Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants: technical guidance

Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants Technical guidance The Migration and Health programme The Migration and Health programme, the first fully fledged programme on migration and health within WHO was established at the WHO Regional Office for Europe to support Member States to strengthen the health sector’s capacity to provide evidence- informed responses to the public health challenges of refugee and migrant health. The programme operates under the umbrella of the European health policy framework Health 2020, providing support to Member States under four pillars: technical assistance; health information, research and training; partnership building; and advocacy and communication. The programme promotes a collaborative intercountry approach to migrant health by facilitating cross-country policy dialogue and encouraging homogeneous health interventions along the migration routes to promote the health of refugees and migrants and protect public health in the host community. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants Technical guidance Abstract This technical guidance outlines current evidence, knowledge and best practice relating to incidences of violence and injuries among refugees and migrants in the WHO European Region. It highlights key principles, summarizes priority actions and challenges, maps existing international commitments and frameworks and provides practical policy considerations for preventing and responding to such challenges. Specific areas for intervention include ensuring safe passage for migration; addressing causes of violence and injuries in transit and destination countries, including changing norms and values; identifying victims and providing care and protection; investigating and prosecuting perpetrators; and strengthening the knowledge base. While the main intended audience of this technical guidance series are policy-makers across sectors at local, national and regional levels, the contents of this publication will also be of value for health-care practitioners and law enforcement and border protection officials. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). 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In no event shall WHO be liable for damages arising from its use. iii Contents Acknowledgements ......................................................................................iv Abbreviations ................................................................................................v Summary ......................................................................................................vi Introduction ...................................................................................................1 Objectives .........................................................................................................................3 Methodology ....................................................................................................................3 Current evidence ...........................................................................................5 Injuries associated with different migratory modes of transport ...............................5 Violence and intentional injuries en route .....................................................................6 SGBV .................................................................................................................................7 Human trafficking and smuggling..................................................................................8 Occupational injuries and violence ................................................................................9 Racially incited violence and hate crimes, and religious discrimination ..................10 What is not known on this topic ...................................................................................11 Areas for intervention ..................................................................................12 Ensure safe passage for migration ..............................................................................12 Address causes of violence and injuries in transit and destination countries ........15 Identify victims and provide care and protection .......................................................20 Investigate and prosecute perpetrators ......................................................................25 Strengthen the knowledge base ..................................................................................27 Policy considerations ..................................................................................30 Ensure safe passage for migration ..............................................................................30 Address causes of violence and injuries in transit and destination countries ........31 Identify victims and provide care and protection .......................................................31 Investigate and prosecute perpetrators ......................................................................32 Strengthen the knowledge base ..................................................................................32 References ..................................................................................................34 Annex 1. Global policies and publications on addressing violence and injuries among refugees and migrants .........................................................46 iv Acknowledgements The technical guidance series on the health of refugees and migrants in the WHO European Region was produced as part of the WHO Knowledge Hub initiative on Health and Migration under the aegis of the Migration and Health programme of the WHO Regional Office for Europe. We would like to thank Santino Severoni, Special Advisor, Migration and Health and Acting Director on Health Systems and Public Health, who leads the Migration and Health programme, including the Knowledge Hub on Health and Migration and related scientific production, within the Office of the Regional Director, WHO Regional Office for Europe. This Technical Guidance on Strategies and Interventions on Preventing and Responding to Violence and Injuries among Refugees and Migrants was authored by Gianfranco Costanzo, Rosario Asciutto, Alessio Petrelli, Anteo Di Napoli, Andrea Cavani and Concetta Mirisola from the National Institute for Health, Migration and Poverty of Italy (INMP) and Kari Pahlman (Consultant, WHO Regional Office for Europe). This publication was produced with contributions at all stages from experts within the Migration and Health programme of the WHO Regional Office for Europe: Santino Severoni; Jozef Bartovic (Technical Officer), who coordinated production; Kari Pahlman (Consultant); Simona Melki (Programme Assistant); Soorej Jose Puthoopparambil (Consultant) and Elisabeth Waagensen (Consultant). The Expert Working Group for Violence and Injuries among Refugees and Migrants further contributed technical advice and expertise. We thank Alexander Butchart (WHO), Bernadette Kumar (Norwegian Institute for Public Health), Jonathan Passmore (WHO Western Pacific Region), Sabine Rakotomalala (Global Partnership to End Violence Against Children), Katsuri Sen (Oxford University) and Yongjie Yon (WHO Regional Office for Europe) for their support in finalizing this publication. vAbbreviations EU European Union GRETA Council of Europe Group of Experts on Action Against Trafficking in Human Beings INMP National Institute for Health, Migration and Poverty, Italy IOM International Organization for Migration MSF Médecins Sans Frontières NGO nongovernmental organization SDG Sustainable Development Goal SGBV sexual and gender-based violence SOGIESC sexual orientation, gender identity and expression, and sex characteristics UNICEF United Nations Children’s Fund UNHCR United Nations High Commissioner for Refugees UNODC United Nations Office on Drugs and Crime vi Summary With more than 70 million people forcibly displaced worldwide as a result of persecution, conflict or generalized violence, global displacement in 2019 is at its highest since the Second World War. At the end of 2018, the United Nations High Commissioner for Refugees (UNHCR) reported that the 49 countries of its European Region hosted more than 6.47 million refugees, more than 1.24 million asylum seekers, 2.71 million internally displaced people and more than 0.5 million stateless people. Refugees and asylum seekers are among the 90.7 million international migrants in the WHO European Region, which accounted for 35% of the global international migrant population and was almost 10% of the European population. Refugees and migrants are at risk for both unintentional injuries (e.g. boating and traffic accidents) and intentional injuries. The latter can result from intrapersonal, self-directed and collective violence, including trafficking, torture, sexual and gender- based violence (SGBV) and exploitation. Violent incidences may occur before departure, during transit and at destination. Generally, many laws and regulations are already in place for the prevention of violence and the protection of vulnerable groups across the WHO European Region. However, problems often stem from lack of awareness of such legislative mechanisms or failure to enforce them. Moreover, violence and punitive approaches to refugees and migrants are bolstered by the current political rhetoric within the WHO European Region regarding migration; such rhetoric is a major contributory factor for risk of violence towards migrant groups and their ongoing insecurity. This technical guidance outlines five key priority areas for intervention in order to effectively respond to and prevent violence and injuries among refugees and migrants in the WHO European Region: „ ensure safe passage for migration „ address causes of violence and injuries in transit and destination countries „ identify victims and provide care and protection „ investigate and prosecute perpetrators „ strengthen the knowledge base. Ensure safe passage for migration Very often, refugees and migrants come to the WHO European Region to escape insecurity, conflict, persecution and poverty, and are left little choice but to migrate irregularly and in unsafe conditions. Consequently, interventions are needed to reduce the toll on human life, and the violence and injuries that occur en route and in destination countries. Expansion and diversification of the available longer-term options for regular migration through resettlement and complementary pathways for admission would help to ensure safe, orderly and regular migration. Member States vii also need to ensure that national and regional responses to irregular migration (e.g. border closures and pushback practices) do not increase the vulnerability of these groups. Greater solidarity with transit and refugee-hosting countries outside of the Region could strengthen access to protection in locations where refugees and migrants are found. It may also be critical to provide viable alternatives to dangerous journeys. Address causes of violence and injuries in transit and destination countries Violence and injuries in transit and destination countries include human trafficking for forced labour and sexual exploitation, insecurity in refugee and migrant reception/ detention centres, unsafe working conditions and racially incited and religiously driven violence. Existing policies and mechanisms need to be strengthened to increase the visibility of trafficking and reduce risk factors for refugees and migrants travelling to and within the Region. Efforts should be in place to reduce the demand from employers, consumers and third parties that can facilitate trafficking, and to punish those who knowingly use services of trafficking victims. Punitive measures must end in reception and detention centres, particularly for children, and alternatives models put in place. Interventions for unsafe labour conditions include promoting channels to safely access the labour market, reducing pressures that encourage working illegally and protecting labour migrants, who may be subject to exploitation irrespective of immigration status. Adopting supportive legislation to ensure protection of human rights of migrant sex workers is also important. Finally, there needs to be meaningful inclusion of refugees and migrants with host populations to reduce discriminatory violence. Penalties ought to be imposed on media outlets that publish misinformation and so-called hate speech in the context of migration issues. Identify victims and provide care and protection Identification of refugee and migrant victims of violence and injuries can be challenging but is essential if appropriate care, including health care, and protection are to be provided. Capacity-building is needed among the relevant professions to help them to identify, communicate with and refer suspected victims of trafficking and exploitation. It is also important to have mechanisms at borders for such identification and referral so that children, victims of trafficking and other vulnerable subgroups have immediate access to health services, psychological support and legal aid. Providing information about how to identify violence and exploitation and how to get access to support services in multiple languages is important, as well as partnering with social sector organizations who provide such services. Furthermore, policies need to be in place that ensure victims of SGBV and domestic violence are supported to leave abusive relationships without consequences to their migration or residence status. Investigate and prosecute perpetrators Where violence and injury is not investigated and perpetrators appropriately dealt with, such incidences can continue with impunity. Member States have a responsibility viii and obligation under international law not only to prevent violent crimes against refugees and migrants but also to act with due diligence to investigate such crimes and prosecute perpetrators. Member States need to advocate for enhanced cross-border cooperation to investigate and prosecute traffickers at all stages of the trafficking chain, including linking with relevant stakeholders such as trade unions, which may be well placed to help states in this capacity. Investigating incidences of violence against migrant workers and prosecuting exploitative employers and recruitment agencies will also be important. Further mechanisms must be in place to investigate, punish and remedy instances of violence perpetrated by state authorities and to ensure that they cease. Finally, efforts should be in place to bolster the capacity of law enforcement to prosecute hate crimes and other discriminatory violence against refugees and migrants. Strengthen the knowledge base Understanding the scope of violence and injuries among refugees and migrants, and how to develop effective and evidence-informed interventions, is currently hampered by incomplete and inconsistent data. The magnitude of the issue is likely to be underestimated because of the volume of movement, the invisibility of many of the forms of violence and injury and the various barriers to the identification and reporting of such cases. This includes racially incited and religiously driven violence and discrimination, and that perpetrated by state authorities. Consequently, establishing an effective knowledge base is important with collection of standardized data that can then be analysed, shared and used to effectively target resources and mount evidence-informed responses to address violence and injury among refugees and migrants. Collected data should include vital indicators for disaggregation, as well as characteristics that may influence vulnerability to violence. Furthermore, all countries, not only coastal states, should work to strengthen systems of investigation with respect to those missing in transit and the recovery of the dead. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 1 Introduction With more than 70 million people forcibly displaced worldwide as a result of persecution, conflict or generalized violence, global displacement is at its highest since the Second World War (1–3). An estimated 13.6 million people were newly displaced in 2018 alone, equivalent to an average of 37 000 forced to leave their homes every day (3). According to the UNHCR’s Regional Bureau for Europe, which covers 49 countries,1 there were more than 6.47 million refugees (including people in a refugee-like situation) at the end of 2018, of which nearly 3.7 million were in Turkey (3). Additionally, the UNHCR’s European Region hosted more than 1.24 million asylum seekers, 2.71 million internally displaced people and 533 000 stateless people (3). Refugees and asylum seekers were among the 90.7 million international migrants in the WHO European Region (referred to simply as the Region in the following text) in 2018, which accounted for 35% of the global international migrant population and constituted almost 10% of the European population (4). Refugees and migrants are at risk for injuries, both unintentional injuries (e.g. during sea or road travel) and intentional injuries, and violence (5–7). „ Injuries are defined in the Injury surveillance guidelines (8) as “the physical damage that results when a human body is suddenly or briefly subjected to intolerable levels of energy. It can be a bodily lesion resulting from acute exposure to energy in amounts that exceed the threshold of physiological tolerance, or it can be an impairment of function resulting from a lack of one or more vital elements (i.e. air, water, warmth), as in drowning, strangulation or freezing”. Injuries may be caused by mechanical, radiant, thermal, electrical or chemical energy and may be unintentional (i.e. accidental) or intentional (i.e. deliberate). „ Violence is defined in the World report on violence and health (9) as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation”. The report distinguished between four types of violence: physical, sexual, psychological and deprivation (including trafficking, torture, sexual abuse and exploitation). SGBV is generally defined as “any act as well as threats of acts of physical, sexual and psychological violence that is directed against any person on the basis of his/her gender or sex” (10). Violence can be: – self-directed, where the perpetrator and the victim are the same individual (self-abuse and suicide); – interpersonal, where violence occurs between individuals (family, intimate partner and community violence); or – collective, where violence is committed by larger groups of individuals (social, political and economic violence). 1 Differs from the WHO European Region in that it includes the Holy See and Liechtenstein and excludes Israel, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan. Technical guidance 2 Violence and injuries can occur at all stages of the migratory process: before departure, during transit and/or at destination. People may migrate precisely to escape violence and persecution in their countries of origin. They may have experienced torture, imprisonment and violation of their human rights, and they may have witnessed the death of family members, with heavy consequences on their physical and psychosocial health (11–15). During transit, the routes undertaken are often extremely risky, with risk of injury and fatalities at sea or on land (16). The escalation of violence and injuries faced by refugees and migrants attempting to reach Europe from Libya are of particular concern, for example, with women and children making up an increasing proportion of those making the journey (4,17,18). Organized criminals, including migrant smugglers and human traffickers, exploit hope and desperation and increase the number of people victimized and exposed to violence en route and in the WHO European Region, including children (19). Refugees and migrants are also exposed to violence perpetrated by border officials and local law enforcement, and even those working in migrant reception centres and refugee camps, who continue to act with impunity through state sanction (6,20). Furthermore, extended living in facilities intended for short-term stays can expose refugees and migrants to various hazards and stressors such as adverse weather, poor sanitation, lack of access to food and/or safe water supplies, as well as fear of intimidation and physical violence from other residents (21,22). Finally, upon reaching countries of destination, or when in reception facilities, refugees and migrants may experience additional forms of violence, including unsafe working conditions or labour exploitation, as well as racially incited violence and other related intolerances (7,20,23). The experience of violence and injury can have devastating consequences for anyone. Long-term and disabling physical, psychological and emotional trauma is not uncommon. Other serious harms include depression, post-traumatic stress, other mental disorders, chronic pain syndromes, unwanted pregnancy, sexually transmitted infections including HIV, and reproductive health problems (24). Children, particularly those exposed to war and armed conflict, are at risk for adverse and long-term developmental consequences (25). Consequently, there is an obligation to protect refugees and migrants, who may be particularly vulnerable to violence, abuse and injuries. There is also an economic aspect in that providing such protection would reduce the immediate and long-term public health and economic consequences of violence for individuals, communities and countries more broadly. In 2015, violence was estimated to have cost the global economy US$ 13.6 trillion, or 13.3% of global productivity (26). Continued instances of violence and injury in the Region, including among refugees and migrants, will undermine investments in education, health and social services and erode the productive capacity of those living in the Region into the future. A number of key regional and global policies and directives contain guidance on preventing and responding to violence, abuse and injuries among refugees and migrants (Annex 1). Preventing violence and injury among refugees and migrants as well as within the broader population requires Member States to fully implement these policies and directives and commit to the 2030 Agenda for Sustainable Development Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 3 (27) in both letter and spirit. Prevention of violence and injuries is reflected in a number of the targets of the Sustainable Development Goals (SDGs) (28). SDG 5 calls for the elimination of all forms of violence and harmful practices against women and girls (targets 5.2 and 5.3), and SDG 16 aims to significantly reduce all forms of violence and violence-related deaths, as well as end abuse, exploitation, trafficking and all forms of violence against children (targets 16.1 and 16.2). SDG 3, which targets good health and well-being for all, also includes reducing deaths and injuries from road traffic crashes. In order to achieve such targets, it is essential that strategies and interventions are put in place to prevent and respond to these forms of violence and injuries among vulnerable populations, which include refugees and migrants. Refugees and migrants will also be supported by synchronizing implementation of those SDGs that target risk factors: eradicating extreme poverty and implementing social protection systems; providing universal health coverage; ensuring access to safe and quality education; ending all forms of discrimination against women and girls; generating income growth; promoting political, social and economic inclusion and promoting equality; ensuring safe and affordable housing and services and sustainable urbanization; and promoting the rule of law and access to justice. Objectives This technical guidance has been developed to improve knowledge and understanding among policy-makers on the magnitude and nature of violence, harms and injuries faced by refugees and migrants during their journeys and upon arrival in countries of transit and/or destination in the WHO European Region. It aims to synthesize best available evidence and put forward practical policy considerations to help to inform policy and programme development and the implementation of effective interventions for prevention. While the intended audience includes policy-makers across sectors at local, national and regional levels, it will also be of value for health-care practitioners, as well as law enforcement and border protection officials. Methodology For the purposes of this review, the terms refugees and migrants are based on internationally agreed definitions provided by UNHCR and International Organization for Migration (IOM) (29–31) and are used to refer to all groups, including asylum seekers (29), unless otherwise specified. A scoping review was conducted in 2017 that identified peer-reviewed articles, policy documents and other grey literature published between 2010 and 2017 in English that contained information on strategies and interventions to address violence and injuries among refugees and migrants in the WHO European Region. Peer-reviewed articles were searched through PubMed, Scopus and Web of Science databases. Grey literature was identified using EastView, GIFT (Global Information Full Text), Google, Google Scholar and Opengrey. Websites of the following organizations were also Technical guidance 4 consulted: Amnesty International, Community of Sant’Egidio, Council of Ministers of the European Union (EU), European Parliament, IOM, Médecins Sans Frontières (MSF), National Institute for Health, Migration and Poverty of Italy (INMP), Save the Children, United Nations Children’s Fund (UNICEF), United Nations Office on Drugs and Crime (UNODC), United Nations Population Fund, UNHCR, WHO and the WHO Regional Office for Europe. A further desk review was conducted in 2019 to update the collected articles and to incorporate recent evidence. The case studies and policy considerations outlined are based on the findings of the review and expert recommendations. Case studies highlight existing good practices within the Region. Care was taken to illustrate a variety of interventions that could be relevant across a range of settings within the Region. The focus of this technical guidance is explicitly on violence and injuries as they affect refugees and migrants in order to inform targeted approaches relevant to their particular circumstances and experiences. However, there is a wider scholarship on preventing and responding to violence among the general population. Such evidence will also be presented where appropriate and includes publications such as the Global status report on violence prevention (32) and INSPIRE: seven strategies for ending violence against children (33). Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 5 Current evidence Despite commitments among Member States to the policies and directives listed in Annex 1, available evidence suggests that incidences of harm are significant among refugees and migrants at all stages of the migratory process. Current knowledge is covered under: „ injuries associated with different migratory modes of transport „ violence and intentional injuries en route „ SGBV „ human trafficking and smuggling „ occupational injuries and violence „ racially incited violence and hate crimes, and religious discrimination. There will also be a brief look at the gaps in the data currently collected. Injuries associated with different migratory modes of transport The crossing of the Mediterranean Sea from Africa and the Middle East continues to be a major route for refugees and migrants coming to the WHO European Region. More than 113 000 refugees and migrants entered the Region by sea in 2018, 168 000 in 2017 and 359 000 in 2016 (34). However, it also continues to be one of the most dangerous routes, and injuries at sea are often fatal. According to the IOM, 17 896 refugees and migrants died attempting to cross the Mediterranean Sea between 2014 and 2018, with most deaths occurring in 2016 (5143) (35). More recently, 2299 migrants died in 2018, and 602 in the first six months of 2019 (35). The figures are minimum estimates from IOM, national authorities and media sources and are likely to be lower than the true number of deaths because of the challenges in acquiring complete and accurate data (35,36). Of the three main migratory routes across the Mediterranean (central, eastern and western), the central Mediterranean route from sub-Saharan and northern Africa to Italy (primarily departing from Libya) has consistently recorded the most deaths. This reflects the length of the journey as well as the increasingly dangerous smuggling strategies (37,38). Afghans, Iraqis and Syrians make up a substantial portion of all sea arrivals in the Region but because they mostly travel via the eastern Mediterranean route, which is safer, deaths are most common among the African migrants who disproportionately use the dangerous central Mediterranean route (37,38). An estimated 343 migrants have already died in the central Mediterranean in the first half of 2019, while 1314 died in 2018 and 2853 in 2017 (35). Although 2018 saw a fall in the number of refugees and migrants making the central crossing, and indeed the number of deaths more than halved in 2018 from 2017, the rate of deaths among those crossing rose sharply (39). In 2018, on the crossing from Libya to Europe, one person died for every 14 arrivals in 2018 compared with one for every 38 arrivals Technical guidance 6 in 2017 (39). Reductions in search and rescue capacity and changes in procedures for disembarkation are likely to have contributed to this outcome (39,40). Drowning as a consequence of embarking on unseaworthy and overcrowded vessels is the most direct cause of fatalities at sea. Many refugees and migrants are smuggled in hazardous conditions. UNHCR in Greece has reported that rubber dinghies arrive from Turkey across the eastern Mediterranean with more than 60 people on board when they are built for only 8–12 (41). Not only are these vessels not fit for purpose they are also not registered with any state (41). Deaths from drowning among refugees and migrants in the Mediterranean have also be linked to the use of illegally manufactured and traded lifejackets filled with foam and other non-buoyant materials that absorb water (41). Hypothermia and chemical burns from leaked petrol mixing with seawater are other injuries that occur in sea crossings (42,43). Along the land routes, injuries and deaths from road crashes are not uncommon. In 2018, more than 130 fatalities were recorded along land routes within Europe or at borders, at least 55 of which were specifically road or railway accidents (39,44). For example, the road inland to Thessaloniki in Greece from the Turkish border is an area of particularly high risk, with 29 people killed in road crashes in 2018. A further seven refugees or migrants were killed by trains in four separate incidents after crossing the Greece–Turkey land border in 2018 (39). The land routes across the Croatian–Slovene and Italian–French borders have also seen a number of fatalities (39). The number of non-fatal road injuries is more difficult to determine and is likely to be much higher. Violence and intentional injuries en route Intentional injuries result from interpersonal, self-directive and collective violence, including physical assaults, torture, SGBV, honour-based violence, domestic and intimate partner violence, trafficking, and sexual and labour exploitation. Importantly, violence also encompasses more than physical acts themselves. Abuse of power relationships, threats, pressure, neglect and maltreatment, for example, can result in psychological and other harms (7,45). Research on the prevalence of violence against refugees and migrants during the migratory journey indicates that it is an enormous problem. A study of 992 migrants and refugees attending MSF mobile mental health clinics in Serbia in 2015–2016 (a main transit hub on the Balkan corridor to northern Europe) found that nearly one third had experienced violent events, including physical trauma, along their journey (46). The most common mechanism of injury was beating and/or robbery (46). The study reported that signs of physical trauma from violence were seen in 22% of individuals, with 65% reporting that the violence had been perpetrated by state authorities such as police and border patrol officials, including trauma in women and children (46). Similarly, a study conducted at a free clinic in Israel to examine exposure to trauma among asylum seekers en route to Israel from Eritrea and Sudan found that almost half (mostly men) reported being victims of violence (47). Exposure to shootings and beatings was most prevalent, yet instances of sexual assault, electric shock, burning, threats of execution and deprivation of food and/or Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 7 water were also recorded (47). A study examined data collected routinely from 23 341 users (with a high proportion of migrants) of Médecins du Monde clinics in 26 cities of 11 countries (Belgium, Canada, France, Germany, Greece, the Netherlands, Spain, Sweden, Switzerland, Turkey and United Kingdom) in 2014. Among 1809 patients interviewed about their experience of violence, nearly 85% had experienced one or more episodes (48). Nearly 10% had experienced violence after arriving in Europe and one in five reported rapes occurred after having arrived in Europe (48). Journeys through sub-Saharan and north Africa on the way to Europe are particularly dangerous. Many people who arrive in Libya with the aim of crossing the Mediterranean by boat have already been exposed to violence and abuses (39). Most arrivals in Europe from Libya in 2018 were from Eritrea, Nigeria and Sudan. Many had been held in Libya for a year or more, often for ransom or forced labour, or had been kidnapped, and subjected to difference forms of violence while being held (44). Available information suggests that the vast majority of women and girls, as well as many men and boys, have been victims of SGBV and torture, including sexual assault and rape, sometimes by multiple perpetrators, during their journeys (39). Many of those arriving by sea from Libya are severely malnourished and suffering from hunger, and have had their belongings confiscated (39,48). SGBV SGBV is in itself a significant public health issue among refugees and migrants. Evidence from the EU suggests that refugees and migrants are more at risk for sexual victimization than are European citizens (49). In a 2012 study of 223 refugees, asylum seekers and irregular migrants interviewed in Belgium and the Netherlands, nearly 60% reported experiences of sexual violence, with 332 separate incidents of sexual violence, including rape and sexual exploitation (50). Over half, 69%, had been victimized since arriving in Europe, with one third of the assaults committed by a European citizen (50). Perpetrators were usually men, most commonly (ex-)partners or officials working in asylum centres (44). Literature shows that being an irregular migrant, asylum seeker or refugee appears to make an individual more vulnerable to SGBV (22,51,52), including rape and sexual assault by smugglers and traffickers (53). The occurrence of transactional sex has also been reported, where women have been coerced into sex in return for help on their passage to Europe or while in detention facilities in return for help with their cases (53). While it is clear that much SGBV against refugees and migrants in the Region is committed by people unknown to victims, familial, domestic and intimate partner violence among these groups remains a serious issue. This includes physical, psychological, sexual and economic harm perpetrated by a current or former partner and can occur throughout the migration process as well as in the destination country (54,55). A study conducted among Pakistani migrant families in Germany showed that, once at destination, various stress factors (e.g. threats to cultural identity, children’s socialization and social isolation) might increase the risk of this type of violence, with Technical guidance 8 psychological violence the most commonly reported (54). In Spain, a cross-sectional study of 10 048 women (9143 host population and 635 migrants, mostly from Latin America) attending primary care centres showed a prevalence of intimate partner violence of 23.1% in migrants compared with 14.5% in women of the host population (55). The likelihood of any type of intimate partner violence was significantly higher for migrant women compared with their local counterparts (55). Human trafficking and smuggling Large-scale migration increases opportunities for trafficking, which is often a cause of direct and prolonged violence, primarily though forced labour and sexual exploitation (56). Globally, more than half of detected trafficking victims are trafficked across borders, and global trafficking routes overlap with common migration routes (56). Trafficking and exploitation are a major concern for migrants and refugees travelling to the WHO European Region, particularly along the western Balkans route and crossing the Mediterranean, which are often linked with migrant smuggling activities (56,57). While the majority of detected trafficking cases in the WHO European Region occur within and between subregions, outside of the Region, sub-Saharan Africa remains the most relevant origin of selected trafficking into the Region (58). Two distinct current phenomena – the scale of movement and the nature of migratory flows – do result in significant points of convergence of trafficking and smuggling (57). Increasingly restrictive border controls, lack of legal alternatives for onward movements and generation of debts to smugglers who are requiring higher fees mean that these smugglers are also perpetrating trafficking (57). Traffickers take advantage of existing migration flows and the vulnerability of refugees and migrants, who often move irregularly and lack protection (56,59). While the full picture of trafficking of refugees and migrants is obscured by lack of data, the IOM has found that nearly one in 10 migrant and refugee respondents in 2016 answered positively to an indicator of the presence of human trafficking and other exploitative practices along the eastern Mediterranean/Balkan migration route (Croatia, Greece, Hungary, North Macedonia, Serbia and Slovenia) (60). Reports even included people who had been approached on the journey by someone offering cash for blood, organs or body parts (60). Children and youths are a particularly vulnerable subgroup for trafficking and exploitation, accounting for nearly one third of all detected trafficked victims globally (56). Migrant children en route to Europe, particularly those unaccompanied, may be at greater risk for exploitation (56). A report by IOM and UNICEF analysing the journeys of more than 11 000 refugee and migrant children and adolescents (aged 14–24 years) travelling along the central and eastern Mediterranean routes found that these groups have higher risk for exploitation than adults, with one in eight reporting exploitation on the central Mediterranean route (56). Forced labour, sexual exploitation, child marriage, captivity and forced begging are the most common forms of exploitation of children (56). Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 9 Occupational injuries and violence Occupational injuries mostly relate to refugees and migrants working in countries of destination, with literature indicating that, overall, the risk of these injuries is higher among foreign-born workers than in host country workers (61–63). This is particularly the case for those without a work or residence permit (61,62). The most common work-related health issues reported among labour migrants include musculoskeletal, respiratory and mental health problems (62). Migrant workers are more likely to work long hours and in high-risk jobs without compulsory safety precautions, and are also more likely to avoid reporting workplace hazards (4). In Czechia, injuries were the most common reason for hospitalization among migrants and the prevalence of work- related injuries specifically was three times higher among migrant workers than in the general Czech population (64). Similarly, in Denmark, incidence of work injuries among migrant workers from both more recently joined EU countries and the rest of the world was higher compared with incidence in Danish workers and those from more established EU and other western countries (65). Evidence from Spain, Sweden and the United Kingdom indicated that work-related serious accidents, including fatalities, increased with a rise in the numbers of labour migrants (63). Violence against migrant workers in the form of exposure to sexual harassment and other forms of psychological pressure and discrimination have also been recorded and are higher than for the local populations (66). Some evidence suggests that there is a gender dimension in occupational injuries, with male migrants generally showing significantly more work-related injuries than females. This may reflect the traditional partition of labour, with men tending to work in sectors with greater risks for physical health, such as construction and mining (4). Female migrants more often work in domestic services or as seasonal farm workers; however, they also face restrictions on occupational safety (4), and domestic workers, in particular, are at risk for psychological threats and violence. Sex work also remains a relevant issue in the Region, with a high burden of violence faced by migrant sex workers, who form more than 65% of the sex worker population in western Europe and around 16% in central Europe (67). In the United Kingdom, there has even been a rise in the reported murders of migrant sex workers, from none in 2006–2013 to 82% of the women killed in 2013–2015 (68). This suggests that migrant female sex workers are being disproportionately targeted in this context, although it is unclear if there are reporting biases or other factors that may have contributed to this increase (68). Lesbian, gay, bisexual and transgender sex workers also experience intensified discrimination on the grounds of their sexual orientation and gender identity, rendering them even more vulnerable to increased levels of violence and human rights abuses, and decreased access to health-care and other services (69). Lack of alternative employment opportunities and trafficking organizations that operate locally and in countries of origin increase vulnerability to violence among these groups. Importantly, child migrants are at high risk for exploitation into child labour (70). Those unaccompanied by families or without proper documentation are are particularly vulnerable (70). Many child migrants work in agriculture or services; Technical guidance 10 some of these children will also be victims of trafficking (70). Girls from communities where educational preferences are given to boys may be at particularly high risk (71). Although most available evidence is from a global context, it is suggested that, among child labourers, migrant children receive less pay, work longer hours, attend school less often and face higher death rates from work-related risks than do local children (70). Experiences of violence and maltreatment is not uncommon for child migrants (70). Racially incited violence and hate crimes, and religious discrimination Finally, another form of violence and injury that has been experienced by refugees and migrants in the WHO European Region is racially incited violence and hate crimes, which can occur in countries of transit and destination. An increase in hate crimes, particularly against asylum seekers, has been recorded over recent years and is more prevalent in regions with limited experience of immigration (72). Such violence occurs against a backdrop of reported increases in intolerance, xenophobia, racism and other forms of discrimination against refugees and migrants across the WHO European Region (20,73). A 2018 report entitled Responding to “hate speech”: comparative overview of six EU countries was funded by the Rights, Equality and Citizenship Programme of the EU (74). It showed that the rise in prejudice and injustice in European countries can often be linked directly to the policies and communication strategies of the governments, and the use of derogatory and inflammatory language directed at refugees and migrants (74). The role of the media in perpetuating violence, injury and crime through the spread of misinformation, xenophobic narratives, religious hate and negative political rhetoric is also critical. The Second EU Minorities and Discrimination Survey in 2015–2016 found that discrimination and hate-motivated harassment was a recurring experience for many, with one in four respondents experiencing such harassment in the year prior to the survey (75). While respondents cited their ethnic or immigrant background as the main reason for facing discrimination, religion was an additional factor (75). Selected findings of the report found that nearly 30% of self-identifying first- or second-generation Muslim migrants experienced harassment or physical attacks because of their skin colour, ethnic or migrant background, or religion (76). People who wore religious symbols in public were also more likely to experience discrimination and harassment, with 39% of Muslim women who wore a headscarf or niqab in public saying they had experienced inappropriate staring or offensive gestures, while 22% experienced verbal insults and 2% were physically attacked (76). Frequent police stops are also reported (76). In nine out of 10 cases of bias-motivated harassment, respondents did not report their most recent incident to the police or any other agency as they believed that nothing would result from this (76). Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 11 What is not known on this topic As will be discussed in the following section, the incompleteness of data pertaining to incidence of violence and injury experienced by refugees and migrants is a major barrier to fully understanding the problem. Knowledge is limited by issues such as the invisibility of victims even within health and social systems, the lack of regulated and effective mechanisms to report incidence and that many refugees and migrants go missing and fatalities are not recorded. Consequently, the evidence identified here is likely to represent a best-case scenario. Further, lack of shared methodologies between studies and lack of recording of factors such as age or socioeconomic status make comparison of such evidence and drawing conclusions about best practices difficult. Technical guidance 12 Areas for intervention Member States of the WHO European Region are currently facing high migratory pressure, and violence and injury among refugees and migrants travelling to and living in the Region is commonplace (77). The development and implementation of interventions to prevent and effectively deal with such incidences are necessary. This section will outline some key strategies and policy considerations, as well as highlighting good practice case studies from around the Region. Supporting the approach put forward by the UNODC and the International Federation of the Red Cross and Red Crescent Societies, there are three key principles that should guide approaches to address violence and injuries among refugees and migrants (20): „ the obligation of Member States to maintain the human rights of refugees and migrants above law enforcement and migration management objectives; „ the obligation to protect the rights of all people in their jurisdiction without discrimination; and „ the obligation to place the needs of victims at the centre of efforts to combat violence. Importantly, violence and injuries among refugees and migrants must also be addressed as a regional issue. While a significant proportion of violence and injuries occur en route to the Region, it is not solely the responsibility of countries of transit or first asylum. It is unfair and ineffective for these Member States to bear the burden of responding to this issue alone and WHO advocates support and solidarity among all Member States. This section details the available knowledge and good practices to protect refugees and migrants from violence and injuries. The critical elements are to: „ ensure safe passage for migration „ address causes of violence and injuries in transit and destination countries „ identify victims and provide care and protection „ investigate and prosecute perpetrators „ strengthen the knowledge base. Ensure safe passage for migration Migration to the WHO European Region is a complex phenomenon, with people having a variety of reasons for migration. Very often, refugees and migrants come to the Region to escape insecurity, conflict, persecution and poverty, and many have little choice but to migrate irregularly and in unsafe conditions (20). While Member States have the right to manage their own borders and determine who may enter and stay, they have obligations under European and international law with regard to migration. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 13 Restricting routes for regular migration means that refugees and migrants are more likely to undertake dangerous journeys (39). In this context, interventions are necessary to reduce the toll on human life, and the violence and injuries that occur en route and in destination countries. Member States need to provide viable alternatives to dangerous journeys through expanding and diversifying available longer-term options for regular migration, such as resettlement and complementary pathways for admission (78,79). The benefits and opportunities that are afforded through regular pathways of migration for both refugees and migrants and the host countries for social and economic development are substantial and often underestimated (80). Examples of interventions to consider include employment initiatives, developing expanded labour mobility agreements plus scholarship and education programmes (39,81). Member States could also build on existing practices related to admission and stay for refugees and migrants for compassionate or humanitarian considerations through provision of humanitarian visas, private sponsorships, temporary work permits and timely family reunification procedures (79,82,83). Greater solidarity with transit and refugee-hosting countries outside of the Region would strengthen access to protection for refugees and migrants in these locations. Greater access to safe and regular pathways for migration is also in accordance with the directives set out in the New York Declaration for Refugees and Migrants (80), and the Global Compact for Safe, Orderly and Regular Migration (83). These pathways must, however, be rights based and gender responsive. The expansion of pathways for safe, orderly and regular migration has the potential to reduce the need for irregular migration, provide alternatives to embarking on potentially deadly journeys and reduce the incidence of violence and injury (39). Improving access to labour mobility schemes for regulated employment may have the potential to reduce preventable occupational injuries. Member States should also engage and cooperate with relevant stakeholders, including trade unions and the private sector (83). The other key aspect of safe passage for migration is to ensure that national and regional responses to irregular migration do not increase vulnerability of those refugees and migrants to violence and injury. Decisions by individual Member States on how they manage their borders, on sea or land, significantly impact the flows of people attempting to reach Europe and their safety. For example, closures of land borders and militarization may force refugees and migrants to alternative and more dangerous routes (46). As emphasized by UNODC, responses to irregular migration that are not in line with international law and standards of human rights may inadvertently make refugees and migrants en route more vulnerable to harm, rather than making them safer (20). Pushbacks – the returning of people to neighbouring countries without allowing them to seek asylum or assessing their needs for international protection – and the use of excessive force and violent deterrence measures at land borders have been consistently reported across many countries in the Region, including involving unaccompanied minors and other vulnerable subgroups (39,84). In 2018, UNHCR and partners in Serbia received reports of more than 400 unaccompanied children being pushed back from neighbouring states, of which 270 reported having been denied access to asylum procedures, and 90 having been subject to physical violence (39). Technical guidance 14 The diminishing of search and rescue operations by nongovernmental organizations (NGOs) in the Mediterranean could also impact on the safety of refugees and migrants (39). In January 2019, the UNHCR reported two shipwrecks killing an estimated 170 people, numerous rescue incidents and an increase in disembarkations in Libya (85,86). While the issue of sea crossings to Europe poses significant challenges, there is a need to improve effective rescue capacity in the Mediterranean to protect lives at sea and to ensure that refugees and migrants are not placed in even greater danger. Member States should seriously consider increasing coordinated multistate rescue efforts, as well as allowing the work of NGO vessels (39). Furthermore, once people have been rescued at sea, there should be capacity for rapid disembarkation in places of safety and for responses to immediate basic needs upon disembarkation, including to international protection and appropriate medical referrals (87). Member States must respect the principle of non-refoulement, which prohibits the return of anyone to a place where there is risk of irreparable harm, and the interception and forcible return of refugees and migrants to Libya is of great concern (88,89). In the current context of a volatile security situation and of widespread human rights abuses, Libya cannot be considered a place of safe disembarkation (89). Importantly, maritime rescue should be considered as an international state responsibility and the burden should not be unfairly carried by coastal countries, which, given the cost of operations, may also lack full capacity for search and rescue on such a scale (90). Italy, as a destination country for many of those attempting to cross the Mediterranean, has set up humanitarian corridors to allow safe regulated passage into the country (Case study 1). Search and rescue is also an issue on land borders, for example for those refugees and migrants attempting to cross mountain or rivers bordering countries such as Bosnia and Herzegovina and Serbia on the Balkan route. Case study 1. Humanitarian evacuations and corridors for refugees An emergency transit mechanism has been set up by the Italian Ministry of Interior and UNHCR, in collaboration with INMP, to move vulnerable refugees and migrants directly from north Africa to Italy (91). From December 2017 to November 2019, assistance has been provided to more than 900 refugees and migrants identified by UNHCR on the basis of their vulnerability. They mainly came from Libyan prisons or UNHCR centres in Niger where they had been transferred after a period of imprisonment in Libya. The migrants, including a high proportion of children under 4 years of age and infants, travel to Italy safely by plane. On arrival at the military airfield of Rome, they receive a health status assessment according to the Italian National Guideline on Border Checks (92), carried out by an INMP team of health professionals (internal medicine and infectious disease clinicians, dermatologists, paediatricians, nurses and transcultural mediators). After a medical examination, the refugees and migrants undergo an identity check by the police and then move to reception centres in Italy. The health clinic at the airfield is organized to guarantee health assessment operations. Those with health-care needs are referred to an emergency department, a specialist hospital department or to a clinician at the reception centre. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 15 Case study 1 contd. In a different arrangement, a self-financed humanitarian corridor to Italy was created at the end of 2015 based on a Memorandum of Understanding between the Italian Government and an ecumenical church initiative (incorporating the Community of Sant’Egidio, Federation of Evangelical Churches and the Waldensian Evangelical Church) (93). The project was intended to reduce the numbers undertaking risky journeys across the Mediterranean and at risk of exploitation by human trafficking. It enables those with “conditions of vulnerability”, such as victims of violence as well as families with children, the elderly, ill or disabled, to enter Italy legally, to be given humanitarian visas with “limited territorial validity”, and to have the possibility of filing for asylum later on. Potential beneficiaries are contacted by project volunteers and are then checked by the Minister of Interior before the visa is granted. Upon arrival in Italy, refugees are welcomed into the homes of volunteers involved with the Churches, who teach them Italian, enrol their children in school, help them find employment and assist with their integration into Italian society. During 2016–2017, approximately 1000 Syrians fleeing conflict have arrived in Italy via these humanitarian corridors. At the end of 2017, another agreement was signed with the Ministry of the Interior and the Foreign Ministry for continuing the project. An additional 1000 beneficiaries will have reached Italy in the period 2018–2019 with this involvement of the Church organizations. Countries of transit and first asylum must fulfil their obligations under international law to fully protect the human rights of all refugees and migrants, regardless of status. For example, refugees and migrants in these countries should have access to adequate reception facilities and procedures (94). This does not simply mean access to housing and medical care but also access to clear and efficient legal procedures, including asylum, family reunification and resettlement (94). Address causes of violence and injuries in transit and destination countries Human trafficking for forced labour and sexual exploitation In line with the Palermo protocols to the United Nations Convention against Transnational Organized Crime (95), Member States need to strengthen existing policies and mechanisms to increase identification of trafficking of refugees and migrants and prevent its occurrence. Central to this is reducing risk factors for refugees and migrants travelling to and within the WHO European Region. Restrictive migration policies in terms of increased border controls and limited legal channels for entering, transiting and residing are key factors that encourage trafficking (57). Consequently, acknowledging refugees and migrants as legal subjects under international law and providing adequate protection measures is a necessary strategy (57). Children, Technical guidance 16 particularly unaccompanied and separated children, should be treated as a priority in terms of special protection measures in order to minimize their risk for exploitation on onward journeys (57). However, to adequately address trafficking of refugees and migrants, Member States will need to address demand for movement into the Region, which is a root cause for trafficking and is often neglected in prevention programmes (96,97). The evaluation report in 2013 by the Council of Europe’s Group of Experts on Action Against Trafficking in Human Beings (GRETA) found that there were few measures and interventions to discourage demand and that there were difficulties in devising such measures (96). Efforts to reduce demand should address employer demand (including subcontractors), consumer demand (within the sex, manufacturing and domestic work industries) and demand from third parties such as recruiters, agents and transporters (96,98). This will require not just strengthened legislation (e.g. through the criminalization of knowingly using the services of a trafficking victims or increased regulation of relevant industries such as domestic services) but also innovative educational, social and cultural measures to reduce demand for the services of victims, whether of sexual exploitation, forced labour or other (97). Potential strategies include the use of social media, where many victims are recruited, to raise awareness; targeted information campaigns; programmes for children to promote human dignity and gender equality; and community-based prevention programmes (96). Public–private partnerships should be utilized, particularly involving business communities and trade unions in the context of preventing forced labour and promoting corporate responsibility (96). Legislation should be in place to require transparency of supply chains by companies and their subcontractors, and vigilance to ensure that trafficking is not represented in any part of their business (99). Awareness raising at the consumer level on the services and products that are the result of trafficking and labour exploitation (e.g. through advertising channels and other platforms) may also be effective, with recommendations on how to contribute to the reduction of the problem (99). Insecurity in refugee and migrant reception/detention centres Violence and insecurity in migrant reception and detention centres are widespread, with extensive reporting of multiple types of violence, and multiple cases of SGBV in asylum settings (100). Residents face not only poor living conditions and lack of privacy but also a constant and high risk for SGBV (100). Staff, guards and volunteers are very often the perpetrators of such violence, including using transactional sex whereby women are promised priority case assessment and faster release if they agreed to sexual activities with male guards (53,100). Sexual violence against men and boys in detention is also a significant issue, occurring in higher numbers than often assumed (4,101). In spite of evidence of the physical and psychosocial harms of migrant detention, it is still widely practised within the Region (4). WHO supports the current international guidelines, which state that detention should only be used in exceptional circumstances and as a last resort after examination on an individual case basis (4,102). Detention Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 17 should be proportionate and, given its administrative purpose, should not be punitive in nature; it should not to be used as a sanction or punishment (4,103). Detainees must be afforded both the regimes and material conditions appropriate to their legal situation and, where possible, Member States should consider alternatives such as community detention models, which have been implemented in some parts of the Region (103,104). In community detention, asylum seekers are released into the community while their status is decided. There are a number of mechanisms used for management, such as community supervision arrangements and case management (102). This is particularly important for children, including unaccompanied minors, and other subgroups more vulnerable to violence and insecurity. More broadly, reception and accommodation conditions in many countries of transit and destination are inadequate because of limited resources. In some parts of the Region where refugees and migrants are arriving, there may not be any accommodation available, and some may be forced to sleep outside or in alternative and unsafe conditions (53). Such insecurity increases vulnerability to violence and injury (53). There are reports that many women particularly fear violence in these settings, for example where men and women have to share sanitary and showering facilities (53). The provision of more secure accommodation and living conditions, and designated safe spaces, is a basic factor for the mitigation of SGBV perpetrated against both male and female refugees and migrants (100). Other preventive strategies that should be considered to prevent violence in reception/detention facilities include increased surveillance and security measures, and more adequate interventions and sanctions following instances of violence (100). Efforts should also be made to involve all stakeholders, including both staff and residents, in order to increase awareness on the issue and promote effective communication and cohesion between them (100). Unsafe working conditions for labour migrants Unsafe working conditions for labour migrants is a significant cause of violence and injury, particularly for those working without a work or residence permit (61,62). Refugees and migrants working in such situations are not protected by relevant laws and industry regulations; they may also not be able to access necessary legal recourse. Consequently, important interventions to address violence and injury among labour migrants are those that reduce pressures to work illegally. Member States should promote channels for refugees and migrants to work in the Region in regular circumstances, including for low-wage employment (81). Member States should also promote unconditional access to the labour market for asylum seekers and beneficiaries of international protection in the Region (81). This would help to reduce vulnerability to unregulated and unsafe employment. There is a responsibility here to disseminate information about safe employment pathways and effectively communicate these options to prospective migrants. Furthermore, Member States must ensure effective polices and directives are in place to protect labour migrants, who may be subject to exploitation (Case study 2). This includes offering support services for victims of trafficking so that they can leave abusive employers without having their immigration status affected where visas are linked to specified employers (99). Technical guidance 18 Case study 2. Revision of the domestic worker visa system, United Kingdom In the United Kingdom, concerns were raised by GRETA that the overseas domestic worker visa system had inadvertently increased the risk of human trafficking for the purpose of domestic servitude, and weakened the position of migrant domestic workers (99). In 2015, the London Metropolitan Police recorded 75 allegations of domestic servitude, 10 of which concerned diplomatic households. Following this, an independent review of the domestic worker visa system was commissioned by the Government. Two key conclusions were put forward. First, that “the existence of a tie to a specific employer and the absence of a universal right to change employer and apply for extensions of the visa are incompatible with the reasonable protection of overseas domestic workers while in the United Kingdom”. Secondly, mandatory group information meetings should be instituted for all overseas domestic workers who remain in the country for more than 42 days to enable identification and self- reporting for victims of abuse, and to provide these victims with the necessary support to leave abusive employers (105). GRETA also requested that the existing link between visas for overseas domestic workers and their employers be removed, thereby allowing them to change employers without their immigration status being affected. In the context of labour migration, it is also important for Member States to consider the issue of sex work. Migration flows of sex workers tend to be for similar reasons as for other labour migrants: to pursue better incomes and living conditions (68). The feminization of poverty, the lack of women’s rights in home countries (including laws protecting against domestic and sexual violence) and the criminalization of sex work in countries of origin have been cited as push factors for migrant sex workers (68). Sex work for both cis-gender and transgender migrant women in destination countries can often be a resilience strategy against this discrimination in their country of origin (68). However, migrant sex workers of all genders face greater vulnerability to abuse, harassment and violence, including from the police (68). This is, at least in part, because sex work is not considered as work and the selling of sex is criminalized in many countries in the Region; sex workers in many countries are not recognized as having rights (68). Migrant sex workers in these situations do not have the protection of the law and may experience higher levels of violence as a result, including, if not particularly, from authorities. Evidence shows that migrant sex workers have been beaten, raped and robbed by police, and in some cases are forced to exchange sexual services for protection (68). Countries are encouraged to adopt supportive legislation and policies to address such structural barriers and to ensure the protection of sex workers’ human rights (106). Not only may this decrease their vulnerability to violence but it may also have additional Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 19 health benefits, including reduction of sexually transmitted infections. For example, a study in 2015 estimated that full decriminalization of sex work could avert 33–46% of HIV infections in female sex workers and male clients over a decade (107,108). The recognition of sex work as work may also have potentially important policy implications. Migrant sex work is often conflated with human trafficking, and a report by the Global Network of Sex Work Projects found that many states within the EU utilize anti- trafficking efforts to curb sex work and migration rather than to create supportive environments (68). While trafficking for sexual exploitation is certainly occurring in the Region, it is not the case for all sex workers, and assuming this link may undermine the agency that some refugees and migrants may feel when engaging in sex work for economic or other reasons (49). It can also result in the disproportionate policing of racial and gender minorities (68). Therefore, it is more appropriate to consider migrant sex work in the context of international labour migration rather than solely in the paradigm of trafficking (68). Even where sex work is recognized as work, migrant sex workers may still face increased discrimination compared with local sex workers, and policy-makers need to address the challenges imposed on refugees and migrants specifically. For example, in many Member States, even where sex work is legal, sex workers are often requested to exit the sex industry before applying for legal assistance (49). This is not always a safe or feasible option, particularly for irregular migrants (49). Moreover, those who engage in prostitution because of restrictive labour laws and discrimination but are not identified as victims of trafficking are often not entitled to any support (109). Migrant sex workers may, therefore, face multiple levels of risk for violence, and policy-makers need to take this into account. Racially incited violence and hate crimes, and religious discrimination Finally, work needs to be done within Member States’ own political jurisdictions to reduce racially incited and religiously driven violence against refugees and migrants. This stems from xenophobic and anti-migration, and even anti-Islamic, sentiments across the Region. Member States must consider increasing opportunities for meaningful inclusion with host communities, and for fostering positive social interaction and cultural exchanges (110). This can include not only social activities but also community-wide education initiatives and public advocacy to promote a positive narrative about the contribution of refugee and migrant groups to host populations (110). This is important to improve host country attitudes towards migration, and to reduce stigmatization and discrimination (110). Imposing penalties on media outlets and publications for the spread of misinformation and untruths is also an important part of stemming discriminatory violence and harm. Anti-hate speech legislation may already be in place, but the rules are often complex, unclear and poorly enforced. Regulatory frameworks pertaining to hate speech should be rationalized and revised for compliance with relevant human rights standards (74). Technical guidance 20 Changing norms and values The success of many of the interventions outlined above to address causes of violence and injuries will also depend on being able to change the embedded norms and social tolerance of such patterns of victimization and perpetration. Often abuse and exploitation is perceived as normal rather than a problem, or at least not one within the control of individuals in communities; importantly, this also contributes to low levels of reporting (33). This tolerance and normalization of violence generally, but particularly of sexual violence, stems from a low status of women and children in many societies, and cultural norms surrounding gender and masculinity. These norms and values are pervasive within the WHO European Region and globally, in countries of origin, transit and destination. Working to change norms and values to promote gender equality and support non-violent, respectful and positive relationships is, therefore, critical, as is addressing attitudes that perpetuate victim blaming and allow impunity for perpetrators (33,111). Transforming social norms and behaviours, however, is a long-term and complex process that requires reinforcement at multiple levels. It will need to be enabled by appropriate legal and policy reforms that address structural inequalities more broadly (112). Identify victims and provide care and protection The second key area for intervention is to identify victims so that care, including health care, and assistance can be provided. This will be discussed primarily in the context of trafficking of refugees and migrants and SGBV, which are not only significant causes of violence and injury but also where victim identification is perhaps most difficult. Identification of victims of violence and injuries can be challenging, with refugees and migrants often in situations where they are less visible. The clandestine nature of human trafficking means that many refugee and migrant victims remain undetected (113). Abuse in domestic and care work, which mostly concerns female victims, may be particularly difficult to detect as it largely takes place within private households where victims may be subjected to a combination of labour and sexual exploitation, and sometimes forced marriages (99). Cases of trafficking for the purpose of exploitation in diplomatic households have also emerged in some countries (99). Many victims remain elusive even where Member States have numerous directives in place to attempt to detect victims of trafficking, including through proactive screening of applicants for international protection or applicants with specific at-risk profiles for indicators of trafficking, as well as practices to identify and refer potential victims in forced return procedures (113). Identification of victims of SGBV, which may be related to trafficking, can also be difficult and there is a need to strengthen capacities in this regard (Case study 3). Physical evidence may not necessarily be obvious, and many survivors are reluctant to discuss their experiences for reasons including stigma, shame and fear of reprisals (53). Additional barriers are fears of being stopped by police and deported or of being Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 21 delayed on onward journeys (53). Lack of knowledge about where or who to report to and unfamiliarity with host languages are also factors to consider as these may significantly impede provision of necessary care and assistance (53). Case study 3. Early identification of health risk conditions in newly arrived foreign women and potential victims of trafficking, Italy The Prevention and Protection: Women’s Health Project, carried out by the INMP, is intended to allow early identification of physical and mental risk conditions among newly arrived foreign women and potential victims of trafficking through a transdisciplinary approach (114). It adopts the Guidelines for the Definition of a Mechanism for the Rapid Identification of Victims of Trafficking and Serious Exploitation, defined by the Italian National Action Plan 2016–2018 against trafficking and severe exploitation. The Project is intended to provide the basis for synergistic work between the actors and institutions involved in the protection of those vulnerable to trafficking and sexual exploitation. More specifically, the goal is to create an accessible health pathway for female migrants arriving in reception centres for identification of needs and activation of emergency procedures, protection, support, screening and care. The Project includes health education and empowerment initiatives in addition to overall health evaluations. Health checks include for infectious, dermatological and gynaecological disorders, plus blood and other diagnostic tests. Interviews evaluate further indicators of trafficking and serious exploitation. Women identified as possibly subjected to sexual exploitation, or at risk for exploitation, are provided with the information needed to be aware of the phenomenon and understand where to turn in necessity. The results of the Project are collected and disseminated to support approaches elsewhere. The target population is female forced migrants mainly hosted in the reception centres of the Lazio Region and who are formalizing the request for international protection. The work team is a gender-oriented and multidisciplinary group, made up of doctors, nurses, psychologists, social workers, anthropologists, transcultural mediators and lawyers. The social–medical staff includes women specialized in international protection and human trafficking. SGBV among refugees and migrants in the WHO European Region has typically been considered as an issue affecting women and girls (49,96). While women and girls do form the majority of known victims of SGBV, it is important to note that men, boys and people with different sexual orientation, gender identity and expression, and sex characteristics (SOGIESC) are also at risk for experiencing such forms of violence (101,115). However, these are even harder to identify, which has important implications when developing interventions to improve victim identification and protection. The health impact of sexual violence presents differently in men and boys than in women and girls, which makes it harder for health professionals to identify; in addition, male survivors are less likely to seek health care (116). There can also be a tendency Technical guidance 22 to mistakenly attribute more agency to male survivors in the sense that “women are victims, men make choices”, which contributes further to their invisibility (117), or for sexual violations to be categorized under a general label of torture (101). Male victims have the same barriers to identification as female survivors, such as shame and stigma, but as the perpetrators are commonly also men, there is often an additional fear of exposure if the victims come from countries where same sex relations are criminalized (115). It has been reported in some contexts that men and boys have difficulty verbalizing sexual violence, preferring to speak about abuse or using euphemisms, as SGBV is frequently understood as something that happens only to women and girls (101). Male survivors have also been reported to avoid seeking medical care for fear that blood tests could be traced back to sexual victimization, given the risk for illnesses such as HIV/AIDS (94). Identifying survivors of SGBV is essential, however, given the risk for ongoing physical and mental trauma (101). Sexualized forms of torture must also be recognized as sexual violence as opposed to solely torture because this has specific legal implications (101). In the light of these problems, efforts should be made to raise awareness and knowledge about indicators in relevant professionals. Training should cover ways to detect vulnerable people who may have been trafficked and/or subject to exploitation, SGBV or other violence and injuries during migration (Case study 4). Case study 4. Beside You – Beside the Victims: knowledge sharing, cooperation and crime investigation across Europe against trafficking in human beings, Italy Although human trafficking has been an issue in Italy for some time, the rapidly changing migration context has given rise to changes in the nature and scale of trafficking. Identifying and protecting victims of trafficking are increasingly challenging. Co-funded by the Council of Europe and implemented by the Institute for Socioeconomic Research of Piedmont and the Prosecutor’s Office of Turin, the project Beside You – Beside the Victims was designed to improve the knowledge and competence of law enforcement officers and social workers to identify possible victims of human trafficking among asylum seekers in order to assist and protect them (59). It was also designed to facilitate the investigation of human trafficking. The project ran between April and October 2017, and 105 law enforcement officers and 225 social workers participated in the training. The course covered all aspects of human trafficking, including available legal instruments to counter it, as well as local victim protection systems in collaboration with institutions, public services and non-profit-making organizations. Furthermore, prosecutors and investigators from Austria, Belgium, Finland and France participated in a technical meeting together with relevant Italian professionals aimed at improving international cooperation in the investigation of cases. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 23 Training should cover profiles of victims and the forms of violence and exploitation they are vulnerable to in order for professionals to become sensitive to the circumstances, mindsets and emotional needs of victims (96). It should also cover the modes of transport likely to be used by victims, as well as characteristics of offenders. It is not simply law enforcement and border and migration officials who should receive training. Other professionals who may come across exploited refugees and migrants include labour inspectors and trade union staff, tax and customs authorities, consular staff, private employment and recruitment agencies, NGO staff, social workers and medical practitioners (Case study 5) (96). Training sessions could be multisectoral, and mechanisms should be developed to facilitate the exchange of experiences among stakeholders, including refugees and migrants, and build networks to address trafficking and exploitation in a more comprehensive manner. Importantly, training should also cover effective communication with victims and the relevant national procedures to follow after identification or suspicion of vulnerable people (96). For example, labour inspectors in parts of the Region were reported by GRETA to lack skills and instruction on how to proceed once they have detected a potential victim of trafficking, thereby limiting the number of victims referred by labour inspectors to appropriate services (99). Case study 5. Third National Action Plan (2015–2019), Belgium In Belgium, the Third National Action Plan puts forward measures to raise awareness about human trafficking, including of refugees and migrants, among sectors where exploitation for economic purposes may be taking place (99,118). In particular, attention is paid to the hospitality, construction, agriculture, manufacturing and fisheries industries. Priority is given to projects developed jointly with trade unions in order to find more effective and robust ways to prevent trafficking. Examples of such measures include targeted information for applicants for asylum or work visas. Additionally, work has been done to improve awareness in the banking sector to transactions that might conceal trafficking. Other measures are intended to improve access of victims to certain rights, such as recovery of unpaid salaries. The National Action Plan also contains several other operational initiatives including optimizing and effectively applying legal instruments; training for relevant professionals; improving victim protection and specialized services; maintaining international attention on the issue and coordinating actions; and sensitizing frontline staff, civil society actors and the general public to trafficking. In addition to training professionals, good practice interventions should include strategies to reach and inform refugees and migrants about their rights in terms of labour laws and protection from violence and injury, and the services available to help them. Accessible multilingual information should also be disseminated about trafficking, ways to protect oneself and where to look for help. This is important to enhance the capacity of victims to self-identify and self-report (113). For example, drop- Technical guidance 24 in centres and telephone hotlines for irregular migrants and undocumented workers could provide basic counselling on labour laws and social security, and assistance with administrative procedures (99). Targeted media campaigns in multiple languages on safe migration and what to do in crisis situations have also been conducted (99). Coordination with countries of origin to provide such information before departure could be considered. Interventions to improve knowledge about workers’ rights, for example, are also important for regular labour migrants, who may be working in unsafe conditions or experience discrimination in the workplace. When implementing these types of intervention, however, impact assessments should be carried out to determine their effects on knowledge and self-identification of victims. Following identification of refugee and migrant victims of trafficking, SGBV or other violence and injuries, Member States are also obliged to protect victims and provide care. Importantly, as is the case already in some countries, suspicion that a person is a victim should be considered sufficient to invoke systems of assistance (59). However, provisions for medical and psychological support on migrant routes to protect and help survivors are largely inadequate. For SGBV particularly, the scarcity of available aftercare for women and children has been noted (53,101). There is also a significant lack of targeted services and safe spaces for adult male and older adolescent survivors (101,115). Consequently, in order to safeguard the health and well-being of refugees and migrants, Member States need to improve the availability of essential care services for victims and suspected victims en route, and have mechanisms in place for referral. NGOs may be important partners in this regard. A comprehensive approach to health care upon arrival in transit centres and at destination should include access to post-exposure prophylaxis against HIV, prophylaxis for sexually transmitted infections and emergency contraception for women (119). Psychological first aid for people who have experienced or witnessed violence is also important, and a basic mental health evaluation should be included as part of the general health assessment with specific consideration of experiences of violence (120,121). Priority should be given to irregular and unaccompanied refugee and migrant children in terms of provision of services and protection, including ensuring that there is sufficient capacity in specialized shelters to reduce their exposure to further risk. Measures should cater not only for women and girls but also for men, boys and victims with different sexual orientation, gender identity and expression and sex characteristics, and for the diverse ways in which these groups may experience violence. Destination countries need to adopt a gender-sensitive approach to understanding different forms of violence perpetrated against refugee and migrant women. This is laid out in the 2014 Istanbul Convention on Action Against Violence Against Women and Domestic Violence, which outlines good practices to protect and assist women (122). For example, granting residence permits for refugee and migrant women who are victims of domestic and intimate partner violence, thus allowing women whose residence depends on that of their partner to leave the relationship without losing residence status (122). The Convention also includes provisions establishing an obligation to recognize gender- based violence against women as a form of persecution in the meaning of the 1951 Refugee Convention, and Member States are called upon to ensure a gender-sensitive Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 25 interpretation is used when assessing applications for international protection (122). Ultimately, it is necessary for Member States to ensure that appropriate and context- specific mechanisms are in place to ensure the protection and assistance of refugee and migrant women who may be subject to violence and harm. Investigate and prosecute perpetrators Where violence and injury is not investigated and perpetrators appropriately dealt with, such incidences can continue to occur with impunity (20). Member States have a responsibility and obligation under international law to prevent violent crimes against refugees and migrants, to act with due diligence to investigate such crimes and to prosecute perpetrators (20). Importantly, domestic laws should be examined in terms of how effective they are in combating violence and exploitation, and strengthened where needed (33). For example, while violence prevention laws are widely enacted, enforcement is often inadequate (32). In 2014, 133 countries worldwide responded to the Global status report on violence prevention (32); almost all countries had laws against rape and statutory rape, but such laws were fully enforced (at least 80% effective) in less than two thirds. The investigation of the trafficking of refugees and migrants for forced labour and sexual exploitation is an enormous challenge given the clandestine nature of the issue and the difficulties faced by victims to report and testify. While the institutional response in the Region is good, with widespread legislation in place that criminalizes trafficking of people, the conviction rate of offenders is variable (58). The 2018 Global report on trafficking in persons, for example, noted that while the rate of victim detection per capita in central and south-eastern Europe2 was among the highest in the world, conviction rates were much lower than in other WHO European subregions (58). By comparison, eastern Europe and central Asia detected fewer victims per capita compared with neighbouring subregions but had higher conviction rates (also above all other regions of the world), potentially owing to long-standing anti-trafficking legislation (58). Convictions related to the use of services of known victims of trafficking, however, remain low across the Region (99). Member States with low conviction rates need to develop a more decisive criminal justice response to trafficking and exploitation of refugee and migrant populations (58). In addition to its punitive function, this may also have a normative effect and increase public awareness of the issue (99). Understanding of what falls under the scope of human trafficking also varies among Member States (99). Where there are restrictive interpretations of what constitutes human trafficking for the purpose of labour exploitation, cases may be considered instead as labour law violations, which do not involve trafficking, or be acquitted (99). Similarly, complaints about exploitation of domestic workers may tend to be treated simply as disagreements between employer and employee (99). Another consideration 2 Bosnia and Herzegovina, Bulgaria, Croatia, Czechia, Estonia, Hungary, Latvia, Lithuania, Montenegro, North Macedonia, Poland, Romania, Serbia, Slovakia and Slovenia. Technical guidance 26 that may be critical for more consistent investigation and prosecution of human trafficking is the relevance of victim’s consent (99). People subject to labour exploitation particularly may not even identify as victims as they have no alternatives to make a living and so may not perceive it as exploitation, and indeed may have consented (99). This may have implications not only for identification of victims but also for deciding on whether to investigate and prosecute cases where victims may have consented, and the penalties for perpetrators (99). Being explicit that consent is irrelevant could assist victims to self-identify and report to authorities or services, as well as potentially strengthen anti-trafficking provisions (99). Emphasis should be placed on trying to prosecute all elements in the trafficking chain, including perpetrators in the home country of the victims (59). This requires stronger and more coordinated cross-border cooperation and information sharing between countries both within the Region and globally. Addressing trafficking as isolated scattered occurrences will only lead to its intensification, and limiting investigations to local territories weakens the response (39,59). Effective measures require a multiagency approach and coordination with all relevant stakeholders, including civil society, the private sector and business, and, importantly, trade unions and industry bodies (99). While trade unions are not recognized as anti-trafficking partners in some countries, they are well placed to promote the prevention of forced labour trafficking and should be encouraged to participate in anti-trafficking coordination and action (99). Efforts should also be made to establish specialized structures and bodies to investigate and combat trafficking and other forms of systematic violence perpetrated against refugees and migrants (99). Ways forward include bolstering surveillance and intelligence gathering, establishing designated public prosecutors for human trafficking cases, using financial investigators and training relevant actors such as law enforcement, prosecution and judges (99). There is also a need for more effective mechanisms to monitor and hold to account law enforcement and border officials who violate their legal obligations, for example during situations of pushbacks at land borders or when committing violence against refugees and migrants in reception and detention centres. National police forces need to be made more aware of the potential for their staff to commit assaults and Member States need to be more proactive in investigating allegations of violence and penalizing malpractice to the full extent of the law. There needs to be functioning and accessible mechanisms for refugees, migrants and others to report incidences without fear of negative consequences. Forced labour can also occur outside the realm of organized crime. Refugees and migrants may even have relevant residence and working permits and have been recruited in normal ways, but their working conditions differ from that of other workers (59). Investigating and prosecuting such circumstances of unsafe and/or illegal labour conditions remain priorities. Member States must ensure that labour legislation is strengthened to be responsive to the particular risks faced by refugees and migrants in destination countries. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 27 Finally, the shortcomings to date of countries and their law enforcement and judiciary bodies to appropriately penalize perpetrators of race and immigration-related violence and hate crimes is another important area for intervention (81). Strengthen the knowledge base Understanding the scope of the issue of violence and injury among refugees and migrants and how to develop effective and evidence-informed interventions are currently hampered by incomplete and inconsistent data (20). The volume of movement, the invisibility of many of the forms of violence and injury to which these groups are subject and the barriers for identification and case reporting mean that the magnitude of the issue is likely to be underestimated. Racially incited and religiously driven violence and discrimination (Case study 6) need to be identified, as does that perpetrated by state authorities. An effective knowledge base requires not just the collection of data but also its analysis, sharing and use to support appropriate responses to address violence and injury among refugees and migrants in the WHO European Region (20). Case study 6. Mapping racist crimes of violence, Sweden The Swedish National Council for Crime Prevention (Brottsförebyggande rådet) has reported that violent crimes stemming from racism and discrimination against refugees and migrants, particularly of African descent, have been steadily increasing (20). In response, the Swedish Government in 2013 commissioned the NGO Mångkulturellt Centrum to map incidences of racism and discrimination against these groups. The project reviewed official data on hate crimes, as well as highlighted examples of good practices to counter the issue, with a particular focus on awareness-raising activities for children and youth. This mapping project is an example of good practice to gather information and data in order to inform appropriate interventions and responses. Member States should work towards developing and maintaining comprehensive statistics of victims of violence that allow for disaggregation by country of origin and/ or destination, migrant status and type of exploitation, among other vital indicators (99). Capturing those characteristics that may influence vulnerability to violence, such as gender, age and disability, will also be relevant for evidence-informed interventions (33). Important to this is the development of national referral mechanisms to gather data across relevant actors, including law enforcement, medical professionals, teachers, labour inspectors and NGOs (59). A collective approach towards documentation, reception and registration is needed, with recording of health needs more broadly, but with clear criteria that are not arbitrary or political. The ability to access and consolidate data across the Region is essential for coordinated responses, as well as for sharing of Technical guidance 28 best practices and effective interventions (39). Necessary measures must be included in data collection to protect personal data and maintain confidentiality of victims, including for information requested from NGOs (99). Improving data on incidence of violence and injuries concerns not only living refugees and migrants but also those deceased and missing, particularly related to migration routes to the WHO European Region (Case study 7). Notwithstanding the difficulties that underresourced states already face in terms of processing and registering living migrants, efforts should also be made to investigate missing people and recover bodies (123). Both international and national legal frameworks impose duties on national authorities to investigate unnatural deaths, such as those occurring at sea in the Mediterranean (123). In practice, however, there is little investigation occurring, even with easily accessible personal effects such as sim cards and bank cards, which may often be found on the shore (123). Case study 7. Mediterranean Missing project, United Kingdom The Mediterranean Missing project 2015–2016 was funded by the Economic and Social Research Council of the United Kingdom in collaboration with the University of York, City University London and the IOM. The project was one of the first efforts to systematically collect data regarding missing people in the Mediterranean and comparatively explore national responses to migrant bodies and their identification (123). The project was also intended to understand better the impact on families of having relatives go missing. Several resources have been produced as an outcome of the project, including a summary of project findings in regard to the impact on families of having a relative missing in migration as well as the law, policy and practice around migrant bodies and their identification. The project has also disseminated specific country reports for Greece and Italy, a study of the situation of families of missing migrants from Iraq, the Syrian Arab Republic and Tunisia, and legal analyses of the obligations of states arising from international human rights law. Capturing the best possible data related to missing and deceased migrants is important for a number of reasons beyond the need to uphold the positive duty of states to investigate suspicious deaths. First, the collection and analysis of such data are necessary for a better understanding of the scale and circumstances related to death and disappearance en route, as well as the contributory factors, which may help to inform effective interventions (123). Secondly, it is important to let families know what has happened and to repatriate bodies where possible (123). States should be encouraged to strengthen systems of investigation with respect to missing people and recovered bodies, including collection of postmortem data and of antemortem data from families that may offer means of identification (123). The collection of antemortem data may require cooperation with state authorities Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 29 in countries of origin to connect with families of the missing (123). Countries should also make use of available civil society actors and international organizations already working in this area (e.g. the Red Cross tracing network), engage with migrant and diaspora communities and liaise with consular and diplomatic authorities to facilitate contacts (123). There is a need to advocate for the development of a regional and global architecture that would enable the collection, storage, centralization and dissemination of both ante- and postmortem data concerning deceased and missing migrants from a range of sources, including state authorities and families (123). Technical guidance 30 Policy considerations Generally, there are many laws and regulations already in place for the prevention of violence and protection of vulnerable groups across the WHO European Region. However, the problem often stems from unawareness or lack of enforcement of such legislative mechanisms. Member States should focus on strengthening existing mechanisms and their enforcement. Based on the evidence presented regarding the magnitude of violence and injury inflicted on refugees and migrants, and existing good practices, the following policy considerations are proposed. Many of the causes of violence and injury among refugees and migrants, and the means for their prevention, are within the remit and responsibilities of sectors other than health care, such as immigration, law enforcement and justice, trades and industry, social services, the media, the private sector, NGOs and civil society. Consequently, the capacity for effective action will depend on the strength of these sectors to act and their ability to coordinate their actions. Finally, any programmes implemented should be accompanied by high-quality evaluation mechanisms to monitor outcomes versus intended impact (33). This is essential to ensure that resources are directed effectively, efficacy improved and investments are cost-effective. Ensure safe passage for migration „ Advocate at the regional level for a coordinated response and strengthened mechanisms for search and rescue operations on land and sea, that procedures are in place with regard to places of safety for those rescued and that these sites have adequate provision for material needs and essential health services. „ Strengthen collaboration between Member States to take charge of safety for refugees and migrants with a Region-wide management system for asylum seekers, thus avoiding overburdening the countries most exposed to first arrivals. „ Use a collaborative process for the relocation of migrants and refugees that takes account of the migratory drivers for individuals as well as their family or cultural ties in specific countries. „ End violent pushback practices and allow fair access to asylum procedures, including for people seeking asylum who arrived irregularly. „ Increase pathways for safe, orderly and regular migration in accordance with the Global Compact to provide alternatives to irregular migration, thereby averting preventable incidences of violence and injury (e.g. expanding labour mobility schemes, education programmes and existing practices related to admission and stay on compassionate or humanitarian grounds). Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 31 „ Increase solidarity and support for refugee-hosting and transit countries along key migratory routes to strengthen protection and reduce pressure for refugees and migrants to undertake dangerous journeys. The principle of international solidarity emphasizes the importance of cooperation and burden sharing in determining international resolutions for refugee protection but also reiterates those of non-refoulement and right of asylum (124). Address causes of violence and injuries in transit and destination countries „ Strengthen existing policies and mechanisms to increase the visibility of trafficking of refugees and migrants and prevent its occurrence, including by reducing risk factors for refugees and migrants travelling to and within Europe. „ Within trafficking prevention programmes, ensure efforts to reduce demand from employers and consumers, as well as third parties who facilitate trafficking. „ End the systemic use of immigration detention centres as a punitive measure, particularly for children, and consider the use of alternatives that are less coercive and minimize the deprivation of liberties, such as community detention (102). „ Implement measures to improve security for residents within reception facilities. „ Reduce pressures on refugees and migrants to work illegally and promote channels to access labour markets safely. „ Ensure effective policies are in place to protect labour migrants who may be subject to exploitation, including offering support services for victims to leave abusive employers without consequences for their immigration status. „ Adopt supportive legislation and policies to ensure the protection of the human rights of migrant sex workers, and implement appropriate professional training and guidance for enforcement of such directives. „ Increase opportunities for meaningful inclusion of refugees and migrants with host populations in order to reduce discrimination and racially incited or religiously driven violence. „ Impose penalties on media outlets that publish misinformation and hate speech in regard to migration, and rationalize relevant regulatory frameworks in order to improve enforcement of legislation. Identify victims and provide care and protection „ Conduct further training to strengthen capacity among relevant professions to identify, communicate with and appropriately refer suspected victims of trafficking and exploitation in a timely manner, including men, boys and survivors of different SOGIESC. Technical guidance 32 „ Strengthen mechanisms for identification and referral at borders to ensure that children (in particular irregular migrants and unaccompanied children), victims of trafficking and other vulnerable subgroups have immediate access to protective health services, psychological support, legal services and accommodation in specialized shelters. „ Consider conducting mental health assessment as part of the general health assessment, with specific evaluation of previous experiences with violence, and provide mechanisms such as support groups for those affected by mental trauma. „ Disseminate information about trafficking and exploitation, including in multiple languages, to encourage and facilitate self-reporting by victims. „ Provide information on the services available and assistance with administrative procedures, plus counselling about issues of labour laws and social security. „ Strengthen collaboration with social sector organizations that are important partners in service provision. „ Strengthen policies to ensure victims of SGBV and domestic violence are provided with support and enabled to leave abusive relationships without consequences to their migration or residence status. Investigate and prosecute perpetrators „ Advocate for enhanced cross-border cooperation for the investigation, identification and prosecution of perpetrators, including traffickers at all stages of the trafficking chain. „ Strengthen coordination with relevant stakeholders to investigate and prosecute traffickers, including with trade unions, which may be well placed to help in cases of trafficking for forced labour. „ Commit to thoroughly investigate incidences of violence against migrant workers and adopt a more directive approach to ensure exploitative employers and recruitment agencies are prosecuted to the full extent of the law. „ Ensure mechanisms are active to investigate, punish and remedy instances of violence perpetrated by state authorities. „ Bolster capacity for law enforcement in destination and transit countries to condemn, investigate and prosecute hate crimes and other racially incited violence against refugees and migrants. Strengthen the knowledge base „ Consider the importance of comprehensive data to provide a more accurate understanding of the scope and circumstances of violence and injury, as well as for evidence-informed responses and more effective targeting of resources. Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 33 „ Strengthen capacity to monitor violence and collect and analyse data, including from other relevant actors who may bear witness to or have information regarding such incidences. „ Work to strengthen Region-wide systems of investigation with respect to missing people and recovered dead bodies, encompassing not just those countries with an access route by sea. „ Advocate for the development of regional standardized tools and methods for data collection on violence and injuries in refugees and migrants, including useful disaggregated indicators such as age or ethnicity. „ Work towards building a transnational database for identification of missing refugees and migrants, subject to relevant data protection standards, that includes postmortem data and antemortem information such as family and country of origin. 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Global policies and publications on addressing violence and injuries among refugees and migrants Publication Description Violence United Nations General Assembly resolution on promoting efforts to eliminate violence against migrants, migrant workers and their families (1) Emphasizes that crimes against migrants, including trafficking in people, require a concerted international assessment and response and genuine multilateral cooperation among countries of origin, transit and destination for the eradication of such crimes UNODC: combating violence against migrants (2) Supports states by offering several measures for legislators, policy-makers and criminal justice practitioners to prevent violence against migrants, investigate and prosecute its perpetrators, and assist and protect migrant victims of violence Highlights the importance of establishing an effective knowledge base to coordinated data collection in order to understand the scale of the problem Sexual violence UNHCR guidelines on prevention and response to sexual violence against refugees (3) Emphasizes the need for refugees to receive legal awareness training, leadership and skills training, and education Most effective measures require refugees to play a prominent role and actively participate in promoting self- protection Actions for protection and medical and psychological support in responding to incidents of sexual violence are suggested European directive 2013/33/ EU laying down standards for the reception of applicants for international protection (4) Requests EU Member States to take “appropriate measures that prevent gender-based violence including sexual assault and harassment” within reception centres and accommodation facilities, and to ensure “access to appropriate medical and psychological treatment or care for vulnerable groups” Human trafficking European directive 2011/36/ EU on preventing and combating trafficking in human beings and protecting its victims (5) Establishes robust provisions on victim protection, as well as supports the principles of non-punishment for petty crimes and unconditional assistance Strategies and interventions on preventing and responding to violence and injuries among refugees and migrants 47 Publication Description EU strategy towards the eradication of trafficking in human beings 2012–2016 (6) Five priorities listed: identifying, protecting and assisting victims of trafficking; stepping up the prevention of trafficking in human beings; increasing prosecution of traffickers; enhancing coordination and cooperation among key actors and policy coherence; and increasing knowledge of and effective responses to emerging concerns related to all forms of trafficking in human beings The STROM Project: strengthening the role of municipalities in combating human trafficking in the Baltic Sea Region (7) Specific objectives include protecting the rights of victims; raising awareness of local actors about human trafficking; highlighting promising activities that have been developed in the Baltic Sea Region and beyond where municipalities and/or local authorities have played an important role in addressing human trafficking issues and providing protection to victims; and involving local stakeholders in combating human trafficking at the local level Refugee and migrant health World Health Assembly resolution 61.17 on the health of migrants (8) Calls upon Member States to promote migrant-sensitive health policies, gather documents and share information and best practices for meeting migrant health needs in countries of origin or return, transit and destination Promotes bilateral and multilateral cooperation on migrant health Strategy and action plan for refugee and migrant health in the WHO European Region (9) Promotes the availability, accessibility, acceptability, affordability and quality of essential services in transit and host environments, including health and social services, together with basic services such as water and sanitation Addresses vulnerability to health risks; exposure to potential hazards and stress; increased susceptibility to poverty, social exclusion, abuse and violence; and stigmatization and discrimination Framework of priorities and guiding principles to promote the health of refugees and migrants (10) Describes a number of overarching guiding principles and priorities to promote the health of refugees and migrants, building on humanitarian principles and existing instruments and resolutions International migration and human rights Convention on the rights of the child (11) Stipulates, under Article 22, that children who come into a country as refugees should have the same rights as children who are born in that country; this includes receiving appropriate protection and humanitarian assistance in the enjoyment of applicable rights set forth in the Convention and other international human rights or humanitarian instruments, such as the right to be protected from violence, abuse and neglect New York declaration for refugees and migrants (12) Commitments by Member States to strengthen and enhance mechanisms to protect refugees and migrants, including to respect human rights, provide additional and predictable humanitarian funding, increase avenues for ordinary migration and resettlement, and support countries affected by large movements of people Technical guidance 48 Publication Description Global compact on refugees (13) Provides a framework for a more predictable and equitable responsibility sharing in reaching a sustainable solution to refugee situations Includes a programme of action setting out concrete measures to help to meet the objectives of the compact, which are to ease pressures on host countries, enhance refugee self-reliance, expand access to third-country solutions and support conditions in countries or origin for safe and dignified return Global compact for safe, orderly and regular migration (14) First United Nations global agreement on a common approach to international migration in all its dimensions With 23 objectives for better management of migration at local, national and global levels to mitigate adverse drivers and structural factors that force people to move, reduce the risks and vulnerabilities faced during different stages of migration, address legitimate concerns of states and communities, and create conducive conditions that enable migrants to enrich the societies in which they live References 1. 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The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. 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