Archive for the 'refugee resettlement' Category

Refugees, 2013: Changing faces, changing places, changing policies

This week’s Economist has a fine summary of how refugees have grown in number and diversity, and the international community’s response to these changes. Among things to note is the continuing trend observed a few years ago in a JAMA commentary (and critiqued by a skeptic or two… oops) of urban resettlement, which UNHCR now says it prefers to people resettling in refugee camps. UNHCR is also more explicit about its policy encouraging local political integration and even economic development as solutions in long-term refugee crises. These efforts are mirrored by changes in policies of countries who receive the most refugees (overwhelmingly in the developing world).

David Apollo Kazungu, Uganda’s Commissioner for Refugees, says it no longer makes sense to treat refugees as a humanitarian issue. “Those who stay for years throw up developmental problems for us, such as how to find enough land, water and jobs for everyone,” he argues. Uganda has already tried to improve the lot for the nearly 200,000 refugees it hosts by placing them in settlements rather than camps, and by giving them land to farm.

Within this discussion is the acknowledgement that forced migration and voluntary (or economic) migration are not entirely separate phenomena. Read the entire article here.

Looking for graduate school applicants for research in forced migration, trauma and stress at Fordham University

Fall is graduate school application time, as many programs have application deadlines in October, November and December. I have recently moved to Fordham University’s Department of Psychology, and will be looking for graduate student applicants to the Clinical Psychology Division for the 2013 cohort. If you read this blog you know my experience and general research interests, so you know what kind of student researchers I am looking for. Current research projects include comparing the social networks of forced and voluntary immigrants and the health and mental health implications of network differences, measuring trauma and stress in different culturally-defined subgroups, and community-based participatory research with immigrant populations in general. If those are topics that interest you (and you want to get a PhD in Clinical Psychology), follow the links on the Clinical Psychology website and apply.

Deadline for 2013 applicants is Wednesday, December 5, 2012.

If you are not sure you want to commit to a PhD, but know that you are generally interested in psychology, program evaluation and related skills, please visit Fordham University’s MS in Applied Psychological Methods page. Fordham’s APM program is a relatively new course of study that draws heavily on it’s well-respected Psychometrics and Applied Developmental Psychology divisions within the Department of Psychology. Admissions are “rolling,” meaning that you can apply at any time and start the following semester. Students can be full- or part-time.

Defining forced migration: Report from the Northwestern University Conference on Human Rights

The Northwestern University Conference on Human Rights (NUCHR) is in its 8th year, and this year’s topic is Human Rights in Transit: Issues of Forced Migration. NUCHR is probably the best student-organized conference on human rights issues, addressing a given topic over a three days of lectures, study sections, and speeches. NUCHR involves college students from around the US through a lengthy application process which attracts hundreds. Successful applicants become NUCHR “Delegates,” with assigned working groups and specific areas in which they become experts. After a day and half here, I can tell you that this is really one top-notch group of thinkers and doers, at any level of the academic hierarchy.

Today’s panels were “Defining Forced Migration” and “The Displaced: The Psychological and Cultural Effects of Forced Migration” (which is why yours truly is here — I was a panelist in the latter). Defining Forced Migration featured legal scholars Deborah Anker of Harvard Law School Immigration and Refugee Clinical Program, Howard Adelman from the Griffith University in Brisbane (Australia), Susan Gzesh of the Human Rights Program at University of Chicago, and Maureen Lynch of Refugees International in Washington, DC. It’s always instructive for refugee service providers (and people who think a lot about providing refugees services, like me) to hear legal perspectives on our field. Anker made the point that refugee law is first and foremost “palliative, not political” — meaning that it is primarily designed to relieve tension instead of solve the difficult situations that cause displacement — and so it’s place in the “human rights regime” (which is political) is tenuous. I have often thought that refugee healthcare — also primarily palliative — is in a similar bind; while healing may have political consequences in that it may make people able to more easily demand that their rights be respected, it is not the case that healing is in and of itself a political act (not usually anyways). When people ask me about “health and human rights” I usually tell them that what I do is health, rarely human rights.

Howard Adelman gave a comprehensive history of refugee policy, and said something I had been completely ignorant of: the first refugee policies in international law were Wilsonian (as in Woodrow Wilson) efforts to bolster the idea of nation states by transferring minority ethnic groups out of one state to others. In other words, their goal was to make homogenous states and these “ethnically pure” states would somehow be less likely to have internal conflicts. It wasn’t until after World War II (during which ethnic purity had some rather nasty consequences) that refugee law began to shift to protection of individuals who would be persecuted if they returned to their home countries. This was primarily designed with Cold War refugees in mind. Adelman also pointed out that the “right of return” — a value at the intersection of human rights and refugee rights — has never been successfully implemented by anything other than force (e.g., Tutsis in Rwanda); most peacefully negotiated returns have involved only a few, mostly older refugee returnees and many who came home, sold their stuff, and went back to their (richer) host countries (e.g., Bosnian refugees). Adelman’s history lesson leaves us with some sobering contemplation about where we go from here — although exactly what we should do differently isn’t quite clear.

Stressors, more stressors, and blaming the victim in wartime

Those people who dedicate their lives to addressing stressors among displaced populations are frequently faced with an uncomfortable truth: people under a lot of stress sometimes create more problems for themselves. This is a well-observed phenomenon across populations, and is generally known as “stress generation.” As regards trauma work, there is good research to show that the best predictor of future trauma is past trauma. For those of you not well-versed in stress generation, see Constance Hammen’s reflection on her career researching stress generation among depressed individuals in the Journal of Clinical Psychology.

The uncomfortable part of all this is that it can move quickly into “blaming the victim” (particularly as it pertains to trauma). If a combat veteran presents with PTSD and marital conflict due to the irritability and anger that is a part of the PTSD diagnosis, it can be very difficult not to get really frustrated with that vet’s anger and sink into “it’s your own damn fault” despite our initial sympathy. An automobile accident survivor has a higher likelihood of getting into another automobile accident than someone who hasn’t been in an automobile accident because the survivors tend to be extra cautious following their first accident, drive more slowly at the wrong times, get distracted by other drivers, etc.; if these things cause an accident, who is responsible?

When it comes to refugees, blaming the victim may result in less critical aid from the international community and stigma upon resettlement. And yet it’s clear to anyone who’s worked in refugee camps that a stressed population is a difficult population is difficult to work with. Indeed, one of the impetuses behind bringing psychosocial interventions into humanitarian aid is the danger that stressed refugees can pose to aid workers. There are numerous reports of refugees striking out against aid workers for small irregularities in aid distribution or changes in policies. (I should add that their are also striking reports of other refugees coming to the aid of aid workers.)

So how do we reconcile stress generation with our discomfort? Well, first by reminding ourselves that the first order of health provision is not morality. (I’ve harped on that before, and you probably don’t need to read it again here.)

Second, by looking further into stress generation research so we know what we’re talking about. In this literature, folks like Hammen make the distinction between “dependent, interpersonal” stressors and “independent, fateful” stressors. It turns out that research with people with mental health diagnoses have (on average) more stress-dependent events than people without mental health diagnoses, but have the same number of independent events. Dependent events are almost uniformly interpersonal in nature — and therefore plausibly related to how one would act towards others if really stressed. Independent events may be interpersonal, but their core feature is their fateful nature — they are not affected by how someone is acting.

How does the dependent-independent dichotomy map on to the typology of conflict-related stressors proposed in the last entry in this blog? Well, it’s pretty clear that mental health problems aren’t to blame for people being attacked or cause them to end up in unstable resettlement contexts — this is the “direct war exposure potentially traumatic events (PTEs)” category. For “collateral” and “other PTEs” (which, as I think through them may not be as distinguishable as they first seemed), the picture is less clear, and that some of these stressors are related to “being stressed” means that education campaigns surrounding the affects of stress (at the very least) are important. “Social ecological stressors” are clearly set off by displacement, but the breakdown of community institutions may be exacerbated by interpersonal problems. This is why the “social” in “psychosocial intervention” has always struck me as the more important of the two traditions. “Daily hassles” are likewise split between those problems that are outside of the control of the individual (e.g., a military checkpoint) and those that are exacerbated (unemotional reactions to hearing of abuse of loved ones). So perhaps the dependent-independent dichotomy is a second axis that runs through the typology proposed a few days ago. (Again, comments encouraged here.)

Important to remember through all of this is that all of these stressors are precipitated by an initial event — the event that was the cause of displacement. It would be difficult to argue that displacement events were dependent stressors. And yet many subsequent stressors, be they mild or traumatic, are dependent to some degree. In order to address these, humanitarian aid workers must remember the latter, and the former; they are equally important.

Article addendum: Stressors during wartime

The April 2010 issue of the American Journal of Orthopsychiatry includes an article comparing the effects of war-related trauma on mental health to effects of the “current stressors” one finds in refugee camps. I’m the first author on this article, and so I’m going to take the privileges afforded by that role and be somewhat critical of the work here.

The article is based around the idea that there are lots of things that happen during wartime that cause emotional and cognitive distress in addition to armed conflict. In order to decide what to do about distress in displacement camps, one should consider these non-conflict stressors. In the paper, we measured war-related traumas (or “potentially traumatic events” to be more precise) separate from other “camp stressors” and examined which was more highly associated with the psychological problems of posttraumatic stress disorder, depression, and two local idioms of distress (local ways of discussing emotional problems). We found that war trauma and camp stressors among Darfur refugees were both related to all four psychological problems, and in several cases the number of camp stressors was actually more strongly associated with these than the number of war traumas. We went on to find that camp stressors partially mediated the effects of war trauma on most psychological problems. We concluded that humanitarian aid agencies interested in addressing general distress in camps thus had empirical support for interventions that target everyday camp stressors, in addition to popular war-related and trauma-focused interventions (which are already empirically-supported for displaced persons with posttraumatic distress).

Since the manuscript was accepted (fall of 2009) I have had a number of opportunities to think about the variability within this category of “current stressors.” Critical to this was the opportunity to co-author an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid with my friend and sometimes collaborator Ken Miller, who is really the pioneer in this work (look up his stuff on Afghanistan and Sri Lanka for examples). Something has always bothered me about the category “current stressors” and a common criticism is that we are throwing a lot of different types of stressors — with different effects — into the same conceptual bag. So, I’d like to propose — really by way of proposing a starting point, not answering the problem outright — a typology of stressors that are critical to consider in studying the psychological consequences of armed conflict and displacement.

1. Direct war exposure potentially traumatic events (PTEs): Direct (both personally experienced and witnessed) exposure to the violence and destruction of war. Examples include (but are in no way limited to) direct attacks by military (or paramilitary) personnel, being pursued by these forces, bombing, and exposure to mines.

2. Collateral PTEs: Direct exposure to trauma collateral to war (i.e., coming about because of war) but not comprising an act of war itself. This may include abuse by non-military persons during flight (e.g., criminals or fellow refugees), attacks by locals in the displacement context, abuse by peacekeeping forces, and motor vehicle accidents occurring during flight.

3. Other PTEs: Non-war-related traumatic events that increase during wartime. It has been noted that all forms of violence increase during wartime (e.g., see the work of James Garbarino for particularly articulate illustrations), whether because of stress on the perpetrators of these events or degraded safety of settings which allow these events to occur more frequently. Examples include domestic violence, child abuse, and attacks by dangerous animals (e.g., poisonous snakes are evidently a big problem in some refugee camps in Sri Lanka).

4. Social ecological stressors: War-related degradation of social institutions (both formal and informal). Examples are destruction of schools and subsequent lack of educational opportunity, diminished health care, loss of social support networks, religious institutions, war-induced poverty, and famine. It may be difficult to distinguish some of these from preexisting conditions (e.g., the difference between war-induced and preexisting poverty may be minimal in some cases).

5. Daily hassles: Daily hassles are those seemingly minor problems of daily life that either come to exist or increase in intensity in wartime. These have shown to be strongly related to mental health problems in non-war contexts, even moreso than stressful major life events. These may include checkpoints along a commute, regular questioning by military or police, mild forms of humiliation (e.g., degradation by authorities, bribes), needing multiple forms of documentation in order to complete simple tasks, long wait times in order to get basic resources (e.g., food distribution at refugee camps), and hearing complaints about such daily hassles from loved ones. All involve some persistent inconvenience or stressor that is not physically abusive or threatening. Some daily hassles may at times come close to collateral trauma (e.g., regular questioning that involves strip searches).

It is important to note that for individuals exposed to the different types of stressors delineated above, differences may seem phenomenologically trivial. Stressors related to direct attacks, harassment and abuse during flight, and loss of social networks may be part and parcel of a single, undelineated narrative of war. Moreover, for many these categories may not be readily distinguishable from non-war-related stressors. War-induced poverty may be seen as an extension of preexisting poverty, increases in domestic abuse may be experienced as an extension of pre-war abusive relationships, and bribes paid to police during wartime may have the same effect as bribes during peacetime. In order to study the effect of conflict, researchers should conduct work that estimates the change in prevalence, incidence, and effect on outcomes of these phenomena over time (i.e., pre-conflict to conflict).

Let me reiterate that these are only a first pass at types of stressors, and I welcome all comments. Next: The sticky problem of stress generation among displaced populations.

37 year-old refugee crisis comes to an end

Where do refugees go after the crises that made them refugees leaves the headlines? The options are: go home, get resettled to a wealthier country, stay in the camps.

The UN estimates that at the end of 2008 (the last year there are reliable numbers for at the moment) there were 15.2 million refugees in the world (a refugee here is a person who has fled across a border because of political violence). Eighty percent of these refugees, or about 12.2 million, lived in camps or urban areas in neighboring countries in the developing world (e.g., the 1.8 million Afghans in Pakistan).

Some refugees go home. How many? In 2008, 600,000 refugees went home; 600,000 / 15.2 million = 4%. This was the lowest number since 2004, suggesting that going home is less and less an option.

What about all the refugees resettled in wealthy Western nations? In 2008, 121,000 were proposed for resettlement to wealthier nations (US, Canada, and Western Europe, primarily), or 0.8% of all refugees at the time.  Only 67,000 of these were actually resettled, about 0.4%.

So, most refugees remain in camps and foreign cities for very long periods of time as refugees. Surely there must be some other plan. Well, recently UNHCR has been proposing a policy of “local integration.” Local integration means what it sounds like  — making refugees part of the local economy and society of the region in which they live, with full citizenship rights and privileges, and no more refugee aid. The involves getting local governments to accept that refugees they have played host to for years are there to stay, and getting the refugees themselves to accept that they cannot receive aid forever. This long-term solution is usually pretty long-term. In Chad, the UNHCR started encouraging local integration for refugees from the Central African Republic who had been there for 1o years.

One of the oldest refugee populations are Burundians in Tanzania. Burundi is now infamous for ethnic conflict in 1994 (similar to neighboring Rwanda’s), but many Burundians in Tanzania are there because they fled from massacres in 1972. In other words, these Burundians have been sitting in camps for 37 years. This week, Refugees International reported that last month Tanzania gave citizenship to 162,000 of these Burundians. This is a welcome and generous move by Tanzania, a country that has been host to several large refugee populations — the price of being a peaceful place in a dangerous neighborhood.

(162,000: That’s 1% fewer refugees, for those of you counting.)

Richer refugees living in cities? A review of refugee trends presented in the Lancet

The Lancet’s special issue on Violent Conflict and Health (featured in the last three posts in this blog) includes required reading for refugee professionals examining trends in health-care needs among conflict-affected populations. The article, “Health-care needs of people affected by conflict: Future trend and changing frameworks,” is a collaborative effort between researchers at the UN High Commissioner for Refugees, the London School of Hygiene and Tropical Medicine, and the International Rescue Commission.

Recent trends include an increase in internally-displaced persons and a decrease in refugees — essentially due to an increase in intrastate conflicts. The concept of refugees fleeing across borders to escape wars between armies is old hat. Much more likely now is the armed conflict that happens within regions of countries, leading primarily to internal displacement. The best example of this is in a nation not often thought of in the refugee cannon. Currently, this country in home to the largest displaced population in the world… Give up? Colombia.

Two trends cited by the paper are worth thinking about a little bit: (1) the urbanization of refugees and (2) higher baseline development index of refugees’ countries of origin.

The urbanization of refugees refers to those people who flee their country and settle in cities rather than in refugee camps. You can think of Somalis in Nairobi (Kenya) and  Zimbabweans in Johannesburg (South Africa). Here’s a chart from the article showing the trend in the growth of urban refugees, 1996-2008. The aqua bar at the bottom is the number of refugees in camps, the next bar (is that khaki?) is the urban population, and the olive bar is the number in rural areas.

Where Refugees Live

Note the jump in the middle bar between 2005 and 2006 on to 2007. What major refugee crisis was coming to head these years? Well, the second largest refugee population in the world (1.9 million last I checked) was from Iraq, and many many many of those are in Damascus, Syria, and Amman, Jordan. So, the urbanization of refugees is certainly a trend in terms of numbers, but this chart doesn’t really tell us much beyond the fact that the Iraq War resulted in a large urban refugee population in neighboring countries. As Iraqis return home (as many have been doing for a year or so now) we shall see whether the urbanization trend is as strong as this article contends.

My guess is that urbanization of refugees is increasing, but that if you removed Iraqi refugees from these data, urbanization would be increasing at a lot slower rate than it appears here (perhaps at the rate urbanization is increasing in general). In any case increasing urbanization of refugees means that aid groups need to shift their strategies for needs assessment and service delivery; a group of refugees that is living dispersed throughout a city is much harder to find and help than a group living enclosed within the well-defined confines of a camp.

Contrast this with the trend examining the increasing baseline development index of refugee “sending countries” (i.e., the socioeconomic status of places where refugees flee has been increasing over time). Here the authors used the “human development index,” or HDI, presented in the chart below. The blue bar indicates refugees from “low human development” countries, the khaki from “medium and high development” countries.

HDI of Refugee Sending Countries

Here too we should think about how Iraq fits into this trend, as Iraq was a relatively well-developed country until recently. Note the general annual decrease of the blue bars from 1993 to 2008; here it looks like there was a trend before the emergence of the Iraqi refugee crisis, and so these data seem to present a more reliable trend than urbanization.

Note here that the HDI is a measure of countries, not people. This matters becasue it’s often the poorest who become refugees. For instance, Sudan has a moderate HDI (lots of oil, decent roads in the north), so the destitute farming refugees from Darfur or the rural cattle herders from the South would be evidence of this trend. It’s not the case that refugees are getting richer, only that the nations they flee from are richer. Indeed, there may be evidence in there somewhere for the hypothesis that an increasing income gap between richer and poorer is an important predictor in modern refugee-producing conflicts.


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