Migration at the core of public health CAMPOSTRINI, Stefano · BARRAGÁN MONTES, Sara DEMBECH,...

EDITORIAL BOARD

BIFFL, Gudrun

CAMPOSTRINI, Stefano

CARBALLO, Manuel

COSTANZO, Gianfranco

DECLICH, Silvia

DENTE, Maria Grazia

GEORGE, Francisco

GUERRA, Ranieri

HANNICH, Hans-Joachim

KONRAD, Helga

KRASNIK, Allan

LINOS, Athena

MCKEE, Martin

MOSCA, Davide

NOORI, Teymur

OROSZ, Éva

PADILLA, Beatriz

PEREIRA MIGUEL, José

Manuel Domingos

REZZA, Gianni

SALMAN, Ramazan

SIEM, Harald

Coordinators

OSTLIN, Piroska

SEVERONI, Santino

SZILÁRD, István

WHO Regional Office

for Europe (Venice)

BARRAGÁN MONTES, Sara

DEMBECH, Matteo

University of Pécs

BARÁTH, Árpád

CSÉBFALVI, György

EMŐDY, Levente

GOLESORKHI, Kia

KATZ, Zoltán

MAREK, Erika

EDITORIAL

Migration at the core of public health

Dr Santino Severoni, Coordinator

Ms Sara Barragan Montes, Technical Officer

Mrs Juliane Koenig, Intern

Public Health and Migration, WHO Regional Office for Europe

(WHO/Europe)

The current global context and health challenges associated with

refugees and migrants represent an unprecedented situation. The

increase in people forced to flee their home countries is the

highest in 70 years. According to a new release from the United

Nations High Commissioner For Refugees (UNHCR), a total of 65.3

million refugees and displaced people were counted worldwide at

the end of 2015 (1).

Global responsibility is needed to successfully address and improve

the situation of refugees and migrants with respect to the

fundamental right of health for all. Comprehensive health care

cannot be seen as an outcome of one sector alone, as sustainable

and equitable improvements in health are the product of effective

health in all policies approaches. Subsequently, successful

implementation of joint policies on migration and health will

require close collaboration between all participating stakeholders.

At the same time, this should also be seen and valued as an

opportunity to act in a concerted manner to address an issue that

transcends borders and sectors.

This increasing interest in and call for international collaboration

was widely discussed at the 69th World Health Assembly in May

2016 and will be one of the main topics for discussion at the

upcoming WHO Regional Committee for Europe in September

2016.

69th World Health Assembly, 23–28 May 2016 in Geneva,

Switzerland

This year’s World Health Assembly included two sessions focused

specifically on the issue of migration and health: a plenary

discussion and a technical briefing. The recent progress report,

entitled Promoting the health of migrants (2) was discussed at the

plenary session, focusing attention on the immense global

dimensions of migration.

About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the

WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the

Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website.

© World Health Organization 2016 1

69th World Health Assembly technical briefing on migration

and health, 27 May 2016

(Mr Steven Corliss, Director, Division of Programme Support and Management, UNHCR; Dr Santino Severoni, Public Health and Migration

Coordinator, WHO; Dr Zsuzsanna Jakab, Regional Director for Europe, WHO; Ambassador William Lacy Swing

Director-General, IOM; Dr Edward Kelley, Director Department of Service Delivery Safety, WHO; Dr Margaret Chan, Director-General, WHO)

Not only did multiple representatives from countries all over

the world give an update on the critical situation, but

representatives of the European Region also reported on

refugee and migrant health becoming a topic requiring

growing attention. Representatives from Greece and Italy

called for tailored policies and highlighted the need to

prevent discrimination and violence to ensure access to

health care for these vulnerable groups. The representative of

Greece pointed out that with an adequate action plan,

countries could move from seeing migration as troublesome

to accepting it as an opportunity to strengthen public health

services throughout the country. The work carried out by

WHO/Europe’s Migration and Health Programme was

acknowledged, and the need highlighted for collaborative

assistance and coordinated international efforts.

The technical briefing on migration and health at the 69th

World Health Assembly was opened by WHO Director-

General Dr Margaret Chan, who highlighted the importance

of advancing the road towards the 2030 Agenda for

Sustainable Development moto “no one should be left

behind”. With this in mind, refugees and migrants should be

wholly recognized as vulnerable groups deserving the full

protection and realization of their human rights. In particular,

forced migration caused by conflict, violence or

circumstances in war-torn countries is higher than ever. Dr

Chan called for more action by pointing out four urgent needs

for ensuring migrants’ access to full health services: not only

are migrant-sensitive health services required, along with

better data on the health needs of migrants, but in particular

policies, legal frameworks, international dialogue and

networks are also essential.

Dr Zsuzsanna Jakab, WHO Regional Director for Europe

presented the extensive work on migration and health

conducted by WHO/Europe since 2012, as well as the ongoing

activities in other WHO regions related to the health of

refugees and migrants. Her co-speakers continued by

underlining the urgent need to address collaboratively and

improve the health care situation of refugees and migrants.

Expressly agreeing that there is “no public health without

migrant health”, they specified that to achieve universal

health coverage, migrant health must be kept on the political

agenda. This crisis of humanity calls for an urgent coordinated

response. With such integrated approaches, more

sustainable, cost-effective programmes can be implemented,

including more comprehensive and equitable health

coverage.

Public Health Aspects of Migration in Europe (PHAME)

WHO/Europe has been working for many years in the field of

vulnerabilities and health, focusing on migrants and other

minority groups. Thanks to the financial support of the

Ministry of Health of Italy, the WHO PHAME project was

established in 2012 to scale-up technical assistance and policy

support tailored to each country. Since then WHO/Europe has

put a great deal of effort into developing mutual policies for

all 53 Member States of the WHO European Region. In the

spirit of the recently adopted 2030 Agenda for Sustainable

Development and the European policy framework for health

and well-being, Health 2020, these policies focus on priority

actions to address the public health and health system

challenges related to migration. At the High-level Meeting on

Refugee and Migrant Health held in Rome in November 2015,

around 50 representatives of European, Eastern

Mediterranean and African countries, along with senior staff

from United Nations agencies and international organizations

agreed on collaborative action to address the health needs of

refugees and migrants in the European Region. This outcome

document, Stepping up action on refugee and migrant health

(3), along with the above-mentioned policy frameworks,

serve now as a foundation for the development of a new

Strategy and Action Plan on Refugee and Migrant Health in

the WHO European Region, which will be accompanied by a

resolution and submitted for discussion and approval at the

Regional Committee in September 2016.





The 69th World Health Assembly demonstrated how migration

and health has become one of the key priorities for ministries of

health today, as well as for WHO as a whole. This commitment to

responding in a spirit of solidarity and mutual assistance –

addressing a global health issue that transcends countries and

regions – shows a strong foundation for a common framework of

collaborative action. Countries within and beyond the European

Region are willing and committed to build bridges and to

collaborate on migration and health. The approval of the

forthcoming Strategy and Action Plan on Refugee and Migrant

Health in the WHO European Region, with its accompanying

resolution, is thereby an essential step towards universal health

coverage; not only for refugees and migrants, but for the whole

population, setting the basis for new collaborative frameworks in

the field of migration and health.





References

1) Edwards A. Global forced displacement hits record high [website]. Geneva: United Nations High Commissioner for Refugees; 2016

(http://www.unhcr.org/news/latest/2016/6/5763b65a4/global-forced-displacement-hits-record-high.html).

2) Promoting the health of migrants. Report by the Secretariat. Provisional agenda item 14.7. In: Sixty-ninth World Health Assembly, Geneva, 8 April 2016. Geneva:

World Health Organization; 2016 (document A69/27) (http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_27-en.pdf).

3) Stepping up action on refugee and migrant health. Towards a WHO European framework for collaborative action. Outcome document of the high-level meeting on

refugee and migrant health, 23–24 November 2015, Rome, Italy. Copenhagen: WHO Regional Office for Europe; 2015

(http://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/publications/2016/stepping-up-action-on-refugee-and-migrant-health).

OVERVIEW

Lessons learned from the Assisting and REeintegrating CHIld VICtims of

trafficking (ARECHIVIC) project1

Istvan Szilard,* Zoltan Katz,* Erika Marek,* Mila Mancheva,** Andrey Nonchev**2

Introduction

In recognition of the importance of adequate support and

protection of child victims of trafficking (VoT) for remedying

abuse, an EU co-financed project has been successfully

completed by the ARECHIVIC consortium, coordinated by the

Center for the Study of Demography (Bulgaria). This overview

describes and draws in large part on the Center for the Study of

Democracy report Assisting and reintegrating child victims oftrafficking: improving policy and practice in the EU MemberStates (1).

The consortium member institutions originate from six EU

Member States. These institutions are:

1. Ludwig Boltzmann Institute of Human Rights (Austria)

2. Center for the Study of Democracy (Bulgaria)

3. University of Pécs (Hungary)

4. CENSIS Foundation (Italy)

5. People in Need (Slovakia)

6. Crime Victim Compensation and Support Authority

(Sweden).

Three countries are prevailingly viewed as destinations (Austria,

Italy and Sweden), while the others are sources (Bulgaria,

Hungary and Slovakia) of trafficked children. It is worth noting

that Hungary could be viewed as a source, transit and

destination country.

1 The project is co-financed by the European Union (EU) Fundamental Rights & Citizenship programme.

2 *University of Pécs Medical School, Hungary; **Center for the Study of Demography, Bulgaria.





Building on previous research in this field, the comparative study

aimed to provide a more in-depth analysis of the efforts made to

assist child VoT in their physical, psychological and social

recovery. It consisted of three analytical levels, each grounded in

a particular methodology.

The three levels of analysis included:

• assessment of the policy, legal and institutional framework

for assistance and (re-)integration of child VoT in source and

destination countries;

• evaluation of programmes for child victim support and

(re-)integration in source and destination countries;

• identification of best practices for support and

(re-)integration of child VoT in six EU countries, in line with

the principles of fundamental children’s rights and of

promoting the best interests of victims.

From among the very comprehensive achievements and results

of the study,3 this overview focuses only on the health-related

aspects of assisting unaccompanied minors and child VoTs.

Psychological and medical care4

Emergency/short-term services

Emergency or short-term services for child VoT are offered in

Austria, Bulgaria, Hungary, Italy and Slovakia. The social welfare

system in Sweden makes no distinction between short-term and

long-term care.

In Austria, health and psychological services, if needed, are

guaranteed to unaccompanied minor foreigners and child VoT

who either fall under the basic welfare support system or qualify

for emergency treatment. The forms of provision of these

services vary in the different regions of the country. For example,

in the Drehscheibe, a specialized socio-pedagogical

institution/shelter administered by the Vienna Youth Welfare

Authority, both medical and social care are provided by external

operators.

Emergency services to child VoT in Bulgaria are provided through

a network of crisis centres, which offer a standard package of

services set out in the “Methodology for Offering the Service of

Crisis Centre”. Medical care, education and psychological

support are mandatory elements of the service structure of the

country’s Crisis Centres. Medical care is usually provided by

means of contracts with general practitioners who visit the

centre 2–3 times per week. Medical screening upon the arrival of

child VoT in Crisis Centres is a standard procedure.

Emergency support measures in Italy are provided for three

months, with the possibility of extending for a further three

months, and include (among others) medical services and

psychological counselling. The implementation of these services

is not regulated by guidelines or standard operating

methodologies and is highly divergent. For this reason it is not

possible to evaluate them as a whole.

Unaccompanied minors in Hungary are entitled to a

Humanitarian Card, which allows free-of-charge medical care

until the child’s legal status is established. Psychological care for

adult and child VoT in Hungary is not adequately provided

through the state health care system, which suffers from a

chronic lack of psychiatrists. The psychological needs of VoT in

the country are met mostly by the Cordelia Foundation, which

offers rehabilitation and psychological services in six centres

throughout the country.

In Sweden, the responsibility for children who are victims of

crime lies primarily with Sweden’s local social welfare

authorities. In accordance with the country’s Social Services Act,

these social welfare authorities should provide child victims of

crime with psychological, social, financial and practical support.

However, one specific programme for support and rehabilitation

of child VoT developed by the Country Administrative Board of

Stockholm foresees the implementation of both short- and long-

term measures. Short-term measures are those aiming to create

security and stability and to provide initial support to the child.

Psychological care could be provided in different settings: at

hospitals, through NGOs and in private therapy centres, with

specific programmes focusing on dealing with trauma. Medical

care for child VoT is provided by non-specialist medical care

institutions, and no specific cooperation exists with medical

institutions with specially trained staff.

In Slovakia it is recommended that a consultation with a

psychologist is carried out immediately after placement of a

child VoT into substitute care. As such, regular visits are

conducted in children’s homes by a psychologist from the

Catholic humanitarian aid organization Caritas and the Slovak

Humanitarian Council.

Good practices

The project collected details of good practices in the

participation countries (described below).

In Hungary, since 2010 the State Children Centre of the

Department of Foreign Children in Fót is responsible for

hosting and assisting all foreign unaccompanied children who

ask for asylum, including VoT. The main strengths and benefits

of this practice are listed here.

3 It is worth noting that since the completion of the study in 2013, some changes in the service provision may have been implemented.

4 Psychological and health assistance are paramount in the rehabilitation of VoTs. See the Further reading section (specifically, Szilard & Barath, 2015) for more detailed analysis.





• It results in the country ranking high in terms of

sustainability, with relevant legislation and a secure state

budget.

• Placement of foreign unaccompanied children and VoT is

well organized and immediate.

• Guardianship services are ensured.

• The approach can be said to be child participatory and

gender sensitive.

• The Centre’s services allow for comprehensive

(re-)integration (including access to education, language

courses and psychosocial care).

• Medical care (including psychiatric treatment) is accessible

free of charge, from arrival.

• Since 2012, a cooperation agreement between the State

Children Centre of the Department of Foreign Children in

Fót and the Cordelia Foundation also provides for long-

term psychosocial therapy.5

The activities of the above-mentioned Cordelia Foundation

should also be acknowledged. The Foundation was

established in 1996 as a nongovernmental institution and has

developed a reputation for providing psychosocial assistance

to children and adults, with particular emphasis on migrants

and asylum-seekers.

The main strengths of the Foundation’s practice include:

• strong expertise in trauma work – the Foundation is the

principal specialist public benefit institution in Hungary;

• provision of a comprehensive and long-term psychosocial

approach to treatment and

(re-)integration by qualified staff, ranging from child and

adult psychiatrists to clinical psychologists, social workers

and qualified interpreters;

• access to services for clients, free of charge.

Lessons learned

The main conclusions that can be drawn from the project are

listed here.

• Professional and well-organized health and psychological

care is inevitably important in providing assistance to child

VoTs.

• The regulations and systems in place for assisting

unaccompanied children and child VoTs vary widely

among EU Member States. EU-level harmonization and

coordination would be highly recommended.

• Follow-up research and/or (eventually) the establishment

of a monitoring system would be an important action

going forward.

5 More information can be found at the Cordelia Foundation website (http://www.cordelia.hu/index.php/en/).

Reference

1) Nonchev A, Mancheva M. Assisting and reintegrating child victims of trafficking: improving policy and practice in the EU Member States. Sofia: Center for the Study

of Democracy; 2013 (http://www.csd.bg/artShow.php?id=16445).

Further reading

Developing indicators for the protection, respect and promotion of the rights of the child in the European Union. Summary report. Vienna: European Union Agency for

Fundamental Rights; 2009

(http://fra.europa.eu/sites/default/files/fra_uploads/358-RightsofChild_summary-report_en.pdf).

Guidelines for the development and implementation of a comprehensive anti-trafficking response. Vienna: International Centre for Migration Policy Development; 2006

(http://www.icmpd.org/Guidelines-for-the-Development-and-Implementation-of-a-Comprehensive-National-Anti-Trafficking-Respo.1851.0.html).

Guidelines on the protection of child victims of trafficking. UNICEF technical notes. New York (NY): United Nations Children’s Fund; 2006

(http://www.unicef.org/ceecis/0610-Unicef_Victims_Guidelines_en.pdf).

Szilard I, Barath A. Trafficked persons and mental health. In: Lindert J, Levav I, editors. Violence and mental health – its manifold faces. Dordrecht: Springer

Science+Business Media; 2015:243–266.

The IOM handbook on direct assistance for victims of trafficking. Geneva: International Organization for Migration; 2007

(http://publications.iom.int/system/files/pdf/iom_handbook_assistance.pdf).

Toolkit to combat trafficking in persons. Global programme against trafficking in human beings. Vienna: United Nations Office on Drugs and Crime; 2008

(https://www.unodc.org/documents/human-trafficking/Toolkit-files/07-89375_Ebook[1].pdf).





The careless reception of UAMs at destination: impact and consequences on

health

Stefano Volpicelli, specialist sociologist in health and social vulnerability

Background

The presence of youth travelling alone, also known as

unaccompanied minors (UAMs) or unaccompanied asylum-

seeker minors (UASMs) have become a common pattern in

today’s global mixed migration flows.1 Pictured as passive players

with no role in the decision-making process, ruled by parents,

relatives or peers, they are considered more as vulnerable

victims than active actors in their lives.

Such supposed vulnerability offers policy-makers good

arguments to draw attention only to the dramatic and

emergency elements of the migration situation, such as

exploitation, abuse and trafficking. Therefore, the impact of the

migratory experience on the health status2 of these young

people is mainly investigated in relation to the traumatic events

suffered while travelling, but the living conditions once they

reach their destination are rarely considered as a source of

illness.

From 2010 to 2014 I designed and coordinated a research

project3 aimed at measuring the propensity to migration of

youth from Egypt, Morocco and Tunisia, to understand the

impact of migration on UAMs from those countries then living in

Italy and France. Although the research did not intend to

investigate the health conditions, its findings confirm that young

migrants suffer severe health consequences due to the harsh

conditions of their trip, consequences worsened by the bumpy

process of reception and varying assistance at destination.4

Migration as a project full of expectations

Regardless of the reasons or motivation for doing so, when a

person leaves their place of residence to move somewhere else,

(s)he travels with two metaphorical rucksacks: the first one is

filled with ideas, projects, objectives and expectations, and it

balances positively the second one, which is packed with

sadness, longing, worries and concerns. The analysis of the data

gathered in the three countries shows that in shaping the

individual’s decision to leave, the drivers related to material

achievements – work, money, clothing and/or possessions –

prove to have only a relatively slight influence. On the contrary,

subjective and relational factors5 represent major forces in the

decision to leave. The research, therefore, shows a more

complex and nuanced portrait, far from the simplistic image of

the migrant (of any age) as a money-maker. Indeed, it confirms

that, today, youth from those countries have developed a sense

of global citizenship that often collides with the poor (economic

and social) atmosphere of where they live. In this context,

migration is considered at best as a legitimate means to achieve

a so-called first class social status (5), while at worst it is the only

possibility to exist.

Obstacles on the road to full emancipation

After leaving their countries with such high aspirations and

expectations, the majority of UAMs encounter traumatic

experiences before arriving at their destination.6 What they find

at their destination is a reception and a care system that is

fragmented at best, or unable to intercept and deal with their

real needs. The assistance – provided rather randomly, owing to

a lack of tailored expertise7 – turns into a source of further stress

and trauma.8

1 The presence of UAMs in Europe has been increasing since the beginning of the year 2000, reaching 88 300 cases in the year 2015 (1).

2 In this article the term health is used according to its wider meaning, based on the WHO definition of health as a state of complete physical, mental and social well-being.

3 The research, entitled “Propension et éxperience migratoire des mineurs marocains, tunisiens et egyptiens” was carried out in the framework of the Solidarity with Children of

Maghreb and Mashreq (SALEMM) project, funded by the European Commission (2). More detailed information on the research framework (hypothesis, objectives, methodology,

sampling and statistical treatment) and outcomes are available from the SALEMM website (www.salemm.org) in French and Italian.

4 Data from the research are in line with those of other studies: a 2012 study examined 222 males from Afghanistan aged 13–18 years who were seeking asylum in the United

Kingdom. The study found that one third were likely to have post-traumatic stress disorder (PTSD) (3). Another study of unaccompanied refugee minors in Belgium followed 103

children for 18 months after their arrival. It found that their generally high levels of anxiety, depression and PTSD did not dissipate over that time period (4).

5 The subjective factors relate to life satisfaction, trust in one’s own abilities, introjected values; while the relational relate to representations of the world, and attachment to the

family and to the group of peers.

6 In the research conducted, only 12 out of the 131 minors interviewed in Italy and France travelled in safe conditions. The remainder made their journey by makeshift means,

boats or trucks. For the majority of them, the trip was long and stressful.

7 See IOM’s Unaccompanied children on the move (6).

8 According to the data, half of the sample of children had to cope with harsh situations, both in and outside the reception centers.





What is most striking is that upon arrival, almost all minors

endured experiences of street life, sleeping in the street, eating

junk food, and living by whatever means necessary until they

were arrested by the police and placed in a community. Ten of

them described being subject to violence from the police, or

exploited in petty crimes and low-paid jobs.9

A total of 40 % of the sample declared that they were unsatisfied

with their migratory experience as a result of the disillusion

suffered upon arrival, the sense of abandonment and solitude

experienced at their destination, and the perceived sense of

being marginalized and socially excluded.

Conclusions

Despite the small size of the sample, the investigation raises the

concern that too many UAMs – and not only those who fall off

the radar of the social institutions after their arrival in Europe10 –

suffer additional traumatic experiences at their destination,

linked to the fragmented and often inadequate assistance

response provided. The following impacts result from this lack of

assistance.

• At clinical level, the negative emotions related to the clash

between expectations and reality can develop into chronic

diseases (in varying forms).11

• At social level, the harsh conditions, leading to suffering and

a prolonged state of anxiety and depression risk removing

from the young migrants the possibility to develop a sense

of belonging to their country of destination, pushing them

instead into a process of self-marginalization and

consolidating the feeling of being unwelcome. This process

of social exclusion can have tragic consequences, in terms of

self-harm or, even worse, thorough violent expression

aimed at demonstrating their “existence”.12

All considered, there is a strong need for European migration

policies to reduce the impact of daily stressors resulting from

UAMs’ living conditions. Greater attention should be paid to the

impact of reception services on youth health, through proper

screening in order to adapt psychosocial and therapeutic care to

the UAMs’ needs.

References

1) Almost 90 000 unaccompanied minors among asylum seekers registered in the EU in 2015. Eurostat press release 87/2016, 2 May 2016

(http://ec.europa.eu/eurostat/documents/2995521/7244677/3-02052016-AP-EN.pdf/).

2) Volpicelli S. Rapport de la recherche. Propension et éxperience migratoire des mineurs marocains, tunisiens et egyptiens. Milan: Milanese International

Cooperation Provincial Fund (FPMCI) Solidarité Avec Les Enfants du Maghreb et Mashreq (SALEEM) project; 2015

(http://salemm.org/sites/default/files/SALEMM_Ricerca_fra18_03_15.pdf).

3) Bronstein I, Montgomery P, Dobrowolski S. PTSD in asylum-seeking male adolescents from Afghanistan. J Trauma Stress 2012;25(5):555–557

(http://www.ncbi.nlm.nih.gov/pubmed/23070950).

4) Vervliet M, Lammertyn J, Broekaert E, Derluyn I. Longitudinal follow-up of the mental health of unaccompanied refugee minors. Eur Child Adolesc Phsychiatry

2014;23(5)337–346.

5) Ferguson J. Global shadows: Africa in the neoliberal world order. Durham (NC): Duke University Press; 2006.

6) Unaccompanied children on the move. Geneva: International Organization for Migration; 2011

(https://publications.iom.int/books/unaccompanied-children-move).

7) Volpicelli S. Who’s afraid of … migration? A new European narrative of migration. IAI working papers 15/32; 2015

(http://www.iai.it/en/pubblicazioni/whos-afraid-migration).

8) Fouad Allam K. Il jihadista della porta accanto. L’Isis a casa nostra [The Jihadist next door. The ISIS in our home, 2nd edition]. Milan: Piemme; 2014 [in Italian]

(http://www.edizpiemme.it/libri/il-jihadista-della-porta-accanto-2).

9) Orioles M. E dei figli, che ne facciamo? L’integrazione delle seconde generazioni di immigrati [And what we are supposed to do with the children? The integration of

the second generation of immigrant]. Rome: Aracne; 2015 [in Italian].

9 These 10 were those who agreed to speak, while many others did not want to talk about what happened when they were on the streets.

10 Around 10 000 UAMs are currently believed to have disappeared, raising fears about their exploitation.

11 This link is also confirmed by the Center for Disease Control and Prevention (CDC), the leading national public health institute of the United States. Its data collection leads to the

(conservative) analysis that 85% of all diseases have an emotional determinant. In the long run, those diseases can lead to further psychological disorders.

12 See for example Volpicelli (7); Fouad Allam (8), and Orioles (9).

NEWS

Press release. UNICEF reports on the dangers facing unaccompanied adolescent refugees and migrants fleeing

to Europe, 14 June 2016

http://www.unicef.org/media/media_91552.html





Syrian refugees: a mental health crisis, 24 May 2016

http://blogs.worldbank.org/arabvoices/syrian-refugees-mental-health-crisis

EVENTS

Eurochild Conference 2016 “Children's rights matter:

why Europe needs to invest in children”

5–7 July 2016, Brussels, Belgium

http://www.eurochild.org/events/eurochild-

conference-2016/

5th European Conference on Mental Health

14–16 September 2016, Prague, Czech Republic

http://www.ecmh.eu/

Migrants United Nations General Assembly High-

level Meeting on Refugees and Migrant Health

19 September 2016, New York (NY), United States

http://www.un.org/pga/70/2016/03/23/united-

nations-summit-on-refugees-and-migrants/

International Dialogue on Migration 2016: Follow-up

and Review of Migration in the SDGs (II)

11–12 October 2016, Geneva, Switzerland

http://sd.iisd.org/events/international-dialogue-on-

migration-2016-follow-up-and-review-of-migration-in-

the-sdgs-ii/

World Health Summit

9–11 October 2016, Berlin, Germany

http://www.worldhealthsummit.org/

9th European Public Health Conference “All for

Health – Health for All”

9–12 November 2016, Vienna, Austria

https://ephconference.eu/

Experts sound alarm over mental health toll borne by migrants and refugees, 8 June 2016

http://www.theguardian.com/global-development/2016/jun/08/experts-sound-alarm-mental-health-toll-

migrants-refugees-depression-anxiety-psychosis

The truth about migration: how it will reshape our world, 6 April 2016

https://www.newscientist.com/article/mg23030680-700-the-truth-about-migration-how-it-will-reshape-our-

world/





Throughout history, refugees have contributed to the

creation of cities and states, to literature, arts and music, but

they have often been perceived as a source of risk, and

villainized as a group of “mentally disordered” people. The

psychological resilience and mental health of refugees coming

into Europe is underresearched. The term mental health is

used here in accordance with the WHO definition, which

stresses the positive dimensions of psychological and social

well-being, rather than focusing on the absence of mental

disorder (1). What can we learn from refugees who risk their

lives to find living opportunities, and how can we provide

adequate mental health support to those in need?

Mental health can give refugees the strength to start a new

life; unrecognized mental disorders can be detrimental, not

only to a person’s health and well-being but also to that of

their families and children. Mental disorders can limit a

refugee’s capacity to integrate into a host country. While the

screening and treatment of infectious diseases for refugees

have been well established for decades, the identification and

appropriate cultural and gender-sensitive interventions for

mental health problems in refugees continue to lag behind

(2,3).

Refugees leave their home countries for a number of reasons,

including experiencing and witnessing war, violence, torture

or the death of family members, or because of a lack of basic

human conditions necessary for survival, such as food and

shelter. During their potentially long and hazardous journeys,

refugees are often exposed to life-threatening conditions, as

well as cruel or abusive treatment. Furthermore, difficulties in

the process of resettlement, such as living in overcrowded

refugee camps or detention centres, ensuing poverty or lack

of opportunities, as well as not feeling welcome and/or

feeling discriminated against in host communities may

increase the risk of refugees suffering from a variety of

mental health issues (4).

The common mental health diagnoses associated with

refugee populations include post-traumatic stress disorder

(PTSD), depression, generalized anxiety and panic attacks,

adjustment disorder, substance abuse and somatization. The

incidence and prevalence of mental health disorders varies

within different populations and with their experiences

before, during and after their flight from the country of origin.

Different studies have shown rates of PTSD and major

depression in settled refugees to range from 10% to 40% and

5% to 15%, respectively. In a systematic review of 826

records, with 72 populations meeting the inclusion criteria

and 70 studies included in a final evaluation, it was found that

the combined prevalence rate for depression was 44% (95%

confidence interval (CI): 27–62) among refugees, while for

anxiety the combined prevalence estimate was 40% (95% CI:

23–49) (5).

While research has focused on mental disorders, the scope

and extent of mental health issues among refugees is still

underinvestigated. The picture remains challenging, as

prevalence of mental conditions varies between available

studies; this variation may result from the differing

experiences of refugees before, during and after their

journeys, or it could relate to the specific contexts and

situations of the host country. Furthermore, variations in

results are associated with variations in study characteristics

and, in particular, with sampling methods, assessment

instruments and the lack of validated cut-off scores in most

refugee populations. There are many challenges in the

identification of mental disorders and resources among

refugees. Often, language and cultural barriers and biases

(whether of the refugee or of the health and social care

provider) can hinder identification of mental health disorders

among refugees. The often limited access to health care also

constitutes a risk factor for the development of somatic and

mental disorders.

OPINION

This article represents the opinion of the author(s) and publications and does not necessarily represent the views of WHO, the

University of Pécs or the Editorial Board of this newsletter.

Mental health of refugees

Prof. Dr Jutta Lindert, University of Emden, Germany





Some of this difficulty may result from missed cross-cultural

symptoms (such as “thinking too much” (6)), or missed

resources (such as social capital), but equally determinant is

the construct and perception of a refugee as having mental

disorders, conflated with a host country’s fears about national

security, exploitation and erosion of resources in times of

economic crisis. The possibility of being connected and having

new opportunities is critical for refugees. Being connected

means continuing to foster networks with relatives and

friends from a refugee’s home country, as well as starting

connections with new individuals in order to access

educational and professional opportunities in the host

country. The lack of opportunities is less associated with

mental disorder but rather with conditions within host

countries, such as a lack of understanding and willingness to

offer opportunities to refugees in the first place.

There are many challenges involved in providing effective

mental health interventions for refugees, such as barriers to

language, addressing specific cultural idioms of distress, legal

barriers to mental health care as well as cultural expectations

of care. It might even be that the care disclosure paradigm,

on which Western psychological interventions are based,

might actually be harmful for refugee population groups (7).Therefore, the strategy identified as most important for

reducing the risk of mental disorders in refugees is the

provision of general support: to meet basic needs, ensure

safety and provide opportunities. Such opportunities may

include offering the possibility for refugee families to stay

together, and the ability to access opportunities in their host

country in order to begin anew. Offering opportunities and

support – such as access to the national education system – is

especially important for children and adolescents (8).

Based on current knowledge, several recommendations for

good practice have been made. They address the issues of

access to and organization of services for the delivery of

mental health care (9), and the integration of services (10) as

well as arguing for a public health approach to strengthen

mental health and reduce mental disorders.

Limited representative data are currently available on refugee

mental health. Longitudinal studies with suitable comparison

groups are greatly needed in research. Equally, evaluation of

refugee interventions is needed, as well as the identification

of resources which would allow refugees to successfully settle

and start anew in their host countries, notwithstanding

pre-, during, and post-flight experiences of suffering,

witnessing violence or being tortured and persecuted.

Providing mental health interventions and care to help repair

the mental health damage of a refugee’s flight experience is

only one part of a host country’s responsibilities; the

prevention of further harm by actively combating

discrimination and working to change perceptions of refugees

are as just as important.

References

1) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July

1946 by the representatives of 61 States (and entered into force on 7 April 1948). Official Records of the World Health Organization 2:100

(http://www.who.int/about/definition/en/print.html).

2) Llosa AE, Ghantous Z, Souza R, Forgione F, Bastin P, Jones A, et al. Mental disorders, disability and treatment gap in a protracted refugee setting. Br J Psychiatry

2014;204:208–213.

3) Murray K, Davidson G, Schweitzer R. Review of refugee mental health interventions following resettlement: best practices and recommendations. Am J

Orthopsychiatry 2010, 80(4):576–85

(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3727171/).

4) Carswell K, Blackburn P, Barker C. The relationship between trauma, post-migration problems and the psychological well-being of refugees and asylum seekers. Int J

Soc Psychiatry 2011;57:1007


5) Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brähler E. Depression and anxiety in labor migrants and refugees--a systematic review and meta-analysis. Soc Sci Med.

2009;69:246–257.

6) Hinton DE, Barlow DH, Reis R, de Jong J. A transcultural model of the centrality of "thinking a lot" in psychopathologies across the globe and the process of

localization: a Cambodian refugee example. Cult Med Psychiatry 2016;Apr 16[Epub ahead of print]


7) Rousseau C, Measham T, Nadeau L (2013). Addressing trauma in collaborative mental health care for refugee children. Clin Child Psychol Psychiatry 2013;18:121–

136.

8) Fazel M, Karunakara U, Newnham EA. Detention, denial, and death: migration hazards for refugee children. Lancet Glob Health 2014;2:e313–314.

9) Lindert J, Brähler E, Wittig U, Mielck A, Priebe S. [Depression, anxiety and posttraumatic stress disorders in labor migrants, asylum seekers and refugees. A

systematic overview]. Psychother Psychosom Med Psychol. 2008;58(3–4):109–122


10) Mollica RF, Brook RT, Ekblad S, McDonald L. The new H5 model of refugee trauma and recovery. In Lindert J, Levav I, editors. Violence and mental health. Its

manifold faces. Dordrecht: Springer Science+Business Media; 2015:341–380.

Contact us

Public Health and Migration Division of Policy

and Governance for Health and Well-being

European Office for Investment for Health and Development

WHO Regional Office for Europe

Castello 3252/3253

I-30122 Venice, Italy

Email: [email protected]

University of Pécs Medical School

Chair of Migration Health

Szigeti St. 12

H-7624 Pécs, Hungary

Email: [email protected]




© World Health Organization 2016

All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning

the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for

which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a

similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without

warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for

damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization.

11

RECOMMENDED READING

Danger every step of the way. A harrowing journey to Europe for refugee and migrant children. New York (NY):

United Nations Children’s Fund; 2016

http://www.unicef.org.uk/Documents/Campaigns-

documents/UNICEF%20CHILD%20ALERT%20Refugee%20Journey.pdf

Myers AL, Christenson JC. Approach to immunization for the traveling child. Infect Dis Clin North Am. 2015

Dec. 29(4):745–757

http://www.ncbi.nlm.nih.gov/pubmed/26610424

Ferrara P, Corsello G, Sbordone A, Nigri L, Caporale O, Ehrich J et al. The “invisible children”: uncertain future

of unaccompanied minor migrants in Europe. J Pediatr. 2016;169:332–333

http://www.ncbi.nlm.nih.gov/pubmed/26810103

Metzner F, Reher C, Kindler H, Pawils S (2016). Psychotherapeutic treatment of accompanied and

unaccompanied minor refugees and asylum seekers with trauma-related disorders in Germany.

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016;59(5):642–651

http://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds[]=citjournalarticle_518

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