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For our parents, Ate, Betty, Gillian, and Kevin whose love and support was a constant in our lives.
Foreword
The rapid movement of large populations is intrinsic to humanity, usually as a result of climate change, famine, earthquake, political or ideological conflict, religious persecution, and war. Societies receiving such populations—now called asylum seekers—may be profoundly affected, sometimes positively through moral, demographic, genetic, economic, and cultural enrichment. Places that lose such populations tend to be diminished. Only some of these groups of people are refugees under international law.
Although in official parlance, at least in Europe, a refugee is an asylum seeker who has been granted leave to stay, the word is highly descriptive of the entire group of people who seek asylum. It captures the sense of pursuit, fleeing, and the perils of the journey much better than the idea of seeking peace and calm portrayed by the phrase ‘asylum seeker’. Setting aside the nuances of these phrases, the challenges to migrants and to the societies they come to join are immense. Recipient populations and their services have a complex tasks of caring for them and ensuring a favourable outcome for all. These tasks are to be accomplished in the context of the myriad of international, regional, national, and even sub-national laws, policies, strategic documents, and service delivery plans. Health and health care are amongst the top priorities in terms of the immediate required actions. Public health is central in ensuring the required actions are taken.
Historically, societies muddled through, with the indomitable human spirit of the migrants and the recipient populations usually overcoming adversity, through a partnership of community organizations (including faith groups), non-governmental organizations, legally required services, and the business/ employment sector. Muddling through doesn’t, however, always work out in the face of social prejudices, language problems, poverty, isolation, detention, unemployment, poor health, and barriers to services.
Over the last 30–40 years there has been a growing realization that laws and even goodwill are not enough. This realization has accelerated in our era of globalization and conflicts with mass movement of people—for example in the Middle East, Myanmar, and the Balkans, to name but a few. We must do better on many fronts. This book shows us how to do so in health and health care in and for asylum seekers and refugee across their journey from exodus, arrival, and settlement.
Sadly, this is a book of and for our times. In awaiting, and dreaming about, a better world, we need to be armed with ethics, legal stances, principles, exemplars, knowledge of best practice, case studies, and resolve. Thank you to the authors and especially the editors for providing us with all this, and much more.
Raj Bhopal CBE, DSE (hon)
Bruce and John Usher Professor of Public Health
Honorary Consultant in Public Health
Edinburgh Migration, Ethnicity and Health Research Group
Centre for Population Health Sciences
Usher Institute of Population Health Sciences and Informatics
The University of Edinburgh 4 April 2018
Contents
Abbreviations xi
Contributors xiii
Part 1 Concepts and contexts
1 Forced migration, globalization, and global public health 3
Pascale Allotey and Daniel D. Reidpath
2 Humanitarianism, refugees, human rights, and health 19
Susan Kneebone
3 Social exclusion, othering, and refugee health policy 39
Daniel D. Reidpath and Pascale Allotey
4 Health in humanitarian crises 54
Mike Toole
Part 2 Health concerns
5 Populations in transition and post-settlement: an infectious diseases and travel medicine perspective 87
Kudzai Kanhutu, Karin Leder, and Beverley Ann Biggs
6 Mental health of refugees 106
Peter Ventevogel, Xavier Pereira, Sharuna Verghis, and Derrick Silove
Part 3 Impacts of displacement
7 Urban refugees: the hidden population 131
Sharuna Verghis and Susheela Balasundram
8 Addressing the rights of women in conflict and humanitarian settings 153
Rajat Khosla, Sandra Krause, and Mihoko Tanabe
9 The health challenges facing children on the move 169
Susan Bissell and Jacqueline Bhabha
10 The health impacts of displacement due to conflict on adolescents 181
Anushka Ataullahjan, Michelle F. Gaffey, Paul B. Spiegel, and Zulfiqar A. Bhutta
Part 4
Case studies in research and ethics
11 Methodological and ethical challenges in research with forcibly displaced populations 209
Veena Pillai, Alison Mosier-Mills, and Kaveh Khoshnood
12 Conducting health research with resettled refugees in Australia: field sites, ethics, and methods 230
Celia McMichael and Caitlin Nunn
13 The politics of immigrant and refugee health in the United States 245
Michael Grodin, Sondra Crosby, and George Annas
14 Dual loyalty, medical ethics, and health care in offshore asylum-seeker detention 260
Deborah Zion
Part 5 Conclusion
15 Controlling compassion: the media, refugees, and asylum seekers 275
Pascale Allotey, Peter Mares, and Daniel D. Reidpath
Index 295
Abbreviations
ACLU American Civil Liberties Union
BCRHHR Boston Center for Refugee Health and Human Rights
BMC Boston Medical Center
BUSPH Boston University School of Public Health
CAR Central African Republic
CBT cognitive behavioural therapies
CESCR Committee on Economic, Social and Cultural Rights
CFR case fatality rates
CMR crude mortality rates
COMPASS creating opportunities through mentorship, parental involvement, and safe spaces
CRC Convention on the Rights of the Child
DACA Deferred Action for Childhood Arrivals
DRC Democratic Republic of the Congo
ECDC European Centre for Disease Prevention and Control
ECOSOC Economic and Social Council
EU European Union
FMEG Forensic Medical Evaluation Group
GBV gender-based violence
GLP Global Lawyers and Physicians
GNB Gram-negative bacteria
HIA Health Induction Assessment
HINAP Health Information Network for Advanced Planning
HRW Human Rights Watch
IASC Inter-agency Standing Committee
IAWG Inter-agency Working Group
ICCPR International Covenant on Civil and Political Rights
ICE Immigration and Customs Enforcement
ICESCR International Covenant on Economic, Social and Cultural Rights
ICMC International Catholic Migration Commission
IDP internally displaced person
IHMS International Health and Medical Services
IRB institutional review board
IRHP Immigrant and Refugee Health Program
ISP Independent Study Project
MDD major depressive disorder
MDG Millennium Development Goals
MDR TB multi-drug-resistant tuberculosis
MHPSS mental health and psychosocial support
MISP minimum initial service package
MMR measles, mumps, and rubella (vaccination)
NCD non-communicable disease
NGO non-governmental organization
NHI National Health Insurance
NHS National Health Service
ODA official development assistance
OECD Organisation for Economic Cooperation and Development
PCTF Polio Control Task Force
PoC person of concern
POV polio oral vaccine
PSSA psychosocial structured activities
PTSD post-traumatic stress disorder
RAN Royal Australian Navy
RPC Regional Processing Centre
RSD refugee status determination
RUTF ready-to-use therapeutic foods
SDG Sustainable Development Goals
SGBV sexual and gender-based violence
SRH sexual and reproductive health
STI sexually transmissible infection
TB tuberculosis
TST tuberculin skin test
UDHR Universal Declaration of Human Rights
UHC universal health coverage
UNHCR United Nations High Commission for Refugees
UNRWA United Nations Relief and Works Agency
VFR visiting family and relatives
WASH water, sanitation, and hygiene
WCH women’s and children’s health
WHO World Health Organization
Contributors
Pascale Allotey
Director, International Institute for Global Health (UNU-IIGH), United Nations University, Kuala Lumpur, Malaysia
George Annas
William Fairfield Warren
Distinguished Professor; Director of the Center for Health Law, Ethics & Human Rights, Boston University School of Public Health, Boston, MA, USA
Anushka Ataullahjan
Research Analyst, Centre for Global Child Health, The Hospital for Sick Kids, Toronto, Canada
Susheela Balasundram
Doctor, United Nations High Commissioner for Refugees, Kuala Lumpur, Malaysia
Jacqueline Bhabha
FXB Director of Research, Professor of the Practice of Health and Human Rights at the Harvard School of Public Health, Cambridge, MA, USA
Zulfiqar A. Bhutta
Co-Director, Director of Research, Centre for Global Child Health, The Hospital for Sick Kids, Toronto, Canada
Beverley Ann Biggs
Professor, Royal Melbourne Hospital, Melbourne, Australia
Susan Bissell
Former Director, Global Partnership to End Violence Against Children, New York, USA
Sondra Crosby
Associate Professor, Center for Health Law, Ethics & Human Rights, Boston University School of Public Health, Boston, MA, USA
Michelle F. Gaffey
Senior Research Manager, Centre for Global Child Health, The Hospital for Sick Kids, Toronto, Canada
Michael Grodin
Professor, Center for Health Law, Ethics & Human Rights, Boston University School of Public Health, Boston, MA, USA
Kudzai Kanhutu
Refugee Health Fellow, Doherty Institute, The Royal Melbourne Hospital, Melbourne, Australia
Kaveh Khoshnood
Associate Professor of Epidemiology (Microbial Diseases); Program Director BA-BS/MPH Program in Public Health, Yale University, New Haven, CT, USA
Rajat Khosla
Human Rights Adviser, Department of Reproductive Health, World Health Organisation, Geneva, Switzerland
Susan Kneebone
Professorial Fellow and Associate, Asian Law Centre, Melbourne Law School, Melbourne, Australia
Sandra Krause
Sexual and Reproductive Health Program, Women's Refugee Commission, New York, USA
Karin Leder
Professor, Head of Infectious Disease Epidemiology Unit, Monash University, Clayton, Australia
Peter Mares
Adjunct Fellow, Swinburne University, Melbourne, Australia
Celia McMichael Lecturer, School of Geography, University of Melbourne, Melbourne, Australia
Alison Mosier-Mills
Fulbright Student Researcher in Public Health, Yale University, New Haven, CT, USA
Caitlin Nunn
Assistant Professor (Research), Department of Sociology; and Fellow of the Wolfson Research Institute for Health and Wellbeing, Durham University, Durham, UK
Xavier Pereira
Associate Professor of Psychiatry, Taylor School of Medicine, Malaysia
Veena Pillai
Doctor, Dhi Consulting & Training, Kuala Lumpur, Malaysia
Daniel D. Reidpath
Professor of Population Health and Director, South East Asia Community Observatory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Malaysia
Derrick Silove
Professor, School of Psychiatry, Brain Sciences, University of New South Wales, Sydney, Australia
Paul B. Spiegel
Director, Center for Humanitarian Health, Johns Hopkins University
Mihoko Tanabe
Sexual and Reproductive Health Program, Women's Refugee Commission, New York, USA
Mike Toole
Professor, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
Peter Ventevogel
Senior Mental Health Officer, United Nations High Commissioner for Refugees, Geneva, Switzerland
Sharuna Verghis
Senior Lecturer, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Malaysia; Director, Health Equity Initiatives, Kuala Lumpur, Malaysia
Deborah Zion
Associate Professor and Chair of the Human Research Ethics Committee, Victoria University, Melbourne, Australia
Part 1
Concepts and contexts
Chapter 1
Forced migration, globalization, and global public health
Pascale Allotey and Daniel D. Reidpath
People move. They move within countries and between countries. They move to improve their opportunities for a better life, and they move to escape intolerable hardship or the threat of intolerable hardship (Triandafyllidou, 2017, p. 3). In understanding the impetus to move, the notions of ‘structure’ and ‘agency’ have often been highlighted. Structure is broadly used to describe the macro-level, sociopolitical, and environmental features that encourage or discourage movement, and agency is used to describe the individual motivations and personal resources that promote or suppress movement.
In social and political theory the interplay between structure and agency has remained fertile territory for academic contest: see for example Squire (2017) and Hay (1995). Our purpose here is not to contribute to that debate but to give a sense of that complexity.
[Structure] and agency logically entail one another—a social and political structure only exists by virtue of the constraints on, or opportunities for, agency that it effects. Thus it makes no sense to conceive of structure without at least hypothetically positing some notion of agency which might be affected (constrained or enabled). (Hay, 1995, p. 189)
For those potentially in search of refuge, the interplay between structure and agency affects who moves and the circumstances under which they move, and how they are received and the opportunities they have to establish or reestablish their lives.
Furthermore, the circumstances of the individual and their country of origin, the circumstances of their movement, the time it takes, the route, and their destination all have individual and population health effects. The trends in forced, global migration since the publication of the first edition in 2003 give some insight into this. It also grounds the remaining chapters of this book in the reality of the early twenty-first century. It is crucial, however, that we have a shared understanding of the population that is the focus of this book, or at
least a shared understanding of the potential disagreements in defining that population.
1.1 Who is a refugee?
In epidemiology and health measurement there is an assumption that the rules for case definition represent natural, intrinsic classes: with disease—without disease. We might therefore expect inclusion or exclusion criteria or a case definition for defining concepts and populations; for separating the refugee from the non-refugee. However, these ‘natural definitions’ are frequently muddied by blurred edges, hubris, and political and disciplinary bias (Reidpath et al., 2003; Reidpath, 2007). The term ‘refugee’ falls into this imprecise category. It is relevant primarily as a sociolegal definition, but in the context of public health and clinical medicine it is important for providing background about exposures, social determinants of health, access to services, and protections by the state and the international community.
In outlining the ‘counting rules’ for refugees, we make it clear that there are arbitrary social dimensions involved, with underlying political agendas (Lomell, 2010). Different authors will use different counting rules, and these rules may not always be explicit. It is incumbent on the reader, therefore, to understand this and understand that any analysis is necessarily embedded in a particular understanding of ‘refugee’. One person’s ‘economic migrant’ is another person’s ‘climate change refugee’, and one person’s ‘refugee’ is another person’s ‘internally displaced person’ (IDP). Even within this volume, authors do not necessarily adopt the same definition of a refugee.
An eminent international lawyer who was once asked what defined a refugee responded: ‘a person who satisfies the criteria laid down in Article 1 of the Refugee Convention’ (Grahl-Madsen, 1966, p. 278). This, of course, is not the definition of a refugee, it is a description of a refugee under international law. In common usage the word refugee is used much more broadly. The English word has its origins in the flight from persecution of the French Calvinists (Huguenots) in Catholic-dominated seventeenth-century France, and their search for refuge in other European countries (and later the North American colonies of European countries), as the Oxford dictionary definition indicates:
Refugee (/rɛfjʊ ˈdʒiː/) Noun: A person who has been forced to leave their country in order to escape war, persecution, or natural disaster. Origin: Late 17th century: from French réfugié ‘gone in search of refuge’, past participle of réfugier.
That idea of fleeing persecution in one place and seeking protection in another, at least in the European tradition, had been known since medieval times
and even earlier. It became more prominent with the Reformation, the growth of Protestantism, and the need for classes of people to flee religious persecution.
The modern European tradition of asylum dates from the year 1685. In that year Louis XIV repealed the Edict of Nantes, while in the same year Friedrich Wilhelm, the Great Elector of Brandenburg, issued his Edict of Potsdam, whereby the French Huguenots were authorised to establish themselves in his territories. (Grahl-Madsen, 1966, p. 278)
In Judeo-Christian tradition one of the best-known refugees was Moses who, according to the second book of the Pentateuch, fled from Egypt to Midian, fearing persecution by the Pharaoh, where he settled, married and had children as ‘a stranger in a strange land’ (Exodus, 2:15–22). Subsequently, Moses returned to Egypt and led the exodus of the Hebrews out of slavery to a place of refuge and final settlement in Canaan—the first recorded mass movement of refugees.
There is an interesting juxtaposition between the refugee status of the Huguenots or the Hebrews and the dictionary definition. The dictionary definition includes natural disaster as a cause to seek refuge—which it certainly is. If there is not enough food and water to sustain life where you currently live, move! In contrast, the Huguenots and the Hebrews sought relief from politicoreligious persecution:
owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it. (Article 1)
As Hathaway put it, the difference between a common-sense refugee who pulls at our heartstrings and a Convention Refugee is the concept of a rights-bearer under international law (Hathaway, 2014).
The legal instruments have been applied to individuals who seek asylum outside their country of nationality for a range of political reasons. Recent examples include Julian Assange who sought protection in the Embassy of Ecuador in London against potential future extradition to the United States where he faces prosecution for publication of leaked documents. Similar asylum regulations have been used by politicians who are in opposition to the prevailing political power in their countries. However, unless they are recognized as refugees under international law, the protection granted is restricted to the countries that grant asylum. From a public health perspective, there is greater concern when the drivers for mobility affect a significant population group.
In its totality, this book considers the common-sense notion of refugees, although some authors may focus more narrowly on ‘Refugees’—under the legal
definition. For that reason, for the most part, we therefore use the umbrella term ‘forced migration’ to emphasize the health implications for a population group. Formal definitions of the different populations affected by forced migration are discussed in detail by Kneebone in Chapter 2.
1.2 Forced migration
The push factors for forced migration can conceptually be divided into precipitating events, and a process of social or environmental change, resulting in a catastrophic failure: a sociopolitical failure, an economic failure, or an environmental failure (Figure 1.1).
Against a backdrop of political, economic, or environmental conditions, changes occur.
◆ Government policy is implemented that blames and targets a minority group.
◆ There is an economic depression.
◆ An economic policy encourages unsustainable farming practice.
◆ The rate of population increase (from birth and migration) is beyond the capacity of the country.
◆ There is an earthquake or other large-scale natural disaster. The sociopolitical failure to protect (sub-)populations, the economic failure removing food from the table, or some sudden or gradual environmental failure becomes the impetus or force to move. The concept map is not intended to identify all contingencies, nor reflect the full complexity of feedback loops, nor address the confluence of inseparable causes. When there is a drought, do people move because of an environmental failure or an economic failure? In times of conflict, is it persecution or a loss of livelihood that creates the duress precipitating movement? What Figure 1.1 does illustrate is that those who move have gone in search of refuge (réfugié). They have gone away from their homes looking for greater safety and security.
The concept map focuses on the structural and is intentionally quieter on agency, although it is implicit. We are not interested in a tally-column of suffering. Who has suffered enough to be a refugee? Who was truly forced? We do not support the argument that one is not allowed to seek refuge until one’s life has been utterly destroyed. It is also clear, however, that the health sequelae will be different for different people. Some of that difference will relate to the extent to which a person can preserve their agency and act within the world rather than have the world act upon them.
Clas s
Refugee s Internally Displaced
Asylum Seeker s
Economic Migrants
Exemplar
Conflict Wa r Persecution
Loss of Livelihoo d
Flood s Droughts Earthquakes
Outcome
Socio-Political Failure
Process
Socia l Change
Economic Failure
Events
Political
Economic
Environmenta l Change
Environmenta l Failure
Natura l
Figure 1.1 Conceptual map of the events, processes, and outcomes leading to forced migration.
Reproduced courtesy of the authors.
1.3 Definitions
The need to categorize and label the types of forced migration is politically expedient to direct public opinion, influence policy, and determine states’ obligation. If health is a public good, the rules for who can access health services and the cost of these services are determined by states. Legal status and citizenship therefore often becomes the primary consideration (regardless of push factors for forced migration) and has fuelled recent debates in the movements of people across borders.
A Refugee is a person who meets the eligibility criteria under the applicable refugee definition, as provided for in international or regional refugee instruments, under the mandate of the United Nations High Commissioner for Refugees (UNHCR), and in national legislation.
An asylum seeker is an individual who is seeking international protection. In countries with individualized procedures, an asylum seeker is someone whose claim has not yet been finally decided by the country in which he or she has submitted it. Not every asylum seeker will ultimately be recognized as a refugee, but every refugee is initially an asylum seeker.
Internally displaced persons (IDPs) are those forced or obliged to flee from their homes, ‘. . in particular as a result of or in order to avoid the effects of armed conflicts, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border’ (UNHCR, 1998, p. 5).
Mandate Refugees are persons who are recognized as refugees by UNHCR acting under the authority of its Statute and relevant UN General Assembly resolutions. Mandate status is especially significant in states that are not parties to the 1951 Convention on Refugees or its 1967 Protocol.
Under national laws, Stateless Persons do not have the legal bond of nationality with any State. Article 1 of the 1954 Convention relating to the Status of Stateless Persons indicates that a person not considered a national (or citizen) automatically under the laws of any State, is stateless. These persons may differ from undocumented migrants, who lack legal documentation and therefore need to make a case for citizenship and migration status.
Persons of Concern to UNHCR is a generic term used to describe all persons whose protection and assistance needs are of interest to UNHCR. These include refugees under the 1951 Convention, persons who have been forced to leave their countries as a result of conflict or events seriously disturbing public order, asylum seekers, returnees, stateless persons, and, in some situations, IDPs. UNHCR’s authority to act on behalf of persons of concern other than refugees is
based on United Nations General Assembly and Economic and Social Council (ECOSOC) resolutions.
1.4 Trends in global forced migration
In the first edition of Health of Refugees, Zwi and Alvarez-Castillo (2003) identified the major forced migration events since World War II. Rather than look back again, we carry that timeline forward to cover the years since that publication.
We have the advantage of better data systems and better tracking. Unfortunately, there are no perfect mechanisms for tracking all formal and informal movements of people. A quick look at the data from the Population Division of the United Nations Department of Economic and Social Affairs (UNDESA, n.d.) reveals the paucity of aggregated migration data. Data challenges notwithstanding, UNHCR tracks their ‘persons of concern’ (PoC) to a greater degree. Within UNHCR, PoC are categorized under ‘Refugee’, ‘Asylum Seeker’, ‘IDPs, ‘Stateless’, and ‘Other’. Each category has a specific legal definition, and while the UNHCR counting rules may not encompass everyone that one might regard as a (small ‘r’) refugee, or might cover additional people one might not regard as a refugee, it does give a snapshot of the broad trends in forced migration.
We reviewed the UNHCR Global Reports from 2004, the year after the first edition was published, to the latest report published in 2016.1 We focused principally on the High Commissioner’s foreword and summary data (Table 1.1). For the majority of those years (2005–2014), the current Secretary General of the United Nations, António Guterres, was the High Commissioner for Refugees. As a lead into those years, it is worth noting that the foreword to the 2003 Global Report opened with the sentence, ‘2003 was a good year for refugee returns’. Since then, and with the exception of 2004, good news openings have been increasingly rare.
The succession of Global Reports characterizes an increasingly fragile global situation. The arc of countries through West Asia, the Middle East, the Horn of Africa, Central Africa, and the Lakes Region have dominated the refugee numbers. Some countries that were host countries for refugees have themselves become destabilized (e.g. Syria and Yemen). Other regions, however, have not been immune, including South and Central America, South East Asia, and Central Asia.
Figure 1.2 uses UNHCR data to illustrate the shift in refugee numbers since 1990 through to 2016.
Table 1.1 Information from uNhCR Global Reports, 2004–16
Year Highlights
2004 Acting high Commissioner wendy Chamberlin
2005 high Commissioner António guterres
The number of Persons of Concern to uNhCR continued to decline. A three-year downward trend with fewer asylum seekers arriving in industrialized countries during 2004 than in any year since 1988.
Crisis in Darfur region, Sudan: 200,000 refugees shelter in arid eastern Chad.
600,000 people in Indonesia and Sri lanka were displaced by a tsunami. In late 2005 the South Asia earthquake levelled hundreds of villages throughout Pakistan-administered Kashmir. Darfur worsened, affecting over 2 million people. Conflicts in burundi and South Sudan continued, raising prospects for two of Africa’s largest refugee populations.
2006 high Commissioner António guterres
2007
high Commissioner António guterres
For the first time since the turn of the century, the number of refugees increased in 2006 by 12% to almost 10 million. This was largely a result of the crisis in Iraq. The overall number of persons of concern to uNhCR rose from 21 million in 2005 to 34.4 million in 2006.
50,000 people a month crossed Iraq’s western border, seeking refuge in Syria and Jordan. by the end of 2006, the cumulative total of displaced Iraqis inside and outside the country had reached 3.8 million. half-way through 2006 there was a 34-day war in lebanon. Around 1 million lebanese were displaced. many sought refuge inside their own country; others fled into Syria.
There were 2 million IDPs in Iraq and 2.2 million Iraqi refugees in neighbouring countries. Insecurity in the Central African Republic (CAR), Chad, and Darfur region brought the overall number of refugees and IDPs in these three places to almost 3 million. In Chad, cross-border raids destroyed several villages and uprooted thousands of people. more than 20,000 Chadians fled into Darfur in 2007. violence in the eastern areas of the Democratic Republic of the Congo (DRC) displaced an additional 435,000 people internally. In south and central Somalia fighting brought the total number of IDPs to 1 million. It also added some 30,000 Somali refugees to some 325,000 refugees already in neighbouring countries.
2008
high Commissioner António guterres
by the end of 2008, the total number of refugees under uNhCR’s mandate exceeded 10 million. The number of conflict-induced IDPs reached 26 million worldwide. Conflicts in an arc from South and South west Asia, through the middle East to Sudan and the horn of Africa generated two-thirds of the total number of refugees worldwide.
In Darfur more than 2 million people remain internally displaced, while nearly a quarter of a million Darfurians remained in exile in Chad. 300,000 people became internally displaced in Pakistan.
Year Highlights
2009 high Commissioner
António guterres
2010 high Commissioner
António guterres
2011 high Commissioner
António guterres
There are 36 million persons of concern to uNhCR including 10 million refugees—the highest number on record. Two-thirds of the world’s refugees are in developing countries, many in the arc of conflict from South west Asia, the middle East, horn of Africa, and the great lakes and Central region. Three-quarters of IDPs are also to be found in this arc.
An estimated 20 million Pakistanis were displaced by floods. Afghan refugees in 19 camps were among those affected, as were people previously displaced internally. The emergency in Kyrgyzstan broke out in the southern city of Osh. Clashes between ethnic uzbeks and Kyrgyz left hundreds dead and as many as 400,000 displaced. Approximately 75,000 refugees, mostly women and children, fled to the Andijon area of neighbouring uzbekistan.
hundreds of thousands of people were forced to abandon their homes as violence erupted in Côte d’Ivoire and libya. The Somali conflict, already 20 years old, degenerated further and, combined with the worst drought in decades, drove close to 300,000 refugees into neighbouring Kenya, Ethiopia, Djibouti, and Yemen— bringing the total number of Somali refugees in the region to some 950,000 by the end of 2011. An upsurge in fighting in Sudan resulted in an influx of nearly 100,000 new refugees into South Sudan and Ethiopia. Old crises in Afghanistan, DRC, and Iraq have not been resolved. As a result, durable solutions have remained elusive for a large number of refugees under uNhCR’s mandate. Over 7.2 million people are now living in protracted situations of exile.
2012 high Commissioner
António guterres
2013 high Commissioner
António guterres
more than 1 million people fled their countries of origin due to conflict and persecution, mainly from Syria, mali, Sudan, and the eastern DRC. That is the highest number of newly displaced refugees during any 12-month period since the beginning of the 21st century.
Nearly 2 million people fled the brutal conflict in Syria and hundreds of thousands escaped war, violence and persecution in the CAR, the eastern DRC, myanmar, South Sudan, and Sudan. by the end of 2013, almost 43 million people—the highest number ever— relied on uNhCR for protection. In just 5 years, from being the second largest refugee-hosting country in the world, Syria has become the second largest refugee-producing country, after Afghanistan. more than 9 million people were in flight inside and outside the country in 2013, and hundreds of thousands were trapped and under siege. Syria’s neighbours shouldered the brunt of the burden, as did other countries in the vicinity of conflict areas.
