Forced migration has occurred from the earliest periods of human history as a result not only of conflict (war or ethnic or religious persecution) but also as an outcome of other disasters. The International Association for the Study of Forced Migration (IASFM) at Georgetown University defines it as “a general term that refers to the movements of refugees and internally displaced people (those displaced by conflicts) as well as people displaced by natural or environmental disasters, chemical or nuclear disasters, famine, or development projects.”
Some examples of disease emergence and reemergence among displaced persons and refugees from conflict include the following:
Forced migration during earlier periods of human history typically resulted from violence (war or civil war) that caused people to flee for their lives. Sometimes countries made war in order to capture people for slave labor or to sell them to other countries as slaves; the medieval Viking raids on what is now England were done for this reason, as were the Aztecs' wars on their neighbors in Central America prior to the coming of the Spanish. People might also leave their homelands because of famine, disease, or other natural disasters beyond their control, as happened to the Irish during the potato famine of the 1840s and 1850s. Forced migration did not, however, become a subject of study and analysis until after World War II, when the establishment of the United Nations provided an international organization and a legal framework for dealing with forced migration. In addition, social scientists began to realize that the relative ease and speed of modern transportation vastly increased the numbers of migrants, and that forced migration anywhere in the world could affect countries far removed from the scene of conflict or disaster.
Examples of different types of forced migration in the twentieth and twenty-first centuries are as follows:
The population of Syria was estimated to be around 23 million in 2011 before the outbreak of civil war. This figure included the 1.5 million refugees from Iraq. The population fell to 17.9 million by 2014, according to the CIA World Factbook, a drop that resulted from an increased number of deaths due to war and disease, and to 5.5 million Syrians fleeing abroad. According to the U.N. High Commissioner for Refugees (UNHCR), Syria was the single greatest source of forced migration in the world as of 2017, its 5.5 million migrants constituting a larger group than the migrants from the next two countries combined, Afghanistan (2.5 million) and South Sudan (1.4 million).
Although most migrants from Syria moved to Turkey, Lebanon, or Jordan when civil war first broke out, after 2015 growing numbers of them sought asylum in Europe. Updated figures from UNHCR indicate that 952,446 Syrians applied for asylum in Europe between 2011 and May 2017, 138,000 in 2014 alone. Two-thirds of the refugees sought asylum in Germany and Sweden; 21% in the Netherlands, Denmark, Hungary, Austria, or Bulgaria; and the remainder in other European countries. Another 7 million Syrians are thought to be IDPs.
Other notable demographic statistics include the fact that the birth rate in Syria dropped from 500,000 births per year in 2011 to 200,000 per year by 2015. In addition, the life expectancy fell from 75.9 years prior to the civil war to 55.7 years in 2016. About 80% of the population remaining in Syria was living in poverty, as the unemployment rate rose from 14% in 2011 to 58% at the end of 2014. The UN estimated that the number of deaths resulting from the conflict was as high as 270,000, a figure higher than the number of people who died from the atomic bombs dropped on Hiroshima and Nagasaki in 1945.
The role of public health authorities in any country receiving forced migrants is complex. One task is verifying the migrant's country of origin in order to keep surveillance statistics on any disease the migrant might have, and determine his or her admissibility to the destination country.
A second task is to screen migrants for communicable and chronic diseases, and, in some countries, mental health issues. The CDC's instruction for physicians states explicitly, “Applicants are inadmissible into the United States if they are determined 1) to have a communicable disease of public health significance; 2) to have a physical or mental disorder and behavior associated with the disorder that may pose, or has posed, a threat to the property, safety, or welfare of the applicant or others; 3) to have a history of a physical or mental disorder associated with behavior which posed a threat to the property, safety, or welfare of the applicant or others and which is likely to recur or lead to other harmful behavior; or 4) to be a drug abuser or addict.” These health examinations may be performed overseas before the applicant travels to the United States.
In the United States, the Secretary of the Department of Health and Human Services (HHS) is empowered by the Immigration and Nationality Act (INA) and the Public Health Service Act to establish requirements for the medical examination of aliens seeking admission to the United States. The CDC's Division of Global Migration and Quarantine (DGMQ) issues medical screening guidelines for all physicians performing health examinations, whether overseas or in the United States. These guidelines describe the scope of the examination in detail.
A major change that has taken place since the influenza pandemic of 2009 is the CDC's requirement that applicants for entry be screened for quarantinable communicable diseases. As of 2017, the list included cholera, yellow fever, plague, viral hemorrhagic fevers, diphtheria, infectious TB, smallpox, severe acute respiratory syndromes, and “influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause, a pandemic.” The reason for the changes was to give the CDC and the examining physicians greater flexibility to respond quickly to rapidly emerging new diseases or reemerging older ones in specific populations, including migrants from specific countries.
It is unlikely that the general problems of conflict and forced migration will end as long as there is a scarcity of any kind of resource, whether land, food, health care, or political power, and as long as human beings are prepared to fight to obtain what they need or to keep what they have. Although various attempts had been made to resolve the civil war in Syria, including United Nations–sponsored peace talks in Geneva in 2016, as of 2017 it appeared that the conflict was likely to continue for the foreseeable future.
See also Antimicrobial resistance ; Cholera ; Globalization and emerging diseases ; Leishmaniasis; Pandemic .
Martin, Susan, Sanjula S. Weerasinghe, and Abbie Taylor, eds. Humanitarian Crises and Migration: Causes, Consequences and Responses. New York: Routledge, 2014.
McDowell, Mary Ann, and Sima Rafati, eds. Neglected Tropical Diseases: Middle East and North Africa. Vienna: Springer, 2014.
Simich, Laura, and Lisa Andermann, eds. Refuge and Resilience: Promoting Resilience and Mental Health among Resettled Refugees and Forced Migrants. New York: Springer, 2014.
Angeletti, S., et al. “Unusual Microorganisms and Antimicrobial Resistances in a Group of Syrian Migrants: Sentinel Surveillance Data from an Asylum Seekers' Centre in Italy.” Travel Medicine and Infectious Disease 14 (March-April 2016): 115–122.
Bloch-Infanger, C., et al. “Increasing Prevalence of Infectious Diseases in Asylum Seekers at a Tertiary Care Hospital in Switzerland.” PLoS One 12 (June 15, 2017): e0179537.
Doganay, M., and H. Demiraslan. “Refugees of the Syrian Civil War: Impact on Reemerging Infections, Health Services, and Biosecurity in Turkey.” Health Security 14 (July-August 2016): 220–25.
Doocy, S., et al. “Health Service Access and Utilization among Syrian Refugees in Jordan.” International Journal for Equity in Health 15 (July 14, 2016): 108.
Heimer, R., et al. “HIV Risk, Prevalence, and Access to Care Among Men Who Have Sex with Men in Lebanon.” AIDS Research and Human Retroviruses [e-pub ahead of print, June 29, 2017].
Heudorf, U., et al. “Multidrug-Resistant Organisms in Refugees: Prevalences and Impact on Infection Control in Hospitals.” GMS Hygiene and Infection Control 11 (August 9, 2016): Doc. 16.
Maltezou, H. C., M. Theodoridou, and G. L. Daikos. “Antimicrobial Resistance and the Current Refugee Crisis.” Journal of Global Antimicrobial Resistance [e-pub ahead of print, June 30, 2017].
Ozaras, R., et al. “The Syrian Conflict and Infectious Diseases.” Expert Review of Anti-Infective Therapy 14 (June 2016): 547–55.
Pfortmueller, C. A., et al. “Adult Asylum Seekers from the Middle East Including Syria in Central Europe: What Are Their Health Care Problems?” PLoS One 11 (February 10, 2016): e0148196.
Taylor, Lin. “Compassion Fatigue: How Much Is Too Much Bad News?” SBS News, August 1, 2014. http://www.sbs.com.au/news/article/2014/08/01/compassionfatigue-how-much-too-much-bad-news .
Doctors Without Borders (MSF-USA). “Syria.” doctor swithoutborders.org . http://www.doctorswithoutborders.org/country-region/syria (accessed September 12, 2017).
Global Health, Division of Parasitic Diseases. “Parasites: Leishmaniasis.” Centers for Disease Control and Prevention. https://www.cdc.gov/parasites/leishmaniasis/index.html (accessed September 12, 2017).
Stark, Craig G. “Leishmaniasis.” Medscape. http://emedicine.medscape.com/article/220298-overview (accessed September 12, 2017).
World Health Organization. “Leishmaniasis.” WHO.int. http://www.who.int/mediacentre/factsheets/fs375/en (accessed July 12, 2017).
American Society of Tropical Medicine and Hygiene (ASTMH), One Parkview Plaza, Ste. 800, Oakbrook Terrace, IL, 60181, (847) 686-2238, Fax: (847) 686-2251, email@example.com, http://www.astmh.org/ .
Centers for Disease Control and Prevention, Division of Global Migration and Quarantine (DGMQ), 1600 Clifton Road, Atlanta, GA, 30329, (800) CDCINFO (232-4636), https://wwwn.cdc.gov/dcs/ContactUs/Form , https://www.cdc.gov/ncezid/dgmq/index.html .
Infectious Diseases Society of America (IDSA), 1300 Wilson Blvd., Ste. 300, Arlington, VA, 22209, (703) 299-0200, Fax: (703) 299-0204, http://www.idsociety.org/Contact_Us , http://www.idsociety.org/Index.aspx .
International Association for the Study of Forced Migration (IASFM), Georgetown University, 3300 Whitehaven St. NW, Ste. 3100, Washington, DC, 20007, (202) 687-2258, Fax: (202) 687-2541, firstname.lastname@example.org, http://iasfm.org .
International Organization for Migration, 17 Route des Morillons, P.O. Box 17, Geneva CH-1211, Switzerland, 19, 41 22 717 9111, Fax: 41 22 798 6150, email@example.com, http://www.iom.int .
Rebecca J. Frey, PhD