Photo by Jonatan Konfino.

‍The authors explore the medical consequences typically experienced by refugees and explain the level of vulnerability these populations are now exposed to. The problem, which has a worldwide scope, demands an update of health care policies. This article first appeared in the Argentinian health publication, Soberanía Sanitaria.

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Some numbers

Displacement is a complex situation that describes the dire state, in terms of safety and human rights, that specific populations find themselves in when an armed conflict occurs. Forced displacement reached its highest level ever in the middle of 2021. UNHCR, the United Nations agency that handles this matter, estimates that global forced displacement figures have exceeded 84 million people as of mid-2021, a large increase compared to the 82.4 million refugees reported at the end of 2020 (see footnote 1).

The displacement statistics for 2022 are not yet fully available, but there is reason to believe that the problem is at its highest point and is growing even more because of the war between Russia and Ukraine. The UN, along with several media outlets (for example, Al-Jazeera) have reported that there are another 6.5 million people who are internally displaced in Ukraine, as well as 3.2 million in other countries (see footnote 2). According to the Global Report in 2021, out of the 84 million displaced persons, 48 million are internal, 26.6 million are refugees, 4.4 million are seeking asylum, and 3.9 million are Venezuelans displaced in foreign countries (see footnote 3).

In the last two years, different conflicts accelerated the increase in forcibly displaced people. The war in Syria (2011-present) provoked the forced displacement of 11.6 million people; the Israeli-Palestinian conflict (1948-present) has resulted in millions of displaced people; the Korean War (1950-1953) caused the displacement of 1 to 5 million people; the war in Iraq (2003-present) has provoked a displacement of 4 million people; the Vietnam War (ended in 1975) caused the displacement of 3 million people; the conflict in former Yugoslavia (1991-1995) provoked the displacement of 2.7 million people; the Afghan conflict (since 1979) has displaced 2.6 million people; the Rwanda genocide (1994) provoked the displacement of 1.5 million people; since the collapse of Siad Barre's regime in 1991, 1.1 million Somalis have been displaced; the violence in the Central African Republic (2013) displaced 850,000 people; the violence in South Sudan (1955-72; 2013) displaced 660,000 people; the wars in the Democratic Republic of the Congo (1996-1998) displaced 516,800 people; the violence in Myanmar (2012) displaced 479,000 people (see footnote 4). The list doesn’t end here, and only comprises the main catastrophes that have altered thousands of lives in several countries and left those affected by the local conflicts without recognition or assistance.

The displacement statistics for 2022 are not yet fully available, but there is reason to believe that the problem is at its highest point and is growing even more because of the war between Russia and Ukraine.

Effects of displacement on health

To analyze the impact of displacement on people’s health, it is important to consider the factors that come before, during, and after migration. Physically, the prevalence of many chronic and infectious diseases is widely different between different countries, and is a factor that must be considered when planning clinical interventions and prevention programs for refugees. For example, smoking is still very frequent in the majority of the Middle East and Africa, but not in the United States or Canada. In addition, refugees must make dangerous and exhausting journeys to reach safety, which increases the risk of traumatic wounds, lack of medication or medical attention, or even the risk of human trafficking, for example.

After refugees are resettled, although they can experience a greater sense of peace and security, they are confronted by new situations: often they face discrimination, interrupted access to medical attention, and cultural and language barriers that interfere with medical attention and with health in general. They are more susceptible to different mental health conditions such as post-traumatic stress disorder, depression, and anxiety, which are caused by traumatic events in each phase of the migration (before, during, or after). These mental health challenges are derived from being mistreated in their place of origin and being forced to seek refuge in another place, being retained in detention centers, and passing through the integration process in their new country, to name a few. A systematic review carried out an exhaustive search of data from 2003 to 2020 to better understand the effects of displacement; a compilation of data from 5,143 people in 15 different countries indicated that 31.5% experienced post-traumatic stress disorder (PTSD), 31.5% experienced depression, 11% experienced an anxiety disorder, and 1.5% experienced psychosis (see footnote 5).

Besides experiencing first-hand extremely stressful factors that negatively alter brain function, the refugee population is also very likely to experiment intergenerational trauma, which defines the way that trauma experienced by one generation affects the health and well-being of the victims’ descendants (see footnotes 6 & 7). This kind of trauma affects many people; however, the majority are descendants of survivors of abuse, armed conflict, and genocide (see footnote 8). According to a qualitative study carried out on the Lebanese and Iraqi population, the children of traumatized parents showed significantly higher levels of attention deficit disorder, depression, post-traumatic stress disorder, anxiety, and psychosocial stress (see footnote 9). Contrary to this group, refugees did not show immediate signs of mental anxiety; rather, the onset of these symptoms takes months and even years. Socially, refugees often face family separation, the loss of social networks and safety networks, and are exposed to racism, which contribute to chronic stress and its consequences, such as blood pressure imbalance, among other things. Displacement doesn’t just have a mental and psychological effect; it also entails a long list of challenges and barriers that limit access to medical attention, which results in more physical health problems. According to the Refugee Resettlement Office, refugees face a wide variety of acute or chronic health problems. Examples include infectious diseases like tuberculosis, intestinal parasites, chronic diseases like diabetes or hypertension, and mental health problems like post-traumatic stress disorder or depression (see footnote 10). Many tend not to receive treatment because of mental restrictions, including mental health conditions, fatalism, mistrust, and perceived or structural discrimination such as lack of accessibility; limited services; inadequate interpretation and translation services; resettlement challenges such as housing, food, and work insecurity; only receiving  medical attention in urgent cases; and lack of cultural competence.

Displacement doesn’t just have a mental and psychological effect; it also entails a long list of challenges and barriers that limit access to medical attention, which results in more physical health problems.

Opportunities for re-insertion and growth

Despite the extreme adversity that they experience, refugees tend to have a positive impact on the country that receives them. It has been proven that they add productivity and stimulate the economy on a large scale. The founder of the Open Political Economy Network states that, when given the opportunity, refugees can add great value to the economic sector as workers, innovators, businesspeople, taxpayers, consumers, and investors. This creates jobs and increases the productivity and salaries of local workers, which increases the return on capital, stimulating trade and international investment and spurring growth (see footnote 11).

Supporting this statement, an analysis of 30 years of Western European data carried out by Amy Maxman refutes suggestions that asylum-seekers represent a financial risk that burdens the country taking them in. There are statistics that prove the positive influence of refugees, since the gross domestic product per capita increases and unemployment is reduced. Refugees can provide a large quantity of knowledge and diversity to stimulate economic growth in their receiving country after being forced to flee circumstances that are impossible for the rest of us to understand. Therefore, we see the need to recognize refugees as a vulnerable population from a humanitarian and medical perspective, as well as recognize the importance of tackling health problems with policies specifically designed to facilitate the best integration possible.

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Maryam Aso is B.S. in Criminal Justice, Research Assistant at San Diego State Research Foundation and The Herbert Wertheim School of Public Health, University of California, San Diego, and Legal Intern at the San Diego Public Defender.

Tala Al-Rousan is Assistant Professor of Public Health at the Herbert Wertheim School of Public Health, University of California, San Diego, Atlantic Fellow for Equity in Brain Health, University of California, San Francisco.

Jonatan Konfino is the Secretary of Health of Quilmes. Public Health Professor at UNAJ and GWU.

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Footnotes:

1 United Nations High Commissioner for Refugees. (n.d.). Mid-year trends. UNHCR. Retrieved March 18, 2022, from https://www.unhcr.org/en-us/mid-year-trends.html

2 Ibrahim, A., Gadzo, M., Rasheed, Z., & Harb, A. (2022, March 18). Un says 6.5 million are internally displaced in Ukraine due to War. Russia-Ukraine war News | Al Jazeera. Retrieved March 18, 2022, from

3 https://www.aljazeera.com/news/2022/3/17/un-says-more-than-700-civilians-killed-ukraine-liveblog

United Nations High Commissioner for Refugees. (n.d.). Refugee statistics. UNHCR. Retrieved March 15, 2022, from https://www.unhcr.org/refugee-statistics/

4 Dow Jones & Company. (n.d.). Migrant crisis: A history of displacement. The Wall Street Journal. Retrieved March 15, 2022, from http://graphics.wsj.com/migrant-crisis-a-history-of-displacement/

5 Blackmore, R., Boyle, J. A., Fazel, M., Ranasinha, S., Gray, K. M., Fitzgerald, G., Misso, M., & Gibson-Helm, M. (2020). The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS medicine, 17(9), e1003337. https://doi.org/10.1371/journal.pmed.1003337

6 Dekel R, Goldblatt H. Is there intergenerational transmission of trauma? The case of combat veterans’ children. Am J Orthopsychiatry. 2008;78(3):281. [PubMed] [Google Scholar] [Ref list]

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8 Han M. Relationship among perceived parental trauma, parental attachment, and sense of coherence in Southeast Asian American college students. J Fam Soc Work. 2005;9(2):25–45. [Google Scholar] [Ref list]

9 Daud A, Skoglund E, Rydelius PA. Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children. Int J Soc Welf. 2005;14(1):23–32. [Google Scholar]

10 Refugee health. The Administration for Children and Families. (n.d.). Retrieved March 23, 2022, from https://www.acf.hhs.gov/orr/programs/refugees/refugee-health

11 OECD yearbook – Organisation for Economic Co-operation and development. OECD Yearbook – Organisation for Economic Co-operation and Development. (n.d.). Retrieved March 23, 2022, from

https://www.oecd.org/forum/oecdyearbook/refugees-are-not-a-burden-but-an-opportunity.htm

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