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The Health of Refugees
The Health
of Refugees
Public Health
Perspectives from Crisis
to Settlement
SECOND EDITION

Edited by
Pascale Allotey and Daniel D. Reidpath

1
1
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 For our parents, Ate, Betty, Gillian, and Kevin
whose love and support was a constant in our lives.
 Foreword

The rapid movement of large populations is intrinsic to humanity, usually as a

result of climate change, famine, earthquake, political or ideological conflict, re-
ligious persecution, and war. Societies receiving such populations—​now called
asylum seekers—​may be profoundly affected, sometimes positively through
moral, demographic, genetic, economic, and cultural enrichment. Places that
lose such populations tend to be diminished. Only some of these groups of
people are refugees under international law.
Although in official parlance, at least in Europe, a refugee is an asylum seeker
who has been granted leave to stay, the word is highly descriptive of the en-
tire group of people who seek asylum. It captures the sense of pursuit, fleeing,
and the perils of the journey much better than the idea of seeking peace and
calm portrayed by the phrase ‘asylum seeker’. Setting aside the nuances of these
phrases, the challenges to migrants and to the societies they come to join are
immense. Recipient populations and their services have a complex tasks of
caring for them and ensuring a favourable outcome for all. These tasks are to be
accomplished in the context of the myriad of international, regional, national,
and even sub-​national laws, policies, strategic documents, and service delivery
plans. Health and health care are amongst the top priorities in terms of the
immediate required actions. Public health is central in ensuring the required
actions are taken.
Historically, societies muddled through, with the indomitable human spirit
of the migrants and the recipient populations usually overcoming adversity,
through a partnership of community organizations (including faith groups),
non-​governmental organizations, legally required services, and the business/​
employment sector. Muddling through doesn’t, however, always work out in
the face of social prejudices, language problems, poverty, isolation, detention,
unemployment, poor health, and barriers to services.
Over the last 30–​40 years there has been a growing realization that laws and
even goodwill are not enough. This realization has accelerated in our era of
globalization and conflicts with mass movement of people—​for example in the
Middle East, Myanmar, and the Balkans, to name but a few. We must do better
on many fronts. This book shows us how to do so in health and health care in
and for asylum seekers and refugee across their journey from exodus, arrival,
and settlement.
viii Foreword

Sadly, this is a book of and for our times. In awaiting, and dreaming about, a
better world, we need to be armed with ethics, legal stances, principles, exem-
plars, knowledge of best practice, case studies, and resolve. Thank you to the
authors and especially the editors for providing us with all this, and much more.
Raj Bhopal CBE, DSE (hon)
Bruce and John Usher Professor of Public Health
Honorary Consultant in Public Health
Edinburgh Migration, Ethnicity and Health Research Group
Centre for Population Health Sciences
Usher Institute of Population Health Sciences and Informatics
The University of Edinburgh
4 April 2018
 Contents

Abbreviations xi
Contributors xiii

Part 1 Concepts and contexts

1 Forced migration, globalization, and global public health 3
Pascale Allotey and Daniel D. Reidpath
2 Humanitarianism, refugees, human rights, and health 19
Susan Kneebone
3 Social exclusion, othering, and refugee health policy 39
Daniel D. Reidpath and Pascale Allotey
4 Health in humanitarian crises 54
Mike Toole

Part 2 Health concerns

5 Populations in transition and post-​settlement: an infectious
diseases and travel medicine perspective 87
Kudzai Kanhutu, Karin Leder, and Beverley Ann Biggs
6 Mental health of refugees 106
Peter Ventevogel, Xavier Pereira, Sharuna Verghis, and Derrick Silove

Part 3 Impacts of displacement

7 Urban refugees: the hidden population 131
Sharuna Verghis and Susheela Balasundram
8 Addressing the rights of women in conflict and humanitarian
settings 153
Rajat Khosla, Sandra Krause, and Mihoko Tanabe
9 The health challenges facing children on the move 169
Susan Bissell and Jacqueline Bhabha
10 The health impacts of displacement due to conflict on
adolescents 181
Anushka Ataullahjan, Michelle F. Gaffey, Paul B. Spiegel, and
Zulfiqar A. Bhutta
x Contents

Part 4 Case studies in research and ethics

11 Methodological and ethical challenges in research with
forcibly displaced populations 209
Veena Pillai, Alison Mosier-​Mills, and Kaveh Khoshnood
12 Conducting health research with resettled refugees in
Australia: field sites, ethics, and methods 230
Celia McMichael and Caitlin Nunn
13 The politics of immigrant and refugee health in the United
States 245
Michael Grodin, Sondra Crosby, and George Annas
14 Dual loyalty, medical ethics, and health care in offshore
asylum-​seeker detention 260
Deborah Zion

Part 5 Conclusion
15 Controlling compassion: the media, refugees, and asylum
seekers 275
Pascale Allotey, Peter Mares, and Daniel D. Reidpath

Index 295
 Abbreviations

ACLU American Civil Liberties Union ICE Immigration and Customs

BCRHHR Boston Center for Refugee Enforcement
Health and Human Rights ICESCR International Covenant
BMC Boston Medical Center on Economic, Social and
Cultural Rights
BUSPH Boston University School of
Public Health ICMC International Catholic
Migration Commission
CAR Central African Republic
IDP internally displaced person
CBT cognitive behavioural therapies
IHMS International Health and
CESCR Committee on Economic,
Medical Services
Social and Cultural Rights
IRB institutional review board
CFR case fatality rates
IRHP Immigrant and Refugee Health
CMR crude mortality rates
Program
COMPASS creating opportunities
ISP Independent Study Project
through mentorship, parental
involvement, and safe spaces MDD major depressive disorder
CRC Convention on the Rights of MDG Millennium
the Child Development Goals
DACA Deferred Action for Childhood MDR TB multi-​drug-​resistant
Arrivals tuberculosis
DRC Democratic Republic of MHPSS mental health and psychosocial
the Congo support
ECDC European Centre for Disease MISP minimum initial service
Prevention and Control package
ECOSOC Economic and Social Council MMR measles, mumps, and rubella
(vaccination)
EU European Union
NCD non-​communicable disease
FMEG Forensic Medical
Evaluation Group NGO non-​governmental
organization
GBV gender-​based violence
NHI National Health Insurance
GLP Global Lawyers and Physicians
NHS National Health Service
GNB Gram-​negative bacteria
ODA official development assistance
HIA Health Induction Assessment
OECD Organisation for Economic Co-​
HINAP Health Information Network
operation and Development
for Advanced Planning
PCTF Polio Control Task Force
HRW Human Rights Watch
PoC person of concern
IASC Inter-​agency Standing
Committee POV polio oral vaccine
IAWG Inter-​agency Working Group PSSA psychosocial structured
activities
ICCPR International Covenant on
Civil and Political Rights PTSD post-​traumatic stress disorder
xii Abbreviations

RAN Royal Australian Navy UDHR Universal Declaration of

RPC Regional Processing Centre Human Rights
RSD refugee status determination UHC universal health coverage
RUTF ready-​to-​use therapeutic foods UNHCR United Nations High
Commission for Refugees
SDG Sustainable Development Goals
UNRWA United Nations Relief and
SGBV sexual and gender-​based
Works Agency
violence
VFR visiting family and relatives
SRH sexual and reproductive health
WASH water, sanitation, and hygiene
STI sexually transmissible infection
WCH women’s and children’s health
TB tuberculosis
WHO World Health Organization
TST tuberculin skin test
 Contributors

Pascale Allotey Susan Bissell

Director, International Institute for Former Director, Global Partnership
Global Health (UNU-​IIGH), United to End Violence Against Children,
Nations University, Kuala Lumpur, New York, USA
Malaysia Sondra Crosby
George Annas Associate Professor, Center for
William Fairfield Warren Health Law, Ethics & Human Rights,
Distinguished Professor; Director of Boston University School of Public
the Center for Health Law, Ethics & Health, Boston, MA, USA
Human Rights, Boston University Michelle F. Gaffey
School of Public Health, Boston, Senior Research Manager, Centre for
MA, USA Global Child Health, The Hospital for
Anushka Ataullahjan Sick Kids, Toronto, Canada
Research Analyst, Centre for Global Michael Grodin
Child Health, The Hospital for Sick Professor, Center for Health Law,
Kids, Toronto, Canada Ethics & Human Rights, Boston
Susheela Balasundram University School of Public Health,
Doctor, United Nations High Boston, MA, USA
Commissioner for Refugees, Kuala Kudzai Kanhutu
Lumpur, Malaysia Refugee Health Fellow, Doherty
Jacqueline Bhabha Institute, The Royal Melbourne
FXB Director of Research, Professor Hospital, Melbourne, Australia
of the Practice of Health and Human Kaveh Khoshnood
Rights at the Harvard School of Associate Professor of Epidemiology
Public Health, Cambridge, MA, USA (Microbial Diseases); Program
Zulfiqar A. Bhutta Director BA-​BS/​MPH Program in
Co-​Director, Director of Research, Public Health, Yale University, New
Centre for Global Child Health, Haven, CT, USA
The Hospital for Sick Kids, Rajat Khosla
Toronto, Canada Human Rights Adviser, Department
Beverley Ann Biggs of Reproductive Health, World
Professor, Royal Melbourne Hospital, Health Organisation, Geneva,
Melbourne, Australia Switzerland
xiv Contributors

Susan Kneebone Daniel D. Reidpath

Professorial Fellow and Associate, Professor of Population Health
Asian Law Centre, Melbourne Law and Director, South East Asia
School, Melbourne, Australia Community Observatory, Jeffrey
Cheah School of Medicine and
Sandra Krause
Health Sciences, Monash University,
Sexual and Reproductive Health
Malaysia
Program, Women's Refugee
Commission, New York, USA Derrick Silove
Professor, School of Psychiatry, Brain
Karin Leder
Sciences, University of New South
Professor, Head of Infectious
Wales, Sydney, Australia
Disease Epidemiology Unit, Monash
University, Clayton, Australia Paul B. Spiegel
Director, Center for Humanitarian
Peter Mares
Health, Johns Hopkins University
Adjunct Fellow, Swinburne
University, Melbourne, Australia Mihoko Tanabe
Sexual and Reproductive Health
Celia McMichael
Program, Women's Refugee
Lecturer, School of Geography,
Commission, New York, USA
University of Melbourne, Melbourne,
Australia Mike Toole
Alison Mosier-​Mills Professor, School of Public Health
‎Fulbright Student Researcher in and Preventive Medicine, Monash
Public Health, Yale University, New University, Victoria, Australia
Haven, CT, USA Peter Ventevogel
Caitlin Nunn Senior Mental Health Officer, United
Assistant Professor (Research), Nations High Commissioner for
Department of Sociology; and Refugees, Geneva, Switzerland
Fellow of the Wolfson Research Sharuna Verghis
Institute for Health and Wellbeing, Senior Lecturer, Jeffrey Cheah School
Durham University, of Medicine and Health Sciences,
Durham, UK Monash University, Malaysia;
Xavier Pereira Director, Health Equity Initiatives,
Associate Professor of Psychiatry, Kuala Lumpur, Malaysia
Taylor School of Medicine, Deborah Zion
Malaysia Associate Professor and Chair of the
Veena Pillai Human Research Ethics Committee,
Doctor, Dhi Consulting & Training, Victoria University, Melbourne,
Kuala Lumpur, Malaysia Australia
Part 1

Concepts and contexts

 Chapter 1

Forced migration, globalization,

and global public health
Pascale Allotey and Daniel D. Reidpath

People move. They move within countries and between countries. They move to
improve their opportunities for a better life, and they move to escape intolerable
hardship or the threat of intolerable hardship (Triandafyllidou, 2017, p. 3). In
understanding the impetus to move, the notions of ‘structure’ and ‘agency’ have
often been highlighted. Structure is broadly used to describe the macro-​level,
sociopolitical, and environmental features that encourage or discourage move-
ment, and agency is used to describe the individual motivations and personal
resources that promote or suppress movement.
In social and political theory the interplay between structure and agency has
remained fertile territory for academic contest: see for example Squire (2017)
and Hay (1995). Our purpose here is not to contribute to that debate but to give
a sense of that complexity.
[Structure] and agency logically entail one another—​a social and political structure
only exists by virtue of the constraints on, or opportunities for, agency that it effects.
Thus it makes no sense to conceive of structure without at least hypothetically positing
some notion of agency which might be affected (constrained or enabled). (Hay, 1995,
p. 189)

For those potentially in search of refuge, the interplay between structure and
agency affects who moves and the circumstances under which they move,
and how they are received and the opportunities they have to establish or re-​
establish their lives.
Furthermore, the circumstances of the individual and their country of origin,
the circumstances of their movement, the time it takes, the route, and their des-
tination all have individual and population health effects. The trends in forced,
global migration since the publication of the first edition in 2003 give some
insight into this. It also grounds the remaining chapters of this book in the
reality of the early twenty-​first century. It is crucial, however, that we have a
shared understanding of the population that is the focus of this book, or at
4 Forced migration and public health

least a shared understanding of the potential disagreements in defining that

population.

1.1 Who is a refugee?
In epidemiology and health measurement there is an assumption that the rules
for case definition represent natural, intrinsic classes: with disease—​without
disease. We might therefore expect inclusion or exclusion criteria or a case def-
inition for defining concepts and populations; for separating the refugee from
the non-​refugee. However, these ‘natural definitions’ are frequently muddied by
blurred edges, hubris, and political and disciplinary bias (Reidpath et al., 2003;
Reidpath, 2007). The term ‘refugee’ falls into this imprecise category. It is rele-
vant primarily as a sociolegal definition, but in the context of public health and
clinical medicine it is important for providing background about exposures,
social determinants of health, access to services, and protections by the state
and the international community.
In outlining the ‘counting rules’ for refugees, we make it clear that there are ar-
bitrary social dimensions involved, with underlying political agendas (Lomell,
2010). Different authors will use different counting rules, and these rules may
not always be explicit. It is incumbent on the reader, therefore, to understand
this and understand that any analysis is necessarily embedded in a particular
understanding of ‘refugee’. One person’s ‘economic migrant’ is another person’s
‘climate change refugee’, and one person’s ‘refugee’ is another person’s ‘internally
displaced person’ (IDP). Even within this volume, authors do not necessarily
adopt the same definition of a refugee.
An eminent international lawyer who was once asked what defined a
refugee responded: ‘a person who satisfies the criteria laid down in Article
1 of the Refugee Convention’ (Grahl-​Madsen, 1966, p. 278). This, of course,
is not the definition of a refugee, it is a description of a refugee under inter-
national law. In common usage the word refugee is used much more broadly.
The English word has its origins in the flight from persecution of the French
Calvinists (Huguenots) in Catholic-​dominated seventeenth-​century France,
and their search for refuge in other European countries (and later the North
American colonies of European countries), as the Oxford dictionary defin-
ition indicates:
Refugee (/​rɛfjʊˈdʒiː/​) Noun: A person who has been forced to leave their country in
order to escape war, persecution, or natural disaster. Origin: Late 17th century: from
French réfugié ‘gone in search of refuge’, past participle of réfugier.

That idea of fleeing persecution in one place and seeking protection in an-
other, at least in the European tradition, had been known since medieval times
 Who is a refugee? 5

and even earlier. It became more prominent with the Reformation, the growth
of Protestantism, and the need for classes of people to flee religious persecution.
The modern European tradition of asylum dates from the year 1685. In that year Louis
XIV repealed the Edict of Nantes, while in the same year Friedrich Wilhelm, the Great
Elector of Brandenburg, issued his Edict of Potsdam, whereby the French Huguenots
were authorised to establish themselves in his territories. (Grahl-​Madsen, 1966, p. 278)

In Judeo-​Christian tradition one of the best-​known refugees was Moses who,

according to the second book of the Pentateuch, fled from Egypt to Midian,
fearing persecution by the Pharaoh, where he settled, married and had chil-
dren as ‘a stranger in a strange land’ (Exodus, 2:15–​22). Subsequently, Moses
returned to Egypt and led the exodus of the Hebrews out of slavery to a place
of refuge and final settlement in Canaan—​the first recorded mass movement
of refugees.
There is an interesting juxtaposition between the refugee status of the
Huguenots or the Hebrews and the dictionary definition. The dictionary def-
inition includes natural disaster as a cause to seek refuge—​which it certainly is.
If there is not enough food and water to sustain life where you currently live,
move! In contrast, the Huguenots and the Hebrews sought relief from politico-​
religious persecution:
owing to 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 his 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, is unwilling to return to it. (Article 1)

As Hathaway put it, the difference between a common-​sense refugee who pulls
at our heartstrings and a Convention Refugee is the concept of a rights-​bearer
under international law (Hathaway, 2014).
The legal instruments have been applied to individuals who seek asylum out-
side their country of nationality for a range of political reasons. Recent examples
include Julian Assange who sought protection in the Embassy of Ecuador in
London against potential future extradition to the United States where he faces
prosecution for publication of leaked documents. Similar asylum regulations
have been used by politicians who are in opposition to the prevailing political
power in their countries. However, unless they are recognized as refugees under
international law, the protection granted is restricted to the countries that grant
asylum. From a public health perspective, there is greater concern when the
drivers for mobility affect a significant population group.
In its totality, this book considers the common-​sense notion of refugees, al-
though some authors may focus more narrowly on ‘Refugees’—​under the legal
6 Forced migration and public health

definition. For that reason, for the most part, we therefore use the umbrella
term ‘forced migration’ to emphasize the health implications for a population
group. Formal definitions of the different populations affected by forced migra-
tion are discussed in detail by Kneebone in Chapter 2.

1.2 Forced migration
The push factors for forced migration can conceptually be divided into
precipitating events, and a process of social or environmental change, resulting
in a catastrophic failure: a sociopolitical failure, an economic failure, or an en-
vironmental failure (Figure 1.1).
Against a backdrop of political, economic, or environmental conditions,
changes occur.
◆ Government policy is implemented that blames and targets a minority group.
◆ There is an economic depression.
◆ An economic policy encourages unsustainable farming practice.
◆ The rate of population increase (from birth and migration) is beyond the
capacity of the country.
◆ There is an earthquake or other large-​scale natural disaster.
The sociopolitical failure to protect (sub-​)populations, the economic failure re-
moving food from the table, or some sudden or gradual environmental failure
becomes the impetus or force to move. The concept map is not intended to
identify all contingencies, nor reflect the full complexity of feedback loops,
nor address the confluence of inseparable causes. When there is a drought, do
people move because of an environmental failure or an economic failure? In
times of conflict, is it persecution or a loss of livelihood that creates the duress
precipitating movement? What Figure 1.1 does illustrate is that those who move
have gone in search of refuge (réfugié). They have gone away from their homes
looking for greater safety and security.
The concept map focuses on the structural and is intentionally quieter on
agency, although it is implicit. We are not interested in a tally-​column of suf-
fering. Who has suffered enough to be a refugee? Who was truly forced? We do
not support the argument that one is not allowed to seek refuge until one’s life
has been utterly destroyed. It is also clear, however, that the health sequelae will
be different for different people. Some of that difference will relate to the extent
to which a person can preserve their agency and act within the world rather
than have the world act upon them.
 Events Process Outcome Exemplar Class

Refugees
Conflict
Political Socio-Political
War
Failure
Persecution
Social
Change Internally
Displaced

Economic Economic Loss of

Failure Livelihood

Environmental Asylum
Change Seekers
Floods
Environmental
Natural Droughts
Failure
Earthquakes
Economic
Migrants

Figure 1.1 Conceptual map of the events, processes, and outcomes leading to forced migration.
Reproduced courtesy of the authors.
8 Forced migration and public health

1.3 Definitions
The need to categorize and label the types of forced migration is politically ex-
pedient to direct public opinion, influence policy, and determine states’ obli-
gation. If health is a public good, the rules for who can access health services
and the cost of these services are determined by states. Legal status and citi-
zenship therefore often becomes the primary consideration (regardless of push
factors for forced migration) and has fuelled recent debates in the movements
of people across borders.
A Refugee is a person who meets the eligibility criteria under the applic-
able refugee definition, as provided for in international or regional refugee in-
struments, under the mandate of the United Nations High Commissioner for
Refugees (UNHCR), and in national legislation.
An asylum seeker is an individual who is seeking international protection. In
countries with individualized procedures, an asylum seeker is someone whose
claim has not yet been finally decided by the country in which he or she has
submitted it. Not every asylum seeker will ultimately be recognized as a refugee,
but every refugee is initially an asylum seeker.
Internally displaced persons (IDPs) are those forced or obliged to flee from
their homes, ‘. . . in particular as a result of or in order to avoid the effects of
armed conflicts, situations of generalized violence, violations of human rights
or natural or human-​made disasters, and who have not crossed an internation-
ally recognized State border’ (UNHCR, 1998, p. 5).
Mandate Refugees are persons who are recognized as refugees by UNHCR
acting under the authority of its Statute and relevant UN General Assembly
resolutions. Mandate status is especially significant in states that are not parties
to the 1951 Convention on Refugees or its 1967 Protocol.
Under national laws, Stateless Persons do not have the legal bond of nation-
ality with any State. Article 1 of the 1954 Convention relating to the Status of
Stateless Persons indicates that a person not considered a national (or citizen)
automatically under the laws of any State, is stateless. These persons may differ
from undocumented migrants, who lack legal documentation and therefore
need to make a case for citizenship and migration status.
Persons of Concern to UNHCR is a generic term used to describe all persons
whose protection and assistance needs are of interest to UNHCR. These include
refugees under the 1951 Convention, persons who have been forced to leave
their countries as a result of conflict or events seriously disturbing public order,
asylum seekers, returnees, stateless persons, and, in some situations, IDPs.
UNHCR’s authority to act on behalf of persons of concern other than refugees is
 Trends in global forced migration 9

based on United Nations General Assembly and Economic and Social Council
(ECOSOC) resolutions.

1.4 Trends in global forced migration

In the first edition of Health of Refugees, Zwi and Alvarez-​Castillo (2003)
identified the major forced migration events since World War II. Rather than
look back again, we carry that timeline forward to cover the years since that
publication.
We have the advantage of better data systems and better tracking.
Unfortunately, there are no perfect mechanisms for tracking all formal and in-
formal movements of people. A quick look at the data from the Population
Division of the United Nations Department of Economic and Social Affairs
(UNDESA, n.d.) reveals the paucity of aggregated migration data. Data chal-
lenges notwithstanding, UNHCR tracks their ‘persons of concern’ (PoC) to a
greater degree. Within UNHCR, PoC are categorized under ‘Refugee’, ‘Asylum
Seeker’, ‘IDPs, ‘Stateless’, and ‘Other’. Each category has a specific legal defin-
ition, and while the UNHCR counting rules may not encompass everyone that
one might regard as a (small ‘r’) refugee, or might cover additional people one
might not regard as a refugee, it does give a snapshot of the broad trends in
forced migration.
We reviewed the UNHCR Global Reports from 2004, the year after the first
edition was published, to the latest report published in 2016.1 We focused prin-
cipally on the High Commissioner’s foreword and summary data (Table 1.1).
For the majority of those years (2005–​2014), the current Secretary General
of the United Nations, António Guterres, was the High Commissioner for
Refugees. As a lead into those years, it is worth noting that the foreword to the
2003 Global Report opened with the sentence, ‘2003 was a good year for refugee
returns’. Since then, and with the exception of 2004, good news openings have
been increasingly rare.
The succession of Global Reports characterizes an increasingly fragile global
situation. The arc of countries through West Asia, the Middle East, the Horn
of Africa, Central Africa, and the Lakes Region have dominated the refugee
numbers. Some countries that were host countries for refugees have themselves
become destabilized (e.g. Syria and Yemen). Other regions, however, have not
been immune, including South and Central America, South East Asia, and
Central Asia.
Figure 1.2 uses UNHCR data to illustrate the shift in refugee numbers since
1990 through to 2016.
10 Forced migration and public health

Table 1.1 Information from UNHCR Global Reports, 2004–​16

Year Highlights
2004 The number of Persons of Concern to UNHCR continued to
Acting High decline. A three-​year downward trend with fewer asylum seekers
Commissioner arriving in industrialized countries during 2004 than in any year
Wendy since 1988.
Chamberlin Crisis in Darfur region, Sudan: 200,000 refugees shelter in arid
eastern Chad.

2005 600,000 people in Indonesia and Sri Lanka were displaced by a

High Commissioner tsunami. In late 2005 the South Asia earthquake levelled hundreds
António Guterres of villages throughout Pakistan-​administered Kashmir. Darfur
worsened, affecting over 2 million people. Conflicts in Burundi and
South Sudan continued, raising prospects for two of Africa’s largest
refugee populations.
2006 For the first time since the turn of the century, the number of
High Commissioner refugees increased in 2006 by 12% to almost 10 million. This was
António Guterres largely a result of the crisis in Iraq. The overall number of persons
of concern to UNHCR rose from 21 million in 2005 to 34.4 million
in 2006.
50,000 people a month crossed Iraq’s western border, seeking
refuge in Syria and Jordan. By the end of 2006, the cumulative
total of displaced Iraqis inside and outside the country had
reached 3.8 million. Half-​way through 2006 there was a 34-​day
war in Lebanon. Around 1 million Lebanese were displaced. Many
sought refuge inside their own country; others fled into Syria.
2007 There were 2 million IDPs in Iraq and 2.2 million Iraqi refugees in
High Commissioner neighbouring countries. Insecurity in the Central African Republic
António Guterres (CAR), Chad, and Darfur region brought the overall number of
refugees and IDPs in these three places to almost 3 million. In
Chad, cross-​border raids destroyed several villages and uprooted
thousands of people. More than 20,000 Chadians fled into Darfur
in 2007. Violence in the eastern areas of the Democratic Republic
of the Congo (DRC) displaced an additional 435,000 people
internally. In south and central Somalia fighting brought the total
number of IDPs to 1 million. It also added some 30,000 Somali
refugees to some 325,000 refugees already in neighbouring
countries.
2008 By the end of 2008, the total number of refugees under UNHCR’s
High Commissioner mandate exceeded 10 million. The number of conflict-​induced
António Guterres IDPs reached 26 million worldwide. Conflicts in an arc from South
and South West Asia, through the Middle East to Sudan and
the Horn of Africa generated two-​thirds of the total number of
refugees worldwide.
In Darfur more than 2 million people remain internally displaced,
while nearly a quarter of a million Darfurians remained in exile in
Chad. 300,000 people became internally displaced in Pakistan.
 Trends in global forced migration 11

Table 1.1 Continued

Year Highlights
2009 There are 36 million persons of concern to UNHCR including
High Commissioner 10 million refugees—​the highest number on record. Two-​thirds of
António Guterres the world’s refugees are in developing countries, many in the arc of
conflict from South West Asia, the Middle East, Horn of Africa, and
the Great Lakes and Central region. Three-​quarters of IDPs are also
to be found in this arc.
2010 An estimated 20 million Pakistanis were displaced by floods.
High Commissioner Afghan refugees in 19 camps were among those affected, as were
António Guterres people previously displaced internally. The emergency in Kyrgyzstan
broke out in the southern city of Osh. Clashes between ethnic
Uzbeks and Kyrgyz left hundreds dead and as many as 400,000
displaced. Approximately 75,000 refugees, mostly women and
children, fled to the Andijon area of neighbouring Uzbekistan.
2011 Hundreds of thousands of people were forced to abandon their
High Commissioner homes as violence erupted in Côte d’Ivoire and Libya. The Somali
António Guterres conflict, already 20 years old, degenerated further and, combined
with the worst drought in decades, drove close to 300,000
refugees into neighbouring Kenya, Ethiopia, Djibouti, and Yemen—​
bringing the total number of Somali refugees in the region to some
950,000 by the end of 2011. An upsurge in fighting in Sudan
resulted in an influx of nearly 100,000 new refugees into South
Sudan and Ethiopia. Old crises in Afghanistan, DRC, and Iraq have
not been resolved. As a result, durable solutions have remained
elusive for a large number of refugees under UNHCR’s mandate.
Over 7.2 million people are now living in protracted situations of
exile.
2012 More than 1 million people fled their countries of origin due to
High Commissioner conflict and persecution, mainly from Syria, Mali, Sudan, and
António Guterres the eastern DRC. That is the highest number of newly displaced
refugees during any 12-​month period since the beginning of the
21st century.
2013 Nearly 2 million people fled the brutal conflict in Syria and hundreds
High Commissioner of thousands escaped war, violence and persecution in the CAR,
António Guterres the eastern DRC, Myanmar, South Sudan, and Sudan. By the end
of 2013, almost 43 million people—​the highest number ever—​
relied on UNHCR for protection.
In just 5 years, from being the second largest refugee-​hosting
country in the world, Syria has become the second largest
refugee-​producing country, after Afghanistan. More than
9 million people were in flight inside and outside the country in
2013, and hundreds of thousands were trapped and under siege.
Syria’s neighbours shouldered the brunt of the burden, as did
other countries in the vicinity of conflict areas.

(continued )
12 Forced migration and public health

Table 1.1 Continued

Year Highlights
2014 Conflict and persecution forced some 13 million people from their
High Commissioner homes in 2014, and thousands died trying to get to safety.
António Guterres
2015 The world witnessed record levels of forced displacement in 2015.
High Commissioner More than 65 million people were uprooted by war, conflict,
Filippo Grand persecution, or human rights abuses by year end, including over
10 million displaced during the year.
The war in Syria was the single largest driver of displacement. At
the end of the year, more than 4 million Syrians were living in exile
in neighbouring countries and 6.5 million people were internally
displaced. Escalating violence in Afghanistan in the second half
of 2015 brought the number of internally displaced people to
a new high of 1 million. In South East Asia, large numbers of
migrants and refugees, including many Rohingya, put their lives
in the hands of smugglers in search for safety and a future. In
Central America, shocking levels of gang violence in El Salvador,
Guatemala, and Honduras displaced tens of thousands of people
and forced many of them along traditional migrant routes, mostly
travelling north, in search of safety and protection.
This was also the year that the global refugee crisis reached
Europe. More than 1 million refugees and migrants arrived on
the southern European shores. Tragically, nearly 4,000 died in the
attempt.
2016 At the end of the year the global number of people of concern
High Commissioner to UNHCR exceeded 67 million. It encompasses those who fled
Filippo Grand conflict and violence in Burundi, Myanmar, the Lake Chad region,
the Northern Triangle of Central America, and Yemen. It includes
millions of refugees, internally displaced people and returnees
affected by the unresolved situations in Afghanistan and Somalia.
Violent conflict and persecution, compounded by rising food
insecurity, environmental degradation, poor governance, and
countless other factors, drove more than three million people to
leave their countries as refugees or to seek asylum.

Figure 1.2a shows that the number of refugees, approximately 18 million in

1990, declined to approximately 10 million by 2004, before rising again to ap-
proximately 17 million in 2016. A dramatic rise in IDPs can be seen from 2003
when the figure hovered around 5 million, rising sharply in 2005, and then
again in 2012 to approximately 37 million people in 2016. The total magnitude
of the problem, however, is best illustrated by Figure 1.2b, which shows the ac-
cumulated numbers of Refugees, Asylum Seekers, IDPs, and ‘Others’ from 1990
to 2016. Until 2003, there was a relatively steady number of people who moved
 The distributive burden 13

IDP
60
30
People (Millions)

People (Millions)
40
20
Refugee

10 Other 20

Asylum-seeker
0 0
90

95

00

05

10

15

90

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00

05

10

15
19

19

20

20

20

20

19

19

20

20

20

20
Year Year
Refugee Other
IDP Asylum-seeker

Figure 1.2 The numbers of refugees, asylum seekers, internally displaced persons, and
‘others’ recorded by UNHCR in each year from 1990 to 2016.
Reproduced courtesy of the authors.

under duress—​a total of around 20 million. Because of the rise in Refugees,

IDPs, and ‘Others’ over the subsequent years, by 2016 the total number of
people exceeded 60 million.
These dramatic increases have been driven by exactly the kinds of processes
described in Figure 1.1—​sociopolitical failures, economic failures, and envir-
onmental failures, often feeding into each other.
The world is facing unprecedented levels of environmental and sociopolitical
failure. Climate change, particularly variations in temperature, has been shown
systematically to drive migration (Berlemann and Steinhardt, 2017). Similarly,
large-​scale environmental events, such as hurricanes, have also been shown
to force migration; and it is middle-​income countries that ‘experience signifi-
cant push and pull effects on migration from natural hazards’ (Gröschl and
Steinwachs, 2017, p. 445). Issues of governance, climate change, water access,
food production, and economic security have been highlighted by UNHCR
Global Reports during the last decade as structural factors leading to forced
migration.

1.5 The distributive burden of forced migration

In 2003 we looked at the inequitable distribution of refugees globally. We ar-
gued that a country’s capacity to support refugees needed to be taken into
14 Forced migration and public health

account in deciding on equitable distribution, where capacity combined con-

siderations of national wealth and population size (Allotey and Reidpath, 2003).
Our analysis showed clearly that the countries with the least capacity bore the
highest burden, and the burden was essentially log-​linearly distributed across
the wealth/​population domains. Currently, it is the proximate states that bear
the heaviest responsibility for supporting refugees (Reeves, 2017). That is, the
countries that share a border with a country in crisis absorb the largest share of
the refugees. Because, globally, regions in crisis tend to be poorer than regions
without crisis, poorer countries carry the greater burden. The challenges, how-
ever, are compounded, particularly when refugees are generated by conflict.
Poorer countries have less capacity to provide appropriate support for the re-
settlement of refugees. Countries proximate to war are more likely to become
destabilized by that war (Phillips, 2015). And the combination of managing
a refugee population and maintaining national security creates a synergistic
burden.
This problem is understood. Reeves (2017, p. 642) in a recent argument on
the moral redistribution of refugees noted that European Union (EU) ministers
suggested relocating refugees to member states along the lines for which we had
argued earlier: by the national wealth, population size, and adding unemploy-
ment rate and current refugee numbers. Increasing xenophobia, nationalism,
and the rise of the #MeFirst movement has unfortunately not worked in favour
of refugees. In Europe for example, EU member states showed they preferred to
‘sacrifice European integration because they are not ready to accept their duties
towards refugees’ (Bauböck, 2017, p. 1).
The problem is not, however, as the French prime minister, Manual Valls,
claimed in 2016, that refugees destabilize the state (Chrisafis, Elliott, and
Treanor, 2016). Instead, it is that,
[R]‌efugee protection and state stability are strongly connected; undermining one factor
weakens the other. Policies to protect refugees, both physically and legally, reduce po-
tential threats from the crisis and bolster state security. Overwhelmed and often im-
poverished, host states cannot provide this protection without significant international
assistance. (Lischer, 2017, p. 95)

1.6 Health and forced migration

Publication of this second edition has been driven by the rapid escalation
in forced migration over the last 10 years and the ‘global migration crisis’.
The numbers of refugees have more than doubled since the first edition
was published. There have been significant shifts in the global landscape;
in the factors that forcibly drive people from their homes creating asylum
seekers, refugees, IDPs, and various categories of economic migrants. The
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