, established to protect patients, that have been set up to verify physicians’ credentials and competence.

The World Medical Association is significantly concerned that patients are put at risk by unregulated medical practices, including the provision of drugs and medical supplies that are improperly labeled and of uncertain origin.

There exists already a duly constituted and legally authorized Bolivian Medical Association, which is charged with the registration of physicians and which is required to be consulted by the Bolivian Ministry of Health.
Therefore, the WMA:

Condemns any collusion of two countries in policies and practices that disrupt the accepted standards of medical credentialing and medical care;
Calls upon the Bolivian government to work with the Bolivian Medical Association on all matters related to physician certification and the practice of medicine and to respect the role and rights of the Bolivian Medical Association;
Urges, as a matter of utmost concern, that the Bolivian government respect the WMA International Code of Medical Ethics that guides the medical practice of physicians all over the world.

Adopted by the 170^th WMA Council Session, Divonne-les-Bains, France, May 2005
and rescinded at the 66^th WMA General Assembly, Moscow, Russia, October 2015

Recognising that the lack of healthcare workers in developing countries, particularly those in sub-Saharan Africa, is one of the most serious global problems of today and that the impact of healthcare worker migration from developing to developed countries is a significant component in the crisis,

Therefore, be it resolved:

That the WMA reaffirms its 2003 Statement on Ethical Guidelines for the International Recruitment of Physicians, particularly para. 14: “Every country should do its utmost to educate an adequate number of physicians, taking into account its needs and resources. A country should not rely on immigration from other countries to meet its need for physicians”; and para. 15: “Every country should do its utmost to retain its physicians in the profession as well as in the country by providing them with the support they need to meet their personal and professional goals, taking into account the country’s needs and resources.”
That developed countries must assist developing countries to expand their capacity to train and retain physicians and nurses, to enable developing countries to become self-sufficient.
That action to combat the skills drain in this area must balance the right to health of populations (Universal Declaration of Human Rights (1948), Article 25.1; International Covenant on Economic, Social, and Cultural Rights (1976), Article 12.1.) and other individual human rights.
That the WMA reconvene the expert working group on physician resources to coordinate development of WMA input to WHO preparations for the decade on human resources for health.
That the WMA commend WHO for taking a leadership role in the global challenges of human resources for health; commend to WHO the afore-mentioned principles (1, 2 and 3); and call upon WHO to convene a global roundtable to discuss HHR issues.