The Biology of Forced Displacement

“Seeking asylum is not illegal under international law and people have a right to be treated humanely and with dignity.”  – UNHCR

“We crossed the Mekong to get to Thailand at night, so no one would see us. We had always lived in the mountains (of northern Laos), so we did not know how to swim. When we came to the river, we used anything to help us float – bamboo, bicycle tubes. But at night, it is easy to get lost. Someone in our group said: ‘Remember, if you get lost when you’re going down the river (with the current), don’t panic. Thailand is on your right.’ ”

 

 

Every refugee has a story. The one above was told to me by a Hmong man I met in French Guiana in 2001. I went to learn about the experiences of the people there and how they had adjusted to being resettled half a world away, from Southeast Asia to a French ‘overseas department’ in Amazonia. They were actually doing quite well at the time, living as independent farmers who had been given land by the government years earlier.

Hmong men in French Guiana going hunting by bike.

They also retained a good degree of cultural continuity. While most are fluent in French, the majority of the 2,000+ Hmong in the country lived in rural, semi-isolated, ethnically homogenous villages. This gave them a buffer of sorts, allowing them to acculturate on their own terms. As they often put it, they were “free to be their own boss,” free to be Hmong, and most said they were happy with life in French Guiana. This combination of traits – economically self-sufficient, culturally distinct, mostly content, living in a rural overseas department – is not the typical refugee story. In fact, because of that relative uniqueness, the French Guiana Hmong have drawn attention from media outlets such as the BBC and the NY Times.

Of course, the life of a refugee does not begin after crossing a border or resettlement. I was also interested in their lives before French Guiana, and how they had gotten there, and whether the war years had affected their physical growth and health. Some people had lived in France for a few years, while others came directly from refugee camps in Thailand.

However, nearly all of the adults I had interviewed – in French Guiana as well as their Hmong and Lao counterparts in the US – were born in Laos during the Second Indochina War. History shows that the war was very hard on civilians, with many people being killed or injured. Others were displaced by the conflict, some several times, forcing people to make long arduous journeys on foot for up to hundreds of miles. One 37 year-old Hmong man revealed that he was displaced six times by the war, all before age 15. He was able to name each place he was forced to leave, and I estimated that these various journeys totaled at least 170 miles, as the crow flies.

For the sample overall, the more times a person was displaced – most of which occurred during childhood or adolescence when they were still growing – the shorter they tended to be as adults (Clarkin 2012). This was an imperfect correlation, as not all displacement events are equivalent (such as the duration or difficulty of the journey, age at which displacement occurred, level of security in place of refuge, etc.). However, it makes sense that children growing in an environment disrupted by war would not grow as well as they would in a more stable place. In a real sense, the experiences of war had become embodied in Hmong and Lao children, remaining there until adulthood. Similar patterns probably occur in most wars.    

Height, by the number of times Hmong and Lao adults were displaced during the war in Laos (from Clarkin 2012).

 

Why Displacement is Often Harmful

To uproot a single life is no small thing. To uproot thousands, or even millions, can be devastating. By now, it can be easy to lose track (and feel overwhelmed by) the staggering numbers of displaced people around the world.

Up-to-date statistics can be hard to find, but at their respective peaks, various recent conflicts have displaced: 9 million Syrians (as of 2013), 4.1 million people from the DRC, 3.5 million Afghans, 520,000 Palestinians in Gaza, 280,000 Ukrainians, 900,000 people from the Central African Republic, 1.5 million South Sudanese, 130,000 Malians, more than one million Somalis, over one million Burmese, 500,000 Pakistanis who fled their homes in North Waziristan,  4 million Iraqis as of 2007 (and 1 million newly displaced), and 3.5 million on Mindanao in the Philippines (from violence, not Typhoon Haiyan). [Note: this is not a complete list, and the numbers may be out of date. I am happy to be corrected.]

Rwandans crossing into Ngara, Tanzania, April 1994. Source: UNHCR.

Asylum seekers from Africa traveling by boat on the Mediterranean, June 7, 2014. (Source: Massimo Sestini—Polaris).

Sudeten Germans make their way to the railway station in Liberec, in former Czechoslovakia, to be transferred to Germany, July 1946. After the end of the war, 12-14 million ethnic Germans were forcibly expelled from other European countries back to Germany, in one of the larger forced displacements in history. Perhaps 500,000 to 2 million died during the expulsion. Source: http://www.theatlantic.com/infocus/2011/10/world-war-ii-after-the-war/100180/#img13

Syrian refugees crossed into Iraq at the Peshkhabour border point in August. (Source – WSJ)

Shoes of Sudanese refugee children age 10 and younger (credit: Shannon Jensen). Source: http://www.shannon-jensen.com/

Iraqis fleeing by car outside the city of Arbil, the capital of the autonomous Kurdish region. June 10, 2014. Source: Der Spiegel.

An ethnic Albanian woman feeds her baby as she and another 2,000 refugees flee Kosovo on March 30, 1999. Source: NATO.

Displaced Hmong from Laos, walking to a refugee camp in Thailand. Source: Roger Warner, 1998.

Kurdish refugees travel by truck, Turkey, 1991. Source: wikipedia.

Central Americans headed north by train (“El bestia”), hoping to make it to the United States. Source: NPR. John Moore/Getty Images.

Still, numbers rarely do justice to actual lived experiences. All displaced people are unique, but what they have in common is that forced displacement is invariably disruptive to normal life. In one sense, refugees are the lucky ones because they are the survivors. But the search for sanctuary from conflict often comes at a severe cost, and there is no place like home. Forced displacement – whether it be among asylum seekers, refugees who cross an international border, or internally displaced persons (IDPs) – can be harmful to health for many reasons.

1. Little or no time to prepare. As involuntary migrants, refugees are often forced to flee without enough time to prepare for a difficult journey. As one elderly widow who fled from Ukraine said, “We ran for our lives and did not think about the future. We had no time to prepare for flight.”

2. Lost resources. The loss of property, capital, family, and social networks further exacerbates the ability of displaced persons to acquire food and other resources, particularly for children separated from their parents.

3. Lack of access to humanitarian aid. For IDPs still near a conflict zone, access to international relief efforts is precarious due to safety concerns which preclude humanitarian aid from reaching them. At present, roughly 50,000 members of the Yazidi religious minority in Iraq are trapped on Mount Sinjar, with minimal food and water after fleeing the Islamic State. One eyewitness said that “Many of these people will die if not evacuated ASAP.”

4. Broken crop cycles. For people from subsistence economies, agricultural cycles broken by war means that it could take months to grow new crops to fruition. In April, UNICEF warned that fighting in South Sudan could affect the planting season, and that the likely missing harvest could mean that “we will see child malnutrition on a scale never before experienced here.” Those warnings now appear prescient.

5. Resettlement areas are unfertile or less productive. Upon reaching safety, displaced persons often end up in areas that are less economically unproductive, or even desolate, compared with their former homes. For example, 87% of villagers evacuated from Quang Tri Province to a resettlement area near Cam Lo during the Vietnam War said their situation was worse than it was in the war zone (Turse 2013, p. 67).

6. Malnutrition. In many instances, displaced children face high rates of malnutrition. An estimated 21% of children displaced by conflict near Zamboanga City in the Philippines were malnourished, while 40% of children from the Central African Republic who fled to Cameroon were. For reference, humanitarian organizations consider malnutrition rates of 10-14.9% to be ‘serious,’ while more than 15% is considered ‘critical’ (cedat). Displaced mothers who themselves face nutritional stress may be unable to provide milk for their infants, or even give birth to low birth weight newborns. One woman from CAR who made a three-month trek to get to Chad told UNHCR that: “I gave birth to my daughter in the bush, in the middle of the forest. I had nothing to eat and so I had no more milk.” [Note: a photoessay of the state of children in Cameroon can be found here].

7. Mental health. The psychological stress from displacement and a sense of loss, as well as witnessing acts of violence, can take a toll (Reed et al 2012). As one Iraqi man said: “When we left Telafar, we felt like we left our homeland. Any person who gets used to a place or lives in a place for more than 20 years, they wish to die than leave their home…This feeling of being a refugee is very difficult, more difficult than illness or even death.”

8. Sexual violence. Refugees are often vulnerable, if not defenseless, and prone to sexual violence (Morgos et al 2007).

9. Infection. Refugees may be placed in crowded, unsanitary conditions that may facilitate the spread of diarrheal and respiratory disease (Yip and Sharp 1993).
10. Viewed as burdens. International refugees or asylum seekers are often seen as burdens by host nations. In developing countries, competition between locals and newly arrived displaced people can create tensions. Even in high income countries, such as Australia, there has been resistance to people seeking asylum. In the U.S., a recent influx of people, particularly children, from Central America (El Salvador, Guatemala, and Honduras) has created tensions. Some of this has revolved around whether the children are legitimate asylum seekers. A UNHCR study found that 58% of the children interviewed were fleeing extreme violence, qualifying them for asylum. To further support that case, the number of asylum seekers fleeing to other stable Latin American countries, such as Mexico, Panama, Nicaragua, Costa Rica and Belize had increased 432%. In other words, the increase of people entering the United States is not unique and does not seem to be merely a matter of economic opportunism, but a sign of desperation.

 

Zaatari camp (Jordan) for Syrian refugees. Source: wiki commons.

 Long-Term Effects of Forced Displacement

It would be misleading to say that the effects of forced displacement are consistent across the board. Sometimes it is the least bad option available, so circumstances certainly matter. In one study of children in Baghdad, those who left home because of violence were not more likely to be malnourished, but those who lived in an insecure area, or who had a family member killed in the last five years, were (Ghazi et al 2013). On the other hand, internally displaced children in Afghanistan and Myanmar were significantly more likely to be malnourished than their non-displaced counterparts or those who became international refugees and were able to find humanitarian aid and more secure living conditions (Mashal et al 2008; Mullany et al 2007).  

In addition to its possible impacts on physical growth, forced displacement may have long-term impacts on health in other ways, though more research is needed. Finnish children who were evacuated to foster homes abroad during WW2 showed higher rates of cardiovascular disease and type 2 diabetes as adults 60 years later, pointing to the role of traumatic separation (Alastalo et al 2009). Another study from WW2 found that elderly Germans who had been displaced had higher levels of anxiety and lower levels of resilience and life satisfaction (Kuwert et al 2009).

Therefore, at least in some cases, forced displacement can have severe, lasting effects. Displacement is not just a temporary inconvenience; rather, it has the potential to adversely affect health for decades.

 

 References

Alastalo H, Raikkonen K, Pesonen AK, Osmond C, Barker DJ, et al. 2009. Cardiovascular health of Finnish war evacuees 60 years later. Annals of Medicine  41(1):66-72. Link

Clarkin PF. 2012. War, forced displacement and growth in Laotian adults. Annals of Human Biology 39(1): 36-45. Link 

Ghazi HF, Mustafa J, Aljunid S, Isa Z, Abdalqader MA. 2013. Malnutrition among 3 to 5 years old children in Baghdad city, Iraq: a cross-sectional study. J Health Popul Nutr. 31(3):350-5. Link

Kuwert P, Brähler E, Glaesmer H, Freyberger HJ, Decker O. 2009. Impact of forced displacement during World War II on the present-day mental health of the elderly: a population-based study. Int Psychogeriatr. 21(4):748-53. Link

Mashal T, Takano T, Nakamura K, Kizuki M, Hemat S, Watanabe M, Seino K. 2008. Factors associated with the health and nutritional status of children under 5 years of age in Afghanistan: family behaviour related to women and past experience of war-related hardships. BMC Public Health 8:301. Link

Morgos D, Worden JW, Gupta L. 2007. Psychosocial effects of war experiences among displaced children in southern Darfur. Omega (Westport) 2007; 56: 229–53. Link

Mullany LC, Richards AK, Lee CI, Suwanvanichkij V, Maung C, Mahn M, Beyrer C, Lee TJ. 2007. Population-based survey methods to quantify associations between human rights violations and health outcomes among internally displaced persons in eastern Burma. J Epidemiol Community Health 61:908-14.

Reed RV, Fazel M, Jones L, Panter-Brick C, Stein A. 2012. Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors. Lancet 379: 250-265. Link

Turse N. 2013. Kill Anything That Moves: The Real American War in Vietnam. Picador. Link

Yip R, Sharp TW. 1993. Acute malnutrition and high childhood mortality related to diarrhea: lessons from the 1991 Kurdish refugee crisis. JAMA 270:587–590.