Comment

www.thelancet.com Published online February 8, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30332-X 1

The academic case for repealing Trump’s refugee and travel banAcademics provide education and undertake research to improve understanding, and hopefully make the world a better place. US President Donald Trump’s recent executive order on Jan 27, 2017,1 banning travel to the USA from seven predominantly Muslim countries (Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen) for 90 days, suspending the US resettlement programme for all refugees for 120 days, indefinitely suspending the entry of Syrian refugees, and reducing the number of resettled refugees from 110 000 to 50 000, has dramatically and negatively affected millions of people’s lives. Academics from around the world have an obligation to provide quality evidence to students, the public, and policy makers about the impact of this order to ensure informed decisions are made. Toward this end, faculty at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, MD, USA, sent the President a letter2 urging him not to sign what was then a draft order, and after its release held a symposium on the executive order and emerging public health crisis on Feb 2, 2017.3 We encourage others to do the same.

The Syrian war has had devastating and long-lasting effects on Syrians and the region. Over 13·5 million people have fled their homes with 6·3 million displaced in Syria and 4·9 million living as refugees scattered throughout the region.4 Syrians constitute the world’s largest refugee population today and the worst exodus since the Rwandan genocide in 1994. About half of registered Syrian refugees living in the region are children and about half are female.4 According to a World Bank and United Nations High Commissioner for Refugees (UNHCR) study, almost 90% of registered Syrian refugees living in Jordan are economically poor or expected to be poor in the near future.5 Over half of Syrian refugees in Lebanon have at least one chronic disease and endure substantial out-of-pocket medical expenses,6 while for refugees in Jordan the cost of care and medicines are major barriers to accessing health care.7 Although data are limited, high levels of gender-based violence and mental health illness have been widely reported among Syrian refugees.8,9

Most refugees chosen for resettlement in the USA are women and children. The current screening process for refugees involves multiple layers of security checks by many US security agencies before entry into the country.

Syrian refugees have additional checks. The average time for process is 18–24 months but it can take much longer10 and is one of the most vigilant on the globe. Furthermore, since the US Refugee Act of 1980 was established, no refugee has been implicated in a major fatal terrorist attack in the USA, and since the 1970s only 20 refugees have been convicted of committing or attempting a terrorist act.11

During previous work with the UNHCR, one of us (PS) travelled repeatedly to Jordan and Lebanon and met with many Syrians from all walks of life. Their living conditions were often dire and worsening by the day as their limited resources dwindled. Chronic medical conditions and difficulties in getting treatment were the norm, mainly because they could not afford treatment; even when such care was free, transportation to the clinics proved too expensive for some. Every Syrian expressed a desire to return to their beloved homeland as soon as they could, but that was impossible. Despite the UN Security Council Resolution 2286 on May 3, 2016, that “Strongly condemns acts of violence, attacks and threats against the wounded and sick, medical personnel and humanitarian personnel exclusively engaged in medical duties,…”12 and demands an end to impunity for those responsible and respect for international law on the part of all warring parties, such attacks continue.13 One Syrian doctor from Aleppo was very upset and frustrated. Many of his fellow health-care workers and friends in Syria had been killed by

Published Online February 8, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30332-X

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2 www.thelancet.com Published online February 8, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30332-X

the deliberate attacks on health-care facilities and personnel. Eventually, he fled to Jordan. But he and thousands of other Syrian health-care personnel are not licensed to practice in their countries of asylum. He remains stuck in Jordan with nowhere to go.

After the US refugee and immigration ban went into effect, it immediately began to have a negative effect on much needed humanitarian aid and technical support, particularly in Iraq, Lebanon, Somalia, Syria, and Yemen. Ambiguity regarding travel to and from these seven countries, particularly for those with dual citizenship and those who are in the USA with work visas, caused confusion. Reciprocal travel bans from some of the seven countries is also a possibility. This would limit the capacity of the US Government and American non-governmental organisations to respond to crises in these countries.

The effects of President Trump’s executive order are being felt globally. The ability of American universities to provide education to students from across the world is important not only for the USA—where students often stay and become leaders in their field—but also for those countries that benefit from their return. The rebuilding of countries after war needs well educated people with a world view; Ellen Johnson Sirleaf, the President of Liberia, is one such example. Given the horrific suffering of the Syrian people, and in solidarity with our colleagues in the health profession, Johns Hopkins Bloomberg School of Public Health in conjunction with the Johns Hopkins Center for Humanitarian Health offered two full scholarships to any qualified Syrian affected by the conflict. The response was tremendous. These scholarships are now in jeopardy. This is just one example of the many negative effects of the ban.

Many foreign students from the seven countries who are studying at US universities are fearful to leave the country to visit family and friends in case they will not be allowed re-entry to the USA. Muslim students from these countries have voiced their concerns and anxiety after the executive order.14

The ban will damage the essential collaboration among US scientists and others in those seven countries and possibly beyond. Former White House science adviser John Holdren under the Obama Administration, recently stated that “if the ban is maintained, it will damage a wide array of collaborations in science and technology around the world”.15 The ban could ultimately affect the health security of the USA by

reducing understanding of the epidemiology of existing and emerging diseases in conflict zones and of surveillance and detection of such diseases.

Suspending the US refugee resettlement programme and ending it indefinitely for Syrian refugees with a temporary travel ban from seven countries does not bring any security gains. It does, however, impose tremendous human costs that can condemn men and women, their children, and even future generations to lives of suffering and desperation. We, as academics, have a responsibility and a duty not to ignore this suffering, and to provide evidence and data in a non-biased manner that illuminates the important issues for policy makers and the public.

*Paul Spiegel, Leonard RubensteinCenter for Humanitarian Health, Johns Hopkins University, Baltimore, MD 21205, USA (PS, LR); and Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (LR) pbspiegel@jhu.edu

PS is the Director of Johns Hopkins Center for Humanitarian Health. We declare no competing interests.

1 The White House. Executive Order: Protecting the nation from foreign terrorist entry into The United States. Jan 27, 2017. https://www.whitehouse.gov/the-press-office/2017/01/27/executive-order-protecting-nation-foreign-terrorist-entry-united-states (accessed Feb 7, 2017).

2 Klag MJ, Baral S, Barry C, et al. Letter from faculty at the Johns Hopkins Bloomberg School of Public Health to President Trump. Jan 27, 2017. http://www.jhsph.edu/research/centers-and-institutes/center-for-refugee-and-disaster-response/News/Johns-Hopkins-faculty-urge-Trump-to-not-issue-Executive-Order-halting-refugee-admissions.pdf (accessed Feb 7, 2017).

3 Johns Hopkins Bloomberg School of Public Health. The executive order on refugees: an emerging public health crisis. Feb 2, 2017. http://www.jhsph.edu/events/2017/the-executive-order-on-refugees/index.html (accessed Feb 7, 2017).

4 UNHCR. Syria emergency. 2017. http://www.unhcr.org/en-us/syria-emergency.html (accessed Feb 6, 2017).

5 Verme P, Gigliarano C, Wieser C, Hedlund K, Petzoldt M, Santacroce M. The welfare of Syrian refugees: evidence from Jordan and Lebanon. Washington, DC: World Bank, 2016. https://openknowledge.worldbank.org/handle/10986/23228 (accessed Feb 6, 2017).

6 Doocy S, Lyles E, Hanquart B, Team LS, Woodman M. Prevalence, care-seeking, and health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon. Confl Health 2016; 10: 21.

7 Doocy S, Lyles E, Akhu-Zaheya L, Burton A, Burnham G. Health service access and utilization among Syrian refugees in Jordan. Int J Equity Health 2016; 15: 108.

8 Yasmine R, Moughalian C. Systemic violence against Syrian refugee women and the myth of effective intrapersonal interventions. Reprod Health Matters 2016; 24: 27–35.

9 Hassan G, Ventevogel P, Jefee-Bahloul H, Barkil-Oteo A, Kirmayer LJ. Mental health and psychosocial wellbeing of Syrians affected by armed conflict. Epidemiol Psychiatr Sci 2016; 25: 129–41.

10 US Refugee Admissions Program. US Department of State. https://www.state.gov/j/prm/ra/admissions/ (accessed Feb 4, 2017).

11 Nowrasteh A. Terrorism and immigration: a risk analysis. Polcy Analysis Sept 13, 2016. Washington, DC: Cato Institute, 2016. https://object.cato.org/sites/cato.org/files/pubs/pdf/pa798_1_1.pdf (accessed Feb 6, 2017).

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12 UN. Security Council Adopts Resolution 2286 (2016), strongly condemning attacks against medical facilities, personnel in conflict situations. May 3, 2016. http://www.un.org/press/en/2016/sc12347.doc.htm. (accessed Feb 6, 2017).

13 Syrian American Medical Society. The failure of UN Security Council Resolution 2286 in preventing attacks on healthcare in Syria. January, 2017 https://foundation.sams-usa.net/wp-content/uploads/2017/01/UN-fail-report-06.pdf (accessed Feb 7, 2017).

14 Al-Mowafak HM. I’m afraid it will make terrorism worse. The New York Times, Feb 6, 2017. https://www.nytimes.com/2017/02/06/opinion/im-afraid-it-will-make-terrorism-worse.html?ref=opinion&_r=0 (accessed Feb 7, 2017).

15 Maxmen A. Obama science adviser: Trump immigration ban “an abomination”. Scientific American, Jan 31, 2017. https://www.scientificamerican.com/article/obama-science-adviser-trump-immigration-ban-ldquo-an-abomination-rdquo/ (accessed Feb 7, 2017).