Health Concerns for Displaced Persons

Original Editor - Nimisha Gorasia, Ayman Baroudi, Chidera Lilian as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Lucinda hampton, Kim Jackson, Jess Bell, Ewa Jaraczewska, Aminat Abolade and Carin Hunter  

Introduction

Around 68.5 million people worldwide are currently displaced, with 25.4 million of these crossing international boundaries in search of protection. Displaced persons are likely to have good general health, but they can be at risk of falling sick in transition or whilst staying in receiving countries due to poor living conditions or adjustments in their lifestyle.

The physical, psychological and social experiences of a displaced person as one flees conflict and persecution and seeks safety are referred to as displaced person experiences. According to 1951 Refugee Convention, a refugee is one who is unable or unwilling to return to ones country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality and membership of a particular social group or political opinion. There is an increased risk of health problems among individuals with refugee experience as they are faced with both mental and physical stress in their home countries and also during the migration process.

Some Key Points

• Immigrant populations are large and heterogeneous which results in a wide variety of different health situations.
• Migration itself is not considered a risk factor for health, and migrants have in general less health problems than the population both in their home country and in their new country. However, forced migration is a completely different situation, and it is very important to acknowledge this difference. 
• People with refugee experience are at risk of complex physical, mental and social problems, which can contribute to poor health outcomes and impede successful social integration. 
• Forced migration has a massive impact on the lives of refugees and asylum seekers including depression, anxiety, post-traumatic stress disorder, sleeping problems, respiratory and digestive infections, among others.
• Individuals struggle with finding a sense of belonging or social recognition, with developing trust and confidence, with maintaining motivation to try to adapt to their new circumstances, with financial and social disadvantages, communication difficulties due to cultural and language differences, instability and a constant fear of being deported, all of which can have an impact on health. 
• A significant proportion of refugees will have been subject to severe physical and/or psychological torture and that this exposure may have long-term physical and psychological consequences.

Impact of Migration on Health

In order to recognise the need for the inclusiveness of health services and to incorporate whole societies (that includes that of refugees and migrants), it is necessary to vocalise the importance of how migration can and has been affecting the refugee population.

• Addressing communicable disease control and immunisation programs holds importance on its own and needs to have increased awareness amongst this population. Research highlights that the number of communicable diseases such as Tuberculosis (TB), and Hepatitis (B & C) are recorded to be on the higher end in migrant populations.
• These vaccine-preventable diseases have vaccines that lie in abundance, however, are not widely known and sought for in the migrant population, particular in those seeking asylum.
• We seek to understand this proposition to fully maximise including the migrant population within the health sector i.e. health services and health whereabouts before their health becomes an unsolvable factor for the country.

Another aspect that comes into role play is what is termed as Health Vulnerability ie the extent to which the individual (in this case, a migrant) can live with anticipation, to cope with, resist and even recover from the impact of post disease/pandemics.

• One of the factors that lead to health vulnerability is socioeconomic status.
• Also relevant to migrants may is the fear/occurrence of isolation, insecurity, and the journey of travelling so far per se.

Challenges in Accessing Health Care

For reasons including their legal status, language barriers and discrimination. Some national health strategies may not make any reference to the health of refugees and migrants or the accessibility of health care for them. WHO calls all countries to implement policies that provide health care services to all migrants and refugees, irrespective of their legal status.

Major Health Concerns

Tuberculosis, nutritional deficiencies, intestinal parasites, chronic hepatitis B infection, lack of immunization, and depression are major problems in many groups. There is also great variation in the health and psychosocial issues, and cultural beliefs, among the refugees.

Examples of refugee health problems include:

• Communicable Diseases
  • Tuberculosis
  • Hepatitis
  • Human Immunodeficiency Virus (HIV)
• Non-communicable Diseases; Non-Communicable Diseases (NCDs) also termed chronic diseases, are collectively responsible for 71% of all deaths worldwide. Almost three quarters of all NCD deaths, and 82% of the 16 million people who die prematurely, occur in low- and middle-income countries..   NCDs also account for 48% of the healthy life years lost worldwide versus 40% for communicable diseases, maternal and perinatal conditions and nutritional deficiencies, and 1% for injuries.
  • Cancer: Displaced persons have a lower risk for all forms of cancer, except cervical cancer. However, cancer is more likely to be diagnosed at an advanced stage in persons who are displaced, which can lead to considerably worse health outcomes compared with the host population.
  • Cardiovascular Disease:
  • Chronic Respiratory Disease:
  • Diabetes: Displaced persons have a higher incidence, prevalence and mortality rate for diabetes than the host population.
• Communicable Diseases
  • Tuberculosis
  • Hepatitis
  • Human Immunodeficiency Virus (HIV)
  • Parasitic Infections;
    • Malaria
    • Giardiasis
    • Leishmaniasis
• Mental Health
  • Post-traumatic stress disorder (PTSD) appears to be more prevalent among displaced persons than their host population;
  • Depression is a common illness worldwide, with more than 264 million people affected and is commonly reported in displaced persons, particularly in those who have lengthy asylum-seeking processes and live in poor socioeconomic conditions, such as unemployment or isolation.
  • Generalized anxiety disorder is one of the most common mental health disorders affecting up to 20% of the adult population worlwide, which produces fear, worry, and a constant feeling of being overwhelmed. Generalized anxiety disorder is often characterized by persistent, excessive, and unrealistic worry about everyday things and is commonly reported, linked to lengthy asylum-seeking processes and poor socioeconomic conditions, such as unemployment or isolation.
• Pelvic Health

• 
• Musculoskeletal Injury: eg Refugees encounter frequent falls during migration process, eg exposing them to ankle sprain, fractures are one of the most prevalent injuries caused by trauma in refugees. The Physiotherapist manages fracture at the acute and post acute phase.
• Burns: According to World Health Organization, a burn is an injury to the skin or other organic tissue primarily caused by heat (hot liquids, hot solids and flames) or due to radiation, radioactivity,electricity, friction or contact with chemicals. This is one of the most common health condition seen in refugees. It becomes life threatening especially in the very young and very old individuals. Due to pain and discomfort, the individuals tend to keep their body in the position of comfort, thus encouraging joint contractures and pressure sore formation. Hence, the physiotherapist plays a role of joint mobilization and turning the individual every 2 hourly during the first few days after a burn injury.
• Spinal cord injury is one of the major types of war injuries experienced by refugees. For war-injured refugees, spinal cord injury (SCI) is a leading cause of catastrophic neurologic injury, the literature focused on the care of this vulnerable population is sparse. There are multiple challenges of caring for international refugees with SCI, an interdisciplinary SCI rehabilitation approach can provide comprehensive care for this vulnerable population.
• Orphans: Children without parents or a guardian are especially vulnerable and at risk for both health and social problems. Risks for abduction and trafficking for sale and exploitation can be exacerbated if border controls are weak, violations of children’s rights already exist and there is easy access to the child. Children are also vulnerable to sexual exploitation and experience higher rates of depression and symptoms of post-traumatic stress disorder.
• Occupational Health, Job Status or Unemployment.

Role of Rehabilitation Services

Refugee populations are likely to present with a series of complex and complicated health and wellness, including impairments, activity limitations, and participation restrictions. Landry et al describe the following:

1. Pre-existing Disability and Physical Limitation
2. Underlying Health Conditions and the Older Adult
3. Post-migration and Displacement Health Condition

The physiotherapist plays its role when these health problems causes pain, limits function and restrict movement of refugees either at ones country or during the migration process. The Canadian Physiotherapy Association describes physiotherapy as a primary care, autonomous, client-focused health profession dedicated to improving quality of life by:

• Promoting optimal mobility, physical activity and overall health and wellness;
• Preventing disease, injury, and disability;
• Managing acute and chronic conditions, activity limitations, and participation restrictions;
• Improving and maintaining optimal functional independence and physical performance;
• Rehabilitating injury and the effects of disease or disability with therapeutic exercise programs and other interventions; and
• Educating and planning maintenance and support programs to prevent re-occurrence, re-injury or functional decline.

An Example of Holistic Refugee Health Care

The World Wellness Clinic in Australia is a service for Refugee & Asylum Seeker. Providing ongoing health care to people from refugee backgrounds, no matter how long they have been in Australia, is an important part of their mission. The practitioners care for:

• People who are newly arrived or at the early stages of their settlement
• People who have lived here for many years
• People who live nearby and others who choose to travel significant distances to attend our service.

The team has a high level of expertise in:

• Refugee and asylum seeker health assessments
• Catch-up immunisations for refugees
• Cross-cultural mental health care
• Refugee health screening
• Injury and trauma rehabilitation
• Refugee dietetics
• Refugee women’s health issues including female genital mutilation
• Health promotion with culturally and linguistically diverse populations
• Holistic approach to refugee health and wellbeing
• Cultural competence in healthcare including working with interpreters