J Immigrant Minority Health DOI 10.1007/s10903-014-0022-y
BRIEF COMMUNICATION
Exposure to Traumatic Experiences Among Asylum Seekers from Eritrea and Sudan During Migration to Israel Ora Nakash • Benjamin Langer • Maayan Nagar Shahar Shoham • Ido Lurie • Nadav Davidovitch
•
Springer Science+Business Media New York 2014
Abstract Little is known about the experiences of displaced individuals en route to destination countries. We investigated the reported prevalence of exposure to traumatic experiences during migration among a consecutive sample of adult asylum seekers (n = 895 Eritrean, n = 149 Sudanese) who sought health services in the Physicians for Human Rights Open-Clinic in Israel. Percentage of Eritrean and Sudanese men and women who reported witnessing violence (Eritrea: men: 41.3 %, women: 29.3 %; Sudan: men: 16.8 %, women: 22.2 %) and/or being a victim of violence (Eritrea: men: 56.0 %, Women: 34.9 %; Sudan: men: 51.9 % women: 44.4 %) during migration varied by gender and country of origin.
O. Nakash (&) M. Nagar School of Psychology, Interdisciplinary Center (IDC) Herzliya, P.O. Box 167, 46150 Herzliya, Israel e-mail: [email protected] B. Langer Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada S. Shoham Physicians for Human Rights-Israel Open-Clinic, Jaffa-Tel Aviv, Israel I. Lurie Abarbanel Mental Health Center, Bat-Yam, Israel I. Lurie Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel N. Davidovitch Department of Health Systems Management, Faculty of Helath Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
Findings highlight the need for a well-coordinated international cooperation to document and prevent these transgressions. Keywords Asylum-seeker Exposure to trauma Eritrea Israel Mental health Sudan
Introduction Political tensions, civil unrest and persecution based on religious affiliation are some of the reasons people are forced to leave their country of origin and flee to safer places where asylum is offered. Section 94(1) of the Immigration and Asylum Act of the United Nations Agency for Refugees defines an asylum seeker as a displaced person who ‘…is not under 18 and has made a claim for asylum which has been recorded by the Secretary of State but which has not been determined’ [1]. The number of asylum seekers worldwide is rapidly growing [2], including in Israel where an estimated 55,000 asylum seekers reside, the majority of whom came from Eritrea and Sudan [3]. Past research, mostly focused on refugees, documented that forced migration serves as a risk factor for physical and mental health problems. Forced migrants may be exposed to starvation and injuries en route [4, 5]. For example, a study among newly arrived African refugees in Australia documented high rates of nutritional deficiencies and infectious diseases (e.g., gastrointestinal infections) [4]. Furthermore, several studies have documented higher prevalence of anxiety, depression and posttraumatic stress disorder (PTSD) among asylum seekers and refugees compared to the general population [6–9]. For example, 19 % of newly arrived African asylum-seekers in Australia
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reported having mental health problems [4]. Similarly, approximately 30 % of asylum-seekers and refugees that received treatment at a mental health clinic in Israel were diagnosed with PTSD [10]. Factors related to pre-migration experiences (e.g., political turmoil and poverty in country of origin) [6, 11], process of migration (e.g., loss of family and friends, physical and psychological traumatic experiences during the migration); and post-migration experiences (e.g., discrimination and restrictive policies) [7, 12, 13] are all likely to play a role in the increased risk for mental health problems. Furthermore, a study that examined medical records of 325 refugees from Africa and Asia who participated in an intervention program for survivors of torture in New York showed that past exposure to multiple traumatic events among participants of the program was common and was associated with mental ill health [11]. Although information on the number of women who are forced to migrate is difficult to ascertain, it is suggested that their numbers are increasing [14]. Some research has examined the way gender shapes access to refugee protection in developed countries [14–16], and the protracted processes around gaining refugee protection. To date, however, studies on gender, transit and refugee protection have mainly focused on the refugee camp experience [17– 19]. This research has detailed shifts in gender roles among families [20], the prevalence of domestic violence and women’s susceptibility to violence in certain camp contexts [21]. Recent research called attention to issues of gender and transit migration outside the refugee camp [22]. For example, a research conducted among Somalian women crossing borders reported experiences of systematic gender-based violence [23]. Although, research in the general population documented that women are more vulnerable to trauma and report higher rates of mental health problems than men, especially depression, anxiety and PTSD symptoms [24, 25], little is known about gender differences in mental health problems among forced migrants. In the current study we explored the reports of exposure to traumatic experiences en route, among asylum seekers for Eritrea and Sudan in Israel. Eritreans claim asylum based on having escaped from an extremely repressive state and compulsory military service in Eritrea, a country that has long been known for its grave violations of human rights; religious and political persecution, disappearances of citizens and use of torture by the government [26, 27]. Men and women from Darfur flee persecution and mass murder of civilian populations perpetrated by the government and armed militia groups. Israel also hosts a smaller, but close community of south Sudanese who have escaped years of governmental persecution, civil war, insecurity, and a lack of social infrastructure [28, 29].
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Asylum seekers from Africa began crossing the Egypt– Israel border in 2006. Reasons for the influx of African asylum seekers entering Israel can be traced to the growing restrictions on migration to Europe and the decline of living conditions for African refugees in Libya and Egypt. Most, if not all, asylum seekers arrive in Israel via the Sinai desert [30]. Since 2007 until 2013 the number of asylum seekers arriving in Israel through the Sinai desert has dramatically increased and reached a peak of over a thousand asylees who crossed the border each month in 2010 [30, 31]. The political unrest, the state of insecurity, and chaos in North Africa were some of the reasons for this influx. The journey of African refugees merges in the Northern Sinai, a region that although is under Egyptian governess is characterized by a political vacuum that is demonstrated by growing lawlessness and impunity [28, 29] particularly, since the emergence of the Arab Spring in 2010. While some fleeing Eritrea and Sudan are able to pay a smuggler who can guide them in relative safety to a refugee camp, a significant number cross the border without help and often fall prey to human traffickers who roam the border region [32]. Traffickers operate within Ethiopian and Sudanese refugee camps as well [33]. A sizable network of smugglers operates across Eritrea, Sudan, Egypt and Israel to smuggle sub-Saharan asylees to their destination in Israel. Notably, the construction of an Egyptian– Israeli border fence and an intensification of policies to restrict immigration diminished the numbers of new arrivals since 2013. African asylum seekers in Israel are densely concentrated in southern Tel Aviv, one of the city’s poorest neighbourhoods. Until recently, Israel’s collective group protection policy, granting Eritrean and Sudanese asylumseekers the right to remain in Israel until their home countries are deemed safe for their return, prevents Eritrean and Sudanese asylum-seekers from applying for official refugee status. The provisional status granted to them must be renewed frequently. As a result of their temporary status, many cannot legally work and have limited access to the national health care system [28, 29]. The hazards and risks asylum seekers may be exposed to during the migratory process have been documented in some media reports, yet few studies currently exist that address this issue in a more rigorous methodological way [5]. In the current study we systematically investigated the reports of exposure to traumatic experiences en route among asylees seeking refuge in Israel. In order to do this we surveyed a consecutive sample of asylum seekers from Eritrea (n = 895) and Sudan (n = 149) who sought health services in the PHR Open-Clinic in a central city in Israel. Participants were interviewed in their native language about their reports of exposure to traumatic experiences in
J Immigrant Minority Health
the Sinai desert, which in recent years has seen a sharp increase in human trafficking and smuggling [28, 30, 31, 33].
Methods Setting The PHR Open-Clinic provides primary care as well as a range of secondary services to uninsured persons, most of whom are asylum seekers and undocumented migrant workers who lack access to medical care. Sample Participants included a consecutive sample of adult (ages 18–40 years old) asylum seekers (n = 447 women, n = 448 men from Eritrea and n = 18 women, n = 131 men from Sudan) who accessed the clinic between fall of 2010 and the spring of 2012. Procedure Upon accessing services at the PHR Open-Clinic, participants were interviewed in their native language by a nurse fluent in Tigrinya and Arabic about their experiences during migration. Structured interviews focused on respondents’ experiences in the Sinai desert, and included the following information: age; gender; country of origin; time of arrival to Israel; number of days spent in the Sinai desert on way to Israel; amount of money being forced to pay smugglers and the number of smuggling groups exposed to en route to Israel; being held against will during migration; witnessing violence, and being deprived of basic needs (i.e., food, water, sleep, medical care), and being a victim of violence (i.e., beating, burning, hanging, electric shock, burying, shooting, threats of execution, organ removal, and sexual assault) while in the Sinai desert. The study was approved by the Ethics Committee of PHR, and data collection was in compliance with human subject protocol. Statistical Analysis Independent samples t tests and Chi square analyses were performed to identify gender differences in dependent variables, for continuous and categorical variables, respectively. Analysis was performed using the SPSS version 20.0 (SPSS Inc., Chicago, IL). Bonferroni correction was applied in order to account for multiple comparisons (a = 0.0025).
Results Table 1 presents frequencies of reported exposure to traumatic experiences among asylum seekers from Sudan and Eritrea during transit to Israel by gender. Significantly more male than female Eritrean asylum seekers reported witnessing violence (n = 185, 41.3 %; n = 131, 29.3 %, respectively; v2(2) = 14.92 p \ .001). A majority of Eritrean men (n = 251, 56.0 %) and little over a third of women (n = 156, 34.9 %) reported being a victim of violence. Exposure to shooting and beating were the most prevalent reported experiences of violence. Significantly more Eritrean men than women reported being shot (n = 157, 35 %; n = 106, 23.7 %, respectively; v2(2) = 15.21 p \ .001) and beaten (n = 157, 35 %; n = 57, 12.8 %, respectively; v2(2) = 65.32 p \ .001). Significantly more Eritrean women than men reported being sexually assaulted (n = 24, 5.4 %; n = 2, 0.4 %, respectively; v2(2) = 19.34 p \ .001). More than a half of the Eritrean men and women reported being deprived of water (n = 229, 51.1 %; n = 243, 54.4 %, respectively; v2(2) = 1.16 n.s.) and/or food (n = 252, 56.2 %; n = 271, 60.6 %, respectively; v2(2) = 1.92 n.s.) during their time in the Sinai desert. Witnessing violence was reported 16.8 % (n = 22) of Sudanese men and 22.2 % (n = 2) of their female counterparts (v2(2) = 0.70 n.s.). Approximately half of male (51.9 %, n = 68) and little less than half of the female (44.4 %, n = 8) Sudanese asylum seekers reported being a victim of violence. No significant differences emerged between men and women in the types of transgressions they were exposed to. Shooting was the most prevalent reported experience of violence Sudanese men and women reported being victim of (n = 62, 47.3 %; n = 8, 44.4 %, respectively; v2(2) = 0.32 n.s.). Approximately half of the Sudanese men and women reported being deprived of water (n = 71, 54.2 %; n = 9, 50 %, respectively; v2(2) = 1.12 n.s.) and/or food (n = 75, 57.3 %; n = 9, 50 %, respectively; v2(2) = 0.33 n.s.) during transit (Table 1). At the time of participation, approximately half of the asylum seekers from Eritrea were men who have been in Israel for an average of 12.9 (SD = 12.5) months which was significantly longer than their female counterparts (M = 10.6 SD = 11.1; t(739) = 2.63; p \ .01). They spent on average 27.5 (SD = 45.3) days in the Sinai desert, which was significantly longer than their female counterparts (M = 16.3 SD = 23.2; t(651) = 4.61; p \ .001). Male migrants from Sudan had spent an average of 8.5 (SD = 9.8) months in Israel while their female counterparts spent 11.5 (SD = 12.5) months in Israel (t(123) = 1.08; n.s.). A majority of Sudanese asylees were men who spent on average 9.3 (SD = 21.6) days in the Sinai desert which was not
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Number of days spent in the Sinai desert on way to Israel (mean, SD)
23 (5.1 %)
Electric shock
2 (0.4 %)
Sexual assault
3 (0.7 %)
Sleep
38 (8.5 %) 118 (26.3 %)
Yes No answer
4 (1.0 %) 9 (2.3 %)
Did not answer
116 (28.0 %)
Tent/hut
Iron/bamboo shelter
149 (38.0 %)
Outdoors
65 (16.6 %)
6 (1.5 %)
Container
Cave
43 (11.0 %)
Building
Held captive while in the Sinai desert in the following places
292 (65.2 %)
No
Held against will during migration to Israel
44 (9.8 %)
252 (56.2 %)
Food
Medical care
229 (51.1 %)
Water
Being deprived of the following things while in the Sinai desert
157 (35.0 %)
29 (6.5 %)
Threat of organ
Shooting
51 (11.4 %)
Threats of execution
1 (0.2 %)
19 (4.2 %) 14 (3.1 %)
Burning Hanging
Burying
157 (35.0 %)
Beating
2 (0.5 %)
0 (0.0 %)
116 (29.6 %)
179 (43.1 %)
70 (16.9 %)
6 (1.4 %)
42 (10.1 %)
26 (5.8 %) 97 (21.7 %)
324 (72.5 %)
62 (13.9 %)
1 (0.2 %)
271 (60.6 %)
243 (54.4 %)
106 (23.7 %)
24 (5.4 %)
11 (2.5 %)
25 (5.6 %)
0 (0.0 %)
4 (0.9 %)
5 (1.1 %) 4 (0.9 %)
57 (12.8 %)
18 (4.0 %)
20 (4.5 %)
Being victim of the following transgressions while in the Sinai desert
No answer
131 (29.3 %)
185 (41.3 %)
Yes
298 (66.7 %)
16.3 (23.2)
243 (54.2 %)
27.5 (45.3)
No
Witnessing violence while in the Sinai desert
.001
v2(2) = 13.87 .007
v2(2) = 9.90
.000
v2(2) = 15.22
.153
v2(2) = 3.76
v2(6) = 10.75
v (2) = 5.96
.096
.051
.511
v2(2) = 1.34 2
.382
v (2) = 1.92
2
.560
.000
v2(2) = 19.35
v2(2) = 1.16
.014
v (2) = 8.56
2
.698
v (2) = 1.007
2
.015 .058
v (2) = 8.44 v2(2) = 5.70
2
.000
.001
v2(2) = 65.32
.000
t(651) = 4.61 v2(2) = 14.92
P
1 (0.8 %)
–
32 (26.9 %)
53 (44.5 %)
29 (24.4 %)
–
4 (3.4 %)
0 (0.0 %) 37 (28.2 %)
94 (71.8 %)
15 (11.5 %)
–
75 (57.3 %)
71 (54.2 %)
62 (47.3 %)
–
2 (1.5 %)
3 (2.3 %)
–
4 (3.1 %)
3 (2.3 %) –
12 (9.2 %)
3 (2.3 %)
22 (16.8 %)
106 (80.9 %)
9.3 (21.6)
Men (N = 131)
Statistic
Men (N = 448)
Women (N = 447)
Sudan
Eritrea
0 (0.0 %)
–
6 (35.3 %)
8 (47.1 %)
2 (11.8 %)
–
1 (5.9 %)
1 (5.6 %) 3 (16.7 %)
14 (77.8 %)
2 (11.1 %)
–
9 (50.0 %)
9 (50.0 %)
8 (44.4 %)
–
0 (0.0 %)
0 (0.0 %)
–
0 (0.0 %)
0 (0.0 %) –
0 (0.0 %)
0 (0.0 %)
4 (22.2 %)
14 (77.8 %)
5.2 (4.7)
Women (N = 18)
Table 1 Exposure to traumatic experiences among asylum seekers from Eritrea and Sudan during migration into Israel by gender and country of origin (N = 1,044)
v2(4) = 1.83
v (2) = 8.15
2
v2(1) = 0.00
v2(1) = 0.34
v2(1) = 0.11
v2(2) = 0.32
v2(2) = 0.45
v2(2) = 0.60
v2(2) = 0.76
v2(2) = 0.60
v2(2) = 2.10
v2(2) = 0.70
t(147) = 0.79
Statistic
.766
.017
.97
.561
.738
.853
.799
.740
.685
.740
.350
.705
.429
P
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.353 t(147) = 0.93 0 (0.0 %) 27.2 (4.3) 15 (3.4 %) 24.6 (4.3) 32 (7.2 %) 27.4 (5.5) [10,000$ Age (mean, SD)
29 (6.6 %) 26 (5.9 %) 4,000–9,999$
20 (4.6 %) 48 (10.9 %)
336 (76.0 %) 2000–3,999$
\2,000$
375 (85.4 %)
t(893) = 8.59
.000
1 (0.8 %) 28.4 (5.1)
8 (6.2 %)
2 (1.5 %)
119 (91.5 %)
1 (7.1 %)
.002 v2(3) = 15.10 .000 v2(3) = 19.97 Amount of money forced to pay to smugglers during migration?
3 (21.4 %)
.937 t(107) = 0.08 2.7 (0.8) .266 t(631) = 1.11
2.7 (1.2) 4.1 (1.0) 4.0 (1.1) Number of smuggling and/or trafficking groups exposed to en route to Israel (mean, SD)
Statistic Table 1 continued
10 (71.4 %)
P Men (N = 131) Women (N = 447) Men (N = 448)
P
Sudan Eritrea
Women (N = 18)
Statistic
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significantly different than their female counterparts (M = 5.2 SD = 4.7; t(147) = 0.79; n.s.; Table 1).
Discussion In this study we recorded reports of exposure to traumatic experiences among Eritrean and Sudanese asylum seekers during their transit in the Sinai desert en route to Israel. Our data show that high percentage of Sudanese and Eritrean men and women reported witnessing violence and/or being a victim of violence (particularly beating and shooting) during their journey to safety. Significant differences emerged between Eritrean men and women in the reported exposure to violence indicating that while men were more vulnerable to witnessing violence and/or being a victim of physical abuse, women were more vulnerable to sexual abuse. Interestingly, no significant differences emerged in the reports of exposure to violence between Sudanese men and women. This is possibly due to the low number of Sudanese women who were surveyed (which is reflective of the relatively low number of Sudanese women who migrate to Israel). This study has several limitations. Firstly, data were collected only among those who sought medical treatment, who may represent a particularly vulnerable or resourceful group. Secondly, data were self-reported approximately a year after arrival to Israel and may be subject to reporting and recall biases. Third, many torture survivors, especially rape victims, may be reluctant to reveal what they had undergone in Sinai [34], thus our data may represent an under-reporting of these experiences. Forth and most importantly, our study included only those who survived the journey. A recent report based on testimonies of tortured Eritrean asylum seekers while in captivity and after, estimated that 4,000 asylum seekers did not survive the torture camps and journey, and lost their lives in the desert in the past five years [32]. Notably, this is a first step in the effort to systematically document the reported traumatic experiences this vulnerable population is exposed to. Future studies should also assess the mental health consequences of such experiences. Special attention should be paid to cultural factors influencing reporting of trauma and help seeking behaviors as some cross-cultural studies among forced migrants suggested cultural specificity in expressing predominantly somatic complaints among asylees from collectivist cultures (e.g., Asian, African countries) rather than emotional problems such as depression that are more prevalent among members of individualistic cultures [34, 35]. Policies of deterrence, including the use of detention and temporary visas, have been widely implemented to dissuade asylum seekers from seeking protection in Western
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countries [3, 36, 37]. Restriction of rights and access to services related to visa status negatively affect the mental health of asylum seekers [38, 39]. Miller and Rasmussen [40, 41] further suggested that stressful social and material conditions (daily stressors) that are exacerbated by the restrictive policies in a growing hostile political situation in many industrial countries, partially mediate, the relationship between war exposure and mental ill-health. In a study among Darfuri Refugees in Eastern Chad, Rasmussen and his colleagues [41] found that although war-related traumatic events were the initial causes of refugees’ distress, the day to day challenges and concerns in the camps mediated the relationship between exposure to traumatic events and emotional distress. The connection between ongoing persistent mental health problems and lack of certainty about protection poses a limitation on service and treatment approaches and raise issues related to government policies contributing to mental disorders. Underestimation of mental health consequences of the asylum seekers’ journey, should lead to a coordinated effort to screen, prevent, and treat this population in the receiving countries. This task has different barriers: Language, shortage of trained health personal, scarcity of financial resources, and above all the political will to engage with the asylum seekers population in a growing hostile political situation. Our data highlight the need for a well-coordinated international effort to improve the well-being of this vulnerable population. Across border cooperation is needed in order to document and prevent the transgressions. The political situation in the region creates a serious impediment for such collaboration, yet international involvement, especially of non-governmental organizations, with the support of interested countries, including those outside the region, is needed. Combating the horrors of forced migration is both a public health and moral imperative. The international medical and non-medical communities should develop a growing awareness of this phenomenon and create more effective identification, documentation, surveillance, mitigation and prevention, management, and finally, treatment for this vulnerable population. Conflict of interest
None.
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BRIEF COMMUNICATION
Exposure to Traumatic Experiences Among Asylum Seekers from Eritrea and Sudan During Migration to Israel Ora Nakash • Benjamin Langer • Maayan Nagar Shahar Shoham • Ido Lurie • Nadav Davidovitch
•
Springer Science+Business Media New York 2014
Abstract Little is known about the experiences of displaced individuals en route to destination countries. We investigated the reported prevalence of exposure to traumatic experiences during migration among a consecutive sample of adult asylum seekers (n = 895 Eritrean, n = 149 Sudanese) who sought health services in the Physicians for Human Rights Open-Clinic in Israel. Percentage of Eritrean and Sudanese men and women who reported witnessing violence (Eritrea: men: 41.3 %, women: 29.3 %; Sudan: men: 16.8 %, women: 22.2 %) and/or being a victim of violence (Eritrea: men: 56.0 %, Women: 34.9 %; Sudan: men: 51.9 % women: 44.4 %) during migration varied by gender and country of origin.
O. Nakash (&) M. Nagar School of Psychology, Interdisciplinary Center (IDC) Herzliya, P.O. Box 167, 46150 Herzliya, Israel e-mail: [email protected] B. Langer Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada S. Shoham Physicians for Human Rights-Israel Open-Clinic, Jaffa-Tel Aviv, Israel I. Lurie Abarbanel Mental Health Center, Bat-Yam, Israel I. Lurie Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel N. Davidovitch Department of Health Systems Management, Faculty of Helath Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
Findings highlight the need for a well-coordinated international cooperation to document and prevent these transgressions. Keywords Asylum-seeker Exposure to trauma Eritrea Israel Mental health Sudan
Introduction Political tensions, civil unrest and persecution based on religious affiliation are some of the reasons people are forced to leave their country of origin and flee to safer places where asylum is offered. Section 94(1) of the Immigration and Asylum Act of the United Nations Agency for Refugees defines an asylum seeker as a displaced person who ‘…is not under 18 and has made a claim for asylum which has been recorded by the Secretary of State but which has not been determined’ [1]. The number of asylum seekers worldwide is rapidly growing [2], including in Israel where an estimated 55,000 asylum seekers reside, the majority of whom came from Eritrea and Sudan [3]. Past research, mostly focused on refugees, documented that forced migration serves as a risk factor for physical and mental health problems. Forced migrants may be exposed to starvation and injuries en route [4, 5]. For example, a study among newly arrived African refugees in Australia documented high rates of nutritional deficiencies and infectious diseases (e.g., gastrointestinal infections) [4]. Furthermore, several studies have documented higher prevalence of anxiety, depression and posttraumatic stress disorder (PTSD) among asylum seekers and refugees compared to the general population [6–9]. For example, 19 % of newly arrived African asylum-seekers in Australia
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reported having mental health problems [4]. Similarly, approximately 30 % of asylum-seekers and refugees that received treatment at a mental health clinic in Israel were diagnosed with PTSD [10]. Factors related to pre-migration experiences (e.g., political turmoil and poverty in country of origin) [6, 11], process of migration (e.g., loss of family and friends, physical and psychological traumatic experiences during the migration); and post-migration experiences (e.g., discrimination and restrictive policies) [7, 12, 13] are all likely to play a role in the increased risk for mental health problems. Furthermore, a study that examined medical records of 325 refugees from Africa and Asia who participated in an intervention program for survivors of torture in New York showed that past exposure to multiple traumatic events among participants of the program was common and was associated with mental ill health [11]. Although information on the number of women who are forced to migrate is difficult to ascertain, it is suggested that their numbers are increasing [14]. Some research has examined the way gender shapes access to refugee protection in developed countries [14–16], and the protracted processes around gaining refugee protection. To date, however, studies on gender, transit and refugee protection have mainly focused on the refugee camp experience [17– 19]. This research has detailed shifts in gender roles among families [20], the prevalence of domestic violence and women’s susceptibility to violence in certain camp contexts [21]. Recent research called attention to issues of gender and transit migration outside the refugee camp [22]. For example, a research conducted among Somalian women crossing borders reported experiences of systematic gender-based violence [23]. Although, research in the general population documented that women are more vulnerable to trauma and report higher rates of mental health problems than men, especially depression, anxiety and PTSD symptoms [24, 25], little is known about gender differences in mental health problems among forced migrants. In the current study we explored the reports of exposure to traumatic experiences en route, among asylum seekers for Eritrea and Sudan in Israel. Eritreans claim asylum based on having escaped from an extremely repressive state and compulsory military service in Eritrea, a country that has long been known for its grave violations of human rights; religious and political persecution, disappearances of citizens and use of torture by the government [26, 27]. Men and women from Darfur flee persecution and mass murder of civilian populations perpetrated by the government and armed militia groups. Israel also hosts a smaller, but close community of south Sudanese who have escaped years of governmental persecution, civil war, insecurity, and a lack of social infrastructure [28, 29].
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Asylum seekers from Africa began crossing the Egypt– Israel border in 2006. Reasons for the influx of African asylum seekers entering Israel can be traced to the growing restrictions on migration to Europe and the decline of living conditions for African refugees in Libya and Egypt. Most, if not all, asylum seekers arrive in Israel via the Sinai desert [30]. Since 2007 until 2013 the number of asylum seekers arriving in Israel through the Sinai desert has dramatically increased and reached a peak of over a thousand asylees who crossed the border each month in 2010 [30, 31]. The political unrest, the state of insecurity, and chaos in North Africa were some of the reasons for this influx. The journey of African refugees merges in the Northern Sinai, a region that although is under Egyptian governess is characterized by a political vacuum that is demonstrated by growing lawlessness and impunity [28, 29] particularly, since the emergence of the Arab Spring in 2010. While some fleeing Eritrea and Sudan are able to pay a smuggler who can guide them in relative safety to a refugee camp, a significant number cross the border without help and often fall prey to human traffickers who roam the border region [32]. Traffickers operate within Ethiopian and Sudanese refugee camps as well [33]. A sizable network of smugglers operates across Eritrea, Sudan, Egypt and Israel to smuggle sub-Saharan asylees to their destination in Israel. Notably, the construction of an Egyptian– Israeli border fence and an intensification of policies to restrict immigration diminished the numbers of new arrivals since 2013. African asylum seekers in Israel are densely concentrated in southern Tel Aviv, one of the city’s poorest neighbourhoods. Until recently, Israel’s collective group protection policy, granting Eritrean and Sudanese asylumseekers the right to remain in Israel until their home countries are deemed safe for their return, prevents Eritrean and Sudanese asylum-seekers from applying for official refugee status. The provisional status granted to them must be renewed frequently. As a result of their temporary status, many cannot legally work and have limited access to the national health care system [28, 29]. The hazards and risks asylum seekers may be exposed to during the migratory process have been documented in some media reports, yet few studies currently exist that address this issue in a more rigorous methodological way [5]. In the current study we systematically investigated the reports of exposure to traumatic experiences en route among asylees seeking refuge in Israel. In order to do this we surveyed a consecutive sample of asylum seekers from Eritrea (n = 895) and Sudan (n = 149) who sought health services in the PHR Open-Clinic in a central city in Israel. Participants were interviewed in their native language about their reports of exposure to traumatic experiences in
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the Sinai desert, which in recent years has seen a sharp increase in human trafficking and smuggling [28, 30, 31, 33].
Methods Setting The PHR Open-Clinic provides primary care as well as a range of secondary services to uninsured persons, most of whom are asylum seekers and undocumented migrant workers who lack access to medical care. Sample Participants included a consecutive sample of adult (ages 18–40 years old) asylum seekers (n = 447 women, n = 448 men from Eritrea and n = 18 women, n = 131 men from Sudan) who accessed the clinic between fall of 2010 and the spring of 2012. Procedure Upon accessing services at the PHR Open-Clinic, participants were interviewed in their native language by a nurse fluent in Tigrinya and Arabic about their experiences during migration. Structured interviews focused on respondents’ experiences in the Sinai desert, and included the following information: age; gender; country of origin; time of arrival to Israel; number of days spent in the Sinai desert on way to Israel; amount of money being forced to pay smugglers and the number of smuggling groups exposed to en route to Israel; being held against will during migration; witnessing violence, and being deprived of basic needs (i.e., food, water, sleep, medical care), and being a victim of violence (i.e., beating, burning, hanging, electric shock, burying, shooting, threats of execution, organ removal, and sexual assault) while in the Sinai desert. The study was approved by the Ethics Committee of PHR, and data collection was in compliance with human subject protocol. Statistical Analysis Independent samples t tests and Chi square analyses were performed to identify gender differences in dependent variables, for continuous and categorical variables, respectively. Analysis was performed using the SPSS version 20.0 (SPSS Inc., Chicago, IL). Bonferroni correction was applied in order to account for multiple comparisons (a = 0.0025).
Results Table 1 presents frequencies of reported exposure to traumatic experiences among asylum seekers from Sudan and Eritrea during transit to Israel by gender. Significantly more male than female Eritrean asylum seekers reported witnessing violence (n = 185, 41.3 %; n = 131, 29.3 %, respectively; v2(2) = 14.92 p \ .001). A majority of Eritrean men (n = 251, 56.0 %) and little over a third of women (n = 156, 34.9 %) reported being a victim of violence. Exposure to shooting and beating were the most prevalent reported experiences of violence. Significantly more Eritrean men than women reported being shot (n = 157, 35 %; n = 106, 23.7 %, respectively; v2(2) = 15.21 p \ .001) and beaten (n = 157, 35 %; n = 57, 12.8 %, respectively; v2(2) = 65.32 p \ .001). Significantly more Eritrean women than men reported being sexually assaulted (n = 24, 5.4 %; n = 2, 0.4 %, respectively; v2(2) = 19.34 p \ .001). More than a half of the Eritrean men and women reported being deprived of water (n = 229, 51.1 %; n = 243, 54.4 %, respectively; v2(2) = 1.16 n.s.) and/or food (n = 252, 56.2 %; n = 271, 60.6 %, respectively; v2(2) = 1.92 n.s.) during their time in the Sinai desert. Witnessing violence was reported 16.8 % (n = 22) of Sudanese men and 22.2 % (n = 2) of their female counterparts (v2(2) = 0.70 n.s.). Approximately half of male (51.9 %, n = 68) and little less than half of the female (44.4 %, n = 8) Sudanese asylum seekers reported being a victim of violence. No significant differences emerged between men and women in the types of transgressions they were exposed to. Shooting was the most prevalent reported experience of violence Sudanese men and women reported being victim of (n = 62, 47.3 %; n = 8, 44.4 %, respectively; v2(2) = 0.32 n.s.). Approximately half of the Sudanese men and women reported being deprived of water (n = 71, 54.2 %; n = 9, 50 %, respectively; v2(2) = 1.12 n.s.) and/or food (n = 75, 57.3 %; n = 9, 50 %, respectively; v2(2) = 0.33 n.s.) during transit (Table 1). At the time of participation, approximately half of the asylum seekers from Eritrea were men who have been in Israel for an average of 12.9 (SD = 12.5) months which was significantly longer than their female counterparts (M = 10.6 SD = 11.1; t(739) = 2.63; p \ .01). They spent on average 27.5 (SD = 45.3) days in the Sinai desert, which was significantly longer than their female counterparts (M = 16.3 SD = 23.2; t(651) = 4.61; p \ .001). Male migrants from Sudan had spent an average of 8.5 (SD = 9.8) months in Israel while their female counterparts spent 11.5 (SD = 12.5) months in Israel (t(123) = 1.08; n.s.). A majority of Sudanese asylees were men who spent on average 9.3 (SD = 21.6) days in the Sinai desert which was not
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Number of days spent in the Sinai desert on way to Israel (mean, SD)
23 (5.1 %)
Electric shock
2 (0.4 %)
Sexual assault
3 (0.7 %)
Sleep
38 (8.5 %) 118 (26.3 %)
Yes No answer
4 (1.0 %) 9 (2.3 %)
Did not answer
116 (28.0 %)
Tent/hut
Iron/bamboo shelter
149 (38.0 %)
Outdoors
65 (16.6 %)
6 (1.5 %)
Container
Cave
43 (11.0 %)
Building
Held captive while in the Sinai desert in the following places
292 (65.2 %)
No
Held against will during migration to Israel
44 (9.8 %)
252 (56.2 %)
Food
Medical care
229 (51.1 %)
Water
Being deprived of the following things while in the Sinai desert
157 (35.0 %)
29 (6.5 %)
Threat of organ
Shooting
51 (11.4 %)
Threats of execution
1 (0.2 %)
19 (4.2 %) 14 (3.1 %)
Burning Hanging
Burying
157 (35.0 %)
Beating
2 (0.5 %)
0 (0.0 %)
116 (29.6 %)
179 (43.1 %)
70 (16.9 %)
6 (1.4 %)
42 (10.1 %)
26 (5.8 %) 97 (21.7 %)
324 (72.5 %)
62 (13.9 %)
1 (0.2 %)
271 (60.6 %)
243 (54.4 %)
106 (23.7 %)
24 (5.4 %)
11 (2.5 %)
25 (5.6 %)
0 (0.0 %)
4 (0.9 %)
5 (1.1 %) 4 (0.9 %)
57 (12.8 %)
18 (4.0 %)
20 (4.5 %)
Being victim of the following transgressions while in the Sinai desert
No answer
131 (29.3 %)
185 (41.3 %)
Yes
298 (66.7 %)
16.3 (23.2)
243 (54.2 %)
27.5 (45.3)
No
Witnessing violence while in the Sinai desert
.001
v2(2) = 13.87 .007
v2(2) = 9.90
.000
v2(2) = 15.22
.153
v2(2) = 3.76
v2(6) = 10.75
v (2) = 5.96
.096
.051
.511
v2(2) = 1.34 2
.382
v (2) = 1.92
2
.560
.000
v2(2) = 19.35
v2(2) = 1.16
.014
v (2) = 8.56
2
.698
v (2) = 1.007
2
.015 .058
v (2) = 8.44 v2(2) = 5.70
2
.000
.001
v2(2) = 65.32
.000
t(651) = 4.61 v2(2) = 14.92
P
1 (0.8 %)
–
32 (26.9 %)
53 (44.5 %)
29 (24.4 %)
–
4 (3.4 %)
0 (0.0 %) 37 (28.2 %)
94 (71.8 %)
15 (11.5 %)
–
75 (57.3 %)
71 (54.2 %)
62 (47.3 %)
–
2 (1.5 %)
3 (2.3 %)
–
4 (3.1 %)
3 (2.3 %) –
12 (9.2 %)
3 (2.3 %)
22 (16.8 %)
106 (80.9 %)
9.3 (21.6)
Men (N = 131)
Statistic
Men (N = 448)
Women (N = 447)
Sudan
Eritrea
0 (0.0 %)
–
6 (35.3 %)
8 (47.1 %)
2 (11.8 %)
–
1 (5.9 %)
1 (5.6 %) 3 (16.7 %)
14 (77.8 %)
2 (11.1 %)
–
9 (50.0 %)
9 (50.0 %)
8 (44.4 %)
–
0 (0.0 %)
0 (0.0 %)
–
0 (0.0 %)
0 (0.0 %) –
0 (0.0 %)
0 (0.0 %)
4 (22.2 %)
14 (77.8 %)
5.2 (4.7)
Women (N = 18)
Table 1 Exposure to traumatic experiences among asylum seekers from Eritrea and Sudan during migration into Israel by gender and country of origin (N = 1,044)
v2(4) = 1.83
v (2) = 8.15
2
v2(1) = 0.00
v2(1) = 0.34
v2(1) = 0.11
v2(2) = 0.32
v2(2) = 0.45
v2(2) = 0.60
v2(2) = 0.76
v2(2) = 0.60
v2(2) = 2.10
v2(2) = 0.70
t(147) = 0.79
Statistic
.766
.017
.97
.561
.738
.853
.799
.740
.685
.740
.350
.705
.429
P
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.353 t(147) = 0.93 0 (0.0 %) 27.2 (4.3) 15 (3.4 %) 24.6 (4.3) 32 (7.2 %) 27.4 (5.5) [10,000$ Age (mean, SD)
29 (6.6 %) 26 (5.9 %) 4,000–9,999$
20 (4.6 %) 48 (10.9 %)
336 (76.0 %) 2000–3,999$
\2,000$
375 (85.4 %)
t(893) = 8.59
.000
1 (0.8 %) 28.4 (5.1)
8 (6.2 %)
2 (1.5 %)
119 (91.5 %)
1 (7.1 %)
.002 v2(3) = 15.10 .000 v2(3) = 19.97 Amount of money forced to pay to smugglers during migration?
3 (21.4 %)
.937 t(107) = 0.08 2.7 (0.8) .266 t(631) = 1.11
2.7 (1.2) 4.1 (1.0) 4.0 (1.1) Number of smuggling and/or trafficking groups exposed to en route to Israel (mean, SD)
Statistic Table 1 continued
10 (71.4 %)
P Men (N = 131) Women (N = 447) Men (N = 448)
P
Sudan Eritrea
Women (N = 18)
Statistic
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significantly different than their female counterparts (M = 5.2 SD = 4.7; t(147) = 0.79; n.s.; Table 1).
Discussion In this study we recorded reports of exposure to traumatic experiences among Eritrean and Sudanese asylum seekers during their transit in the Sinai desert en route to Israel. Our data show that high percentage of Sudanese and Eritrean men and women reported witnessing violence and/or being a victim of violence (particularly beating and shooting) during their journey to safety. Significant differences emerged between Eritrean men and women in the reported exposure to violence indicating that while men were more vulnerable to witnessing violence and/or being a victim of physical abuse, women were more vulnerable to sexual abuse. Interestingly, no significant differences emerged in the reports of exposure to violence between Sudanese men and women. This is possibly due to the low number of Sudanese women who were surveyed (which is reflective of the relatively low number of Sudanese women who migrate to Israel). This study has several limitations. Firstly, data were collected only among those who sought medical treatment, who may represent a particularly vulnerable or resourceful group. Secondly, data were self-reported approximately a year after arrival to Israel and may be subject to reporting and recall biases. Third, many torture survivors, especially rape victims, may be reluctant to reveal what they had undergone in Sinai [34], thus our data may represent an under-reporting of these experiences. Forth and most importantly, our study included only those who survived the journey. A recent report based on testimonies of tortured Eritrean asylum seekers while in captivity and after, estimated that 4,000 asylum seekers did not survive the torture camps and journey, and lost their lives in the desert in the past five years [32]. Notably, this is a first step in the effort to systematically document the reported traumatic experiences this vulnerable population is exposed to. Future studies should also assess the mental health consequences of such experiences. Special attention should be paid to cultural factors influencing reporting of trauma and help seeking behaviors as some cross-cultural studies among forced migrants suggested cultural specificity in expressing predominantly somatic complaints among asylees from collectivist cultures (e.g., Asian, African countries) rather than emotional problems such as depression that are more prevalent among members of individualistic cultures [34, 35]. Policies of deterrence, including the use of detention and temporary visas, have been widely implemented to dissuade asylum seekers from seeking protection in Western
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countries [3, 36, 37]. Restriction of rights and access to services related to visa status negatively affect the mental health of asylum seekers [38, 39]. Miller and Rasmussen [40, 41] further suggested that stressful social and material conditions (daily stressors) that are exacerbated by the restrictive policies in a growing hostile political situation in many industrial countries, partially mediate, the relationship between war exposure and mental ill-health. In a study among Darfuri Refugees in Eastern Chad, Rasmussen and his colleagues [41] found that although war-related traumatic events were the initial causes of refugees’ distress, the day to day challenges and concerns in the camps mediated the relationship between exposure to traumatic events and emotional distress. The connection between ongoing persistent mental health problems and lack of certainty about protection poses a limitation on service and treatment approaches and raise issues related to government policies contributing to mental disorders. Underestimation of mental health consequences of the asylum seekers’ journey, should lead to a coordinated effort to screen, prevent, and treat this population in the receiving countries. This task has different barriers: Language, shortage of trained health personal, scarcity of financial resources, and above all the political will to engage with the asylum seekers population in a growing hostile political situation. Our data highlight the need for a well-coordinated international effort to improve the well-being of this vulnerable population. Across border cooperation is needed in order to document and prevent the transgressions. The political situation in the region creates a serious impediment for such collaboration, yet international involvement, especially of non-governmental organizations, with the support of interested countries, including those outside the region, is needed. Combating the horrors of forced migration is both a public health and moral imperative. The international medical and non-medical communities should develop a growing awareness of this phenomenon and create more effective identification, documentation, surveillance, mitigation and prevention, management, and finally, treatment for this vulnerable population. Conflict of interest
None.
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