The current refugee crisis is once again testing the limits of the international community’s ability to provide for the needs of people who do not have the protection of a state. The last time the world saw a crisis on this scale, it responded by building institutions to safeguard access to welfare services as a human right, a right that did not depend on citizenship. It is now commonplace to say that the current refugee crisis is matched historically only by the displacement of people after the Second World War. The UNHCR announced in 2014 that the world refugee population surpassed the number from 1945 for the first time, and in 2015 the number reached 60 million refugees displaced either within or beyond their states. More than 4 million are refugees who left Syria, of whom the European Union debates accepting only 160,000.
What does the comparison between the end of World War II and today’s refugee crisis mean beyond numbers? And, more importantly, what can the response to that earlier crisis teach us today? A new international system capable of protecting the wellbeing of stateless people on a large scale emerged in the midst of the refugee crisis following the Second World War. Its history shows us that the international community can be more than an assemblage of states; that drawing on the refugees’ own skills and initiative to make the most of limited resources can make possible an international structure capable of responding to human need. History also shows us that such structures upholding the rights of refugees and assisting their integration in new societies can offer innovative ideas for improving institutions designed to protect rights and welfare within states.
The refugee crisis in Europe after the Second World War was far worse than the EU faces today, but a successful structure arose in 1945 because the world assumed it could solve the refugee problem – that people would figure out what was necessary to find everyone a home. Today, we accept refugees as a permanent consequence of modern global affairs and respond to each individual crisis without looking for long-term solutions. To find stability and hope for refugees, we must think our way out of our current assumptions and imagine new international structures that function beyond any one state. Europe should invest in developing new approaches now, before the next emergency, and with its response suggest a broader international solution for the global refugee crisis.
Continent of the Displaced
Europe was a continent of refugees when the Second World War ended in 1945. People who had fled war, occupation, and persecution joined others deported by the Germans to work as slave labor or by the Soviets to the Gulag, as well as newly freed prisoners of war and the survivors of the Holocaust. The survivors were a haunting reminder of what could happen when the protection of citizenship failed. There were perhaps 30 million people spread through nearly every country on the continent, and millions more in other parts of the world. The Allied Armies and then the United Nations Relief and Rehabilitation Administration assumed responsibility for about 8 million refugees in Germany alone. While this number was a fraction of the total, it was unprecedented for an international community to become the guardian of so many people.
Since the Allies originally assumed the displaced persons would return home, they had prepared to provide emergency care only. They thought they would set bones and contain outbreaks of influenza in the weeks or months it took to repatriate. Instead, the refugees required food, lodging, clothes, medical care, schools, and jobs on a long-term basis.
By the end of 1945, approximately 1.2 million refugees eligible for United Nations relief remained in Central Europe. The United Nations termed them “displaced persons” to give them a blameless quality, a fiction that they found themselves without state protection for non-political reasons. In truth, whatever causes forced them from their homes, they were now stateless: refugees without the securities that citizenship could provide.
The danger was yet another large-scale humanitarian crisis in Europe. Under these circumstances, welfare structures emerged on an international level mirroring services that states commonly offered their citizens in the interwar years. From these structures a new system emerged, as social welfare concerns such as healthcare and education became through daily practice human rights, recognized as necessary parts of modern human existence regardless of state-based politics. Even welfare services that provoked domestic political debate took on a clearer life and death nature when refugees, alone in a foreign land, had none of the support systems they might have had at home. As a consequence, international welfare institutions became a space for meaningful initiative
This case was especially evident when it came to medical care for the refugees. When the war ended, the Allies were unprepared to provide routine health services, ordinary preventative medicine, and pediatric clinics. They were not ready to meet the needs of orphans, the elderly without families, or people whom the war had left chronically ill or disabled. Yet, during the period between the two world wars, states had increasingly provided these services to their citizens. Public health experts had even established a precedent for the international community to take an active part in assisting states to develop these services. If the state were no longer able to play its role, it now seemed the international community had a direct obligation to assist the people in something beyond emergency relief. As autumn turned to winter and more than a million refugees settled – overcrowded and undernourished – into improvised camps in devastated Europe, the international community responded.
Despite lack of advance planning for these circumstances, the United Nations Relief and Rehabilitation Administration (UNRRA) stepped up its healthcare operations. Going beyond providing the services necessary to avert the public health disaster its authorities feared, UNRRA at its best was able to offer as broad a range of health services as any state. In addition to general healthcare, it offered dental care, home-health visits, an extensive maternity service and milk kitchens to assist with nutrition for young children, specialty medical clinics, and long-term care for chronic conditions. UNRRA authorities acknowledged that they came to provide these services through a combination of refugee need and refugee initiative.
Refugees themselves – doctors, nurses, and other personnel – in large part made this response possible. No international health program would have functioned without them. UNRRA originally planned to bring 450 doctors with its teams, but had difficulty recruiting. After a year it had a core staff of only 266 medical officers who were full UNRRA employees, while the United States zone of control alone supplemented this number with more than 800 refugee physicians. Refugee physicians therefore provided much of the general care and nearly all the specialty care. UNRRA aided them with refresher courses to bring them up to date, as they had been cut off from medical developments for five years. By the autumn of 1946, UNRRA opted to decrease its core medical staff while at the same time expanding services to meet growing demand. The refugee physicians took over operations of the international health service at all levels, from physicians who volunteered part-time in clinics to some who assumed responsibility as chief medical officers for UNRRA regions.
Numerically, refugees played an even greater part as nurses and in auxiliary medical positions. In the summer of 1946, UNRRA had 349 full staff nurses across Europe, while one camp alone, staffed by only 3 of these nurses, had more than 100 refugee nurses. A nurse-training program augmented the existing number among the refugees. Authorities recognized that they found themselves managing the largest international health service ever known. It was so successful that there was even a suggestion UNRRA might extend the service for refugees to Germans.
Although this international health services did not in fact become directly responsible for German state services, it did become increasingly integrated with local institutions. The health service adapted as some refugees became more settled and began to make use of surrounding facilities. UNRRA had originally requisitioned local hospitals, which they gradually handed back to native authorities while promoting further cooperation between the health services rather than reducing use of the hospitals for refugees. As refugees found jobs, they became increasingly likely to avail themselves of additional doctors in surrounding towns. At first, the practice seemingly reflected a public healthcare versus private medicine model, but refugees sustained it by taking out German or Austrian insurance. Officials from the international organizations encouraged this transition, seeing it as the natural endpoint of their operations. At the same time, the number of refugee medical personnel declined as they developed new practices in Germany or Austria, or found themselves increasingly able to emigrate.
Refugees who chose to settle in West Germany and Austria gradually created a stable life for themselves with the support of services the international community offered to refugees. With new homes, jobs, and insurance, they became active in rebuilding the devastated countries. One of the reasons West Germany recovered so quickly was due to the influx of refugees.
This period of emigration and settlement did not mark the end of the international refugee health service, but the beginning of a new phase. Now the international and national health services interacted still more closely as an increasing number of the refugees left behind in the camps were those most in need of long-term medical care and assistance. No country was willing to take refugees who did not meet a standard of health that guaranteed the immigrant would have the physical capacity to work a 40-hour week and would not seek public assistance or expect free medical care. These standards meant that countries refused to accept pregnant women or widows with young children; rejected men and women deemed past their working prime; and even sent back refugees who contracted tuberculosis after arriving in their new country. On a personal level, it meant families had to make the hard choice to leave a child with disabilities in an institution in Germany or Austria so they could give their other children a new start.
The strict physical standard countries imposed on immigrants directed the refugee health service to develop innovative rehabilitation practices. Interaction with national health services meant these efforts also contributed to reforming German and Austrian strategies for long-term care, and ultimately also those of Israel once it eventually agreed – after a regrettable delay – to accept not only the fit but also Holocaust survivors with chronic conditions. Again, it was often refugee physicians who experimented with new programs and who brought the reforms to local institutions.
Securing Human Rights for the Stateless
Altogether, it took three phases to build an international health service in response to refugee need and with refugee initiative. In turn, these phases contributed to the understanding of access to healthcare as a right, and developed the necessary institutions. The first phase was the immediate emergency relief international institutions expected to provide at the end of the war; the second a full health service run on an international scale, sponsored by international contributions and staffed largely by refugees; and the third a program for physical rehabilitation and long-term care that contributed to reform of these fields beyond the refugee camps. The development of this unprecedented international service acted on an implicit premise that access to medical care enabling the best quality of life was a right surmounting states and citizenship.
It was an important lesson at that moment, as the Second World War revealed that the collapse of a modern state made most vulnerable the people whose rights were contingent on that state. The postwar rhetoric of commitment to a new conception of universal human rights was one thing, but it was the new international institutions and structures that realized this rhetoric. The refugee health service – although it certainly had its flaws and limitations – was an example that such a structure could function successfully and that the protection of rights related to human wellbeing need not depend only on the state.
What is different now? When the United Nations established its permanent health branch, the World Health Organization, it did not incorporate the international health service. It reverted to a system of state-based collaboration and distanced itself from advocates of a more involved program, whose opponents used rising Cold War politics to paint direct international participation in welfare as dangerously close to socialist thought. It is time to move past this Cold War setback in international human rights.
Today, limitations in the institutions existing to cope with refugees are forcing people to make their own way out of camps to seek illegal entry to Europe, where countries are unprepared to do more than allot refugees state by state. We do not currently know how to adapt the institutions to provide more than emergency relief and to incorporate a significant and ever-increasing number of refugees. We need to consider their needs as an impetus to create new institutions rather than as the object of humanitarian charity alone, or as a burden on individual states. We can start to make this change by recruiting the talents of the refugees themselves, people who have no desire to be a burden but to share in establishing a new and better society.
As autumn turns to winter again, and refugees – many of them professionals, including doctors, nurses, teachers, social workers, scientists, architects, and artists all eager to contribute vitality to their new homes – continue to risk their lives for a better future, will Europe respond? Can it respond without throwing fuel to the nationalist far-right?
History shows us that more is possible. International structures have in the past successfully responded to refugee welfare needs and enabled refugees to integrate as productive members of their new countries. The structures have existed in Europe before, on a far larger scale than the EU requires now. Knowing this, we can think our way forward. By investing now, Europe can break the cycle of constant crisis and be in the vanguard of imperative global reforms. The discourse of human rights – of what human rights mean for people without European citizenship – and the establishment of practical structures to protect the wellbeing of all people must and can be foremost in building new international solutions.
Sara Silverstein is a Ph.D. candidate in modern history at Yale University and was a junior visiting fellow at IWM in 2014. Her research is focused on healthcare provisions for refugees after the Second World War.
 On the relationship of the United Nations relief efforts to the postwar international human rights project, see G. Daniel Cohen, In War’s Wake: Europe’s Displaced Persons in the Postwar Order (New York: Oxford University Press, 2012).
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