Health Rentierism and Displacement: The Case of Syrian Refugees in Jordan

Sigrid Lupieri, Stanford University

 

Introduction

With forced displacement at its highest levels since World War II, refugee movements often place a considerable strain on the infrastructure and resources of host communities. Yet, hosting refugees can also confer some advantages, especially in negotiations between host states in the Global South and wealthier donor states in the Global North (Greenhill 2010; Norman 2020a; Oyen 2016; Thiollet 2011). Recently, scholarship has begun to explore the ways in which refugee host states engage in “refugee rentierism” by leveraging the presence of refugees in their territories for material and political gain, as well as to renegotiate the stakes and balances of a fundamentally asymmetrical refugee regime (Adamson & Tsourapas 2018; Freier et al. 2021; Tsourapas 2021b).

Refugee rentierism has been instrumental in explaining how states such as Türkiye, Lebanon, and Jordan have at times wielded considerable influence over the politics of donors, such as the United States (US) and European Union (EU) member states, in exchange for hosting refugees (Adamson and Tsourapas 2018; Norman 2020a). While capitalizing on refugee flows is not a new phenomenon, a focus on “rent extraction” emphasizes how refugee populations are increasingly commodified in the national and international politics of rent-seeking states (Lynch and Tsourapas 2024). So far, however, little attention has been paid to the emergence of what I call “health rentierism,” or the progressive commodification of vital medical aid and health care services as a foreign policy tool. More specifically, I define health rentierism as a strategy through which states attempt to extract material and political resources from donors by strategically providing and withholding health care services from marginalized refugee populations in their territories.

In this contribution, I consider the case of Jordan, which hosts one of the largest refugee populations in the world (relative to its national population). Since the arrival of an estimated 650,000 Syrian refugees from 2012 onward, Jordan has also become one of the top recipients of foreign aid globally. This essay examines the processes through which health care for refugees has become commodified and ultimately leveraged to extract “health rent.” This commodification occurs through a securitization process, which frames both refugees and certain diseases—mainly those that can spread across international borders—as threats to national and international security. As a result, health rentierism allows state actors to leverage the presence of refugees on their territories to gain concessions from bilateral donors and international organizations. The COVID-19 pandemic highlighted some of these themes, including the increasing securitization of health and infectious diseases on a global scale. There are many examples of attempts at containing the spread of the virus becoming conflated with measures aimed at protecting national borders and preventing the onward movement of refugees and migrants (Crawley 2021; Ferhani & Rushton 2020).

 

Health Rentierism and the Jordanian Case

Refugee host states, especially in the Middle East, have a long history of leveraging the presence of refugees in their territories for political and material gain (Lynch and Tsourapas 2024). Refugee rentierism can take various forms, depending on the political and geographic position of the host state. For instance, states close to Europe’s borders, such as Türkiye, have engaged in forms of blackmailing to gain concessions from EU member states (Micinski 2021; Tsourapas 2021a). Such blackmailing strategies include commodifying the presence of refugees by threatening EU member states with the arrival of greater refugee flows at their borders. For states where blackmailing is not always an option, strategies include back-scratching to receive concessions from donors (Tsourapas 2019). Back-scratching involves appealing to the solidarity of donors to respond to the needs of refugees and implicitly agreeing to host refugees for the foreseeable future, in return for grants and concessions. The success of such strategies is dependent on the migration policies of donor states (Thiollet and Tsourapas 2024). Wealthy donor states with externalization policies—which aim to prevent asylum seekers and migrants from reaching their borders by enlisting third countries in the Global South—are more likely to engage in migration diplomacy and comply with the demands of refugee rentier states (Freier et al. 2021; Vaagland 2023).

Scholars are increasingly analyzing Jordan’s historical and contemporary attempts at leveraging the presence of refugee populations residing in its territory (Almasri 2024, Parker-Magyar 2024; Baylouny 2020; Fakhoury 2019; Lenner and Turner 2018). Historically, Jordan has hosted large refugee populations, including successive arrivals of Palestinian refugees since 1948, Iraqi refugees between 2003 and 2006, and, more recently, Syrian refugees since 2012. As such, Jordan has capitalized on its refugee presence by attempting to extract grants and concessions from the donor states and international organizations operating in the country since its independence in 1946 (Frost 2024). With the arrival of Syrian refugees, rent-seeking behavior has become increasingly normalized. Recent examples include the adoption of nationality-based aid responses, which limit refugee integration while maximizing rent (Almasri 2024), and the commodification of refugees in the provision of educational opportunities (Parker-Magyar 2024).

Based on extensive fieldwork in Jordan and interviews with government officials, donors, and United Nations (UN) and international non-governmental organization (NGO) workers involved in providing medical aid to Syrian refugees, I find that lifesaving health care and medical aid have become the new battleground on which power struggles and negotiations between Jordan and often reluctant Western donors play out. As such, I find that health rentierism occurs through a two-step process, which includes the securitization of refugee health and the subsequent commodification of health care services as a bargaining strategy.

 

Securitizing Refugee Health

Over the past two decades, securitized discourses have raised the visibility of migration and forced displacement and increased the relevance of such issues in the international arena (Bigo & Tsoukala 2008; Lahav & Messina 2023). The growing focus on migration issues has begun to affect mainstream understandings of interdependence among states and the balance of power in North–South relations (Norman 2020b; Paoletti 2011). The migration crisis in 2014 and 2015, which saw more than one million Syrian asylum seekers and refugees arriving in Europe, was met with increased concern over national security and the tightening of borders in the West (Arar 2017; Baldwin-Edwards et al. 2019).

While the links between migration and security have long been established (Huysmans 2006), a growing global focus on transnational threats to national security has spilled over into the realm of public health. Over the past decade, infectious diseases, such as HIV/AIDS, Ebola, and more recently COVID-19, have been declared a “threat to international peace and security” by the UN Security Council (Agostinis et al. 2021; Hanrieder & Kreuder-Sonnen 2014; Kamradt-Scott 2016). Crawley notes that pandemic-related health crises have a long history of leading to the stigmatization and othering of people, with a particular focus on linking minorities, racial groups, and specific communities to disease (Crawley 2021). In many cases, the discursive securitization of refugees and their health needs has become integrated into efforts to marginalize refugees and create the perception of a widespread crisis that requires emergency responses.

Jordan has historically framed the presence of refugees as a security threat based on domestic and geopolitical considerations. Since the 1967 Arab–Israeli War, which precipitated the arrival of an estimated 150,000 Palestinian refugees, Jordan has successfully linked its Palestinian population with security threats that resonate with relevant major donors (see Frost 2024). Securitized discourses have ensured a constant stream of international aid in exchange for hosting refugees and have also persuaded wealthy donors to support Jordan’s security through arms deals. Such deals have benefited donors commercially and diplomatically while securing Jordan’s regime survival (Frost 2024). Over the past decade, Jordan has similarly framed the presence of Syrian refugees as a security crisis, with refugees as potential terrorists who threaten the stability of the Jordanian state in a volatile Middle East region. Initially hailed as “brothers and sisters,” over time, Syrian refugees have been increasingly depicted as “foreigners” and marginalized in Jordan (Lupieri 2020).

At the same time, health security has come to dominate the agenda of medical aid. During interviews, Jordanian government health officials and Western donor representatives acknowledged that rumors of terrorists posing as refugees to enter Jordan had become conflated—even before the pandemic—with the framing of refugees as carriers of infectious diseases. Citing national security concerns, Jordan closed its borders with Syria in 2016. This left tens of thousands of refugees stranded at the border, living in makeshift shelters with limited access to clean water, sanitation, and medical care (Awad 2019). Donor representatives coordinating health care aid confided that the humanitarian crisis at the border had become the spatial embodiment of national and international fears over security and the spread of diseases such as tuberculosis. These fears were exacerbated by the COVID-19 pandemic, with Syrian refugees widely regarded as potential sources for the spread of coronavirus. In 2021, one of the world’s strictest lockdowns effectively imprisoned Syrian refugees in camps in Jordan and threatened the flow of international assistance to refugees (Dhingra 2020).

 

Commodifying Health Care

A host state commodifies vital health care services by providing and withholding them from its refugee population to create a growing perception of an imminent crisis or catastrophe. This crisis requires the immediate mobilization of resources from donors. Despite sustained and unprecedented international aid to support both refugees and Jordanian host communities, health care policies in Jordan have progressively marginalized the health care needs of Syrian refugees. In 2012, all Syrian refugees could access the national health care system at the same rate as Jordanian citizens with health insurance. By 2014, however, the sudden population increase had placed a considerable strain on health care resources, leading Jordanian officials to classify Syrian refugees as “uninsured Jordanians.” Access to health care resources remained subsidized, with refugees expected to pay approximately 20% in out-of-pocket expenses (Lupieri 2020). In 2018, the Jordanian government announced a policy change that required refugees to pay the equivalent of the “foreigner rate.” The foreigner rate is two to four times higher than the uninsured rate and is usually reserved for tourists seeking specialized medical care in Jordan. A year later, this policy was reversed, and Syrian refugees have since continued to pay the “uninsured rate” (Lupieri 2020).

Jordan has withheld services to refugees at critical junctures as a negotiating tactic to pressure donors into supporting refugees in Jordan in exchange for hosting them. Withholding occurs especially before large donor conferences, as these determine the amount of funding allocated to each country hosting Syrian refugees (Lupieri 2020). Without access to affordable health care, vulnerable refugees have sought services from international NGOs and UN organizations, placing more strain on the humanitarian system. In some cases, desperate refugees have returned to Syria to seek affordable care (Amnesty International 2016).

 

Health Rentierism: A Successful Strategy?

Without discounting the impact of the presence of more than half a million Syrian refugees on Jordan’s infrastructure and health care system, Jordan has wielded both the securitization of refugee health and withholding of health care services at critical junctures in time as foreign policy tools. Strategic border closures in 2016 resulted in the abandonment of refugees caught in an inhospitable patch of land known as “the berm” at the border between Syria and Jordan. Such strategic closes and the marginalization of the health needs of refugees since 2014 have increased the international visibility of the refugee and health crisis. This visibility has allowed Jordan to employ a combination of appeals to solidarity and blackmailing negotiation tactics to keep donors’ attention despite continued refugee arrivals in Western states and the EU and the subsequent mounting “donor fatigue.”

Blackmailing tactics have included threats to discontinue Jordan’s open-door policies toward Syrian refugees, to reduce access to vital services for refugees, and to step back as a key Western security partner. As King Abdullah II of Jordan warned in a British Broadcasting Corporation (BBC) interview in 2016: “How can we be a contributor to regional stability if we are let down by the international community?” With refugees expected to reside in host countries for an average of two decades, the King reiterated the effects of hosting refugees on Jordan’s host communities. “Sooner or later, I think, the dam is going to burst,” he stated ominously (BBC 2016).

The combination of blackmail and international appeals for solidarity toward refugees have yielded mixed results. The increased visibility of Syrian refugees, alongside Jordan’s geostrategic position as an important ally to the US and other Western states, has ensured a constant flow of international humanitarian funding. More than a decade since the arrival of Syrian refugees, Jordan remains one of the top 10 recipients of humanitarian aid worldwide. Moreover, successful negotiation tactics resulted in the Jordan Compact, a novel agreement between donors and the Jordanian government that has guaranteed a constant stream of overseas development aid to Jordan in exchange for hosting Syrian refugees. The Compact has been hailed as a groundbreaking development and highlighted as an example to be emulated in future refugee crises (Arar 2017).

Yet health rentierism—as in the case of refugee rentierism—is generally only effective if the refugee host country can leverage fears that refugees and infectious diseases will cross borders into wealthy donor states. In the case of Syrian refugees in Jordan, strategies for health and refugee rentierism have been most successful with donors (such as EU member states) that have the greatest vested interest in preventing the onward movement of refugees toward Europe and the West (Lupieri 2020). For donors such as the US, which considers Jordan to be an important ally in the Middle East, the arrival of Syrian refugees has prompted unprecedented amounts of bilateral and multilateral aid to ensure the country’s stability and security. Though the urgency of the Syrian refugee crisis had begun to fade among donors and their governments by 2017, the COVID-19 pandemic has sparked renewed interest in refugee health in Jordan.

 

COVID-19 and Concluding Remarks

The growing importance of health and health care policy in international relations has become increasingly apparent during and after the COVID-19 pandemic. In many ways, the pandemic strengthened the link between migration, health, and security, cementing perceptions of refugees and migrants as potential carriers of infectious diseases. Fears of refugees spreading infectious diseases across borders, particularly among wealthy donor states, have encouraged various forms of health rentierism. In the wake of the pandemic, global health financing for infectious diseases has grown by 700% since 2019, with a particular focus on the COVID-19 virus and on preventing future epidemic outbreaks (IHME 2023). In Jordan, financing for Syrian refugees has once again increased after a brief slump between 2017 and 2019, with the spread of the novel coronavirus (European Commission 2020). There is even a new area of humanitarian and development aid, which focuses specifically on responding to COVID-19.

Despite increases in financing, however, the pandemic has also limited the effectiveness of health rentierism as a strategy for subverting some of the intrinsically unequal power dynamics between donors and refugee host states. Policies enacted at the height of the pandemic, which drastically restricted human movement, have reduced legal avenues for migration and seeking asylum. Under the guise of public health measures aimed at curbing the spread of the coronavirus, such global policies have not only strengthened perceptions of refugees as dangerous to public health and security but have also drastically reduced their human rights, at times imprisoning asylum seekers in crowded, unsanitary camps (Lupieri 2021).

For instance, in March 2020, President Donald Trump enacted a public health policy called Title 42. This policy allowed US officials to turn away migrants who came to the US–Mexico border on the grounds of preventing the spread of COVID-19. Although human rights organizations emphasized how Title 42 violated the rights of migrants and asylum seekers (Human Rights Watch 2021), and the Centers for Disease Control and Prevention highlighted its lack of effectiveness as a public health policy, Title 42 was only lifted in May 2023. With many borders around the world closed, such health policies have effectively reduced the effects of threats and bargaining from refugee host states in the Global South. As a result, states such as Jordan have increasingly resorted to appeals for solidarity to secure donor support.

It is my hope that future research will continue to expand on the framework of health rentierism and explore its applications in other contexts. For instance, in what ways—and under what circumstances—do refugee host states in the Middle East and elsewhere instrumentalize refugee health for political and material gain? Beyond refugee states, how do governments worldwide leverage health policies and medical aid as a form of rent? Such questions are especially relevant following the COVID-19 pandemic and the growing securitization of health and infectious diseases worldwide. Ultimately, it is as important as ever to understand the ways in which health and health care policies are a political endeavor—one that increasingly intertwines with national security concerns and migration control.

 

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