Advancing the Health of Refugees and Displaced Persons

  • Date: Nov 13 2018
  • Policy Number: 20188

Key Words: Immigrants, Immigration, Refugees

Violent conflict, unstable states, an inequitable distribution of power and resources, and environmental disasters have fueled global instability to unprecedented levels, resulting in more displaced persons than at any point in history. Refugees and displaced people face significant health challenges from the time of displacement to integration, repatriation, or resettlement. The United States, historically the leader in championing human rights, can take the lead in strengthening international protections for displaced individuals, uphold its global commitment to resettle more refugees, and do so without discriminating on the basis of race, ethnicity, religion, sexual orientation, or membership in a particular social group. Increased funding and cooperation among multilateral agencies, governments, nongovernmental organizations, and local communities can reduce violent conflicts and promote peace, create resilience in vulnerable societies through strengthening social support, and mitigate the detrimental effects of climate change. Each actor must work cooperatively to ensure safe passage for displaced individuals, adequately fund refugee aid, and integrate responses to meet the long-term social, health, and economic needs of refugees.

Relationship to Existing APHA Policy Statements
The following APHA policy statements are relevant to the current statement:

  • APHA Policy Statement 20157: Public Health Opportunities to Address the Health Effects of Climate Change
  • APHA Policy Statement 20095: The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War
  • APHA Policy Statement 20094: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health
  • APHA Policy Statement 200030: Preventing Genocide
  • APHA Policy Statement 8011: Cuban and Haitian Refugees

Problem Statement
In the aftermath of World War II, 40 million displaced people prompted the international ratification of declarations granting formal legal status to refugees.[1] The 1948 Universal Declaration of Human Rights, 1951 Convention Relating to the Status of Refugees, and 1967 Protocol Relating to the Status of Refugees legally defined a refugee as a person who has fled her or his country of origin and is unable or unwilling to return due to a well-founded fear of persecution based on race, religion, nationality, political opinion, or membership in a particular social group.[1]

Individuals granted refugee status by the Office of the United Nations High Commissioner for Refugees (UNHCR) are entitled to the rights of non-refoulement (prohibiting forcible return), freedom of movement within and outside of their host country, family reunification, legal representation, and access to education and health services.[1] Asylum seekers are individuals who have fled their country of origin and applied for recognition as refugees, and they are entitled to freedom from detention and the opportunity to be employed while awaiting status determination.[1] Notably, this legal framework does not include internally displaced persons, environmental migrants, or economic migrants, who lack the legal protections of asylum seekers and refugees.

Multilateral organizations, governments, and nongovernmental organizations (NGOs) help determine one of three pathways for refugees: integration into their country of asylum, repatriation to their country of origin, or resettlement in a third country.[2] Only a minority of refugees are referred for third-country resettlement, with prioritization of those who have experienced violence or torture, have medical needs exceeding the capacity of their host country, or are at physical or legal risk of harm.[1] The health of refugees and displaced persons is shaped by the destabilizing factors leading to forced displacement, the refugee resettlement system, and the health services available during each phase of the resettlement process.

Causes of instability and displacement: War and conflict are the main causes of displacement. They are rooted in complex interactions between conflicting nation-states, foreign interference, ethnic/religious differences, the legacy of colonialism, the arms and drug trade, and poor governance.[3,4] For example, in the Northern Triangle of Central America representing El Salvador, Guatemala, and Honduras, organized gang violence drives upwards of 500,000 refugees into Mexico every year.[2] This complex conflict is driven by drug cartels that connect South American drug production to North American drug markets and is exacerbated by porous borders based on colonial boundaries, weak governance from lingering Cold War effects, high youth unemployment, and an abundance of illegal weapons.[5] In certain cases, U.S. foreign policy has historically created instability, such as the role of the Central Intelligence Agency (CIA) in the 1954 Guatemalan coup d’etat.

Weakening of social structures from poverty, overcrowding, unfair trade agreements, or minority persecution can create unstable communities at risk of displacement.[4] For example, the Rohingya Muslim ethnic minority group of Burma has suffered systemic exclusion by the government for generations.[6] Starting with British colonization and extending into World War II, members of the Rohingya population were targeted through legal, physical, and social campaigns characterizing them as “illegal Bengali inhabitants” of Burma.[6] Systematic denial of access to education, health care, employment, freedom of movement, and religion has resulted in a fractured and vulnerable society, setting the stage for massive displacement of Rohingyas triggered by the Burmese military ethnic cleansing campaign.[2]

Environmental factors, such as crop failures, natural disasters, and pollution of water, air, and soil, increasingly contribute to instability and will likely worsen displacement if global warming continues unabated.[7] Droughts and other environmental disasters can exacerbate food insecurity and increase the likelihood of conflict and displacement of vulnerable populations.[8] For example, a severe drought in the Euphrates basin from 2007 to 2010 resulted in livestock failure, higher food prices, and mass urban migration, which exacerbated existing ethnic tensions between the majority Sunni population and the minority Alawite ruling party and ultimately led to the Syrian civil war.[9]

The refugee resettlement process: Of the 17.2 million refugees in 2016, 1 million were identified for resettlement, and yet only 189,000 were resettled worldwide.[2] In 2016, all United Nations members signed the New York Declaration for Refugees and Migrants, which pledged support for a comprehensive refugee response framework called the Global Compact for Migration.[10] The United States has historically been the leader in refugee resettlement, and in 2016 the country admitted 85,000 refugees, the largest number since 1995.[2,11] However, countries closer to regions of conflict support larger refugee populations, with the top three being Turkey (2.77 million refugees), Pakistan (1.57 million), and Lebanon (1.03 million).[12]

Refugees identified for U.S. resettlement undergo a rigorous 18- to 24-month vetting process including biometric screening, multiple background checks through law enforcement and intelligence agencies, in-person interviews with the Department of Homeland Security, medical screening, and cultural orientation.[13] Upon arrival in the country of resettlement, refugees are assisted by their volunteer resettlement agency with housing, public health screening, referral to primary care, employment, and integration for a finite time period.[13,14] The federal government decides where refugees are resettled. Coordination with state and local governments is often limited, leading to gaps in the integration of refugees.[15]

The U.S. president has broad powers to determine the number of refugee admissions. A series of executive orders in 2017 temporarily restricted entry by individuals from primarily Muslim-majority countries, paused the refugee admission program for 120 days, and decreased the refugee cap for fiscal year 2018 from 110,000 to 45,000. As a result, only 53,716 refugees were admitted in fiscal year 2017 and only an estimated 20,000 in fiscal year 2018.[16] The refugee cap for fiscal year 2019 has been decreased to 30,000, representing the lowest number since the cap was created in 1980.[16] The U.S. government has continued to reduce its obligation to refugees and displaced individuals by withdrawing from the Global Compact for Migration; ending the temporary protected status program for 300,000 immigrants from Nicaragua, El Salvador, Honduras, Nepal, Sudan, and Haiti fleeing natural disasters; withdrawing from the UN Human Rights Council; eliminating funding for the UN Relief and Works Agency (UNRWA); and establishing a zero-tolerance policy at the southern U.S. border resulting in separation of parents from their children.[17,18]

Health effects of forced migration: Displaced individuals are extremely vulnerable to structural and interpersonal violence, including war, physical endangerment, rape, intimate partner violence, and torture.[19] Women, children, and sexual minorities are at especially high risk of sexual and gender-based violence, including rape, transactional sex, and human trafficking on the part of husbands, smugglers, police, and even refugee camp staff.[20,21] For children, these adverse experiences can later manifest as increased morbidity and mortality from chronic diseases.[22] Individuals exposed to war, state-sponsored violence, separation and loss of family members, human trafficking, torture, or prolonged internment in refugee camps are at heightened risk for long-term psychiatric illnesses including depression, posttraumatic stress disorder (PTSD), and anxiety disorder.[23,24]

International law calls for displaced people to submit a claim for refugee status after crossing a national border. Several conflict-adjacent countries that host displaced people lack sufficient resources for this task. Refugees commonly live in camps, shanty towns, or slums where they are vulnerable to violence and lack access to health services, often violating their human rights.[2] Lack of sufficient sanitation, hygiene, and clean water also places them at higher risk for infectious diseases such as malaria, tuberculosis, meningitis, viral hepatitis, measles, cholera, and intestinal parasites.[2,14,25] As a result of food insecurity, many refugees suffer from malnourishment and vitamin deficiencies, which impair host immunity and increase mortality.[25,26] Fear of deportation may adversely affect psychological well-being, prevent early use of medical services, and lead to underreporting of crimes such as sexual violence. Finally, medical systems for refugees are structurally designed for emergency care such as traumatic injuries or infectious disease outbreaks, resulting in undertreated or undiagnosed chronic medical conditions.[2,27]

Refugees face long-term mental health challenges due to the triple trauma paradigm: primary trauma during displacement, secondary trauma during flight, and tertiary trauma during resettlement.[28] Fear of jeopardizing applications or refugee status, stigma, and unfamiliarity with mental health all lead refugees to underreport psychiatric symptoms and more frequently express them as somatic complaints such as headaches, stomachaches, or back pain.[14] It is estimated that the prevalence of both depression and PTSD is 30% in postconflict populations.[29] Trauma-related mental health disorders are also associated with a higher risk of chronic diseases, including cardiovascular disease, diabetes, and dementia.[30]

Refugees face significant challenges in accessing medical care.[15] During resettlement, there are a myriad of competing housing, language, educational, health, and cultural demands on refugees’ limited resources. Language barriers further exacerbate this challenge and quality interpretation can be limited, especially in rural areas. Finally, refugees are less familiar with preventive medicine and managing chronic conditions, resulting in lower uptake of cancer and cardiovascular screening relative to the general population.[31]

Asylum seekers not granted refugee status and forcibly repatriated to their country of origin face all of the health effects just outlined, and these effects are compounded by reexposure to the original war and conflict.[2]

Evidence-Based Strategies to Address the Problem
Preventing the root causes of forced displacement: Diplomacy, early warning systems, and timely interventions to address ongoing wars can mitigate conflict.[32] A priori legal and policy instruments such as human rights conventions, laws regulating weapons or scarce resources that drive conflict, and international criminal courts that discourage state violence can promote environments resistant to conflict and establish global norms.[32] Ad hoc instruments such as cease fires, peacekeeping missions, economic sanctions or assistance, natural resource management, and aid for institutions that promote peace and civil society can also be used to address ongoing conflicts.[32] The U.S. government plays a central role in resolving global conflicts and mediating disputes through its work at the United Nations and the U.S. State Department. Cuts to these organizations cripple their ability to function.[33] The United States can do more by rejoining the UN Human Rights Council, joining the International Criminal Court, signing on to treaties that limit the legality of weapons, and restricting arms sales.

Improving access to education, employment, and medical care can strengthen societies vulnerable to displacement.[34] Bilateral official development assistance, equitable trade partnerships, academic partnerships with U.S. universities, and NGOs each have complementary roles in promoting resilient societies and building capacities.[34] For instance, the Global Health Security Agenda, an international partnership between 50 nations and multiple NGOs to increase the capacity of health systems to respond to pandemic threats, has helped detect and control outbreaks of measles, cholera, and Ebola.[35] The U.S. government plays a large role in humanitarian assistance, civil society strengthening, and global health security through various federal agencies.[36,37] Improved funding and coordination of these programs can strengthen civil society, prevent pandemic disease, and reduce displacement.[33,35,36]

Climate change increasingly threatens the stability of societies, and addressing the environmental determinants of displacement is crucial in tackling the refugee crisis.[24] Effective environmental policies include implementing laws that protect public control of and access to water, air, and soil.[38] Research and investment in alternative energies such as wind, solar, hydroelectric, and geothermal can spur economic growth and combat climate change.[38] Shifting agricultural practices, streamlining irrigation, and climate proofing rainfall systems may mitigate severe droughts.[39] Finally, international cooperation to reduce global warming is needed to avoid the catastrophic effects of climate change. The termination in 2017 of the U.S. commitment to the 2016 Paris Climate Agreement is detrimental to these efforts.[40] Sound environmental regulation, investments in green technologies, and reentry into the Paris Agreement would reduce the environmental conditions leading to displacement.[7,24,38,40]

Improving the resettlement process: The 2016 New York Declaration for Refugees and Migrants commits UN member states to work through the Global Compact for Migration to strengthen emergency responses to displacement crises, provide predictable humanitarian and development funding to support host countries and promote refugee resilience, and ease the process of third-country resettlement and repatriation to streamline the global response to large refugee movements.[33] As a leader in refugee resettlement, the United States could engage in efforts through the Global Compact for Migration to help craft the new framework for responding to displacement crises. Pushing this declaration further by using a human rights framework to establish legal mandates to enact these measures can facilitate more sustained cooperation among stakeholders, meet resettlement needs, and protect the health of migrants.[33,34]

The United States has for decades accepted the most refugees for third-country resettlement.[11] To meet the challenges of the current refugee crisis, the U.S. president has the power to raise the cap on the number of refugees admitted to the country, prioritize the most vulnerable refugees, provide adequate resources for timely vetting of refugees assigned for resettlement, and ensure that there is no discrimination in acceptance of refugees based on race, ethnicity, religion, sexual orientation, or membership in a particular social group.[16] The United States can commit to upholding the rights of asylum seekers with pending cases and protecting immigrants under special programs such as temporary protected status to prevent deportation to unstable environments.[17] Finally, state and local host communities can work with resettlement agencies to advocate the federal government for increased refugee referrals.

The United States is the largest contributor to the multilateral organizations that support refugees, including UNHCR, UNRWA, the United Nations Children’s Fund, the World Food Program, the International Committee of the Red Cross, and the International Organization for Migration.[33] Increased and sustained funding to these organizations and local refugee resettlement agencies would enhance the protection of refugees and improve their integration into society.[33,37]

Improving the health of refugees: Once displacement occurs, mitigating physical threats and ensuring safe passage of refugees and internally displaced persons can minimize future physical and mental health problems.[2] In the absence of formalized legal protections for displaced persons not meeting refugee legal status, countries hosting and resettling refugees can work together to ensure mechanisms of safe passage for displaced populations, restrict passage through unsafe migration routes and use of human smuggling, and equally distribute the burden of hosting refugees worldwide.[41] Asylum seekers should not be detained or imprisoned, and children should not be separated from their parents (a major adverse childhood experience).[22]

To enhance medical care in refugee camps and other semi-permanent living situations, thoughtful expansion of effective public health interventions, health care staffing, referrals to primary care, and improved data collection are essential. As infectious diseases and malnutrition represent a large burden of illness in this population, improved water systems and waste management, enhanced vaccination coverage, support of breastfeeding, and provision of adequate nutrition can reduce malnutrition, morbidity, and mortality.[1,2,25,26,42] Most refugee camps have established partnerships with NGOs and local hospitals, and provision of adequate resources, appropriate staffing, and fair compensation are necessary for effective health service delivery and prevention of burnout among health care professionals.[43] For refugees who live long term in camps and semi-urban or urban settings, improved referrals to primary care are important in managing chronic medical conditions.[43] Enhanced data collection in these settings can improve resource allocation, detect public health threats, and link progress to existing Sustainable Development Goals.[44] Finally, establishing a right to health care with legally enforceable requirements in conjunction with provision of adequate resources to host countries would strengthen refugee health services.[45]

Refugees who are integrated into their country of asylum or resettled in a third country require a comprehensive set of wrap-around services, including assistance with housing, employment, and education, to promote self-sufficiency.[46,47] The federal government can work more closely with state and local partners to coordinate provision of social services, language instruction, education strategies, and community engagement.[15] Combining housing or legal support with primary care is an effective way of improving access to both.[28] Data on integration and health outcomes of refugees should be collected and shared to facilitate dissemination of innovative models of care and improve accountability.[15]

Medical care should be provided in culturally and linguistically sensitive ways, with an effort to include traditional healing practices through integrative medicine.[14] Community health workers drawn from existing immigrant populations are effective messengers and advocates for refugees.[14] Use of trauma-informed medical care wherein health services are modified to address how trauma impacts the life of the patient can improve trust in providers, enhance health outcomes, and contribute to peace building.[48,49] These aims can be achieved by using qualified interpreters, respecting privacy concerns, and working closely with other refugee organizations to advocate for housing, economic, or legal needs.[50]

Opposing Arguments/Evidence
Refugees are a burden to society: Certain groups argue against accepting refugees as a result of their increased use of welfare programs, including food stamps, Medicaid, and cash and housing assistance.[51] They also cite lower rates of education and low household earnings that lead to long-term dependence on the social safety net.[51] While newly arrived refugees have higher rates of unemployment and welfare utilization, they become a net economic benefit to society after only 8 years in the United States.[52] Over a period of 20 years, refugees are more likely to start a business and be employed than their native-born counterparts.[47,52] Refugees who have been in the United States for more than 20 years have similar rates of home ownership and pay on average $21,000 more in taxes than they have received in benefits.[47,52]

Refugees are security threats: Some hold concerns that refugee admissions could be exploited by would-be terrorists.[53] However, the United States is geographically isolated from conflict zones, and most arrivals are third-country resettlement refugees who have undergone extensive vetting over a period of 18 to 24 months.[11] Most foreign-born terrorists enter the United States on tourist or student visas or enter the country illegally.[54] Of the 3,252,493 refugees admitted between 1975 and 2015, 20 (0.00062%) became terrorists, with only three successful attacks that killed a total of three people.[54] Therefore, while thorough vetting of refugees is important for national security, the reduction of the threat of terrorism by reducing refugee admissions is negligible.

Refugees should be settled only in the regions they come from: Some argue that instead of admitting refugees, donor countries should fund countries bordering conflicts to care for refugees.[55] For example, the European Union (EU) reached an agreement with Turkey after large influxes of refugees in 2015–2016 stipulating that migrants crossing over from Turkey to the European Union via Greece would have their asylum claims processed and then be returned to Turkey.[55] In exchange, the European Union offered $3.3 billion in foreign aid to Turkey and agreed to settle a refugee from Turkey who has not tried to illegally enter the European Union for each migrant returned from Greece to Turkey.[55] While this stanched the flow of migrants, it reduced the possibility of resettlement for the most vulnerable refugees who had experienced persecution or torture, had unmet medical needs, or were at risk of exploitation.[2,55,56]

Action Steps

Preventing the Root Causes of Forced Displacement

  • The U.S. government should fully invest in and cooperate with the international community on efforts to prevent conflict through diplomacy, regulation, peacekeeping missions, and human rights promotion.
  • Multilateral organizations, NGOs, and governments should engage in partnerships aimed at strengthening the economic, educational, and health sectors of countries with populations vulnerable to displacement.
  • The U.S. government should reenter the Paris Climate Agreement, strive to reach targets on greenhouse emissions, implement laws protecting the environment, and invest in green technologies and infrastructure to mitigate severe droughts and flooding.

Improving the Resettlement Process

  • The U.S. government should reaffirm the New York Declaration for Refugees and Migrants and rejoin the Global Compact for Migration to coordinate a multisectoral response to the refugee crisis.
  • The U.S. government should oppose discriminatory bans on refugees, uphold the rights of asylum seekers, and increase refugee resettlements by raising the cap on refugee admissions. States, local governments, and NGO partners can advocate for increased refugee resettlement.
  • The U.S. government should increase and sustain funding to the multilateral institutions, NGOs, and resettlement agencies that support integration of refugees into their communities.

Improving the Health of Refugees

  • The U.S. government and multilateral institutions should work cooperatively to ensure safe passage for refugees. The international community should adopt legal protections for displaced persons not currently included under existing international law.
  • Developed countries should adequately fund multilateral, governmental, and nongovernmental organizations that improve transitory living conditions in countries of asylum, focusing especially on public health, surveillance, water and sanitation, primary care, and mental health.
  • The U.S. government should work with state and local partners to strategically coordinate provision of housing, educational, and health services to ease refugee integration and develop systems of data sharing to spread innovative approaches and promote accountability.
  • Health care systems and providers should tailor their services to meet the needs of refugee populations and promote independence by delivering culturally competent care via trauma-informed approaches, integrating social services with primary care, and utilizing interpreters and community health workers from the refugee community when possible.


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