Resources Lesson 1: Health Effects
There is an excellent and growing series of papers under the heading of Migrant and refugee health in BMC Medicine. 'This article collection covers recent advances in infectious and non-communicable disease research, tropical medicine, and global health policy that have both broad interest and high clinical and public health relevance due to their impact on migrant health'.
Mental Health impact of mass violence.
The paper Mass violence and mental health--recent epidemiological findings by Murthy is not recent anymore, but is a good summary of the problems faced by many refugees. The Abstract includes: "There is sufficient evidence from the variety of mass violence/conflict situations, that a significant proportion of the exposed population develops different mental disorders. There are vulnerable groups like women, children, widows, orphans, elderly, disabled, those exposed to severe pain and loss of body parts. There is also a consistent finding of the dose-response to the amount of trauma and the prevalence of mental disorders. There is growing recognition that there is need to consider a variety of syndromes, in addition to post-traumatic stress disorder (PTSD) like acute stress disorder (ASD), depression, complicated bereavement reactions, substance use disorders, poor physical health, fear, anxiety, physiological arousal, somatisation, anger control, functional disability and arrest or regression of childhood developmental progression. The challenge is to reach all of the ill persons and provide mental health services."
A 2016 Health Evidence Synthesis Report Public Health Aspects of Mental Health Among Migrants and Refugees: A Review of the Evidence on Mental Health Care for Refugees, Asylum Seekers and Irregular Migrants in the WHO European Region summarise as follows: "The increasing number of refugees, asylum seekers, and irregular migrants poses a challenge for mental health services in Europe. This review found that these groups are exposed to risk factors for mental disorders before, during, and after migration. The prevalence rates of psychotic, mood, and substance use disorders in these groups are variable but overall are similar to those in the host populations; however, the rates of post-traumatic stress disorder in refugees and asylum seekers are higher. Poor socioeconomic conditions are associated with increased rates of depression five years after resettlement. These groups encounter barriers to accessing mental health care. Good practice for mental health care includes promoting social integration, developing outreach services, coordinating health care, providing information on entitlements and available services, and training professionals to work with these groups. These actions require resources and organizational flexibility."
Refugees experience high rates of mental, neurological, and substance use (MNS) problems, contributing to a higher burden of disease in displaced populations. This report explains the various risk factors that may contribute to higher levels of substance use in refugee populations. It also provides recommendations for feasible and cost-effective mental health and substance use interventions to improve refugees' health and quality of life. Read the content under the headings "Executive Summary" on pages 6-8 and "1.4 Risk factors for alcohol and substance use among refugees" on page 12.
Children and young people
Detention, denial, and death: migration hazards for refugee children by Fazel et al, is a very important paper. It starts: "Organised violence, persecution, and community instability cause millions of children to flee their native countries every year. About 7·6 million people were newly displaced by conflict or persecution in 2012 (the highest number in a decade), of which approximately half were younger than 18 years. Regions prone to disaster and adversity often have disproportionately young populations, and thus larger numbers of children and adolescents are now moving across country borders, with or without their families. The journey to countries of refuge can be perilous; thousands of migrants have died in poorly equipped and heavily laden boats traveling across the Mediterranean, the Gulf of Mexico, and the Indian Ocean. These figures constitute only a fraction of the unnamed lives lost on irregular and dangerous routes to safe countries. Children are particularly vulnerable in these unstable and insecure situations. Their unmonitored movement across borders places them at increased risk of abuse, exploitation, sexual violence, forced labor, and trafficking"
A paper by Drury and Williams, Children and young people who are refugees, internally displaced persons or survivors or perpetrators of war, mass violence and terrorism summarises: "Much of the recent research confirms earlier findings, which demonstrate that their exposure to war and collective violence leads to distress for many children and/or mental disorders for a smaller but substantial minority of them. The literature shows interest in identifying and measuring protective factors. The emphasis in the articles we reviewed on social as well as personal factors that confer psychosocial resilience reflects the broad interest in the two canons of literature on children's development and disasters. The findings point powerfully to people's needs for holistic and community-level interventions."
Access to health services.
The UN Refugee Agency, UNHCR, in its web site section on Public Health quotes: "The 1951 Refugee Convention states that refugees should enjoy access to health services equivalent to that of the host population, while everyone has the right under international law to the highest standards of physical and mental health." It goes on to say: "Among forcibly displaced populations in developing countries, the top five killers of children under the age of five are malaria, malnutrition, measles, diarrhoea and respiratory tract infections. The priorities for UNHCR and its partners at the start of an emergency are measles immunization, nutritional support, control of communicable diseases and epidemics, implementation of the reproduction health measures and public health surveillance. As the situation stabilizes these services are enlarged. In more developed and urban settings, public health priorities among adults shift toward cardiovascular and chronic diseases and cancers."
The UNHCR site Access to healthcare is worth exploring. There is access to a number of relevant documents, including the UNHCR Global Strategy for Public Health which "..encompasses four major-related sectors that are of vital importance in providing protection and services to refugees and other persons of concern....These are public health itself; human immunodeficiency virus (HIV) and reproductive health; food security and nutrition; and water, sanitation and hygiene (WASH)."
There is also access to a section on Reproductive Health which includes a number of links to documents and the comment: "Access to quality reproductive health services, including adequate emergency obstetric care, can drastically reduce the number of women who die during or after child birth and ensure that mothers and their children enjoy a healthy life. Reproductive health education for adults and young people is also important, helping to raise awareness about, among other things, maternal health; family planning; the fall-out from sexual violence; female genital mutilation; sexually transmitted diseases; and HIV."
There are a number of health conditions found among refugees, even if these are not caused by their refugee status. Health services might need to be aware of these. The 20 high priority conditions for which guidelines are required are listed in Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions: "Nine infectious diseases were selected, as well as four mental health conditions, three maternal and child health issues, caries and periodontal disease, iron-deficiency anemia, diabetes, and vision screening."
10 things to know about the health of refugees and migrants from WHO offers other perspectives, including that "Migrants and refugees are likely to be healthy in general".
However, Health in camps by UNHCR provides a more urgent perspective "The provision of health services is one component of an overall public health response to emergencies. The overall aim of any public health intervention is to prevent and reduce excess mortality and morbidity.
In the first phases of an emergency, the public health response focuses on identifying and addressing life-saving needs. The best outcome is to provide refugees with full access to essential health services and wherever possible to ensure access to national services. To achieve this, it is crucial to collaborate closely and support from the beginning the ministries and local authorities responsible for public health.
Public Health interventions in camp settings aim to meet the basic health needs of refugees. Health services are closely linked to nutrition and WASH services to prevent disease outbreaks and reduce public health risks as well as providing a favorable environment for protection of nutrition status and food security."