Child migration: from social determinants of health to the development agenda and beyond

Since 2011, there have been over 750,000 combined deaths from violence and non-communicable diseases due to the Syrian crisis (Cousins 2015; New York Times 2016). Millions of people have been displaced, half of them children (Cousins 2015), and over four million Syrian refugees have migrated to neighbouring countries. They face poor food security, unsanitary water and inadequate clothing, and they are susceptible to malnutrition and disease. They live in overcrowded shelters and are vulnerable to sexual abuse, trafficking or recruitment as soldiers (Cousins 2015). This crisis, described more accurately as a ‘refugee crisis’ rather than ‘migration crisis’ (Organisation for Economic Co-operation and Development 2015), has challenged the international community’s moral reflexes, readiness and notion of humanity. In the light of recent tragedies in Syria, the Mediterranean Sea, and beyond, there is an urgent need to consider child migration not only from a human rights perspective, but from a long-term development perspective. Two historical texts, the Convention on the Rights of the Child and the Refugee Convention, provide the substantive human rights framework. Through this prism, Bhabha (2009) eloquently emphasized that child migrants autonomously possess ‘a right to have rights’. Practically securing these rights would have a massive impact on achieving humanitarian law enforcement and, concomitantly, the implementation of relevant social policies. In fact, international organizations and civil society urgently need to elaborate such resilient policies to provide care to the oft-ignored needs of child migrants, who face in host countries the biggest ‘silence of law’ in Thomas Hobbes’s terms. Migration is expected to double to more than 400 million international migrants by 2050 (Miramontes et al. 2015); it is clearly a long-term problem. However, rhetoric regarding what actions should be taken regarding child migrants are usually considered in the immediate term and take the form of ‘return them to their countries’ or ‘do not let them cross our borders’. Hostile as

it may sound, many people intentionally ignore the fact that significant numbers of migrants are young, disoriented children. Even as children, migrants are often considered outlaws that should be ostracized, an attitude pervaded by nationalistic attitudes and xenophobic sentiments. Ignoring the fact that many children are struggling with the difficulties that migration creates calls our humanity -and the role of international organizations -into question. To deport children back to their countries of origin and condemn them to lifelong poverty is an act of brutality from a humanistic perspective (Mentis 2015).

Child migration: an emerging social determinant of health
The health hazards faced by children during their journeys to the 'Promised Land' , an Odyssey of the modern world, must be considered in tandem with the health hazards generated by the underlying causes of migration, their communities of origin and their standards of living. Tractable and long-term solutions to health hazards are essential so that stakeholders can be held accountable not only for the fate of child migrants but also the effect on wider society. First, prejudices must be tackled. For example, contrary to lay misconceptions, epidemiological studies show that the majority of infectious diseases affect migrants after entry into the recipient country, as most refugees are young and previously healthy (Tsiodras 2016;Khan et al. 2016). The spread of such diseases is avoidable if treated appropriately in a suitably resourced shelter system with medicines, vaccines and specialized medical personnel who can provide health services including counselling.
Even more broadly, these children are in urgent need of access to better physical and psychological health (i.e. due to war-related post-traumatic or acculturative stress), and a child-, gender-and culture-friendly protective environment to engender future self-sufficiency, including health literacy, and ultimately the right to 'self-determination' . This fundamental right for all people to choose their personal destiny can and should be expanded to those under age, because children are children with no punctuation, including quotation marks. In parallel, threatening the humane treatment of children with dental age testing (putting aside the inaccuracy of the test itself) -as witnessed recently in the 'Jungle' camp in Calais and endorsed by British politicians and the tabloid press -is much more damaging than any unjustified fear of admitting small numbers of ineligible individuals. It also represents a lack of historical memory (i.e. the mistakes made in the deportation of European children during the post-war period).
Migration results in persistent physical and mental stress. These hardships do not automatically resolve if and when migrants reach their destination country due to frequent socio-economic or other exclusions. Relatively unexplored, child migration demands further research to enforce best practices on how to respond to their health needs (Bocquier et al. 2011). I postulate that addressing the social determinants of health (SDH) would be a good step towards long-term solutions. SDHs are defined by the WHO as 'the circumstances in which people are born, grow up, live, work and age and the systems put in place to deal with illness' (WHO 2016). While migration is accepted as being socially determined, considering it an SDH is much more recent (Castañeda et al. 2015). Migration is a catalyst for risk, with migrants struggling to access public health services. Since migration is becoming an integral part of socialization, understanding how SDH such as the migrants' living conditions, poverty, access to food, employment issues, social services and legal status affect child migrants' health is imperative. Therefore, consonant with previous studies (Miramontes et al. 2015;Davies, Basten, and Frattini 2009), child migration, which negatively impacts health status and well-being, should be regarded as an SDH in its own right and separately from cultural, ethnic or religious factors. This approach provides an important conceptual framework for addressing children's health and its challenges, invigorating how to approach the unique needs of not only child migrants but also coevals of the host country with whom they will interact, e.g. while in school. This definition also has an operational function by prompting novel field research and health-generating policy in response to the global growth in migration. As children, let alone as unaccompanied minors or asylum seekers, they are unable to protect their health so there is a dire need for societal interventions (Frieden 2015). To this end, characterizing child migration as an SDH, not least associated with human rights issues, can only be helpful. Efforts to understand and develop appropriate policies for child migrants are the responsibility of public health researchers and practitioners. Measures that ought to be implemented include: (i) ameliorating adverse conditions that affect the daily lives of child migrants; (ii) increasing public awareness of this issue; and (iii) confronting the structural determinants of these conditions, namely inequity, across the entire spectrum (Marmot et al. 2008).
Approaches that deal with SDHs are behavioural, cultural and structural, as presented elsewhere (Castañeda et al. 2015). Expanding on this article's elements, the behavioural approach might focus on improving personal hygiene (e.g. through educational workshops), on standards of living, and on emphasizing the role of parents in taking adequate care of their children; however, this neglects the social determinants of poverty and inaccessibility of food and health services. The cultural approach focuses on maintaining positive cultural practices but only partially addresses health issues arising from community influences due to shared beliefs and traditions. Finally, the structural approach deals with social disparities that adversely affect access to health care such as racial discrimination and social exclusion.

Child migrants and the development agenda
The actions taken by the WHO on migrant health, which is regarded as 'one of the most pressing moral issues facing the world' , include policy formulation, assessing health systems, and providing in-field technical assistance (Jakab et al. 2015). The 61st World Health Assembly already addressed a call to 'promote migrant-sensitive health policies' (Miramontes et al. 2015). In this context, all relevant international organizations should formulate policies that respect this value-laden issue.
A major reason for the doubling of life expectancy during the twentieth century has been the reduction in child mortality (Frieden 2015). As a source of future human capital from the twenty-first century onwards, even a single child's health is of intrinsic interest, in accordance with the UN Agenda for Sustainable Development Goals (SDG) context to 'leave no one behind' and 'endeavour to reach the furthest behind first' (The Lancet 2016). Indeed, every person has the right to enjoy the 'highest attainable standard of physical and mental health' (Bhabha 2009).
Aside from the general conclusion from a World Economic Forum survey that 'large-scale involuntary migration [is] one of the greatest risks to the world economy' (Khan et al. 2016), economists should examine the potential health consequences of child migration given its exponential growth. Physical and mental health are equally important for creating an efficient, effective and welltrained workforce. Most developed countries are disproportionally burdened with the expenses caused by demographic problems, resulting in budget deficits and the deterioration of insurance systems. The socio-economic integration of migrants could partially alleviate the above problem, which currently shows no sign of reversing. Sociocultural integration into a new environment is much easier for minors if the necessary conditions are met. Instead of posing questions such as 'do these people threaten our status quo?' we would be better off reflecting on the potential mutual benefits of integration. Accordingly, the emphasis should be placed on children's health perspectives given that investing in health, a productivity factor, provides at least nine times the value of investing in socio-economic factors (Jamison et al. 2013).
Failing to recognize the needs and rights of child migrants threatens the implementation of the SDGs. Malnutrition (sustainable goal number 2.2), obstacles to free and equitable education (4.1), discrimination against girls (5.1), often forced marriage (5.3), and a lack of safe drinking water (6.1), and adequate sanitation (6.2), are all prevalent during migration, and work against achieving the SDGs. Underestimating the situation or marginalizing child migrants is also a threat to good quality early childhood development (4.2). Given the importance of early childhood development in health and its deterioration (including cancer and ageing) (Mentis and Kararizou 2010), early childhood programmes must include child migrants to improve physical and behavioural health that persists into adulthood (Campbell et al. 2014). Developed countries need to understand that preserving and fostering the health of child migrants -full of hope and with a zest for life -will benefit their economies, such as via a reduction in morbidity-related labour market costs when the children become adults. Given the interrelated nature of development and health -with one being a precondition of the other (Dora et al. 2015) -child migration should be highly ranked on the SDGs. Concurrently, the so-called 'health in all policies' can also be implemented with respect to child migrants.

Human ontology: from the focus on to the step beyond the development agenda
In contrast to the zeal of NGOs and many common citizens, governments have often failed to show adequate interest towards the current refugee crisis, let alone child migrants. Regrettably, there is no foreseeable hope of improvement in this situation if these governments continue their inaction. Decision-makers have become rather myopic; having entered adulthood they seem incognizant -or even apathetic -to the undeniable calamities and mishaps facing child migrants. This has not gone unnoticed: the political declaration from the High-Level Summit at the 2016 UN General Assembly has been criticized for its vagueness and legally non-binding character (The Lancet 2016). Even if this declaration was less obscure, it would not reverse the prevailing 'de facto rightlessness' of child migrants (Bhabha 2009), to whom the interplay between legal frameworks (i.e. the 'de jure'), and reality (i.e. the 'de facto') is meaninglessly complex.
More than ever, the refugee crisis is rhetorically presented as a short-term humanitarian crisis. Empathic as it may sound, this well-publicized approach fails to deal with the deeper character of the crisis, which is a combined human rights issue and long-term development issue. In other words, what is practically threatened by this crisis is 'the right to development' . The above, albeit actually not enshrined, constitutes 'an inalienable human right by virtue of which every human person and all peoples are entitled to participate in [and] contribute to' where 'the human person is the central subject of development and should be the active participant and beneficiary of the right to development' (United Nations 2016). It is also a development issue in the sense that the failure of global governments to bridge the inequity gap (both intra-and inter-nationally) is a major trigger of waves of refugees, including children (Khan et al. 2016).
It is with this perspective that child migration as an SDH will continue to threaten the SDGs unless action is taken. However, with regard to whether this action should be limited to the institutional level, I propose an ontological approach according to its classical definition: meaning a child's being and existence as having value in its own right. Although autopsies on child migrants recently lost in the Mediterranean Sea were not possible, their lifeless bodies echo the words of George Seferis, Nobel Laureate: 'So many bodies thrown into the jaws of the sea … so many souls fed to the millstones like grain' . The cause of their death was the strong desire for life. It is in this ontological context that the humanitarian approach, the SDHs, and the SDGs can be mutually integrated (Sami et al. 2014); it is both a desideratum and a moral imperative of our society. Overall, improving the lives of vulnerable children can only benefit our future.