Offering sanctuary to those fleeing war is a pressing human rights issues in the world today. Globally, there are currently 25.4 million people forced to leave their home to seek safety. Half of these people are children. Despite these staggering statistics, governments seem to have ignored their duty of care to children.
Refugee children are children first, and as children, they need special care and assistance. The sudden onset of emergencies, the disruption of families and community structures, as well as the acute shortage of resources, can harm their physical, intellectual, psychological, cultural and social development.
The World has a moral duty to aid and protect refugee children because paying attention to the physical and mental health of refugee children is crucial for their healing, preventing psychopathology and encouraging strength. We should fulfill our humanitarian obligation and welcome, nurture and invest in refugee children whether they are at our doorsteps, or in remote borderlands.
“We are at a watershed, where success in managing forced displacement globally requires a new and far more comprehensive approach so that countries and communities aren’t left dealing with this alone.”
—World Health Organization
Conflicts and war don’t just lead to widespread death but massive displacement, tremendous fear, and economic damage. Conflicts divide communities, deteriorate social relations, and undermine a family’s capacity to care for its most defenseless members, i.e., children. War every year kills and displace countless numbers of children, weakens thousands of others psychologically, and deprives a lot of children from the educational, health, economic and social opportunities which are considered as crucial for their effective growth and wellbeing.
In the 21st century, armed conflicts have grown significantly. The disturbing fact that most modern-day conflicts are domestic, makes children at particular risk. Combat takes place in homes and streets and involves acts of extreme ruthlessness and personal violence. As a result, a large number of people, including children are forced to migrate, which has a considerable impact on their health and well-being. Forced migration of children has a grave impact on their development. Seeking refuge from conflict is a human right and wealthy countries have an ethical duty to help and protect refugee children.
International Migration of Children at a Glance
Article 1 of the 1951 UN Refugee Convention defines refugees as “people whose lives have been torn apart when violence arrives at the doorstep, or when they are persecuted for their religious and political beliefs.” This group of people is pushed from their homes and communities by issues that are out of their control. According to the reports by United Nations High Commissioner for Refugees (UNHCR), in recent years, displacement and international migration have reached a record high number. Every day, 44,400 people are forced to leave their homes because of conflict and oppression. Children and young adults constitute the majority of refugees. Out of 25.4 million refugees, 52% are under the age of 18 years, most of whom will spend their whole childhood away from home, sometimes separated from their families. The following table gives a quick overview of the current situation.
|Total number of people displaced by conflict||68.5 million|
|Refugees||Asylum Seekers||Internally Displaced|
|25.4 million||3.1 million||40 million|
|Top three countries of forced migration||South Sudan||2.4 million|
|Top refugee hosting countries||Turkey||3.5 million|
Source: UNHCR, U. N. R. a. (2018). “Figures at a glance.” Retrieved from http://www.unhcr.org/figures-at-a-glance.html.
The refugee children represent one of the most vulnerable populations in the world and are at risk of ill-treatment, neglect, violence, trafficking, and dangerous survival strategies such as child labor or young marriages.  In the context of migration, the international community has paid very little attention to this most vulnerable group. The world wake ups to help only when a toddler loses the battle of life during forced migration and is washed away on the seashore.
Effects of Conflict and Migration on Child Health
Health is defined as “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”  Despite the fatalities and devastation caused by conflicts, little attention has been given to the health outcomes of these situations on the children who are exposed to disputes.
It is well known that persistent, highly stressful experiences during childhood, like displacement from one’s house and family separation, cause long-term injury to the developing brain, and harms general health as the displaced household suffer a substantial reduction in food provision and worsened access to water and sanitation. 
The existence of a family unit is essential for child survival especially during war. The separation of families due to war and civil disturbance has a significant effect on a child’s physical and psychological development.  In the absence of their parents or caregivers, children become increasingly susceptible to abuse, exploitation, abduction, physical and mental health problems, and death. UNHCR (2017) defines separated children as “those individuals under 18 years of age who are separated from both parents or their previous legal or customary primary caregiver” There were 173,800 unaccompanied and separated refugee children in 2017. Children get separated from their parents during the war while escaping from attacks or trying to avoid forced military recruitment or while looking for food. Parents may die or get killed while fleeing. Occasionally parents have to leave their children at camps with the hope that the children will be safe. Other parents send the children away with the faith that they will seek refuge. Separation can be a challenging experience for both parents and the child.
Effect on Psychological Development
When discussing the psychological impact of family separation on children, the age of the child at the time of separation is the most important factor. If children get separated from the family under the age of 5, they are at high risk because separation at this age disturbs a child’s social development and the growing sense of autonomy.  Their parents are unavailable to help familiarize a child with the world, which makes the appreciation and adjustment to circumstances difficult for them. They feel a permanent loss and feeling of powerlessness. This feeling may manifest in developmental regression (bed- wetting, fear, loss of language).  Children older than five years are generally considered to manage family separation in a better way because they are more self-governing and competent, they have already developed cognitive skills and a little experience of life.
Conflicts can also have a profound impact on a child’s cognition, including “memory, problem-solving and moral reasoning, emotional expression, and social development (parent-child interaction, peer and sibling relations).” Evidence suggests that childhood trauma does affect brain anatomy and function and hormonal and psychophysiological regulation which permanently changes the developmental pathways.  Childhood mistreatment is associated with psychiatric symptoms such as post-traumatic stress disorder (PTSD), depression, anxiety, sleep difficulties, somatization and stress (pre-flight, flight and resettlement stress). 
Effect on Physical Development
Hunger and malnutrition, poor sanitary conditions affect the growth and wellbeing of children. Children residing in the war-torn areas are susceptible to different communicable diseases. The situation does not get better after they flee from their country. In the host countries, governments usually treat arriving migrants as a problem, the examples can be seen all over the world. Host countries do not spend a significant amount of money for the health and optimum sanitation of the refugee camps and detention centers.  Most of these camps are overcrowded and become a source of communicable disease transmission which can result in a disease epidemic.
Forced Migration and Global Health Ethics
Fair and just societies protect children. Justice is the fundamental principle of global health.  We have a duty to the 68.5 billion people who are displaced, and half of them are children. The principles of global health ethics are based on Utilitarian theory and positive and negative duties.  Using these ethical approaches, it can be argued that other countries have positive duties to help alleviate the sufferings and eradicate harm that they did not cause. There are few conditions which give rise to such duties: (1) if there is a dire need (2) the responder is capable of helping (3) the agent is the last hope of help (4) the responder is not being harmed while helping and even though, distance and proximity are only geographical limitation and don’t have moral significance, for practical reason, (5) the potential first responder has to be in close proximity.  This criterion can help us think about our duties to the refugees, especially children.
The society where the crisis is happening bears the primary responsibility to resolve those issues. The government and the opponents in each country under conflict have the negative duty to halt the killings that are triggering the crisis and the positive duty to help remove the suffering. But, the duty to take positive action is not limited to the national border of the affected country.
When the neighbors or even the distant nations become aware of a grave need for help, they come in moral proximity to the people who are suffering. It is also important to consider who can help. A person who doesn’t know swimming does not have a duty to help a drowning child, whereas a good swimmer has a moral duty to respond. When a country is under conflict, neighboring countries have to step up and provide asylum to refugees, especially children, and provide basic facilities to the refugees. Other distant countries have the responsibility to provide economic and other forms of assistance to the neighboring countries and share the burden. It is a test of the commitment of wealthy countries to respect human dignity and equality. If they accept refugees, the contributions these refugees can make for that country will be an indicator that they are ready to accept the obligation of globalization and the concept of global citizenship.
Health, Human Rights, and Forced Migration of Children
Article 33 (1) of the 1951 convention states that ” No Contracting State shall expel or return a refugee in any manner whatsoever to the frontier of territories where his life or freedom would be threatened on account of his/her race, religion, nationality, membership of a particular social group or political opinion.”
Human rights are there to protect people against actions that restrict their dignity and fundamental freedom and are legally guaranteed. These rights are applicable universally and include political, economic, social, and civil rights. International human rights acknowledge that human rights, which include health-related rights apply to refugees as well.
Health is a fundamental human right of every human being that should be enjoyed without discrimination. Vulnerable populations like refugee children require priority attention because, with the arrival of globalization and the increasing international migration, the world has turned into a “Global Village.” This global village has only one global public health. Tuberculosis can be seen as a practical example of the significance of providing health care to migrants. Human rights law and public health obligations require that refugees should be given at least minimum public health protection that is promised to them, but refugees are denied their basic human rights at various stages of migration.
Detention of refugee children at the border
Refugee children arriving in a country without proper paperwork usually face a long process of asylum. Children in US detention centers are the example of the continuity of stress even after reaching a conflict-free area. In the USA, children are detained for up to two years in INS detention facilities, sometimes in juvenile jails while awaiting asylum hearings.  Detention also negatively impact access to health care and the right to privacy. Literature has reported that access to medical care has to under official supervision. 
Screening refugee children at the border
At the border, refugee children are reported according to their health. Some countries use this screening to obtain the necessary information to refer these children to health care, while others use it to block their entry. As refugees only have the right to emergency medical care, these restrictions force them to wait until their condition is grave enough to justify emergency treatment. This criterion is very irrational as minor problems can be treated at early stages before they become serious and require expensive treatment. By ensuring early access to healthcare, there will be no strain on the emergency care service, and health care resources will be used efficiently.
The fear of being reported to the immigration authorities also prevents refugees from seeking healthcare.  The government of host countries should ensure that health care professionals should be committed to the notion of health as a human right and should respect the ethical principle of patient confidentiality.
“The right to health” necessitates authorities to ensure that health facilities are available and accessible to the refugee children without discrimination of race, color, gender, language, religion, physical and mental disability, and health status. Public health initiatives are universal and should be accessible to the entire community.
The right to adequate food and housing
Housing is typically problematic for refugees. Numerous studies have highlighted the frequency with which refugees are forced to stay in impoverished areas of towns and inadequate housing with overcrowding and poor sanitation being the norm. Social difficulties strengthen this further by allowing refugees to reside in selected areas.
The right to education
The right to education is protected by International law for refugee children.  Educational opportunities are as important for human survival as is food, medicine, and shelter. All children, regardless of where they are from or what circumstances encircle them, must obtain an education to appreciate the full potential of what they are capable of accomplishing and contributing to society, and to prevent a vicious cycle of global violence.
Interrupted formal education disadvantages children academically, emotionally, and psychologically. During resettlement, children may be dispersed across schools in a region depending on their placement. They may struggle to engage with peers and become integrated into a foreign classroom.
In many English-speaking countries, refugee children are separated from the larger student body and kept in the classroom for children who speak English as a second language (ESL).  This separation may affect their social integration and put them at high risk for academic failure. Refugee children must be provided with equal opportunities to develop language and literacy skills and should not be deprived of their right to education.
Refugee children fleeing war or persecution can be very vulnerable. They are mostly separated from their families and have no protection from their own country. Good health is considered a pre-requisite for peace and human rights. Paying attention to the physical and mental health of refugee children is crucial for their healing, preventing psychopathology, and encouraging strength. If wealthy countries do not protect refugee children, they may be destined to an intolerable situation where their basic right to life, liberty, and security and even their lives will be in danger. Fillipo Grandi, the United Nation’s High Commissioner for refugees once said:
“We are at a watershed, where success in managing forced displacement globally requires a new and far more comprehensive approach so that countries and communities aren’t left dealing with this alone.” 
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
The authors have disclosed no conflicts of interest.
Affiliations and Correspondence
Asma Fazal, MD
Department of General Pediatrics, Children Health Ireland at Crumlin, Dublin, Republic of Ireland.
Joint Centre of Bioethics, Dalla Lana School of public health, University of Toronto, Canada.
Grattan Court, Inchicore Terrace South, Dublin 8, Republic of Ireland
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