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 83.9 million people worldwide are currently displaced, with 30.7 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, and there is an increased risk of health problems among individuals who have been displaced 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 experience of displacement 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 displaced persons including depression, anxiety, post-traumatic stress disorder, sleeping problems, respiratory and digestive infections, among others.
• Individual who have experienced displacement can 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 displaced persons will have been subject to severe physical and/or psychological torture and that this exposure may have long-term physical and psychological consequences.

Problems and stressors facing Displaced Persons

Displaced persons often face various problems and stressors which can take place at various stages of the migration process:

1. Pre-migration:
   • Lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.
2. Migration travel and transit:
   • Exposure to challenging and life-threatening conditions including violence and detention and lack of access to services to cover their basic needs.
3. Post-migration:
   • Barriers to accessing health care and other services to meet their basic needs as well as poor living conditions, separation from family members and support networks, possible uncertainty regarding work permits and legal status (asylum application), and in some cases immigration detention.
4. Integration and settlement:
   • Poor living or working conditions, unemployment, assimilation difficulties, challenges to cultural, religious, and gender identities, challenges with obtaining entitlements, changing policies in host countries, racism and exclusion, tension between host population and migrants and refugees, social isolation and possible deportation.

Impact of Migration on Health

In order to recognise the need for the inclusiveness of health services and to incorporate whole societies, it is necessary to vocalise the importance of how migration can and has been affecting displaced persons.

• 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 i.e. 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 disease, and in particular pandemics.

• One of the factors that lead to health vulnerability is socioeconomic status
• Also relevant to migrants 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 displaced persons or the accessibility of health care for them. the World Health Organisation calls all countries to implement policies that provide health care services to all migrants and displaced persons, irrespective of their legal status.

Major Health Concerns

Tuberculosis, nutritional deficiencies, intestinal parasites, hepatitis B, lack of immunisation, and mental health conditions are common difficulties seen in displaced persons, with great variation in the health and psychosocial issues, and cultural beliefs, also seen depending on country of origin and the migration process.

Examples of displaced persons health problems include:

• Non-communicable Diseases
  • 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.
  • Generalised anxiety disorder is one of the most common mental health disorders affecting up to 20% of the adult population worldwide, which produces fear, worry, and a constant feeling of being overwhelmed. Generalised anxiety disorder is often characterised 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 Pain and Dysfunction
• Musculoskeletal Injury
  • Displaced persons encounter frequent falls during migration process, eg exposing them to ankle sprain, fractures are one of the most prevalent injuries caused by trauma in displaced persons.
• Burns
  • According to the 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 conditions seen in displaced persons. 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.
• Spinal Cord Injury
  • Significant life changing injury seen in war, conflict or disaster injuries experienced by displaced. For war-injured displaced persons, spinal cord injury (SCI) is a leading cause of catastrophic neurologic injury, with evidence focused on the care of this vulnerable population. There are multiple challenges of caring for displaced persons with SCI in low and middle income countries where most displaced persons are based, an interdisciplinary SCI rehabilitation approach can provide comprehensive care for this vulnerable population.
• Unaccompanied Children or Orphaned Children
  • 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 rehabilitation professional plays a role when health problems causes pain, or limits function of displaced persons either in their country of origin or during the migration process and are involved in;

• 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
• Educating and planning maintenance and support programs to prevent re-occurrence, re-injury or functional decline

Example of Holistic Refugee Health Care

The World Wellness Clinic in Australia is a service for displaced persons providing ongoing health care to people, 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:

• Displaced person health assessments
• Catch-up immunisations for displaced persons
• Cross-cultural mental health care
• Displaced person health screening
• Injury and trauma rehabilitation
• Displaced persons dietetics and nutritional assessment
• Displaced women’s health issues including female genital mutilation
• Health promotion with culturally and linguistically diverse populations
• Holistic approach to displaced persons health and wellbeing
• Cultural competence in healthcare including working with interpreters