In recent decades, the world has experienced unprecedented levels of human migration due to globalization, changing international economic patterns, and ethnic conflict. Between 1980 and 1997 the worldwide refugee population increased from 9 million to over 41 million persons. Approximately 20 million of these individuals are formally classified by the United Nations as "refugees," meaning they have been forced to flee across their own international borders. The others are classified as "internally displaced persons," meaning they have fled their homes but have not been able to leave their countries. These numbers do not include the millions of voluntary economic migrants who leave their homes in impoverished rural communities in developing countries in order to take manufacturing and related jobs in larger cities or foreign countries.
Forced human migration is a significant public health challenge. The United Nations High Commissioner for Refugees estimates that one in every thirty persons in the world will be a formal or informal refugee at some point in his or her life. Furthermore, 95 percent of all refugees are estimated to come from, and reside in, developing countries in Asia, Latin America, and Africa, where health status is already compromised. Refugee health is also a critical mother-and-child issue, as approximately 80 percent of all refugee populations around the world are comprised of women and children, with children accounting for 50 percent of these groups.
A HISTORY OF REFUGEEISM
While refugees have existed throughout human history, the term was first formally used in 1573 to describe Calvinists fleeing political repression in the Spanish-controlled Netherlands. Refugees were not only defined as victims of persecution, but were also seen as individuals with political, religious, economic, or other affiliations that aroused solidarity.
Providing aid and protection to refugees has increasingly become the collective duty of the international community. After the end of World War I and the creation of the League of Nations, refugee assistance began to be institutionalized. At the end of World War II, the United Nations superceded the League of Nations and created the International Refugee Organization (IRO) in 1946. In 1950, the IRO was replaced by the office of the United Nations High Commissioner for Refugees (UNHCR), which was mandated to encourage countries to receive refugees, prevent them from being forcibly returned, and provide assistance and protection to them.
The 1951 United Nations Convention on Refugees has been ratified by almost 120 countries. It defines a refugee as "any person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in 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" (Médecins Sans Frontières, 1997). This definition reflects the reality of postwar Europe, but has since been found inadequate in dealing with the special situations faced by refugees from other continents. Therefore, in 1967, this protocol abolished geographic restrictions on the scope of the convention.
National wars of liberation and post-independence conflicts in both Africa and Asia greatly contributed to the problem of mass refugee movements in the early 1960s. During this period, the UNHCR began to give more attention to the new reality of refugees in developing countries due to war and insecurity, and it expanded its definition of refugees to include those who fled general danger rather than just those who feared persecution. In 1969, due to significant refugee problems in Africa, the UNHCR definition was formalized by the Organization of African Unity (OAU) to include those refugees who were forced to leave their native countries not only because of persecution, but also aggression, occupation by an outside force, foreign domination, or disturbance of peace by the country of origin. In 1984, the Cartagena Declaration was added to the OAU definition to include victims of massive humanrights violations.
Significant legal and socioeconomic differences exist between formally recognized "refugees," "internally displaced persons," and "economic migrants." Refugees that have been officially recognized by the United Nations and other international political bodies are generally entitled to a number of legal benefits and to humanitarian assistance. In general, these refugees are individuals that did not want to flee their homes, but were forced to do so. However, once resettled or repatriated, many of these families are reunited to some extent. The protection and services that can be offered to internally displaced persons is generally much more limited because they are still located in what might be defined as "enemy territory." Their health status is usually even lower than that of refugees because they do not have access to humanitarian assistance.
Millions of people around the world, though, leave their homes more willingly, particularly in impoverished rural areas in developing nations, in order to migrate to larger urban centers or even other countries in search of a better standard of living. While these "economic migrants" may not be facing violence or persecution, they nonetheless are generally experiencing extreme levels of poverty. Many of these economic migrants must move into larger cities in their own countries in order to survive, and they often take up residence in dangerous, crowded shantytowns and work in menial jobs. Indeed, for the first time in human history, more people on earth will soon be living in cities rather than in rural areas due to these new migration patterns. Some economic migrants seek work and better opportunities in foreign countries, sometimes entering these countries illegally. However, many others are recruited legally by developed nations to work in low-paying, dangerous, and mundane jobs in agriculture, manufacturing, meatpacking, and other fields. In general, economic migrants are entitled to fewer formal benefits than refugees when moving to a new country, particularly if they are there illegally. They typically have experienced far less trauma and violence during their flight than refugees, but nonetheless can suffer from acculturation stress and depression due to their resettlement. Economic migrants are often younger men who may send much of their salaries back home to their families.
CAUSES OF MIGRATION
Refugeeism, as well as migration in general, is not a new problem, but rather one that dates back to the earliest human times. There are many reasons beyond those in the UNHCR and OHR definitions to explain widespread forced human migration.G. Loescher and A. D. Loescher (1994) suggest that external aggression, internal civil strife, and massive violation of human rights are also reasons for migration. Similarly, the International Committee of the Red Cross and the Johns Hopkins School of Public Health indicate that political and ethnic conflicts are currently among the most important reasons for refugeeism.
Political persecution is a major cause of forced migration, and this often depends on what group controls a nation and its resources. Violence tends to decrease as per capita income rises, which means that weak states are prone to internal violence. Similarly, population displacement is associated with economic tension. Again, when economic tensions rise, poverty may increase as well, which can lead to ethnic conflict. These kinds of tensions can easily interact with other factors that lead to population displacement and prolonged conflicts. As discussed previously, people who leave their country willingly because of economic hardships do not qualify for UNHCR protection or assistance, except in cases when their situations are exacerbated by political violence. However, in reality, there are millions of people worldwide who are forced to leave their homes annually due to severe economic hardships.
Environmental and ecological factors can also be root causes of migration. For instance, migration occurs as food supplies dwindle due to over-grazing, topsoil erosion, deforestation, conversion from food crops to cash crops, inadequate reserves, water deficits, overpopulation, and related issues. If natural disasters occur on top of these existing problems, they may then have an impact on existing tensions, which may ultimately turn into armed conflicts.
Ethnic tensions, based on race, language, culture, and religion, are also among the reasons people seek refuge. Examples of ethnic conflicts in recent years include those in Yugoslavia, Somalia, Burundi, and Rwanda. Ethnic conflict increasingly affects civilians, rather than military troops. Ethnic tensions may cause displacement for two reasons. First, when ethnicity is highly susceptible to political exploitation, some groups seek community support by fanning ethnic antagonism, reactivating tensions that may have been dormant for a long time. This is more likely to happen when one ethnic group captures control of a given state. Second, when a sense of oneness starts to disintegrate, those groups that have become disenfranchised may be seen as obstacles to nation building. However, many ethnic conflicts are not truly about cultural identity, but rather about the control of resources.
Finally, human rights abuses are another cause of refugeeism and international migration. Research indicates that human rights violations do not occur in a vacuum. As mentioned earlier, they coexist with economic constraints, disruptions in food supplies, political weakness and instability, ethnic conflicts, traditional violence, and ecological deterioration. Human rights are usually at the core of humanitarian emergencies, and they become international responsibilities when states fail to respond.
THE REFUGEE AND IMMIGRANT EXPERIENCE
There are three phases of the refugee experience: preflight, flight, and settlement. During these phases, refugees go through common experiences. During the preflight phase, refugees may encounter economic hardship, social disruption, political oppression, and physical violence, triggering a need to leave their home. Hazards include imprisonment, death or disappearance of family members, loss of property and livelihood, physical assaults, witnessing assaults or murders of loved ones, fear of the unexpected, famine, and starvation.
In the second phase, the flight period, refugees face many dangers, including physical hardships such as rape, witnessing others being beaten or killed, anxiety about forced repatriation, family separation, robbery, illness and injuries, and malnutrition. They must also go through a difficult formal process to qualify for final resettlement in a third country. Economic migrants usually have less urgency in their need to flee, and may experience fewer traumatic events.
Refugees ultimately either repatriate to their home country, reside permanently in a second neighboring community, or move to a third country of asylum. Repatriation to their home country is the best solution if it is safe to do so, but millions of refugees and migrants around the world are unable to return home and must remain in second or third countries of asylum. During the resettlement phase, significant sources of stress come from feelings of loss, social isolation, culture shock, accelerated modernization, and minority status. The experience of economic migrants that resettle in a third country will vary dramatically, in part based on whether they are there legally or illegally. They generally do not garner the same level of sympathy and humanitarianism from the host community that may be shown to newly arrived refugees fleeing a war.
The time it takes to adjust to a new culture varies with each migrant, influenced by the stability of life before becoming a migrant, personality, level of trauma experienced, skills possessed, and the amount of support and resources available. There are a number of phases of adjustment that refugees experience as they resettle in the United States: the arrival phase; the reality phase; the negotiation or alienation phase; and the integration or marginalization phase. During the arrival phase, immigrants typically have very high expectations and are filled with hopes about the future. During the reality phase, migrants may realize that what they expected is not necessarily what they are experiencing, and they recognize that there are many obstacles to achieving their expectations. Many experience stress as a result of any trauma and cultural bereavement they may have experienced. If they receive enough support during this phase, they can often cope well and make a smooth move to the next stage.
The third phase of refugee resettlement consists of either negotiation or alienation. During this stage, refugees start making moves toward cultural and physiological integration. However, if adequate support is not available for them during this stage, the stresses of their new lives, combined with the consequences of their past trauma, may move them into alienation rather than integration, and they may experience serious psychological, social, and legal problems. This stage is characterized by apathy, isolation, and dysfunctional attitudes, which leads refugees to become marginalized.
However, if refugees receive early support, they may move into the stage of integration rather than marginalization. In this stage, refugees find satisfactory long-term adaptation to their new society and start to settle into routine lives. A very early network of support is critical to help refugees achieve integration. Economic migrants can experience each of these phases as well.
REFUGEE AND IMMIGRANT RESETTLEMENT IN THE UNITED STATES
Since World War II, more refugees have found permanent homes in the United States than in any other country. In order to be designated as refugees by the United States, they must have a well-founded fear of persecution in their countries of origin because of race, region, nationality, membership in a particular social group, or political opinion.
The U.S. government works closely with the UNHCR, other international and nongovernmental organizations, and other governments to protect refugees, displaced persons, and victims of conflicts. According to the U.S. Committee for Refugees, the United States resettled up to 76,554 refugees in fiscal year 1998. The United States spends millions of dollars each year in order to ensure that the survival needs—such as food, health care, and shelter—of these refugees are met.
According to the U.S. Committee for Refugees, the United States is ranked first among the top twenty donor nations that contribute funding for programs that assist refugees. The U.S. government provided $364 million in 1999 to the UNHCR, the International Organization for Migration (IOM), and the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA).
There are four refugee-processing priorities that have been established and are used to process refugee cases during resettlement programs. These priorities are as follows:
Priority One. UNHCR or U.S. embassy identified cases, including persons facing compelling security concerns in countries of first asylum; persons in need of legal protection because of the danger of refoulement; those in danger due to threats of armed attack in an area where they are located; persons who have experienced recent persecution because of their political, religious, or human rights activities (prisoners of conscience); women-at-risk; victims of torture or violence; physically or mentally disabled persons; persons in urgent need of medical treatment not available in the first asylum country; and persons for whom other durable solutions are not feasible and whose status in the place of asylum does not present a satisfactory long-term solution. All nationalities are eligible for this processing priority.
Priority Two. Groups of special humanitarian concern to the United States.
Priority Three. Spouses, unmarried sons and daughters, and parents of persons lawfully admitted to the United States as permanent resident aliens, refugees, asylees, conditional residents, and certain parolees; over-21-year-old unmarried sons and daughters of U.S. citizens; and parents of U.S. citizens under 21 years of age. (Spouses and unmarried sons and daughters under 21 of U.S. citizens; and the parents of U.S. citizens who have attained the age of 21 are required by regulation to be admitted as immigrants rather than as refugees.)
Priority Four. Grandparents, grandchildren, married sons and daughters, and siblings of U.S. citizens and persons lawfully admitted to the United States as permanent resident aliens, refugees, asylees, conditional residents, and certain parolees.
Most decisions on refugee admission ceilings, adjustments, and appropriations to refugee agencies are made by the United States Congress. However, the State Department, the attorney general, and the president's office can help decide special cases.
Each year the United States admits large numbers of legal immigrants from around the world to join family members or to work in jobs with labor shortages or special needs. Millions of illegal immigrants are also believed to live in the United States. While some of these individuals have entered the country illegally, many of them have simply overstayed their tourist visas for employment reasons. These economic migrants, particularly those from developing nations in Africa, Asia, and Latin America, have traditionally been concentrated in large metropolitan areas in the United States, particularly along the southern border and coastal areas. However, in recent years, this diversity has spread to rural Midwestern regions, particularly where meat processing or agricultural jobs exist. Many of these communities in rural states are now experiencing a "rapid ethnic diversification" due to a sudden influx of refugees and economic migrants.
REFUGEE AND IMMIGRANT HEALTH CHALLENGES
Refugees are among the most at-risk populations for poor health status in the world. Most of them flee countries where their health status was already compromised. When refugees and some economic migrants first leave their homes, they often spend an initial period of time in a temporary camp or squatter settlement where their health status can be seriously compromised. During the emergency phase following the initial arrival of a large number of migrants to these camps, mortality rates are very high due to crowded conditions, trauma, limited medical care, poor sanitation and drinking water resources, and other factors. The diseases that are highly prevalent during the emergency phase typically include measles, malnutrition, diarrhea, respiratory infections, malaria, meningitis, and hypothermia. Most of these conditions develop because of the rapid nature in which emergency housing is established, often by the refugees themselves. Many of these "camps" consist of nothing more than temporary tents made from blankets, and they often spring up directly on the other side of the border from the country the people fled.
Military units from their own country may periodically conduct illegal raids on the refugees. Young children and women, who often leave the refugee camps to get water and firewood, are frequent targets of sniper fire or victims of landmines of enemy forces. Many of these emergency camps are also built in poor conditions, such as near swamps or wetlands where mosquitoes and other insect vectors are common.
During the postemergency or consolidation phase in refugee camps, the mortality rates decline to the level of the surrounding host population. Specific health issues that need to be addressed during this phase include curative health care, reproductive health care, child health, sexually transmitted diseases, tuberculosis, and psychosocial and mental health needs. In order to reduce mortality and morbidity rates, general public health measures must include the following: initial assessment, immunizations, water and sanitation, food provision, shelter and site planning, emergency medicine, control of communicable diseases and epidemics, public health surveillance, human resources and training, and coordination of services.
The United Nations feels that the most desired solution, where possible, is to assist refugees in returning to their own countries. However, many millions are unable to ever go home due to continuing political unrest and other factors. Therefore, refugees and immigrants experience health problems not only during their departure phase, but also at the time of their resettlement in a host country. Such problems vary depending on immigration status and area of origin. For example, refugees from developing countries in Africa may have not experienced Western medicine, whereas those who come from countries such as Cuba, Bosnia, and Russia have some familiarity with Western-style health care. Similarly, immigrants who come from tropical areas could present with conditions that Western physicians might not recognize immediately, such as malaria and schistosomiasis.
However, despite their different backgrounds, most refugees share common experiences related to wars, extreme poverty, and other disruptions— such as physical and psychological health problems prior to and during their resettlement. T. Gavagan and L. Brodyaga recommend physical examinations and laboratory tests, as well as screenings for nutritional status, mental health, and infectious diseases. Within thirty to ninety days of arriving in their resettlement country, all refugees should have a domestic health assessment for the purpose of reducing health-related barriers to successful resettlement while protecting the health of the general population. Similarly, L. K. Ackerman emphasizes that a health assessment done in the resettlement country can detect important medical conditions and protect the health of the host population. In the United States, these programs are typically managed by refugee health offices, which vary from state to state. Components generally include a health history, physical examination, immunization updates, and screenings for anemia, hepatitis B, parasitic infections, pregnancy, tuberculosis, vision, hearing, and dental abnormalities. Mental health challenges such as depression, post-traumatic stress disorder, and acculturation shock are among the most frequently seen conditions among refugees from around the world.
Some research done specifically on the health status of Bosnian and other refugees that have resettled in the United States indicates that they initially tend to have a poorer health status than other people in the host community. This can be characterized by poor appetite, high smoking rates, poor dental health, decreased memory, limited leisure time, mood swings, sleep problems, and decreased energy and patience. According to Ackerman, some refugees that resettle in the United States may suffer from malnutrition, tuberculosis, low immunization rates, depression, hepatitis B, poor dental health, and war-related injuries. Some of the most significant psychological conditions may be experienced by many refugees who are victims of ethnic cleansing. For example, Ackerman states that 65 percent of Bosnian refugees in the United States were found to have post-traumatic stress disorder, and 35 percent suffered from depression.
There is a need for ongoing health assessments to explore more fully not only the medical and psychological problems of refugees, but also their health beliefs. Findings from a complete health history and physical examination, awareness of the physical and mental health problems encountered by migrants, and familiarity with their cultural beliefs will enable health care providers to provide complete and compassionate care to this very high-risk population.
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