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.

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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.

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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.

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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: /sph/category/news/deans-notes/