The United Nations (UN) defines an international migrant as “any person who changes his or her country of usual residence.”1 Migration can be voluntary or involuntary, the latter being considered reluctant when situations encourage relocation or forced when people relocate to avoid direct harm.2 Forced relocation occurs within a country or across countries for asylum seekers and refugees who cannot return home.2 The rise in violence worldwide raises questions if international agreements secure the health rights of various types of migrant minors and what more can be done.
The political crisis at the United States’ southwestern border exemplifies how health rights vary by migrant type. Since 2016, 147 745 unaccompanied minors and 253 000 families with at least 1 child aged ≤18 years have migrated from 4 countries to escape violence.3 El Salvador, Guatemala, Honduras, and Mexico have homicide rates of 82.84, 27.26, 56.52, and 19.26 per 100 000 people, respectively, compared with a global average of 5.30.4 Invoking national security, the Department of Homeland Security (DHS) has discouraged asylum seekers from illegal border crossings by separating children from adults, who are tried for prosecution,5 leading to >2737 separations in 2018.6 Unaccompanied minors and families are processed at centers whose conditions are inconsistent with American Academy of Pediatrics (AAP) guidelines on caring for children.7 Minors released into the public for asylum hearings must determine if local laws cover health services because there is no uniform national policy. DHS arranges services for detainees,8 which have not followed evidence-based guidelines.9 UN officials have found that although 48% of asylum seekers migrated to escape threatened or actual harm, the remainder migrated voluntarily or reluctantly for better social, economic, and political circumstances.10
Conflicts in the Middle East demonstrate how migrant minors face health restrictions during humanitarian emergencies. The Iraq War has produced >277 000 refugees, 13 000 asylees, and 47 000 stateless persons.11 The Syrian Civil War has produced >18 000 asylees and 160 000 stateless persons11 with >5 637 000 refugees abroad.12 Lebanon accepted >1 million Syrians by June 2017; although 58% of households included children aged ≤5 years, only 17% registered children as refugees, limiting access to government health care.13 Jordan accepted >660 000 Syrian refugees, most of whom are minors, but nearly half of those aged ≤5 years cannot access vaccinations, and 16% have no birth certificate.14 Parents joining militant groups have also forcibly relocated children. In Syria, officials have detained 1200 children from 44 countries whose relatives joined the Islamic State of Iraq and the Levant.15 Over 800 children of foreign fighters from 14 countries are jailed in Iraq.16 Minors can be prosecuted as adults for terrorism-related charges from the ages of 9 years in the Netherlands and 12 years in Belgium.17 Belgium, Germany, and the United Kingdom use DNA tests to determine if these minors’ parents are citizens, but orphans will likely not be repatriated.17 Migrant youth without legal identities, due to parental oversight or government policies, are stateless with limited health access.
Militant groups have forced minors to migrate for combat. In Syria, Islamic State,18 Hezbollah,19 Kurdish,20 and opposition forces21 have enlisted boys aged ≤16 years, leading to >200 deaths.20 In Yemen, government and Houthi movement forces recruited 842 boys by 2017, some 11 years old.22 By 2014, government and rebel forces recruited >9000 children in South Sudan.23 The Lord’s Resistance Army has abducted >20 000 children, internally displacing >1.7 million Ugandans24 and >430 000 people in the Central African Republic, the Democratic Republic of the Congo, and South Sudan.25
These diverse settings share 2 trends: the transnational effects of contemporary violence and threats to the health rights of migrant minors.
International Agreements Protecting Health Rights for Migrant Youth
International laws require children displaced within a country to have access to their government’s health system.26 In contrast, human rights agreements protect migrant children.27 The Universal Declaration of Human Rights (1948) enshrines the rights of legal recognition as a person, asylum in other countries to flee persecution, a nationality, and a standard of living adequate for health.28 Geneva Convention IV protects civilians during war, specifying that children <15 years old and separated from families shall be entrusted to adults from a “similar cultural tradition,” warring parties shall facilitate family reunifications, and governments shall register children’s parentage.29 Protocol I of the Geneva Conventions specifies that parties shall not recruit children <15 years old into armed forces without exceptional circumstances.30 The UN Convention Relating to the Status of Refugees and its 1967 protocol protect guardianship and adoption rights for refugee minors, prohibiting countries from repatriating those whose lives or freedoms would be threatened because of race, religion, nationality, membership in a social group, or political opinion.31 Goal 16 of the UN’s Sustainable Development Goals (SDGs) promotes peaceful and inclusive societies for sustainable development, justice for all, and effective, accountable institutions.32
Certain agreements protect children. The UN Declaration of the Rights of the Child enshrines rights to a nationality and basic medical services.33 The UN Convention on the Rights of the Child asks states to register children after birth to prevent statelessness, avoid family separations except during parental abuse and neglect, provide relatives with contact information when separation occurs, reunite families expediently, adhere to international treaties on child protection, and provide access to primary health care.34 The Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict encourages state and nonstate actors to prevent children <18 years old from armed recruitment or combat.35 The UN International Children’s Emergency Fund interprets SDG 16 as reducing all violence and death for minors; ending child abuse, trafficking, and exploitation; and ensuring a legal identity for all by 2030, including birth registration.36
The countries above risk violating international laws that protect migrant children. The United States has separated families of asylum seekers and not provided evidence-based health services to youth consistently. Lebanon and Jordan have not registered children for legal identities despite acknowledged lapses. Belgium, Iraq, the Netherlands, and Syria have processed children of foreign fighters through criminal justice systems rather than safeguarding their legal rights. Belgium, Germany, and the United Kingdom may not honor the citizenship rights of children without DNA tests. State and nonstate actors in South Sudan, Syria, Uganda, and Yemen have conscripted children. What more can be done to protect minors?
Migrant Health and International Advocacy
The World Health Organization encourages collaborations between governments, nongovernmental organizations (NGOs), and individuals to end violence by exchanging knowledge, policies, and interventions.37 The AAP and International Pediatrics Association (IPA) can lead advocacy for migrant minors consistent with their goals to improve health for all children everywhere.38,39 Although the AAP is the United States’ national pediatric society, and the IPA represents pediatricians internationally, with 139 national, 10 regional, and 13 specialty societies,40 the AAP works with and through the IPA. AAP members serve in the IPA’s leadership, advise technical groups, and organize humanitarian responses; indeed, the Turkish Pediatric Association coordinated care for Syrian refugees in Turkey, Lebanon, and Jordan.41 The AAP also independently consults for US, UN, and World Health Organization policy makers on child health.42
With calls for pediatricians to participate in global health through direct care, research, and advocacy,43 how can the AAP and IPA address these conflicts? The AAP’s 2016 Blueprint for Children focuses on children fleeing violence, with domestic and international recommendations.44 Coordinating national and international actions can highlight the transnational dimension of violence. For example, the AAP, IPA, and Turkish Pediatric Association partnership is a model for national pediatrics societies to provide care within a country while cooperating internationally. Advocacy could encompass SDG 16 to register all asylee and refugee children from Iraq and Syria, involving UN agencies and the Union of Arab Pediatric Societies as needed. In the United States, the AAP advocates for avoiding family separations, closing family detention centers, and ensuring that all children receive comprehensive health services irrespective of legal status, consistent with international agreements.44 Through the IPA, the AAP could collaborate with Salvadoran, Guatemalan, Honduran, and Mexican pediatrics societies and the Asociación Latinoamericana de Pediatría and Pan American Health Organization to coordinate services for minors along paths of migration. A regional response matches DHS’s recent policy to shelter asylum seekers in Mexico.45
Finally, all parties should abide by The Paris Principles to disarm children for societal reintegration.46 Compared with voluntary migrants, children in conflicts have greater protections under international agreements, such as health care access47 and freedom from prosecution as victims of violence.46 The UN has worked with governments in the Central African Republic, the Democratic Republic of the Congo, South Sudan, and Yemen to reintegrate child soldiers.48 Recognizing that the human rights approach to SDG implementation suffers from voluntary national reviews, the UN’s accountability mechanisms include referrals to its Human Rights Council and specific treaty bodies for independent investigations.49 The UN International Children’s Emergency Fund has partnered with NGOs to provide technical assistance for governments, forward information to UN Security Council Sanction Committees, and refer parties to justice mechanisms, such as the International Criminal Court.50 The AAP, IPA, and other pediatric societies could explore such advocacy, partnering with human rights NGOs and UN agencies to hold parties accountable in Europe, the Middle East, and Africa so that all children, irrespective of any affiliation to armed groups, have the right to the highest standards of health.
FUNDING: No external funding.
American Academy of Pediatrics
Department of Homeland Security
International Pediatrics Association
Sustainable Development Goal
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.