Public health aspects of migration in Europe: newsletter: issue 9, July 2016

EDITORIAL BOARD BIFFL, Gudrun CAMPOSTRINI, Stefano CARBALLO, Manuel COSTANZO, Gianfranco DECLICH, Silvia DENTE, Maria Grazia GEORGE, Francisco GUERRA, Ranieri HANNICH, Hans-Joachim KONRAD, Helga KRASNIK, Allan LINOS, Athena MCKEE, Martin MOSCA, Davide NOORI, Teymur OROSZ, Éva PADILLA, Beatriz PEREIRA MIGUEL, José Manuel Domingos REZZA, Gianni SALMAN, Ramazan SIEM, Harald Coordinators OSTLIN, Piroska SEVERONI, Santino SZILÁRD, István WHO Regional Office for Europe (Venice) BARRAGÁN MONTES, Sara DEMBECH, Matteo University of Pécs BARÁTH, Árpád CSÉBFALVI, György EMŐDY, Levente GOLESORKHI, Kia KATZ, Zoltán MAREK, Erika EDITORIAL Migration at the core of public health Dr Santino Severoni, Coordinator Ms Sara Barragan Montes, Technical Officer Mrs Juliane Koenig, Intern Public Health and Migration, WHO Regional Office for Europe (WHO/Europe) The current global context and health challenges associated with refugees and migrants represent an unprecedented situation. The increase in people forced to flee their home countries is the highest in 70 years. According to a new release from the United Nations High Commissioner For Refugees (UNHCR), a total of 65.3 million refugees and displaced people were counted worldwide at the end of 2015 (1). Global responsibility is needed to successfully address and improve the situation of refugees and migrants with respect to the fundamental right of health for all. Comprehensive health care cannot be seen as an outcome of one sector alone, as sustainable and equitable improvements in health are the product of effective health in all policies approaches. Subsequently, successful implementation of joint policies on migration and health will require close collaboration between all participating stakeholders. At the same time, this should also be seen and valued as an opportunity to act in a concerted manner to address an issue that transcends borders and sectors. This increasing interest in and call for international collaboration was widely discussed at the 69th World Health Assembly in May 2016 and will be one of the main topics for discussion at the upcoming WHO Regional Committee for Europe in September 2016. 69th World Health Assembly, 23–28 May 2016 in Geneva, Switzerland This year’s World Health Assembly included two sessions focused specifically on the issue of migration and health: a plenary discussion and a technical briefing. The recent progress report, entitled Promoting the health of migrants (2) was discussed at the plenary session, focusing attention on the immense global dimensions of migration. About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 1 s 69th World Health Assembly technical briefing on migration and health, 27 May 2016 (Mr Steven Corliss, Director, Division of Programme Support and Management, UNHCR; Dr Santino Severoni, Public Health and Migration Coordinator, WHO; Dr Zsuzsanna Jakab, Regional Director for Europe, WHO; Ambassador William Lacy Swing Director-General, IOM; Dr Edward Kelley, Director Department of Service Delivery Safety, WHO; Dr Margaret Chan, Director-General, WHO) Not only did multiple representatives from countries all over the world give an update on the critical situation, but representatives of the European Region also reported on refugee and migrant health becoming a topic requiring growing attention. Representatives from Greece and Italy called for tailored policies and highlighted the need to prevent discrimination and violence to ensure access to health care for these vulnerable groups. The representative of Greece pointed out that with an adequate action plan, countries could move from seeing migration as troublesome to accepting it as an opportunity to strengthen public health services throughout the country. The work carried out by WHO/Europe’s Migration and Health Programme was acknowledged, and the need highlighted for collaborative assistance and coordinated international efforts. The technical briefing on migration and health at the 69th World Health Assembly was opened by WHO Director- General Dr Margaret Chan, who highlighted the importance of advancing the road towards the 2030 Agenda for Sustainable Development moto “no one should be left behind”. With this in mind, refugees and migrants should be wholly recognized as vulnerable groups deserving the full protection and realization of their human rights. In particular, forced migration caused by conflict, violence or circumstances in war-torn countries is higher than ever. Dr Chan called for more action by pointing out four urgent needs for ensuring migrants’ access to full health services: not only are migrant-sensitive health services required, along with better data on the health needs of migrants, but in particular policies, legal frameworks, international dialogue and networks are also essential. Dr Zsuzsanna Jakab, WHO Regional Director for Europe presented the extensive work on migration and health conducted by WHO/Europe since 2012, as well as the ongoing activities in other WHO regions related to the health of refugees and migrants. Her co-speakers continued by underlining the urgent need to address collaboratively and improve the health care situation of refugees and migrants. Expressly agreeing that there is “no public health without migrant health”, they specified that to achieve universal health coverage, migrant health must be kept on the political agenda. This crisis of humanity calls for an urgent coordinated response. With such integrated approaches, more sustainable, cost-effective programmes can be implemented, including more comprehensive and equitable health coverage. Public Health Aspects of Migration in Europe (PHAME) WHO/Europe has been working for many years in the field of vulnerabilities and health, focusing on migrants and other minority groups. Thanks to the financial support of the Ministry of Health of Italy, the WHO PHAME project was established in 2012 to scale-up technical assistance and policy support tailored to each country. Since then WHO/Europe has put a great deal of effort into developing mutual policies for all 53 Member States of the WHO European Region. In the spirit of the recently adopted 2030 Agenda for Sustainable Development and the European policy framework for health and well-being, Health 2020, these policies focus on priority actions to address the public health and health system challenges related to migration. At the High-level Meeting on Refugee and Migrant Health held in Rome in November 2015, around 50 representatives of European, Eastern Mediterranean and African countries, along with senior staff from United Nations agencies and international organizations agreed on collaborative action to address the health needs of refugees and migrants in the European Region. This outcome document, Stepping up action on refugee and migrant health (3), along with the above-mentioned policy frameworks, serve now as a foundation for the development of a new Strategy and Action Plan on Refugee and Migrant Health in the WHO European Region, which will be accompanied by a resolution and submitted for discussion and approval at the Regional Committee in September 2016. About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 2 The 69th World Health Assembly demonstrated how migration and health has become one of the key priorities for ministries of health today, as well as for WHO as a whole. This commitment to responding in a spirit of solidarity and mutual assistance – addressing a global health issue that transcends countries and regions – shows a strong foundation for a common framework of collaborative action. Countries within and beyond the European Region are willing and committed to build bridges and to collaborate on migration and health. The approval of the forthcoming Strategy and Action Plan on Refugee and Migrant Health in the WHO European Region, with its accompanying resolution, is thereby an essential step towards universal health coverage; not only for refugees and migrants, but for the whole population, setting the basis for new collaborative frameworks in the field of migration and health. About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 3 References 1) Edwards A. Global forced displacement hits record high [website]. Geneva: United Nations High Commissioner for Refugees; 2016 (http://www.unhcr.org/news/latest/2016/6/5763b65a4/global-forced-displacement-hits-record-high.html). 2) Promoting the health of migrants. Report by the Secretariat. Provisional agenda item 14.7. In: Sixty-ninth World Health Assembly, Geneva, 8 April 2016. Geneva: World Health Organization; 2016 (document A69/27) (http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_27-en.pdf). 3) Stepping up action on refugee and migrant health. Towards a WHO European framework for collaborative action. Outcome document of the high-level meeting on refugee and migrant health, 23–24 November 2015, Rome, Italy. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/publications/2016/stepping-up-action-on-refugee-and-migrant-health). OVERVIEW Lessons learned from the Assisting and REeintegrating CHIld VICtims of trafficking (ARECHIVIC) project1 Istvan Szilard,* Zoltan Katz,* Erika Marek,* Mila Mancheva,** Andrey Nonchev**2 Introduction In recognition of the importance of adequate support and protection of child victims of trafficking (VoT) for remedying abuse, an EU co-financed project has been successfully completed by the ARECHIVIC consortium, coordinated by the Center for the Study of Demography (Bulgaria). This overview describes and draws in large part on the Center for the Study of Democracy report Assisting and reintegrating child victims of trafficking: improving policy and practice in the EU Member States (1). The consortium member institutions originate from six EU Member States. These institutions are: 1. Ludwig Boltzmann Institute of Human Rights (Austria) 2. Center for the Study of Democracy (Bulgaria) 3. University of Pécs (Hungary) 4. CENSIS Foundation (Italy) 5. People in Need (Slovakia) 6. Crime Victim Compensation and Support Authority (Sweden). Three countries are prevailingly viewed as destinations (Austria, Italy and Sweden), while the others are sources (Bulgaria, Hungary and Slovakia) of trafficked children. It is worth noting that Hungary could be viewed as a source, transit and destination country. 1 The project is co-financed by the European Union (EU) Fundamental Rights & Citizenship programme. 2 *University of Pécs Medical School, Hungary; **Center for the Study of Demography, Bulgaria. About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 4 Building on previous research in this field, the comparative study aimed to provide a more in-depth analysis of the efforts made to assist child VoT in their physical, psychological and social recovery. It consisted of three analytical levels, each grounded in a particular methodology. The three levels of analysis included: • assessment of the policy, legal and institutional framework for assistance and (re-)integration of child VoT in source and destination countries; • evaluation of programmes for child victim support and (re-)integration in source and destination countries; • identification of best practices for support and (re-)integration of child VoT in six EU countries, in line with the principles of fundamental children’s rights and of promoting the best interests of victims. From among the very comprehensive achievements and results of the study,3 this overview focuses only on the health-related aspects of assisting unaccompanied minors and child VoTs. Psychological and medical care4 Emergency/short-term services Emergency or short-term services for child VoT are offered in Austria, Bulgaria, Hungary, Italy and Slovakia. The social welfare system in Sweden makes no distinction between short-term and long-term care. In Austria, health and psychological services, if needed, are guaranteed to unaccompanied minor foreigners and child VoT who either fall under the basic welfare support system or qualify for emergency treatment. The forms of provision of these services vary in the different regions of the country. For example, in the Drehscheibe, a specialized socio-pedagogical institution/shelter administered by the Vienna Youth Welfare Authority, both medical and social care are provided by external operators. Emergency services to child VoT in Bulgaria are provided through a network of crisis centres, which offer a standard package of services set out in the “Methodology for Offering the Service of Crisis Centre”. Medical care, education and psychological support are mandatory elements of the service structure of the country’s Crisis Centres. Medical care is usually provided by means of contracts with general practitioners who visit the centre 2–3 times per week. Medical screening upon the arrival of child VoT in Crisis Centres is a standard procedure. Emergency support measures in Italy are provided for three months, with the possibility of extending for a further three months, and include (among others) medical services and psychological counselling. The implementation of these services is not regulated by guidelines or standard operating methodologies and is highly divergent. For this reason it is not possible to evaluate them as a whole. Unaccompanied minors in Hungary are entitled to a Humanitarian Card, which allows free-of-charge medical care until the child’s legal status is established. Psychological care for adult and child VoT in Hungary is not adequately provided through the state health care system, which suffers from a chronic lack of psychiatrists. The psychological needs of VoT in the country are met mostly by the Cordelia Foundation, which offers rehabilitation and psychological services in six centres throughout the country. In Sweden, the responsibility for children who are victims of crime lies primarily with Sweden’s local social welfare authorities. In accordance with the country’s Social Services Act, these social welfare authorities should provide child victims of crime with psychological, social, financial and practical support. However, one specific programme for support and rehabilitation of child VoT developed by the Country Administrative Board of Stockholm foresees the implementation of both short- and long- term measures. Short-term measures are those aiming to create security and stability and to provide initial support to the child. Psychological care could be provided in different settings: at hospitals, through NGOs and in private therapy centres, with specific programmes focusing on dealing with trauma. Medical care for child VoT is provided by non-specialist medical care institutions, and no specific cooperation exists with medical institutions with specially trained staff. In Slovakia it is recommended that a consultation with a psychologist is carried out immediately after placement of a child VoT into substitute care. As such, regular visits are conducted in children’s homes by a psychologist from the Catholic humanitarian aid organization Caritas and the Slovak Humanitarian Council. Good practices The project collected details of good practices in the participation countries (described below). In Hungary, since 2010 the State Children Centre of the Department of Foreign Children in Fót is responsible for hosting and assisting all foreign unaccompanied children who ask for asylum, including VoT. The main strengths and benefits of this practice are listed here. 3 It is worth noting that since the completion of the study in 2013, some changes in the service provision may have been implemented. 4 Psychological and health assistance are paramount in the rehabilitation of VoTs. See the Further reading section (specifically, Szilard & Barath, 2015) for more detailed analysis. About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 5 • It results in the country ranking high in terms of sustainability, with relevant legislation and a secure state budget. • Placement of foreign unaccompanied children and VoT is well organized and immediate. • Guardianship services are ensured. • The approach can be said to be child participatory and gender sensitive. • The Centre’s services allow for comprehensive (re-)integration (including access to education, language courses and psychosocial care). • Medical care (including psychiatric treatment) is accessible free of charge, from arrival. • Since 2012, a cooperation agreement between the State Children Centre of the Department of Foreign Children in Fót and the Cordelia Foundation also provides for long- term psychosocial therapy.5 The activities of the above-mentioned Cordelia Foundation should also be acknowledged. The Foundation was established in 1996 as a nongovernmental institution and has developed a reputation for providing psychosocial assistance to children and adults, with particular emphasis on migrants and asylum-seekers. The main strengths of the Foundation’s practice include: • strong expertise in trauma work – the Foundation is the principal specialist public benefit institution in Hungary; • provision of a comprehensive and long-term psychosocial approach to treatment and (re-)integration by qualified staff, ranging from child and adult psychiatrists to clinical psychologists, social workers and qualified interpreters; • access to services for clients, free of charge. Lessons learned The main conclusions that can be drawn from the project are listed here. • Professional and well-organized health and psychological care is inevitably important in providing assistance to child VoTs. • The regulations and systems in place for assisting unaccompanied children and child VoTs vary widely among EU Member States. EU-level harmonization and coordination would be highly recommended. • Follow-up research and/or (eventually) the establishment of a monitoring system would be an important action going forward. 5 More information can be found at the Cordelia Foundation website (http://www.cordelia.hu/index.php/en/). Reference 1) Nonchev A, Mancheva M. Assisting and reintegrating child victims of trafficking: improving policy and practice in the EU Member States. Sofia: Center for the Study of Democracy; 2013 (http://www.csd.bg/artShow.php?id=16445). Further reading Developing indicators for the protection, respect and promotion of the rights of the child in the European Union. Summary report. Vienna: European Union Agency for Fundamental Rights; 2009 (http://fra.europa.eu/sites/default/files/fra_uploads/358-RightsofChild_summary-report_en.pdf). Guidelines for the development and implementation of a comprehensive anti-trafficking response. Vienna: International Centre for Migration Policy Development; 2006 (http://www.icmpd.org/Guidelines-for-the-Development-and-Implementation-of-a-Comprehensive-National-Anti-Trafficking-Respo.1851.0.html). Guidelines on the protection of child victims of trafficking. UNICEF technical notes. New York (NY): United Nations Children’s Fund; 2006 (http://www.unicef.org/ceecis/0610-Unicef_Victims_Guidelines_en.pdf). Szilard I, Barath A. Trafficked persons and mental health. In: Lindert J, Levav I, editors. Violence and mental health – its manifold faces. Dordrecht: Springer Science+Business Media; 2015:243–266. The IOM handbook on direct assistance for victims of trafficking. Geneva: International Organization for Migration; 2007 (http://publications.iom.int/system/files/pdf/iom_handbook_assistance.pdf). Toolkit to combat trafficking in persons. Global programme against trafficking in human beings. Vienna: United Nations Office on Drugs and Crime; 2008 (https://www.unodc.org/documents/human-trafficking/Toolkit-files/07-89375_Ebook[1].pdf). About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 6 The careless reception of UAMs at destination: impact and consequences on health Stefano Volpicelli, specialist sociologist in health and social vulnerability Background The presence of youth travelling alone, also known as unaccompanied minors (UAMs) or unaccompanied asylum- seeker minors (UASMs) have become a common pattern in today’s global mixed migration flows.1 Pictured as passive players with no role in the decision-making process, ruled by parents, relatives or peers, they are considered more as vulnerable victims than active actors in their lives. Such supposed vulnerability offers policy-makers good arguments to draw attention only to the dramatic and emergency elements of the migration situation, such as exploitation, abuse and trafficking. Therefore, the impact of the migratory experience on the health status2 of these young people is mainly investigated in relation to the traumatic events suffered while travelling, but the living conditions once they reach their destination are rarely considered as a source of illness. From 2010 to 2014 I designed and coordinated a research project3 aimed at measuring the propensity to migration of youth from Egypt, Morocco and Tunisia, to understand the impact of migration on UAMs from those countries then living in Italy and France. Although the research did not intend to investigate the health conditions, its findings confirm that young migrants suffer severe health consequences due to the harsh conditions of their trip, consequences worsened by the bumpy process of reception and varying assistance at destination.4 Migration as a project full of expectations Regardless of the reasons or motivation for doing so, when a person leaves their place of residence to move somewhere else, (s)he travels with two metaphorical rucksacks: the first one is filled with ideas, projects, objectives and expectations, and it balances positively the second one, which is packed with sadness, longing, worries and concerns. The analysis of the data gathered in the three countries shows that in shaping the individual’s decision to leave, the drivers related to material achievements – work, money, clothing and/or possessions – prove to have only a relatively slight influence. On the contrary, subjective and relational factors5 represent major forces in the decision to leave. The research, therefore, shows a more complex and nuanced portrait, far from the simplistic image of the migrant (of any age) as a money-maker. Indeed, it confirms that, today, youth from those countries have developed a sense of global citizenship that often collides with the poor (economic and social) atmosphere of where they live. In this context, migration is considered at best as a legitimate means to achieve a so-called first class social status (5), while at worst it is the only possibility to exist. Obstacles on the road to full emancipation After leaving their countries with such high aspirations and expectations, the majority of UAMs encounter traumatic experiences before arriving at their destination.6 What they find at their destination is a reception and a care system that is fragmented at best, or unable to intercept and deal with their real needs. The assistance – provided rather randomly, owing to a lack of tailored expertise7 – turns into a source of further stress and trauma.8 1 The presence of UAMs in Europe has been increasing since the beginning of the year 2000, reaching 88 300 cases in the year 2015 (1). 2 In this article the term health is used according to its wider meaning, based on the WHO definition of health as a state of complete physical, mental and social well-being. 3 The research, entitled “Propension et éxperience migratoire des mineurs marocains, tunisiens et egyptiens” was carried out in the framework of the Solidarity with Children of Maghreb and Mashreq (SALEMM) project, funded by the European Commission (2). More detailed information on the research framework (hypothesis, objectives, methodology, sampling and statistical treatment) and outcomes are available from the SALEMM website (www.salemm.org) in French and Italian. 4 Data from the research are in line with those of other studies: a 2012 study examined 222 males from Afghanistan aged 13–18 years who were seeking asylum in the United Kingdom. The study found that one third were likely to have post-traumatic stress disorder (PTSD) (3). Another study of unaccompanied refugee minors in Belgium followed 103 children for 18 months after their arrival. It found that their generally high levels of anxiety, depression and PTSD did not dissipate over that time period (4). 5 The subjective factors relate to life satisfaction, trust in one’s own abilities, introjected values; while the relational relate to representations of the world, and attachment to the family and to the group of peers. 6 In the research conducted, only 12 out of the 131 minors interviewed in Italy and France travelled in safe conditions. The remainder made their journey by makeshift means, boats or trucks. For the majority of them, the trip was long and stressful. 7 See IOM’s Unaccompanied children on the move (6). 8 According to the data, half of the sample of children had to cope with harsh situations, both in and outside the reception centers. About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 7 What is most striking is that upon arrival, almost all minors endured experiences of street life, sleeping in the street, eating junk food, and living by whatever means necessary until they were arrested by the police and placed in a community. Ten of them described being subject to violence from the police, or exploited in petty crimes and low-paid jobs.9 A total of 40 % of the sample declared that they were unsatisfied with their migratory experience as a result of the disillusion suffered upon arrival, the sense of abandonment and solitude experienced at their destination, and the perceived sense of being marginalized and socially excluded. Conclusions Despite the small size of the sample, the investigation raises the concern that too many UAMs – and not only those who fall off the radar of the social institutions after their arrival in Europe10 – suffer additional traumatic experiences at their destination, linked to the fragmented and often inadequate assistance response provided. The following impacts result from this lack of assistance. • At clinical level, the negative emotions related to the clash between expectations and reality can develop into chronic diseases (in varying forms).11 • At social level, the harsh conditions, leading to suffering and a prolonged state of anxiety and depression risk removing from the young migrants the possibility to develop a sense of belonging to their country of destination, pushing them instead into a process of self-marginalization and consolidating the feeling of being unwelcome. This process of social exclusion can have tragic consequences, in terms of self-harm or, even worse, thorough violent expression aimed at demonstrating their “existence”.12 All considered, there is a strong need for European migration policies to reduce the impact of daily stressors resulting from UAMs’ living conditions. Greater attention should be paid to the impact of reception services on youth health, through proper screening in order to adapt psychosocial and therapeutic care to the UAMs’ needs. References 1) Almost 90 000 unaccompanied minors among asylum seekers registered in the EU in 2015. Eurostat press release 87/2016, 2 May 2016 (http://ec.europa.eu/eurostat/documents/2995521/7244677/3-02052016-AP-EN.pdf/). 2) Volpicelli S. Rapport de la recherche. Propension et éxperience migratoire des mineurs marocains, tunisiens et egyptiens. Milan: Milanese International Cooperation Provincial Fund (FPMCI) Solidarité Avec Les Enfants du Maghreb et Mashreq (SALEEM) project; 2015 (http://salemm.org/sites/default/files/SALEMM_Ricerca_fra18_03_15.pdf). 3) Bronstein I, Montgomery P, Dobrowolski S. PTSD in asylum-seeking male adolescents from Afghanistan. J Trauma Stress 2012;25(5):555–557 (http://www.ncbi.nlm.nih.gov/pubmed/23070950). 4) Vervliet M, Lammertyn J, Broekaert E, Derluyn I. Longitudinal follow-up of the mental health of unaccompanied refugee minors. Eur Child Adolesc Phsychiatry 2014;23(5)337–346. 5) Ferguson J. Global shadows: Africa in the neoliberal world order. Durham (NC): Duke University Press; 2006. 6) Unaccompanied children on the move. Geneva: International Organization for Migration; 2011 (https://publications.iom.int/books/unaccompanied-children-move). 7) Volpicelli S. Who’s afraid of … migration? A new European narrative of migration. IAI working papers 15/32; 2015 (http://www.iai.it/en/pubblicazioni/whos-afraid-migration). 8) Fouad Allam K. Il jihadista della porta accanto. L’Isis a casa nostra [The Jihadist next door. The ISIS in our home, 2nd edition]. Milan: Piemme; 2014 [in Italian] (http://www.edizpiemme.it/libri/il-jihadista-della-porta-accanto-2). 9) Orioles M. E dei figli, che ne facciamo? L’integrazione delle seconde generazioni di immigrati [And what we are supposed to do with the children? The integration of the second generation of immigrant]. Rome: Aracne; 2015 [in Italian]. 9 These 10 were those who agreed to speak, while many others did not want to talk about what happened when they were on the streets. 10 Around 10 000 UAMs are currently believed to have disappeared, raising fears about their exploitation. 11 This link is also confirmed by the Center for Disease Control and Prevention (CDC), the leading national public health institute of the United States. Its data collection leads to the (conservative) analysis that 85% of all diseases have an emotional determinant. In the long run, those diseases can lead to further psychological disorders. 12 See for example Volpicelli (7); Fouad Allam (8), and Orioles (9). NEWS Press release. UNICEF reports on the dangers facing unaccompanied adolescent refugees and migrants fleeing to Europe, 14 June 2016 http://www.unicef.org/media/media_91552.html About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 8 Syrian refugees: a mental health crisis, 24 May 2016 http://blogs.worldbank.org/arabvoices/syrian-refugees-mental-health-crisis EVENTS Eurochild Conference 2016 “Children's rights matter: why Europe needs to invest in children” 5–7 July 2016, Brussels, Belgium http://www.eurochild.org/events/eurochild- conference-2016/ 5th European Conference on Mental Health 14–16 September 2016, Prague, Czech Republic http://www.ecmh.eu/ Migrants United Nations General Assembly High- level Meeting on Refugees and Migrant Health 19 September 2016, New York (NY), United States http://www.un.org/pga/70/2016/03/23/united- nations-summit-on-refugees-and-migrants/ International Dialogue on Migration 2016: Follow-up and Review of Migration in the SDGs (II) 11–12 October 2016, Geneva, Switzerland http://sd.iisd.org/events/international-dialogue-on- migration-2016-follow-up-and-review-of-migration-in- the-sdgs-ii/ World Health Summit 9–11 October 2016, Berlin, Germany http://www.worldhealthsummit.org/ 9th European Public Health Conference “All for Health – Health for All” 9–12 November 2016, Vienna, Austria https://ephconference.eu/ Experts sound alarm over mental health toll borne by migrants and refugees, 8 June 2016 http://www.theguardian.com/global-development/2016/jun/08/experts-sound-alarm-mental-health-toll- migrants-refugees-depression-anxiety-psychosis The truth about migration: how it will reshape our world, 6 April 2016 https://www.newscientist.com/article/mg23030680-700-the-truth-about-migration-how-it-will-reshape-our- world/ About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 9 Throughout history, refugees have contributed to the creation of cities and states, to literature, arts and music, but they have often been perceived as a source of risk, and villainized as a group of “mentally disordered” people. The psychological resilience and mental health of refugees coming into Europe is underresearched. The term mental health is used here in accordance with the WHO definition, which stresses the positive dimensions of psychological and social well-being, rather than focusing on the absence of mental disorder (1). What can we learn from refugees who risk their lives to find living opportunities, and how can we provide adequate mental health support to those in need? Mental health can give refugees the strength to start a new life; unrecognized mental disorders can be detrimental, not only to a person’s health and well-being but also to that of their families and children. Mental disorders can limit a refugee’s capacity to integrate into a host country. While the screening and treatment of infectious diseases for refugees have been well established for decades, the identification and appropriate cultural and gender-sensitive interventions for mental health problems in refugees continue to lag behind (2,3). Refugees leave their home countries for a number of reasons, including experiencing and witnessing war, violence, torture or the death of family members, or because of a lack of basic human conditions necessary for survival, such as food and shelter. During their potentially long and hazardous journeys, refugees are often exposed to life-threatening conditions, as well as cruel or abusive treatment. Furthermore, difficulties in the process of resettlement, such as living in overcrowded refugee camps or detention centres, ensuing poverty or lack of opportunities, as well as not feeling welcome and/or feeling discriminated against in host communities may increase the risk of refugees suffering from a variety of mental health issues (4). The common mental health diagnoses associated with refugee populations include post-traumatic stress disorder (PTSD), depression, generalized anxiety and panic attacks, adjustment disorder, substance abuse and somatization. The incidence and prevalence of mental health disorders varies within different populations and with their experiences before, during and after their flight from the country of origin. Different studies have shown rates of PTSD and major depression in settled refugees to range from 10% to 40% and 5% to 15%, respectively. In a systematic review of 826 records, with 72 populations meeting the inclusion criteria and 70 studies included in a final evaluation, it was found that the combined prevalence rate for depression was 44% (95% confidence interval (CI): 27–62) among refugees, while for anxiety the combined prevalence estimate was 40% (95% CI: 23–49) (5). While research has focused on mental disorders, the scope and extent of mental health issues among refugees is still underinvestigated. The picture remains challenging, as prevalence of mental conditions varies between available studies; this variation may result from the differing experiences of refugees before, during and after their journeys, or it could relate to the specific contexts and situations of the host country. Furthermore, variations in results are associated with variations in study characteristics and, in particular, with sampling methods, assessment instruments and the lack of validated cut-off scores in most refugee populations. There are many challenges in the identification of mental disorders and resources among refugees. Often, language and cultural barriers and biases (whether of the refugee or of the health and social care provider) can hinder identification of mental health disorders among refugees. The often limited access to health care also constitutes a risk factor for the development of somatic and mental disorders. OPINION This article represents the opinion of the author(s) and publications and does not necessarily represent the views of WHO, the University of Pécs or the Editorial Board of this newsletter. Mental health of refugees Prof. Dr Jutta Lindert, University of Emden, Germany About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 10 Some of this difficulty may result from missed cross-cultural symptoms (such as “thinking too much” (6)), or missed resources (such as social capital), but equally determinant is the construct and perception of a refugee as having mental disorders, conflated with a host country’s fears about national security, exploitation and erosion of resources in times of economic crisis. The possibility of being connected and having new opportunities is critical for refugees. Being connected means continuing to foster networks with relatives and friends from a refugee’s home country, as well as starting connections with new individuals in order to access educational and professional opportunities in the host country. The lack of opportunities is less associated with mental disorder but rather with conditions within host countries, such as a lack of understanding and willingness to offer opportunities to refugees in the first place. There are many challenges involved in providing effective mental health interventions for refugees, such as barriers to language, addressing specific cultural idioms of distress, legal barriers to mental health care as well as cultural expectations of care. It might even be that the care disclosure paradigm, on which Western psychological interventions are based, might actually be harmful for refugee population groups (7). Therefore, the strategy identified as most important for reducing the risk of mental disorders in refugees is the provision of general support: to meet basic needs, ensure safety and provide opportunities. Such opportunities may include offering the possibility for refugee families to stay together, and the ability to access opportunities in their host country in order to begin anew. Offering opportunities and support – such as access to the national education system – is especially important for children and adolescents (8). Based on current knowledge, several recommendations for good practice have been made. They address the issues of access to and organization of services for the delivery of mental health care (9), and the integration of services (10) as well as arguing for a public health approach to strengthen mental health and reduce mental disorders. Limited representative data are currently available on refugee mental health. Longitudinal studies with suitable comparison groups are greatly needed in research. Equally, evaluation of refugee interventions is needed, as well as the identification of resources which would allow refugees to successfully settle and start anew in their host countries, notwithstanding pre-, during, and post-flight experiences of suffering, witnessing violence or being tortured and persecuted. Providing mental health interventions and care to help repair the mental health damage of a refugee’s flight experience is only one part of a host country’s responsibilities; the prevention of further harm by actively combating discrimination and working to change perceptions of refugees are as just as important. References 1) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (and entered into force on 7 April 1948). Official Records of the World Health Organization 2:100 (http://www.who.int/about/definition/en/print.html). 2) Llosa AE, Ghantous Z, Souza R, Forgione F, Bastin P, Jones A, et al. Mental disorders, disability and treatment gap in a protracted refugee setting. Br J Psychiatry 2014;204:208–213. 3) Murray K, Davidson G, Schweitzer R. Review of refugee mental health interventions following resettlement: best practices and recommendations. Am J Orthopsychiatry 2010, 80(4):576–85 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3727171/). 4) Carswell K, Blackburn P, Barker C. The relationship between trauma, post-migration problems and the psychological well-being of refugees and asylum seekers. Int J Soc Psychiatry 2011;57:1007 (http://www.ncbi.nlm.nih.gov/pubmed/21343209). 5) Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brähler E. Depression and anxiety in labor migrants and refugees--a systematic review and meta-analysis. Soc Sci Med. 2009;69:246–257. 6) Hinton DE, Barlow DH, Reis R, de Jong J. A transcultural model of the centrality of "thinking a lot" in psychopathologies across the globe and the process of localization: a Cambodian refugee example. Cult Med Psychiatry 2016;Apr 16[Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/27085706). 7) Rousseau C, Measham T, Nadeau L (2013). Addressing trauma in collaborative mental health care for refugee children. Clin Child Psychol Psychiatry 2013;18:121– 136. 8) Fazel M, Karunakara U, Newnham EA. Detention, denial, and death: migration hazards for refugee children. Lancet Glob Health 2014;2:e313–314. 9) Lindert J, Brähler E, Wittig U, Mielck A, Priebe S. [Depression, anxiety and posttraumatic stress disorders in labor migrants, asylum seekers and refugees. A systematic overview]. Psychother Psychosom Med Psychol. 2008;58(3–4):109–122 (http://www.ncbi.nlm.nih.gov/pubmed/18421650). 10) Mollica RF, Brook RT, Ekblad S, McDonald L. The new H5 model of refugee trauma and recovery. In Lindert J, Levav I, editors. Violence and mental health. Its manifold faces. Dordrecht: Springer Science+Business Media; 2015:341–380. Public Health and Migration Division of Policy and Governance for Health and Well-being European Office for Investment for Health and Development WHO Regional Office for Europe Castello 3252/3253 I-30122 Venice, Italy Email: euphame@who.int University of Pécs Medical School Chair of Migration Health Szigeti St. 12 H-7624 Pécs, Hungary Email: mighealth-unipecs@aok.pte.hu About this newsletter: The newsletter has been established within the framework of the WHO Public Health Aspects of Migration in Europe (PHAME) project, based at the WHO European Office for Investment for Health and Development, Venice, Italy, in collaboration with the University of Pécs. The WHO PHAME project is funded by the Italian Ministry of Health. The quarterly newsletter is published by WHO/Europe and archived on its Migration and health website. © World Health Organization 2016 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. 11 RECOMMENDED READING Danger every step of the way. A harrowing journey to Europe for refugee and migrant children. New York (NY): United Nations Children’s Fund; 2016 http://www.unicef.org.uk/Documents/Campaigns- documents/UNICEF%20CHILD%20ALERT%20Refugee%20Journey.pdf Myers AL, Christenson JC. Approach to immunization for the traveling child. Infect Dis Clin North Am. 2015 Dec. 29(4):745–757 http://www.ncbi.nlm.nih.gov/pubmed/26610424 Ferrara P, Corsello G, Sbordone A, Nigri L, Caporale O, Ehrich J et al. The “invisible children”: uncertain future of unaccompanied minor migrants in Europe. J Pediatr. 2016;169:332–333 http://www.ncbi.nlm.nih.gov/pubmed/26810103 Metzner F, Reher C, Kindler H, Pawils S (2016). Psychotherapeutic treatment of accompanied and unaccompanied minor refugees and asylum seekers with trauma-related disorders in Germany. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016;59(5):642–651 http://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds[]=citjournalarticle_518 157_21 Contact us Document number: WHO/EURO:2016-7218-46984-68651