The Health of Refugees.

Before I move on to today’s topic, a note that this week marked the 14th anniversary of the September 11, 2001, terrorist attacks in the United States. Nearly 3,000 people died in those attacks, and the health consequences of the attacks continue to linger among those who were affected by them in New York, Pennsylvania, and Washington. We are now also seeing the long-term health consequences of war among the hundreds of thousands of soldiers and civilians who were injured in Operations Iraqi Freedom and Enduring Freedom that followed. I had the privilege of being a part of several studies in the aftermath of these attacks. Our group published a review of the state of our knowledge to date a few years ago and, more recently, a review of the long-term mental health consequences of deployment among reservists. I link to these papers here, and will comment on the consequences of war in another Dean’s Note, but my thoughts today are with those directly affected by the attacks, both in the US and globally, and with the families of those who died as a consequence of the attacks, both on September 11, 2001, and in the decade-plus that followed.

On to today’s topic. It has been heartbreaking to read of the recent refugee crisis in Europe. Two Syrian boys died while trying to cross into Turkey. Seventy-one dead refugees were found in a truck on an Austria highway. Refugees drown with some regularity as they attempt to cross from North Africa into Malta, Italy, or Spain. European leaders publicly fret about the issue, but, until a few days ago, very little had been concretely done to either stem the tide of refugees or to make sure they are well-received in the countries they are attempting to migrate to. The refugee crisis is not particular to Europe, although the spotlight has been on European countries of late. The United Nationals Refugee Agency (UNHCR) estimates that 59.5 million people are currently forcibly displaced worldwide. Conflict and persecution force 42,500 persons per day to seek protection either within their countries or in other countries. By the end of 2014, there were 19.5 million refugees throughout the world. This number is considerably higher than the previous 10 years, mostly due to the refugee crisis in Syria. There it is estimated that more than 4 million people have been forced to leave, most commonly settling in Turkey, making it the country hosting the largest number of refugees worldwide. As of March 2015, more than half of all Syrians had been forced to flee their homes, including 7.6 million people displaced internally in the country. Iraq has also displaced more than 9 million people since the 1980s, most leaving Baghdad and settling in Jordan and Syria. According to the United Nations, two-thirds of the world’s refugees are in exile for more than five years, many without a return date. About half of all refugees are women, children constitute about 41 percent, and about four-fifths of refugees are hosted in low-income countries.

In 1951, UNHCR defined a refugee as someone who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country.”

Although research with refugee populations faces substantial logistical challenges, there has now emerged an empiric literature that has documented health among refugees, showing that refugees carry a substantial burden of the non-communicable and communicable diseases that characterize the health of vulnerable populations in different parts of the world.

For Iraqi refugees, major disease burdens have been identified as diabetes, hypertension, and malnutrition. Prevalence of malnutrition among refugee children in 2011 was 4.5 percent in Syria, and more than 90 percent of households reported food aid receipt. Of almost 12,000 adult refugees who were screened in International Organization for Migration clinics in Jordan, 38 percent were considered overweight and 34 percent were obese. Smoking levels are also very high among male refugees. On the other side of malnutrition, among Iraqi refugees who have lived in the US for up to three years in 2012, 13 percent reported anemia among their household members. In the same survey, 43 percent reported delaying or not seeking care for a problem in the past year, and 60 percent reported a chronic condition. Certain groups are at particular risk as refugees. Among women, domestic violence is common. Women and girls escaping the Iraq war report rape by armed groups and civilians in Iraq, even though sexual violence is likely underreported due to cultural stigma and shame. Many are forced into sex work for financial support, with estimates at the population level being very hard to come by. Pregnant women are particularly vulnerable as international humanitarian funds run low and women are giving birth in unsafe conditions.

Mental health among refugees has justifiably received more attention recently, especially in the context of Syria. The International Rescue Committee reports a high prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) among refugees in general, and a 2012 CDC survey of Iraqi refugees living in the US found that half of participants reported anxiety, depression, and emotional distress. Consistent with evidence in non-refugee populations—and showing the potential to mitigate the consequences of the refugee experience—Fazel and colleagues recently reviewed available evidence on mental health in children who are displaced to high-income countries and found that social support and stable settlement in the host country have the potential to mitigate exposure to violence and have a positive effect on psychological functioning.

Systematic data on the health of refugees from other parts of the world is sparser. Infectious disease burden has been high among refugees from the Central African Republic who settled in the Democratic Republic of Congo, fighting parasites, malaria, typhoid fever, and respiratory infections in a place where infections are easily spread through camps and makeshift housing without sanitation infrastructure. Central African refugees have also arrived in Cameroon extremely malnourished. About 25 percent of Central African Republic’s population has also been internally displaced since 2013.

The causes of refugee health reflect the lifecourse determinants that we noted in a previous Dean’s Note on migration and health. The Refugee Health Technical Assistance Center breaks down the refugee experience into three stages—preflight, flight, and resettlement—each of which involves unique potentially traumatic exposures that are likely to be associated with health. For example, pre-flight experiences in the context of Iraqi refugees in Syria include air bombardments, shelling, witnessing shootings, harassment by militias, and death of loved ones. The conditions of flight have been harshly visible in the global press in the past week, perhaps casting a much-needed spotlight on the global refugee challenge. Ongoing stressors can continue in settlement camps, such as uncertain access to food and water and poor living accommodation.

The recent European refugee crisis has also highlighted some of the challenges the world faces in attempting to address the needs of refugees vis a vis resettlement. Encouragingly, there has been a shift in the past few years in policies related to international refugees, with recent policies advocating for the integration of refugees into the health systems of their host countries rather than the creation of parallel, often substandard, systems. The UNHCR policy on alternatives to camps is a good example of this shift. The initiative calls for policies enabling refugees to live in communities lawfully and without harassment. Moreover, following the steady increase of the number of refugees in urban areas (more than half), UNHCR introduced a policy on refugee protection and solutions in urban areas. This policy acknowledges that refugees in urban areas lack even the community support often offered to poor citizens and focuses on reinforcing and supporting existing systems rather than creating parallel ones. As such, the policy works with authorities on behalf of refugees to provide healthcare freely or with a limited cost, monitor the health status of refugees, and augment the existing service providers. The shift to integration can be seen on a country level as well. For example, the government of New Zealand has adopted a refugee resettlement strategy to integrate refugees, where maintaining the health and wellbeing of refugees is one of the main declared goals of the strategy. It is worth repeating, however, that the vast majority of the world’s refugees are in low-income countries, many of which are struggling with the provision of sustainable and effective health systems for their countries’ residents, and for whom the influx of refugees represents an additional challenge for already strained systems.

Compounding this, climate change, the topic of last week’s Dean’s Note, is clearly emerging as a concern in efforts to address the flow of, and well-being of, refugees. In his opening remarks on the 2010 dialogue, the UN commissioner for refugees, Antonio Guterres, addressed the connection between climate change and forced displacement: “Today’s challenges are interconnected and complex. Population growth, urbanization, climate change, water scarcity, and food and energy insecurity are exacerbating conflict and combining in other ways that oblige people to flee their countries.” Other entities such as Refugees International have expressed increased concern about climate change as a reason for population displacement. The Bacon Center for the Study of Climate Displacement, for example, aims to improve the understanding of the relationship between natural disasters, environmental degradation, climate change, and displacement. This represents an understanding of the interlinked and complex roles of climate change and the refugee crises as determinants of population health. In a future Dean’s Note, I shall comment on how we may grapple with such complexity by increasing our understanding of the processes that may generatively influence the development of solutions.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful for the contributions of Laura Sampson and Salma MH Abdalla MBBS to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/