Sm. Sci. Med. Vol.35, No. 4, pp. 507-513, Printed in Great Britain



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LORDCLINTON-DAVIS and YOHANNE!S FA~SIL The Refugee Council, 3 Bondway, London SW8 ISJ, U.K. Abstract-Today over 15 million refugees are scattered around the world, most of them in poor Third World countries [New Sci.. DD. 1415. September 19911.But whether they seek ‘safe havens’ in rich or poor countries thky continhd -to suffer. from the malaisd of being uprooted, struggling to survive in new and alien environments. Their health and social problems extend beyond the obvious emergency short-term phase. It is now clear that the number of refugees has increased beyond expectations and most have stayed long enough to expect final resettlement in their countries of asylum, a process which requires wider, more comprehensive and long-term management and rehabilitation interventions. This paper will attempt to highlight issues of health and social problems in their wider context, surveying comprehensive and integrated approaches in assessing the needs of refugees, whether they are in developing or industrialised countries, with emphasis on the latter and, when appropriate, using the United Kingdom experience as an example. Key work-refugee,

refugee’s health, health and social problems

INTRODUCTION Since the end of the Second World War, it is estimated that over 15 million people have become refugees. This does not include the millions of people displaced within the borders of their home countries. According to the United Nations High Commission for Refugees (UNHCR 1990 figures) most of these (63%) are in developing countries, 20% in the Middle East, and only 17% in the industrialised countries of Western Europe, the United States of America, Canada and Australia. Actual numbers, however, may well be much larger and are constantly changing [II-viz. the 2 million Iraqis displaced as a result of the Gulf War, and the thousands of Yugoslav refugees created by the present civil disturbances. The displacement of large numbers of people inevitably has a great impact on the health and social life of those who become refugees, those left behind and the host communities. There is no doubt that the urgent response to such an influx of people is more of providing emergency relief operations, i.e. shelter, food and medical supplies. Systematic and long-term strategies for resolving these problems and the experience gained thereby is not well documented or analysed. The relationship between the health of refugees and their movements, though complicated and varying from one refugee group to the other, should be examined in its broader context: different aspects of their movements and the cultural, socio-economic and political situations in countries of origin; the circumstances of flight within and across the national boundaries; the situation in the refugee camps; the breaking up of families; and whether the displace-

ment is temporary, permanent or cyclical [2]. It is also important to look into the type of assistance provided to refugees or displaced people. This paper will therefore discuss the health and social problems of refugees based on a wide range of factors associated with their situations at home and during flight, in refugee camps and in third countries of asylum, particularly related to those in Britain. Emphasis will be given to health and social problems which are either specific to refugees or are more prevalent among refugees as a result of their predicament. In an attempt to indicate the areas which need to be explored when considering refugee health and social problems a more causation oriented classification would be relevant and, as Dick pointed out, “they also provide an indication of possible levels of intervention” [2].


Today tens of millions of people are forced to leave their homes as a result of widespread violation of human rights, political intolerance, repression, civil war and famine. “Some estimate that as many as 140 million people have been forcibly uprooted in this century” [3]. The countries of origin of most of the ‘uprooted are the poor Third World countries and unfortunately they are also the hosts of a large number of them. Before considering the health and social implications of this huge displacement, it is important to understand the legal definition of ‘refugee’, their distribution and movements.







The international legal definition of a refugee is that adopted in the 1951 United Nations Convention: a refugee is a person 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 nationality and is unable, or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, unwilling to return to it [4]. Clearly, this definition ignores the legal status and consequent lack of international assistance for the millions of internally displaced people who, in order to become ‘refugees’ and therefore qualify for international assistance, must first cross national frontiers. The other limitation of this definition was also the fact that it has been devised to reflect the post war European refugees---though in 1967 a Protocol was introduced to extend its benefits to refugees in other parts of the world. Distribution The ever growing number of refugees and displaced people scattered all over the world indicates the viciousness of the problem. Without greater attention from the international community to both the needs of refugees and displaced people, as Martin puts it, “finding durable solutions to what in many places have become seemingly intractable refugee problems will be still more difficult” [5]. It is also unfortunate that most refugees are in poor African and Asian countries that are also the main refugee-producing countries worldwide (Table 1).

I. Refugee distribution by region and prinicpal world refugees

No. of refugees

I. Africa

sources of

Principal sources of world refuses


Mozambique, Sudan, Somalia and Ethiopa



Sri Lanka



Iraq, Iran

4. Central and South America

I, 196,950

El Salvador, Cuba. Guatemala, Nicaragua

5. North America


2. Asia 3. Middle


6. Europe


7. Australia


Poland, Rumania, Albania, U.S.S.R.

Source: adapted from the Refugee Population

by Region


Recognised as such by the Convention they receive international assistance and protection. There is also a possibility of resettlement in a third country of asylum. Between 1975-86 less than 2 million refugees have been resettled in advanced industrialised countries [5]. However, there also exists the risk of forced deportation and life in refugee camps can be unbearable. In recent years, as a result of political changes and the end of civil wars in some countries, refugees have returned voluntarily; 3. Organised departure with travel documents to a third country of asylum is possible for those who, anticipating prosecution, can plan. This group of asylum seekers joins others already there. Such journeys are often easier and less traumatic, but rejection of claims to asylum and subsequent deportation is possible. The number of asylum seekers granted refugee status in Western Europe is declining. In 1987

Movement The movement of refugees does not follow one direction or path. Often being unplanned and sudden, refugee flows take any route or direction to reach safety. Figure 1 illustrates the push-pull factors attendant in all refugee movements. Flight to an unknown destination may start in three possible ways: 1. Internal displacement caused by pull factors of relative and temporary safety, hope of going back to their habitual homes, easier to escape prosecution, join opposition movements, to avoid capture by border guards, gives them a chance to plan their further movements and make contacts with relatives or friends who fled before them. It is very difficult to document the number of people who are internally displaced, although estimates suggest they number over 30 million [l]. Lack of assistance and extension of civil war might eventually force those internally displaced to cross the border and become refugees; 2. Direct flight across the national borders into neighbouring country. It is estimated that nearly 8 million refugees live in camps and settlements [6].

Fig. 1. The push/pull


of refugee movements.

Health and social problems of refugees the average number of refugees granted asylum in Western Europe was 35%; a further 20% were allowed to remain and 45% were rejected [l]. REFUGEES:




The World Health Organisation definition of health includes physical, mental and social wellbeing, and not merely the absence or presence of a disease. Understanding the state of health of refugees on arrival at camps is crucially important. Urgent medical treatment in order to save lives, particularly of the most vulnerable groups such as children, the elderly or serious war victims, may be needed. However, while many studies and surveys emphasise emergency medically oriented survival interventions, the equally important post-emergency phase of refugee problems have been overlooked. It is because of such emphasis that the health and social problems of refugees have been considered as short-term and crisis oriented, while in reality, more comprehensive and long-term treatment, promotion and rehabilitation assessments and interventions are required. This paper will look into the postemergency comprehensive approaches without disregarding diseases, the medical dimension or the emergency phase. Refugees, whether they seek asylum in developing or industrialised countries, experience similar emotional and social problems. As Hear points out. “Separation from family members and friends, plunged into new and alien environment, they must come to terms with the trauma of the past, the hardship of the present, and the uncertainty of the future” [6]. For purposes of presentation and clarity the health and social problems of refugees in the first country of asylum and the third-country of resettlement will be discussed separately. Refugees in camps and settlements Most refugees in first countries of asylum live in camps and settlements run by UNHCR or other UN agencies, the host governments and other nongovernmental organisations (NGOs). The siting of the camps is generally based on political or other pragmatic considerations such as security. In a majority of cases, camps are built along the borders of the country of origin. The environmental unsuitability of settling thousands of refugees with inadequate supplies of water, sanitation facilities and shelter, transport routes, etc. tends to be deliberately overlooked [2]. The health of those live in violent or ridden countries generally poorer higher morbidity mortality rates, malnutrition of more 25%. The of flight safety may include rape, or further suffering e.g. on antipersonmines and arrive in severely debilitated The conditions the camps--overcrowded


tents, inadequate nourishment and poor sanitationadd further risks to already diminished health [7]. Many also suffer from emotional and social problems. Common diseases in refugee camps The diseases which affect the health of refugees are similar to those in stable communities in most poor countries. But refugees are particularly vulnerable and are exposed to many risk factors which make the effects of the diseases more virulent and therefore serious. There are 3 major groups of diseases which are common among refugees and refugee like situations: 1. Malnutrition. Malnutrition is a cause of death both in refugee camps and in transit, particularly among children under 5 years of age. It is also a factor in causing other diseases such as beri-beri, scurvy, vitamin A deficiency and pellagra which account for most deaths of refugee children. A recent study by UNHCR’s Technical Support Service (TSS) indicated an increase in childhood malnutrition and identified the cause of the problem as lack of food [6]. The report also pointed out that, “many of the refugees who find themselves in this desperate situation have no immediate prospect of a solution to their plight. They cannot integrate into the local society and economy, but the persistence of conflict and violence in their homeland rules out voluntary repatriation. The usual short-term food aid package provided to refugees in an emergency is simply not adequate for those who have to rely on rations for months or even years” [6]. The problems are also exacerbated by the lack of health care and medical supplies such as supplementary vitamins. 2. Infectious diseases and epidemic in refugee camps. Refugee camps constitute a conducive pathogenic environment for a host of infectious diseases. Table 2 lists refugee diseases or epidemics which are closely associated with inadequate or inappropriate provision of basic services including food, accommodation, sanitation, immunisation and health care

PI. diseases and affect children the elderly the two vulnerable groups. mortality and rates in and the during displacement in the was reported Gardener [9] Dick has out that implication of mortalities has changes in demographic structure their communities. social environment the camps also have number of effects on refugees’ health. policies, communication host government employment opportunities, and even rights violamay make a situation is already as a of the family and disruption. Whilst factors may physical health, is likely their major will be the mental of refugees”



Table 2. Selected ‘epidemic’ in refugee camps Disease







10,000 deaths in 8 months.




Basic rations-polished

Basic ration:



Four South African




A deficiency



33% of children rations




More than 2000 cases: refugees distributed rations




Two outbreaks resulting from uncontrolled water supplies




Inadequate nutrition, water and sanitation: for over 60% of all illness in the camp

Acute haemorrhagic conjunctvitis



29,000 casesovercrowding,





and hepatitis

Source: Adapted

and North


East Africa

1300 kcal/day


diet: maize for more than 2 months I-10 years affected: vitamin




A deficient






lack of water, soap, etc. refugee communities


from selected ‘epidemic’ in refugee camps [2].

3. Mental health problems of refugees in the camp.

roughly estimated. Nearly 20,000 Vietnamese refugees and a large number of Ugandan Asians came to the U.K. as refugees. An increasing number of asylum seekers are also arriving directly; this has reached sufficiently high levels to become the subject of intense public and political debate. In the last 10 years the total number of applications for asylum has increased from under 2500 in 1980 to over 30,000 in 1990, and an estimated 45,000 in 1991. While the number of applications has increased the decision to grant refugee status has dropped from 64% in 1980 to 26% in 1990 [8]. In the last mentioned year about 65% were granted exceptional leave to remain (ELR), the remainder being refused. The average time it takes to reach decisions varies from 18 months to 2 years and this period of uncertainty inevitably has serious implications for the already susceptible health of refugees. The early period of adjustment to a new environment and coming to terms with past traumatic experience need much more sensitive and humane reception particularly for the most vulnerable refugees such as victims of torture and rape, and for unaccompanied children. Within the early period of arrival the health and Third-country of resettlement: refugees in U.K. social needs are greater. Proper assessment of these needs would result in an early resolution of urgent Voluntary repatriation, integration in first country of asylum or resettlement in a third country are the problems before they affect health and social wellthree possible solutions proposed by many agencies being irreversibly. At present there is no policy to deal with refugee including UNHCR. Neuwirth has pointed out that, health and social problems. As a result there is a lack “of these three solutions, resettlement of refugees into of systematic information or data on the general industrialized societies is considered to be the preferred option when neither permanent settlement in demographic characteristics of different refugee the asylum country nor repatriation is feasible in the ’ groups, their physical and mental health problems forseeable future” [7]. In practice, however, none of and their entitlements to health and social service the three solutions have been carried out with a provisions. It is therefore very difficult to give a wellstrong commitment to end refugee crises. The number documented and informed list of health and social of refugees is still increasing and unfortunately most problems of refugees in the U.K. However, agencies continue to live in camps. Similarly each of the three involved in the reception and resettlement of refugees solutions has different potential effects on the health and other academic and research organisations have of refugees and the host communities [2]. reported the common problems, though in most cases The number of refugees resettled in the U.K. the evidence is anecdotal. It is perhaps arbitrary to and elsewhere in the industrialised countries is only Despite the fact that refugee camps still exist after several years, their temporary nature and emergency orientation of their services remain unchanged. In the face of overwhelming efforts to deal with serious physical health prolems including epidemics, malnutrition and other diseases, refugees with mental health problems receive little or no attention. It is a well established fact that, while their experiences can generate a number of mental health problems, refugees’ cultural reluctance to seek help and their tendency to somatize emotional problems is particularly common because they come from societies that stigmatise mental illnesses. As a result it is not easy to estimate the scope of the problem particularly among those in the camps. As Steketee pointed out “. . . it is very difficult to approach ‘situational disturbances’ when the situation is nothing other than disturbing” [lo]. Though anecdotal, there is some evidence on common mental illnesses which may manifest themselves in severe depressive, selfdestructive and violent or disruptive behaviour, alcohol or drug abuse, and a high degree of psychosomatic illness [ 111.

Health and social problems of refugees separate social from physical and mental health problems. But they are handled separately by different specialising institutions and agencies, and their presentation in this paper corresponds with this approach. Social problems of refugees in U.K.

In the initial stage of resettlement many problems are related to basic needs such as accommodation, education for their children, employment, etc. There is already a chronic housing shortage in the U.K. particularly in London where most refugees are housed in temporary accommodation in bed and breakfast or hostels. Homelessness in London among refugees is high and has considerable impact on their health. Similarly, unemployment rates among refugees in the U.K. is certainly higher than the national average; Jones reported that in 1981 only 16% of the Vietnamese refugees in the U.K. who were eligible for work had jobs [12]. For many refugees especially for men, finding a job is quite important in regaining their social status and the traditional value of men as bread winners, which is the case in most African cultures. Demand in the labour market is sometimes greater for women than men, particularly in domestic jobs. It is also easier for women to start new jobs than for men to adjust their occupation to low paying jobs which may involve some degree of downward social mobility. This reversal of social roles, i.e. women goes to work while men stay at home, may lead to conflicts. Similarly, the reversal of the traditional family order which may create tensions between the young and older members of the family, occurs when the young learn the language and interpret the new culture faster and drift away from the traditions of birth. At a later stage when basic social needs are met, continued displacement causes considerable social problems. All refugees have to look for new social status and identity, try to learn English, get used to new food, unfamiliar cultural and social traditions. The combined effort of coping with this social process puts a considerable pressure on refugees which may reflect in their physical and mental well-being. Physical and mental health problems

As discussed earlier in reference to the health of refugees in the camps, uprooting, loss of family, tension of coping with a new life, uncertain future, homelessness, unemployment, etc. are the main risk factors which seriously affect the physical and mental health of refugees. The lack of proper needs assessment and background information, the absence of basic medical screening, cultural and language barriers to access health and social services all add to the difficulties. Health services in the U.K. are different from the type of health care many refugees get in their country of origin or in the camps. Many do not


understand that they need to register with their general practitioners and dentists. Therefore, their common physical ailments remain untreated or selfmedication is attempted if there is financial and social support. What most refugees need is a basic medical check-up when they arrive in the U.K. and, where necessary, referred to specialised services if serious health problems are presented. In the absence of a systematic health recording system for refugees and other basic information, analysis of physical and mental health problems is difficult. But the following main areas of problems have been identified: l Maternal and child health care: refugees do not use family planning services or ante-natal and well-women clinics and prefer to see a female doctor; men do not attend ante-natal sessions. Many are single women parents who find the domiciliary services provided by Health Visitors and District Nurses easier to use and more appropriate to their needs. Their fear of medical institutions and authorities is often the reason for using less formal home visits carried out mainly by female Primary Care Teams; l Unaccompanied children: they represent a small but very vulnerable group of refugees. It is estimated that there are at least 242 unaccompanied refugee children in U.K. Some of them have already experienced detention by Immigration Services on their arrival [ 131.Separation from families at an early age (7-16 years old) causes considerable mental health problems; l Mental health problems: information on specific disorders and the estimated number and scope of refugees with mental health problems is not available. At present, there are only two programmes in London that provide specialised services to victims of torture and refugees with psycho-social problems. Except in these two voluntary organisations refugees are not identified as special needs groups. They are registered with their GPs in the same way as non-refugees and there is little data on mental health problems. Similarly, cultural/linguistic barriers and the inadequacies of the standard mental health assessment often produce wrong diagnoses. An examination of state hospital admissions in the United States showed that, “almost 60% of the refugee patients were diagnosed as schizophrenic, but the study raised questions about the diagnosis. Only 11% of the cases had an interpreter although almost 30% of the patients had no knowledge of English and another 50% had limited knowledge. Moreover, the history of their past traumatic experiences was not found in their records” [1I]. On the other hand, under-diagnosis can also undermine the incidence as well as the experience of mental distress-anxiety, grief, depression is expressed under the guise of physical symptoms such as headaches, fatigue, nervousness, insomnia, etc. Such



cases may occur in the the U.K. National Health Services. To avoid such problems a standard monitoring mechanism for refugees would help to assure a higher quality of service. In many developing countries mental health problems are stigmatised. Many refugees indicate their reluctance to see mental health professionals for fear of being labelled as ‘crazy’. Such labelling would isolate them socially from their communities; they fear it may affect their refugee status or employment; they fear referral to mental health institutions where injections are perhaps given which makes ‘someone zombie’. This is a serious problem which makes early detection of mental illness difficult. The introduction of health education for refugees, involving their community leaders, and awareness courses for health professionals about the experience of refugees as a special group would be helpful. Advocates/ interpreters and link workers could do much to help improve the availability and appropriateness of mental and physical health services, particularly if the focus is on local development and initiatives. Other groups of refugees whose problems fall through the net of the National Health Services are the victims of torture and rape. It is not common for victims of torture and rape to seek help and talk about their experiences. Specialised centres and experts are needed to identify and make contact with victims as early as possible in order to provide special care. Specialist reports have confirmed that “some traumas continue to show their effects until the third generation, so that even grandchildren may suffer from the experience of the torture victim” 1141. l HIV/AIDS: refugees may be reluctant to seek help and there is a need to provide information on where to go. Also, refugees may need assurance that their legal status or asylum claim will be not be prejudiced by their medical condition. Health and social needs assessment

Needs assessment of refugees can provide important information to identify risk groups, common health and social needs of different groups of refugees and above all involve refugees in determining and expressing their own needs. Several factors may be taken into account depending on the size and diversity of refugee groups, which are rarely homogenous. Each group of refugees has distinct problems and needs, and require particular resources. They have, however, many things in common. All have lost a homeland, most of them have to try to learn a new language, cope with a new culture, way of life, diet and adapt to a new social position. Needs assessment of refugees is not without some limitations; many refugees are reluctant to talk and express their needs to authorities or health workers because they fear that if they divulge their health problems it may affect their status or their application for resettlement.

The main factors or issues any needs assessment would address include: The cultural and socio-economic background, urban or rural origin, pasturialist/nomadic or agropasturialists, etc. The root causes of crisis i.e. war, violation of human rights, repression, famine, etc. General health status of home country, major pattern of diseases, morbidity or mortality rates and incidence of endemic infectious diseases, chronic malnutrition. The use of traditional medicine, concepts and understanding of health if related to certain health practices and stigma linked with mental illness, food and other habits such as smoking, alcohol, sexual behaviour and drugs. Understanding of torture and rape victims expressed in different cultures and societies. The appropriateness and adequacy of basic needs in reception centres. Ability to adapt socially and biologically to their new conditions, and the degree of the host society’s xenophobia and attitudes towards ethnic minorities. Despite the problems and complexities of refugee assessment, both in terms of lack of information, and reluctance to express needs and communication problems, it is a very useful step to take when planning for the long-term rehabilitation and resettlement programmes in countries of asylum. The agencies working with refugees and policy-makers in health and social services could also benefit from such type of needs assessment process in setting up their priorities, resource allocation, evaluation and monitoring of the services. It is also a crucial step to undertake when agencies plan for concerted and integrated post-emergency settlement and voluntary repatriation programmes. Another underlying problem is the lack of active participation of refugees in expressing their needs. But if adequate information and explanation is given, it would improve their participation both at consultative and implementation levels. Once their needs were matched with resources and the results become tangible i.e. health and social well-being improves, refugees will be encouraged to play a greater role in future needs assessment programmes and other local initiatives and developmental interventions.

REFERENCES The dispossessed. New Internationalist (Edited by Shaw S.). 14-15 September, 1991. Dick B. Diseases of refugees-causes, effects and control. Trans. R. Sot. Trap. Med. Hygiene 18, 734-741, 1984. Harrell-Bond B. The sociology of involuntary migration. Curr. Social. 36, 14, 1988. Field S. Resettling Refugees: the lessons of research. Home Office Res. Study, 87, l-8, 1987.

Health and social problems of refugees 5. Martin F. Issues in Refugee and Displaced Women and Children. Refugee Policy Group, Washington DC, 1990. 6. Hear Van N. Refugee health. Refugees, pp. 19-31, 1990. 7. Neuwirth G. Refugee resettlement. Curr. Social. 36, 2741, 1988. 8. Refugee Council. Asylum-Seekers in the United Kingdom. Essential Statistics. The Refugee Council, 1991. 9. Gardener P. et a/. Health priorities among Bangladesh refugees. Lancet, i,83436, 1972. IO. Steketee R. W. and Mulholland K. Primary care medicine in the refugees relief programme of Eastern Sudan. Disasters 6, 176-182,



11. Promoting Mental Health Services for Refugees: A Handbook on Model Practices. U.S. Department of Health and Human Services, Washington DC, 1991. 12. Jones P. Vietnamese refugees: a study of their reception and resettlement in the United Kingdom. Research and Planning Unit Paper 13. Home Office, London, 1982. 13. LJnaccompanied Refugee Children: A monitoring report. British Refugee Council, 1990. 14. Hengesbach S. Treatment of refugees victims of torture. Refugee 29, 32, 1986.

Health and social problems of refugees.

Today over 15 million refugees are scattered around the world, most of them in poor Third World countries [New Sci., pp. 14-15, September 1991]. But w...
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