31.5: Refugees
By the end of this section, you should be able to:
- Differentiate between a refugee and an asylum seeker.
- Describe common health conditions affecting population health in refugee camps.
- Explain the unique health challenges for refugees and asylum seekers.
- Discuss why promoting the health of refugees is a matter of social justice.
- Explain the nurse’s role in addressing the refugee crisis to uphold nursing’s mission to society.
Refugee and asylum seeker both refer to people who have left their homes, and they are often used interchangeably. Although the two groups flee their homes for similar reasons, they use different means to reach the United States. The different designations have separate legal statuses with consequent legal obligations and protections.
According to the 1951 Convention Relating to the Status of Refugees, a refugee is “a person who, as a result of a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion” has crossed an international border and cannot return to their home (United Nations [UN], 2023a). Recently, more people have been forced to flee their homes than at any time since World War II, with about 110 million individuals displaced worldwide (International Rescue Committee, 2023; UN Higher Commission for Refugees [UNHCR], 2023b). Child refugees face numerous risks and dangers, including disease, malnutrition, violence, labor exploitation, and trafficking.
The UN Higher Commission for Refugees (UNHCR, 2023b) defines forced displacement “as a result of persecution, conflict, generalized violence or human rights violations” and a stateless person (UNHCR, 2023a) as someone who is “not considered as a national by any state under the operation of its law.” Some stateless people are also refugees. However, not all refugees are stateless, and many people who are stateless have never crossed an international border (U.S. Department of State, n.d.).
Asylum is a form of legal protection that prevents individuals from being deported to a country where they might experience harm and may legally remain. An asylum seeker is someone who has fled persecution and serious human rights violations in their home country but who has not yet been legally recognized as a refugee or received a decision on their asylum claim. Seeking asylum is a human right (Amnesty International, 2023), and individuals can apply for asylum either at another country’s border or from within the country where they would like to resettle. An individual cannot seek asylum in the United States from their native country—individuals may file for asylum only if they are in the United States or at a port of entry.
International law protects refugees. Under the 1951 Refugee Convention (and its 1967 Protocol), refugees cannot be returned to their home country after fleeing and seeking asylum in another country. Before leaving their geographical home of legal affiliation (i.e., where they would hold a passport of issuance), they must apply for refugee status through the United Nations High Commission for Refugees (UNHCR; 2023c) and then be selected for resettlement. Refugees do not get to choose the country where they will be resettled; they are more likely to be resettled in the United States if they already have family members living there. Refugees are thoroughly vetted, with multiple background checks and medical screenings. Once they have passed all checks and are approved, they are flown to the United States, where a local resettlement agency helps them during a transition period when they first arrive. Table 31.3 presents definitions of the terms used to describe these populations.
| Term | Definition |
|---|---|
| Asylum seeker | Someone whose request for sanctuary has yet to be processed. Every year, around one million people seek asylum. |
| Immigrant | A person living in a country other than that of their birth. |
| Migrant | An umbrella term, not defined under international law, reflecting the common lay understanding of a person who moves away from their place of usual residence, whether within a country or across an international border, temporarily or permanently. |
| Refugee | Someone forced to flee their home because of war, violence, or persecution, often without warning. They cannot return home unless and until conditions there are safe for them again. |
Common Conditions Affecting Health in Refugee Camps
Many who flee their homes or are forcibly displaced find themselves in a refugee camp , a temporary settlement built to accommodate displaced people who have fled their home country; however, camps are also made for internally displaced people (Figure 31.7). Usually, refugees seek asylum after escaping war in their home countries, but some camps also house environmental and economic migrants. Refugee camps with over a hundred thousand people are common; however, the average-sized camp houses approximately 11,000 people (Daynes, 2016; USA for UNHCR, 2023). The Kutupalong-Balukhali refugee settlement in Bangladesh includes over 800,000 refugees, over half of them children, making it one of the largest such settlements in the world (USA for UNHCR, 2023).
Refugee camps are usually built and run by a government, the UN, international organizations (such as the International Committee of the Red Cross), or nongovernmental organizations (NGOs). Refugee camps generally develop impromptu to provide people with protection and assistance. Shelters include rental units, prefabricated containers, tents, plastic sheeting, and other materials based on available supplies (UNHCR, n.d.-a; n.d.-b). Space in the camps is often tight, so shelters are often crowded together. It is common for several families to live together in the same dwelling.
The quality and quantity of sanitation facilities vary among camps. While some may have communal toilet facilities and running water, others may rely on pit latrines dug by residents. Few or no sanitary facilities may be accessible for people with disabilities (CARE Staff, 2020). Poor drainage, seasonal flooding, and inadequate cleaning increase infectious disease risk. According to the UNHCR Emergency Handbook , each person should be allocated 15 liters (about 4 gallons) of water per day in an emergency situation and 20 liters (about 5.25 gallons) in a nonemergency situation for personal and domestic needs (UNHCR, n.d.-a). However, the UNHCR estimates that over half of existing camps lack the water to meet these guidelines (The Borgen Project, 2020).
Unique Health Challenges
Refugees and asylum seekers can have complex health needs. Overcrowding, poor water and sanitation conditions, lack of vaccinations, delayed diagnosis, and reduced access to treatment can increase the occurrence, severity, and case fatality of infectious diseases (Altare et al., 2019). For example, viral hepatitis A, B, and C (CDC, 2020; Taha et al., 2023), measles, diarrheal diseases, acute respiratory infection, and malaria account for 60 to 80 percent of all reported causes of death among refugees (Johns Hopkins Bloomberg School of Public Health, 2018). Cholera outbreaks may also occur because camps have ideal conditions for its spread: inadequate water treatment, poor sanitation, and inadequate hygiene (Bonyan Organization, 2023). For children, key priority infectious diseases among refugee populations include tuberculosis, hepatitis B, and vaccine-preventable and parasitic diseases (Shetty, 2019). COVID-19 took a devastating toll on refugee resettlement. In addition to exposure to infectious diseases, individuals may have preexisting or poorly controlled chronic conditions, such as diabetes, cardiovascular diseases, respiratory conditions, and cancer. Many have psychiatric illnesses like post-traumatic stress disorder and depression (Abbas, et al., 2018) as well as maternity care needs.
Holistic and person-centered care is essential to support resilience and help refugees and asylum seekers adapt to life in the United States. When a nurse treats a refugee or asylum seeker, they should screen for infectious diseases that are common in countries where these clients have spent time. The nurse may also identify symptoms of communicable diseases when clients present with other routine issues. In some countries, screening for infectious diseases, such as HIV and hepatitis, may not be easily accessible, or people may not seek testing due to fear of stigma or lack of treatment options. Nurses should discuss the possibility of receiving a positive result in advance with clients from countries with high rates of certain diseases. They should find out what vaccinations refugees and asylum seekers have received and offer missing vaccinations to children and adults based on the latest national immunization schedule. As with all clients, nurses should inform refugees and asylum seekers about any testing, treatment, or vaccinations offered to them. This may require extra care in explaining their rights to confidentiality. For example, a nurse may need to reassure a client that a positive test result will not negatively affect asylum applications. Some clients may need additional health education in an appropriate language to understand their options, which may require an interpreter, or it may be appropriate to give the client written information in their language to take away, depending on their literacy level. Specialist client support organizations may also be able to assist with educating and informing clients about their rights and health care options.
Women who have experienced female genital mutilation (FGM), and their female children if they are considered to be at risk of FGM, may require additional support. FGM can cause ongoing physical and mental health issues, including complications during pregnancy and childbirth, which should be planned for. It may also deter women from being screened for cervical cancer (United Nations Population Fund, 2022).
Although refugees and asylums seekers do not display mental health problems frequently (Gov.UK, 2017; Hynie, 2018), they can be at increased risk, particularly if they have experienced violence and trauma, including exploitation, torture, or sexual and gender-based violence. Issues can range from low to moderate levels of anxiety and depression to more severe mental disorders. People from different cultural backgrounds can have different conceptions and experiences of mental illness. For example, clients may complain about nonspecific pain, frequent headaches, and stomachaches rather than emotional distress. In such cases, the nurse should sensitively investigate their history, as well as current circumstances, to establish whether such complaints may be an expression of mental health or other social issues. This approach can help minimize unnecessary referrals for investigations and medication prescribing. It can be helpful to consider dialect, culture, gender, and sexual orientation when selecting a language interpreter. It may also be beneficial to link clients with support organizations with expertise in supporting refugees and asylum seekers.
Providing TIC for people who have experienced violence or persecution—particularly torture—can be challenging. Refugees and asylum seekers are also at risk of exploitation, trafficking, and modern slavery. According to the British Medical Association, “recent estimates suggest that on average 44 percent of asylum seekers have experienced torture, although this can vary significantly by country” (BMA, 2023). This can often involve experiences of mental, physical, and sexual violence. They may be unable to discuss their health problems openly or fear examination. They may also have difficulty trusting people in positions of authority, including doctors. Experiences of torture and other violence can cause deep-rooted feelings of shame, humiliation, and guilt, and many clients may be reluctant to disclose to a relative stranger. Nurses should respond compassionately and sensitively and be aware that building a relationship of trust and support to facilitate disclosure can take some time. If clients are willing to talk about what happened to them, the situation described can be disturbing for the nurse and the client. This is a time when the nurse can maximize their use of the TIC steps presented earlier in the chapter.
Promoting Social Justice
As a term, “social justice” must consider four principles: access, human rights, participation, and equity (Soken-Huberty, 2023; WHO, 2022b):
- Access: Countries that have signed the 1951 Convention are obliged to protect refugees on their territory and treat them according to internationally recognized standards. Subsequently, protecting refugees is the primary responsibility of states.
- Human rights : Refugees have human rights, the inalienable rights to which a person is entitled merely for being human. Refugees must respect the laws and regulations of the United States. Refugees should receive at least the same rights and basic help as any other foreigner who is a legal resident, including freedom of thought and movement and freedom from torture and degrading treatment.
- Participation: Refugees bring productivity to host countries, where they are integrated across communities. They enrich those communities, helping to nurture understanding and appreciation for social diversity.
- Equity : To fulfill physical protection minimum standards, refugees need to be provided with adequate food, sanitation, hygienic products, and any nonfood items that are needed in a specific context or emergency.
Nurses have a professional and ethical responsibility to advocate for social justice (ANA, 2015). Refugees are one of the most vulnerable populations in the United States, and they interact with nurses at all levels of the health care system. As nurses become increasingly educated and skilled in cultural competence, they can make the transition to immigration less chaotic and subsequently enhance well-being and promote healthy lifestyles.
The Nurse’s Role in Addressing the Refugee Crisis
It is a human right to seek asylum from persecution or safety from war or disaster, and in doing so, people should not be subjected to cruel, inhumane, or degrading treatment or circumstances. Nurses need to foster a healthy and adaptive environment in which people can thrive despite personal, political, emotional, physical, or social adversity. Nursing care is indispensable for the easing of human distress and for the promotion of comfort and coping. Nurses are essential in advocating for policies that will enhance immigrants’ access to health care and mental health services and address barriers irrespective of their status as migrants, refugees, or asylum seekers (Desmyth et al., 2021). At the macro level, based on the New York Declaration for Refugees and Migrants , signed by the United Nations (2016b), it is the obligation of a state not to hinder refugees seeking to enter it, nor to return them forcibly to the country they have fled (the principle of nonrefoulement), which is grounded in the natural duty not to harm the innocent.
At the more micro level, nurses need to understand the legal and systemic difference between an individual seeking asylum for fear of persecution and someone who has been granted refugee status and offered humanitarian protection. While health care entitlements between these groups remain inconsistent, the principle of access to equitable health care as a fundamental human right must be upheld (Desmyth et al., 2021). The codes of ethics of the ANA and the International Council of Nurses (ICN) mandate that all nurses work to advocate for social justice (ANA, 2015; ICN, 2012). Thus, nurses are expected to apply these ethical principles in practice.
Nursing care and advocacy must be in the context of justice and equity, which requires ongoing awareness of and involvement with the resources in communities. Nurses can collaborate with organizations to acknowledge and dismantle racism and sexism and foster human rights. Instead of giving a “voice” to migrants and refugees, nurses provide opportunities for them to tell their own stories as well as to identify their own health needs and the best ways to address those needs (Commodore-Mensah et al., 2021).
A focal point for the Healthy People 2030 initiative is Social Cohesion . Social cohesion has significant ramifications for health. For example, one study examined the link between four measures of social capital (perceived fairness, perceived helpfulness, group membership, and trust), income inequality, and mortality. The authors found that all four measures of social capital were associated with mortality. They also found that the relationship between income inequality and mortality may be partially explained by reductions in social capital as income inequality increases. Collective efficacy, an aspect of social capital and social cohesion, is grounded on mutual trust and describes a community’s ability to create change and exercise informal social control (i.e., influence behavior through social norms). Collective efficacy is associated with better self-rated health, lower rates of neighborhood violence, and better access to health-enhancing resources like medical care, healthy food options, and places to exercise. Social institutions like religion and the family are common sources of social capital and social control as well as social networks and social support.