Author: Bryan P. White
Original Publication: 03/03/2019
The presence of refugee and migrant camps as the result of violent conflicts and economic distress is a global phenomenon that effects upwards of 21 million people globally (Esses et al., 2017) and presents numerous public health concerns. In order to understand the health impacts of individuals encountering refugee camp-type living conditions, I reviewed the literature and identified 10 recent articles published in the scientific literature. I identified a diverse array of published papers that represent camps from around the world and a broad range of health concerns including increased exposure to infectious diseases, reduced economic potential, and mental health concerns. In this review article, I identify and summarize the scenarios described in these articles and highlight the diverse array of public health concerns experienced by refugee/migrant populations globally.
The number of international migrants worldwide was 244 million as of 2015, with 3.8 million immigrating to one of the EU-28 Member States during 2014 (Pavli and Maltezou 2017). Globally, over 65 million people were displaced due to violent conflicts, most notably Syria, Afghanistan, and Somalia. Many of these migrants arrive to Southeastern Europe as migrants and refugees. Migrants and refugees traveling to Europe face a high risk of death simply from mode of travel, for example, with 3,700 migrants having drowned or went missing at sea during 2015. Furthermore, these displaced persons face the same suite of public health problems as other refugee populations, including increased risk of communicable disease, respiratory illness, mental health problems, resurgence of vaccine-preventable diseases, and other problems arising from lack of adequate healthcare. Lack of social status in the country they migrated to further exacerbates the problem since they cannot obtain employment. This general suite of problems affecting migrant/displaced persons highlights the need for the development of healthcare programmes targeted specifically for these at-risk populations.
In Europe, refugee movement represents a large portion of people displaced. Calais, a long-standing refugee camp located in northern France, is marked by the slow accumulation of refugees from other smaller, disbanded camps into a single larger camp (Dhesi et al., 2018). Currently governmental resources (French and British) are underutilized towards the health aspects of the occupants of the Calais camp which is leading to negative health outcomes for its occupants. Since refugee camps lack an international standard minimum of health requirements, they are typically prone to negative health outcomes, and the extreme density of the Calais camp makes it more so. Lack of access to sanitation resources leads to a prevalence of gastroenterological infections and other parasitic infections. This paper seeks to understand what public health policies could be implemented (like the distribution of handwashing facilities) that could have a broad, positive impact on health impacts in refugee camps. Since Calais is a longstanding camp, implementation of sanitation improvements would likely benefit the population, which highlights one of the most critical public health concerns facing refugees/migrants globally: sanitation.
According to Crea et al. (2015), understanding the actual differences and perceived differences in the quality of life between refugees placed in urban settings compared to those in camp-based settings in Sub-Saharan Africa has a significant impact on refugee well-being. Previous studies have shown that refugees placed in camps are at greater risk of poor health outcomes due to a combination of factors including poor hygiene, poor sanitation, lack of shelter, and lack of medical services to name a few. Since camp-based refugee settings lack access to basic medical and sanitation necessities, they are more prone to be exposed to environmental hazards like weather conditions, lack of clean water, and other environmental factors controlled in urban settings. Conversely, urban refugee centers are at higher risk for communicable diseases like tuberculosis or HIV due to higher population density. While both settings have factors that contribute towards negative health outcomes, in general this study found that refugees perceive urban settings as being better than camp-based settings. This study could likely be extrapolated into other areas beyond Sub-Saharan Africa, suggesting that globally the well-being of refugees/migrants living in camps are at high risk for experiencing negative health-outcomes.
A different population of refugees in western Sahara Africa (the Saharawi peoples) is experiencing a high rate of goiter, a disease due to excessive iodine intake (Barikmo et al., 2011). This paper sought to identify a potential source for this excessive iodine. They confirmed that the population of the Saharawi refugee camps did indeed excrete excessive iodine in their urine, meaning the source of goitre was from iodine. They also found two major sources of intake for the excessive iodine: locally produced milk and water. The levels of iodine found from local water sources far exceeded normal, safe contents meaning that consuming a recommended 2L per day of water would lead to over exposure of iodine. The high levels of iodine in locally produced milk were in some cases caused by direct exposure to high levels of iodine in water, but also due to a bioaccumulation effect of iodine in milk excretion, meaning that even moderate exposure of animals to iodine in water can lead to excessive exposure to humans that drink that milk. In order to purify the local water sources to safe levels of iodine, reverse osmosis would have to be used. Access to healthy water sources is another major health impact facing refugee/migrant populations globally.
Looking at a different part of the world (modern-day Jordan, Lebanon, Egypt and Syria), the historical Palestinian peoples are now largely considered refugees displaced from their traditional homes into permanent refugee cities. Documenting the history of public health concerns in these camps is an important report conducted by Al-Khatib et al. (2003). Initially, these camps were constructed from tents, but later international organizations facilitate the construction of permanent structures using bricks and asbestos. Construction continued on through the 1950’s and 1960’s, many times unregulated scenarios as populations expanded in these areas. While construction became regulated through the 1980’s and 1990’s, population density continued to increase resulting in overcrowding of living spaces. This led to very high rates of respiratory infections due to dampness, mold, other fungal exposures, environmental tobacco smoke, burning mosquito repellant, and many other potentially harmful exposure sources. This study sought to ascertain the current effects of housing crowing on respiratory health outcomes in the al-Ama’ri refugee camp (West Bank). Since population density and overcrowding are a major problem for the sizable population of Palestinian peoples, this would suggest that the persistence of refugee-like camps will present an ongoing public health problem.
The Democratic Republic of the Congo (DRC) has experienced many years of internal violent conflict that have led to a severe disruption of its social and health systems making its inhabitants highly vulnerable to both poverty and infectious disease (Charchuk et al., 2016). Due to its weakened infrastructure, the DRC faces one of the highest rates of malaria with 6 million known infections annually leading to over 40 thousand deaths (in 2013). Furthermore, the DRC has a very high internally displaced person (IDP) rate, which are similar to refugees but instead of originating from another country, originate within the country. IDPs, like refugees, face negative health outcomes due to their displaced status (lack of work) and habitation scenarios (camps). This study identifies a clear relationship between malaria infection rate and population displacement (IDPs) compared to non-displaced populations. Increased malaria rates in IDPs are likely due to increased abundance of standing water and lack of malaria prevention strategies like night shelter and protective bed nets. Malaria and other vector borne diseases represent another major health impact for refugee/migrant populations.
Another population affected by violent conflict, the Rohingyan people (a stateless ethnic group that historically resides from modern Myanmar) refugees fled to Bangladesh due to increased violent conflicts in their home territory (Chan et al., 2018). The surviving groups of refugees established camps in southern Bangladesh with the aid of the local military and hospitals but were given only minimal supplies and help. As additional refugees began to accumulate to the area, additional camps were founded, but resources remained stretched throughout the region. As populations grew from a continued influx of refugees and live births occurring in the camps, several major health problems arose. First, high population density leads to extremely low air quality, which in term increases risks of respiratory infections, measles, tuberculosis, as well as increased risks for fire and injury. Second, for children under the age of 5 (either born locally or migrated), the lack of vaccinations, or unknown vaccination status, exacerbates risk for water borne illness such as cholera. Third, lack of sanitation creates a major risk for oral-fecal borne disease such as diarrhea, typhoid, cholera, and hepatitis. The conditions faced by the Rohingyan people again reflect the common themes of improper sanitation requirements and the negative impacts of population density on human health.
Similar to the previous paper, Khan et al. (2019) assessed the conditions of refugee camps harboring around 700,000 Rohingyan people as of 2018. While the previous paper focused on infectious disease, this paper focuses on mental health of children. Other studies have suggested that children in refugee scenarios are more at risk of mental health and neurodevelopmental problems. One of the major findings of the study was that children’s mental health issues was strongly associated with being parentless. Identified mental health problems included emotional symptoms, peer problems, prosocial behavior (abnormal), conduct problems, and hyperactivity in order of prevalence. These findings suggest the need for interventions related to children’s mental health in refugee camps, which may be a underrepresented factor incorporated in public health interventions globally.
In South America, Venezuela has a high degree of displaced persons within its country leading to a very high expatriate rate as well as a high migrant population in and out of the country due to both economic collapse and violent conflict (Tuite et al., 2018). This creates a breeding ground for the spread of infectious disease within an already disrupted healthcare system, leading to a public health crisis. The health implications of a high migrant population along with lacking healthcare infrastructure include lack of vaccination programmes, which leads to high rates of vaccine-preventable diseases like measles and diphtheria. Venezuela also has an extremely high malaria infection rate (at least 319,000 cases in 2017) coupled with a lack of anti-malarial drugs and vector control efforts. Water shortages, HIV epidemics, and other vector-borne diseases are also of major concern. Prevention efforts should be focused on areas most likely to experience high levels of population movement. The conditions in Venezuela highlight the importance of developing public health interventions that target regions of high migration due to their propensity for experiencing high rates of infectious disease transmission.
Climate change has a broad range of implications for health impacts, many of those related to an interaction effect between displaced populations and the spread of infectious and vector-bone diseases (Desoky, 2017). Since climate change will change landscapes through many mechanisms (rising sea levels, desertification, and more), how and where the spread of infectious and vector-borne diseases will change is uncertain. People displaced from extreme weather events will typically be both more vulnerable to communicable diseases. Increased precipitation coupled with increased global temperatures might cause increased instances of malaria. Combined with increased migrant populations that are already more vulnerable to standing populations, climate change becomes a major public health risk. Understanding how climate change might differentially impact the most sensitive populations globally is an important consideration for public health agencies worldwide.
The negative health impacts of living in a migrant/refugee camp are broad and range from inadequate access to water, lack of basic sanitation principles, overpopulation, lack of mental health care, and increased risk of exposure to infectious disease. In this article, I identified 10 recent descriptions of the health conditions presented to those living in camps. Globally, the persistence of refugee/migrant populations represents a major health concern for the host countries and suggests a major research effort is needed to better understand how to implement public health interventions that both solve the immediate health crises and reduce the long-term need for these camps to begin with.
Al-Khatib, I. A., Ju'ba, A., Kamal, N., Hamed, N., Hmeidan, N., & Massad, S. (2003). Impact of housing conditions on the health of the people at al-Ama'ri refugee camp in the West Bank of Palestine. International Journal of Environmental Health Research, 13(4), 315-326.
Barikmo, I., Henjum, S., Dahl, L., Oshaug, A., & Torheim, L. E. (2011). Environmental implication of iodine in water, milk and other foods used in Saharawi refugees camps in Tindouf, Algeria. Journal of Food Composition and Analysis, 24(4-5), 637-641.
Chan, E. Y., Chiu, C. P., & Chan, G. K. (2018). Medical and health risks associated with communicable diseases of Rohingya refugees in Bangladesh 2017. International Journal of Infectious Diseases, 68, 39-43.
Charchuk, R., Paul, M. K. J., Claude, K. M., Houston, S., & Hawkes, M. T. (2016). Burden of malaria is higher among children in an internal displacement camp compared to a neighbouring village in the Democratic Republic of the Congo. Malaria Journal, 15(1), 431.
Crea, T. M., Calvo, R., & Loughry, M. (2015). Refugee health and wellbeing: differences between urban and camp-based environments in Sub-Saharan Africa. Journal of Refugee Studies, 28(3), 319-330.
Desoky, A. S. S. (2017). The Risks of Climate Change from Infectious Diseases. Open Access J Sci, 1(5), 00025.
Dhesi, S., Isakjee, A., & Davies, T. (2018). Public health in the Calais refugee camp: environment, health and exclusion. Critical Public Health, 28(2), 140-152.
Esses, V. M., Hamilton, L. K., & Gaucher, D. (2017). The global refugee crisis: Empirical evidence and policy implications for improving public attitudes and facilitating refugee resettlement. Social Issues and Policy Review, 11(1), 78-123.
Khan, N. Z., Shilpi, A. B., Sultana, R., Sarker, S., Razia, S., Roy, B., … & McConachie, H. (2019). Displaced Rohingya children at high risk for mental health problems: Findings from refugee camps within Bangladesh. Child Care, Health and Development, 45(1), 28-35.
Pavli, A., & Maltezou, H. (2017). Health problems of newly arrived migrants and refugees in Europe. Journal of Travel Medicine, 24(4).
Tuite, A. R., Thomas-Bachli, A., Acosta, H., Bhatia, D., Huber, C., Petrasek, K., … & Khan, K. (2018). Infectious disease implications of large-scale migration of Venezuelan nationals. Journal of Travel Medicine, 25(1), tay077.