An Uncertain Safety

An Uncertain Safety Integrative Health Care for the 21st Century Refugees Thomas Wenzel Boris Drožđek Editors 123 An Uncertain Safety Thomas Wenzel · Boris Drožđek Editors An Uncertain Safety Integrative Health Care for the 21st Century Refugees Editors Thomas Wenzel Boris Drožđek World Psychiatric Association Scientific PsyQ/Parnassia Group Section, Psychological Aspects Rosmalen/Eindhoven of Persecution and Torture The Netherlands Geneva Switzerland ISBN 978-3-319-72913-8 ISBN 978-3-319-72914-5 (eBook) https://doi.org/10.1007/978-3-319-72914-5 Library of Congress Control Number: 2018941840 © Springer International Publishing AG, part of Springer Nature 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by the registered company Springer International Publishing AG part of Springer Nature. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword Continuity and Shifts in Contemporary Refugee History Human beings are and have always been both a territorial species, defending aggres- sively what they consider as their land, and a migratory species, exploring and investing new territories according to complexly entangled push and pull factors. Across millenaries and centuries, human groups have fled adverse environments: extreme climate, infertile lands, wars, and extermination by other human groups [1]. They have also always searched (like all other living beings) for better opportunities, in particular when local resources were not sufficient to meet the needs of a growing population. Myths, tales, history, and fiction testify to the richness of migration trajectories and to the multiple obstacles associated with fleeing persecution or war. Mirroring both human generosity and our capacity for cruelty, all these narratives also reflect the multitude of discursive strategies that people in search of asylum have employed across ages [2, 3]. During the twentieth century the two worldwide conflicts have brought forward the contradictions between the emerging human right discourse and the appalling reality of asylum. The story of the St-Louis, this transatlantic ship carrying 800 Jews fleeing Nazi Germany, which was refused landing in Cuba, United States, and Canada before returning its passenger to their death in Europe, is exemplary. The 1951 Geneva Convention was the first international agreement defining who is a refugee and outlining what is the basic protection which states should offer to the persons they welcome as refugees. This international convention stipulates that refugees who flee persecution because of political, ethnic, or religious reasons should not be expelled and returned to countries where their life and freedom would be threat- ened. According to the United Nations High Commissioner for Refugees (UNHCR), refugee protection includes access to fair asylum procedures and living conditions that allow refugees to live in dignity and safety. With time and social transformations in European and North American countries, gender and sexual orientations have progressively been recognized as legitimate reasons to be granted asylum. One of the important, and ongoing, debates about asylum has been the tension between resettlement in the country of asylum and longer term solutions decided either by the states or by the refugees themselves. According to Chimni [4] the v vi Foreword history of durable solutions to refugee movements after the Second World War can be divided into two distinct phases. From 1945 to 1985, resettlement in the country of asylum was promoted, although voluntary repatriation was considered as a better solution. In the second phase, repatriation became the overall objective. From 1985 to 1993, voluntary repatriation was advocated as the durable solution, while still insisting on the voluntary nature of the move. The notion of safe return, introduced in 1993, comforted the temporary protection regimes established in Western Europe. From then on, the doctrine of imposed return gradually gained credence, while the reality of involuntary repatriation grew. Chimni [4] argues that involuntary repatriation is now the favored solution for the northern states because in the post-Cold War era there are no more geopolitical reasons to share the burden represented by the southern refugees, which require important resources. The relatively recent distinction between migrant and refugees is both interesting, because it helps to secure protection and limit abusess toward groups in very precarious situations, and problematic because the emphasis on vul- nerability tends to minimize refugee resiliency and agency and it does not represent adequately the heterogeneity across migrant and refuge groups (UNHCR, 2016). Refugees are, by definition, individuals fleeing armed conflict or persecution, while migrants are often believed to migrate mainly to improve their lives through better job opportunities or education. Although this is partially true, the reality is much more complex and the two groups overlap widely: increasingly migrants change country because of political and social turmoil, and a significant number have expe- rienced persecution or witnessed organized violence [5]. On the other hand, many refugees flee very adverse economic conditions, the absence of life perspectives, and (increasingly) climate change adversity associated with hunger and poverty. From Being “At Risk” to Becoming “A Risk” The contribution of growing migration waves with difficult socio-economic conditions in receiving countries has sharply shifted the perceptions about migrants and refugees. The representation of refugees as vulnerable because of their exposure to war trauma and their multiple experiences of losses and separation has been progressively replaced by representations of the potentially criminal refugee, perceived as abusing the benevolence from naïve host countries. This shift in discourses around refugees takes different forms. For example, it includes a transformation of representations of refugee children who become suspect of being disguised adults (with the battle around age determination) or of manipulating host country profes- sional in benefit of their parents asylum claim in the case of the pervasive refusal syndrome [6]. Children and women are also frequently portrayed as victims of their own families, which are perceived as the barbaric other [7]. In this context the social rights associated with asylum have shrunk. Concepts of privilege and deservingness are progressively replacing the notion of rights in the field of education and of health care. In some countries access to services is limited or has been reduced directly through legislation [8]. But entitlement is not linearly Foreword vii associated with access to services. Numerous obstacles at the institutional and clini- cal levels, from lack of information to negative attitudes of health professionals toward refugees, can interfere with access [9, 10]. On the refugee side fear, lack of information, and past experiences of discrimination may also prevent them from accessing care [11]. A Public Health Challenge The physical and mental health needs of refugees differ from those of host country residents. The prevalence of disease can differ because of higher exposure to infec- tious agents in unsafe environments or prolonged lack of access to health care [12]. Premigratory stress, complex and stressful migration trajectories, living conditions in host country, and genetic predispositions also play an important role. In addition, language and cultural differences, along with distrust toward institutions and discrimination experiences in the resettlement environment, have been repeatedly shown to interfere with appropriate access to health care services [12]. A review of the evidence on mental health care for refugees, asylum seekers, and irregular migrants [13] underlines that the increasing number of these vulnerable migrants is a challenge for mental health services in Europe. As was emphasized in prior reviews [14] refugee and asylum seekers have higher rates of stress-related disorders than the generals population. They may also have more depression than host country residents if they still live in poverty five years after resettlement [13]. They have no more other specific mental health disorders

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