Climate Change Refugees and Public Health Implications
Climate Change Refugees or Environmental Migrants
Climate change and severe weather events are displacing people in growing numbers. The link among climate change, severe weather events, and long-term population shifts is increasingly receiving attention from human rights, migration, public health, security, economic, and other global professional sectors. Environmentally induced migration involves “persons who, predominantly for reasons of sudden and progressive change in the environment that adversely affects their lives or living conditions, are obliged to leave their habitual homes, or chose to do so, either temporarily or permanently, and who move either within their country or abroad” (IOM 2007). Within this context, people may be forced to leave their homes to save their lives because of an environmental emergency. Their migration may be environmentally forced to avoid “environmental deterioration with rapid-onset hazards.” Environmentally motivated migrants may migrate in the future in response to environmental degradation (Renaud et al. 2011).
The International Organization for Migration (IOM 2009) stated that “gradual and sudden environmental changes are already resulting in substantial population movements. The number of storms, droughts and floods has increased threefold over the last 30 years with devastating effects on vulnerable communities, particularly in the developing world.” Already, millions of people have become climate change refugees or environmental migrants, and their numbers are expected to grow. Forecasts for the number of environmental refugees between now and 2050 range from 25 million to 1 billion.
Growth in the number of global environmental refugees was first recognized as an emergent security issue as early as 1995. At that time, the conservative estimate was that there were 25 million environmental refugees in the world, with the largest acknowledged population found in Africa. In any location, these refugees “are people who can no longer gain a secure livelihood in their homelands” because of rising sea levels, drought, desertification, and other environmental issues. “In their desperation, these people feel they have no alternative but to seek sanctuary elsewhere…all have abandoned their homelands on a semi-permanent if not permanent basis, with little hope of a foreseeable return” (Myers and Kent 1995: 1; Myers 2001:609). It was also recognized as early as 1995 that one critical challenge for people displaced by climate change is the reluctance of governments and international agencies to even recognize the environmental refugee problem and/or to even determine an appropriate label for these migrants (Myers 2005). These people do not fit under the category of “forced migrants,” nor do they readily fit United Nations or US Department of State definitions of “refugees” or even Internally Displaced Persons (IDPs).
The accumulating literature on environmental refugees has a strong emphasis on the concepts and theory of vulnerability. The generally accepted and shared definition for “vulnerability” was provided by Blaikie et al. (1994): “By vulnerability we mean the characteristics of a person or group in terms of their capacity to anticipate, cope with, resist, and recover from the impact of a natural hazard. It involves a combination of factors that determine the degree to which someone’s life and livelihood is put at risk by a discrete and identifiable event in nature or in society.”
Overview of Human Migration in the Twenty-first Century
The early years of the twenty-first century have seen major changes in the world’s demographic profile. The world’s total population is currently just over seven billion. Mid-range projections by the United Nations Population Fund (2015) suggest the world’s population will grow to 10 billion by about 2050 and about 11 billion at the end of the century. Higher and lower projections for the end of the twenty-first century are 16.5 billion and 7 billion, respectively, depending on trends in fertility rates, which in general are projected to decline. Downward trends in global average fertility rates have already occurred, dropping from 4.5 children in 1970 to about 2.5 children in 2014. Although fertility rates are falling, the world’s total population will continue to grow since people are living longer. The average global life span in the early 1990s was 64.8 years, but today the average lifespan is 70.0 years. Expectations are for this upward trend to continue.
In addition to growth in the world’s total population, nations and communities will face challenges associated with expanding and changing forms of human migration. Although humans have moved from one region to another for millennia, there are five current and future migration trends that warrant attention by public health observers and health care providers: continued international economic migration, urbanization, clustering populations along coastlines, forced migration, and environmental refugees. Forced, human-induced environmental migration will have significant impacts on the health of refugee populations and the communities that host them.
Since 1950, the general flow of economic migrants has been from low-income nations in the Global South towards wealthier nations in the Global North. Between 1950 and 2015, Europe, North America, and Oceania have been net receivers of international migration. Africa, Asia, Latin America, and the Caribbean have been net exporters of migrants. Between 2000 and 2015, the world’s high-income nations like the United States and Germany received an average of 4.1 million net migrants annually. Larger numbers of migrants are expected from poor nations to middle-income developing nations like Brazil in the Global South (United Nations Economic and Social Affairs 2015).
Income disparities, though, between low- or middle-income nations and the world’s wealthier nations will continue to drive most economic migration. Indeed, between 2015 and 2050, the top net receivers of international migration will be the United States, Canada, the United Kingdom, Australia, Germany, the Russian Federation, and Italy. In these nations and others, net international migration will provide badly needed workers, as total births in high-income nations will continue to decline as the population ages. For some high-income nations, net migration may account for as much as 82% of population growth between 2015 and 2050 (United Nations Economic and Social Affairs 2015).
Even if they were welcomed in limited numbers in European nations with shrinking working age populations, recent large-scale influxes of refugees and other irregular migrants to the continent have created rifts in the European Union (EU). Since 2014, about two million refugees have arrived in Europe, with more than one million arriving in 2015 due to many Syrians escaping a violent civil war. But large numbers of refugees and other irregular migrants also arrive in the EU from Africa and the Middle East via the Mediterranean Sea. Italy, Greece, and Spain receive most of these newcomers, straining local resources. A growing number of EU member nations now reject an “open door” policy for migrants, citing burdens on housing, job markets, and the ability to integrate. In addition, some European leaders contend most migrants are not refugees fleeing war, but rather economic migrants seeking work. One result has been the externalization of borders, or the establishment of systems to screen potential migrants before they attempt crossing the Mediterranean Sea.
Another emerging trend is urbanization. Urbanization is the process through which nations and regions see the proportion of people living in rural areas decline, while the proportion of people living in cities, suburbs, and extra-legal settlements (“slums”) grows. Urbanization has been underway for thousands of years, but it has accelerated in recent years. According to the United Nations (UNESA 2015), 2007 was the first year during which more than half of human beings lived in urban areas. By 2050, about 66% of the world’s population will live in cities with most living in peri-urban environments (Davis 2006). By 2030, the world will have 43 megacities with ten million or more inhabitants. Most of these megacities will be found in developing nations (UNESA 2018).
Closely related to urbanization is the tendency of human populations to cluster along coastlines. Around 80% of human migration takes place within nations (UNDP 2009), with the bulk of these migrants leaving mountains and drylands to live in coastal cities. The tendency of populations to live along coastlines is often referred to as littoralization (Kilcullen 2013). Populations living near coastlines are particularly vulnerable to rising sea levels, extreme weather events, and salination of fresh water supplies. As many as 1 billion people will be vulnerable to sea-level rise, although some estimate that 20% of the world’s projected population of 9 billion will be forced to move to higher ground.
Forced migration refers to populations leaving their home communities due to war, inter-ethnic conflict, and other reasons that would make people fear death or persecution. There are more forcibly displaced people in the world today than at any time since World War II. Indeed, the United Nations High Commissioner for Refugees (UNHCR) (2018a) estimates that 68.5 million people in the world have been displaced. Most, about 44 million, were displaced from their homes but remained in their nations of origin. Because they cross international borders, refugees around the world garner more media attention, but Internally Displaced Persons (IDPs) that never leave their own countries outnumber refugees by a ratio of almost two-to-one. The UNHCR estimates the world’s refugee population today at 25.4 million, more than half of whom are under 18 years of age. In addition, there are some ten million “stateless” people in the world with no nationality or rights to basic needs such as health care, employment, freedom of movement, and education. Because of conflict or persecution, about 34,000 people are forcibly displaced every day.
Among the most disturbing outcomes of these new trends in human migration and environmental degradation is the health burden that will likely be experienced by these refugees, who are some of the world’s most vulnerable populations, and the communities that resettle them. The health implications of human-induced climate change and human migration on refugees are not yet fully understood for several reasons. First, large-scale, human-induced climate change is a relatively new phenomenon, and some public health concerns and changes, such as those related to chronic disease rates, can take decades to fully manifest in a population. Second, human-induced climate change can be a slow-moving disaster for some populations. For instance, it would be unlikely that an entire community would immediately migrate to a new country, just because the population experienced a very severe hurricane. Many choose to initially rebuild or merely move to higher ground, for example, in their home community rather than flee to a completely different nation. Only after years of severe disruption of their environment would many become international migrants. Thus, it can be difficult to accurately identify what populations have been affected by climate change and to what level that has affected their wellbeing. Third, from a public health status, it can be difficult to determine whether climate change directly has forced people to leave their homes permanently, or whether it has indirectly contributed to their departure because of its impact on local economies, conflict, or the ability to farm.
The health problems that could affect environmental migrants are complex and multifaceted, and require long-term, intensive interventions. The burden of poor health will likely be significant among these persons along the entire spectrum of displacement, ranging from their homelands that may be experiencing environmental degradation, to refugee camps where the persons may flee, and even to more permanent resettlement communities in third countries of asylum. The health challenges go beyond just clinical medical conditions that directly affect individual patients, such as infectious diseases, but also include socio-economic and related consequences that can indirectly affect the public health status of entire refugee populations and the communities that host them.
Disaster Morbidity and Mortality: Global warming is creating climate change around the world, which is leading to storms and other disasters that are more intense and frequent than ever. Hurricanes, floods, storm surges, tornadoes, wildfires, droughts, and typhoons are among the numerous kinds of disasters that appear to be increasing, leading to billions of dollars of damage to national economies, agricultural land, and fisheries, as well as contributing to increased morbidity and mortality rates of humans and animals. Much of the morbidity and mortality from disasters is occurring, in part, due to increased human density and poverty in slums, delta flood plains, and other environmentally unstable areas that are already home to some of the world’s most vulnerable and poorest populations. Many of these populations are socially the most vulnerable in their nations and are the least able to recover from climate change disasters. A recent example is the tremendous loss of life in Puerto Rico resulting from Hurricane Maria. Initial official estimates placed the number of deaths at 64 but follow-up research indicated the actual number of deaths was closer to 5,000 resulting from the territory’s crumbling inadequate infrastructure (Kishore et al. 2018). Another recent example is the mass loss of life amount refugees and other migrants seeking entré into Europe by crossing the Mediterranean Sea from North Africa and the Middle East. Between 2014 and 2017, approximately 1.7 million people arrived on European shores, of whom about 25% were children. Another 15% were women. However, the UNHCR (2018b) estimates that during the same 4-year period, at least 15,544 migrants drowned on the way with significantly higher numbers of deaths possible.
Food Insecurity and Water Shortages: Climate change refugees are experiencing and fleeing severe, long-term environmental degradation and disruption of the integrity of their land and ecosystem. The environmental impact of climate change can affect the nutritional health status of populations through increased food insecurity, crop failures, livestock and fish deaths, fresh water shortages, malnutrition, famines, and other critical problems. For example, public health conditions could occur that include food insecurity, low caloric intake, and micronutrient imbalances (Johns and Eyzaguirre 2002). More than 700 million people in the world are already malnourished but “climate change will act as a hunger risk multiplier exacerbating current vulnerabilities.” Up to 20% more people will be at risk of hunger of whom most (65%) will be found in sub-Saharan Africa (Met Office/World Food Programme 2012). As many as two billion people in the world already lack access to clean drinking water. Climate change and rising temperatures are expected to exacerbate shortages of drinking water and water to grow food. There is a global agreement that water insecurity contributed to the outbreak of the civil war in Syria. Water insecurity will promote mass migration in parts of Africa, the Middle East, and parts of Asia. Although many of these migrants will remain in their home countries, many will be forced to cross international borders, leading to potential conflict over dwindling water resources (Jägerskog and Swain 2016).
Infectious Diseases, Poor Hygiene, and Urbanization: People may flee more environmentally precarious areas of their nations, move to urban slums with poor infrastructure systems, and/or establish new migration routes out of their region or nation for better economic opportunities (McMichael 2015). The increased density of these populations, irregular access to clean water, and poor sanitation can lead to the rapid spread of many infectious diseases such as tuberculosis and cholera that are particularly deadly to pregnant women, children, and the elderly. These epidemics can spread beyond environmental migrants in some cases and pose a health risk to host communities if disease surveillance and outbreak interventions are not managed. Infectious disease patterns can also change over time. For instance, in some communities with increased rainfall and flooding, vector-borne infectious illnesses such as malaria, dengue fever, and chikungunya can spread into areas not previously considered at-risk and can create new infectious disease patterns (World Health Organization 2003).
Toxic Environments, Pollution, and Poor Living Conditions: Rising seas, increased flooding, storm surges, and the like can deeply affect the quality of the environment in which humans reside. Environmental conditions can degrade. For example, greater exposure to solar radiation can increase in some areas with climate change, contributing to higher skin cancer rates (World Health Organization 2003). Broken sewers, nonexistent or collapsed sanitation systems, exposed burial sites, and flooded landfills and dumps can be affected by climate change and disasters, thus creating toxic living conditions, polluted water and soil, and poisonous chemical runoffs for those living near these problems. Environmental migrants typically live in substandard housing in urban shanty towns, refugee camps, or low-income migrant apartments in resettlement communities which can be particularly affected by these climate changes along deltas, low-lying rivers, and other vulnerable areas such as in Bangladesh (McPherson 2015).
Noncommunicable Diseases: Chronic diseases that are strongly associated with lifestyles and personal behaviors are expected to increase with climate change migration (The Lancet 2016). For example, environmental migrants that move to live in urban slums from the countryside may experience micronutrient deficiencies, dental caries, obesity, and higher diabetes rates due to consuming more simple carbohydrates and processed foods. They may also be less physically active due to dense urbanization. Even eventual resettlement in another country may lead to significant dietary and exercise changes that can contribute to overweight, heart disease, cancer, hypertension, and other noncommunicable conditions.
Mental Health and Substance Use: Acculturation stress, cultural bereavement, anxiety, depression, and posttraumatic stress can affect refugees for years due to climate change disasters, forced migration, and resettlement (American Psychiatric Association 2017). This can be particularly challenging among cultures with strong stigmas against recognizing or treating mental health problems. Many of these problems are particularly exacerbated by the separation of family members and the break-up of extended clans and tribes. Tobacco, alcohol, and illicit drug use can also increase among these migrant populations to cope with the stress, depression, and uncertainty of forced migration.
Re-traumatization from Multiple Exposures to Disasters: Environmental refugees may experience multiple exposures to trauma and severe stress from large-scale disasters (McPherson 2015). As noted in the introduction to this chapter, environmental refugees are typically poor and live in disaster-prone areas such as river deltas or along coastlines. As was the case in 2005 after Hurricane Katrina devastated New Orleans, Louisiana, many people fled permanently to neighboring states and cities perceived as safer and less prone to disasters. However, when Hurricane Harvey hit in 2017 and shattered records for flooding, Katrina migrants that moved to Houston, Texas, were re-exposed to forced environmental migration because they had resettled in lower-income, disaster prone areas after fleeing Louisiana (Grey and Devlin 2017).
Violence, Security Threats, Unintentional and Intentional Injuries, and Trafficking: Forced human migration is often fraught with risk, danger, violence, injuries, and conflict. In environmentally unstable and impoverished areas affected by climate change, children and women can become victims of sex trafficking, forced marriage, and violent crimes before, during, and after migration (International Organization for Migration 2016). Domestic and sexual violence can occur, particularly in densely packed urban areas or in new resettlement communities where traditional social structures have been broken (Fisher 2010; Wenden 2011; Terry 2009). The forced environmental displacement of millions of poor people from vulnerable and degraded areas can present physical security threats to these refugees, such as new tribal conflicts, ethnic warfare over limited water supplies, terrorism, and other potential violent acts. Injuries, both intentional (suicide and murder) and unintentional (accidents), can be common among refugees during the flight phase, as well as during the resettlement where they may work in dangerous, low-paying jobs.
Public Health Disparities: Vulnerable populations that are forced to flee due to environmental degradation and climate change can experience a host of negative factors that contribute directly or indirectly to public health disparities within their communities. These can include, for instance, lower literacy levels due to breaks in their education; higher poverty rates as unskilled immigrants in new communities; language and cultural barriers to health care; limited geographic and financial access to medical services; political isolation; and so on. These factors can contribute to ethnic and racial health disparities in a host community (Levy and Patz 2016).
Special Gender and Age Considerations: According to UNHCR in 2016, approximately 80% of the world’s refugees are women and children, with young people comprising 41% of the world’s displaced individuals. Half of these children are unable to go to primary school and may not ever finish their education as refugees, thus impacting the socioeconomic growth potential and public health status of their families and communities for future generations. Gender and age disparities are significant when assessing the public health burden on climate change refugees (World Health Organization 2014; Zeman et al. 2017). Female refugees, for instance, are also more likely than men to experience assault, including rape, during their flight and resettlement phases, and many mothers, children, and the elderly face severe food insecurity and malnutrition challenges while refugees. Higher rates of maternal mortality, low birthweight, and infant mortality can occur due to overcrowding, stress, migration, and resettlement, and even traditional breastfeeding patterns may be disrupted. Relief rations in refugee camps, if not managed well, can end up in the hands of organized gangs or political strongmen, and do not necessarily reach the mothers, children, and elders that need the assistance the most. Poverty is also more likely to leave female migrants at risk because they often do not share the same rights or access as men to jobs, property, financial institutions, aid, and health care. All these challenges can translate into higher morbidity and mortality rates for women, children, and elders during every phase of migration, including flight, encampment, and resettlement. Even resettlement in a third country for the small number of refugees that are eventually granted asylum can be a difficult process that disproportionately affects women. Refugee and immigrant women often face significant language, cultural, gender, financial, geographic, transportation, social, and related barriers to services and care.
Traditional Health Practices: Climate change and forced environmental migration can have a significant impact on the traditional health patterns of populations and on the vulnerable indigenous populations that practice them (Nakashima et al. 2012). The rich body of cultural health beliefs, practices, and knowledge of a community can become completely disrupted, if not eliminated, during the forced migration and resettlement of indigenous groups. Traditional healers may not be able to pass on their knowledge to younger generations or may not have access to the plants, herbs, and other medicinal products used historically to heal residents of their communities. These items may no longer be able to be grown or harvested due to climate change or urbanization and are often difficult to replicate in resettlement communities where they are often misunderstood by western health providers.
Stressors on Health Care Systems in Resettlement Communities: Depending on the size of an environmental migrant population and where they eventually resettled, significant challenges could be experienced by the health care system in the receiving community (Langlois et al. 2016). For instance, environmental migrants may or may not have the financial, linguistic, cultural, or other means to access medical care and may rely on expensive emergency room charity care that must be supported by hospitals or governments. The tremendous variety in languages, rare languages, and low literacy rates that can be seen in many refugee populations, as well as larger family sizes, can also place a financial and operational burden on health systems in receiving nations.
Much remains to be seen and understood about the future of public health among environmental migrants fleeing global warming and human-induced environmental change. The predictions for the wellbeing of environmental refugees are concerning, even dire, and requires future research from long-term quantitative and qualitative perspectives. Under some circumstances, particularly for future generations, it may be possible that environmental migrants fleeing to higher income countries will have economic, educational, and social opportunities they did not have previously in less developed areas that could have a positive impact on their health status. However, it is much more likely that millions of refugees forcibly displaced by global warming, climate change, and environmental degradation will experience significant health disparities in their resettlement communities for years to come.
With predictions that the size of “climate change refugees” could grow to 150 million by 2050, far surpassing the current number of refugees displaced by conflict, and that 41 persons are displaced every minute by climate change (Environmental Justice Foundation 2017), urgent steps at the global, regional, national, and local levels must be taken to address the public health implications of this rapidly growing crisis. The strategies to address these public health concerns must be multifaceted, well-funded, proactive, and ongoing; they also should be integrated with programs and policies that address the broader socio-economic wellbeing of these migrants. Strategies will also need to have a focus on protecting the most vulnerable of these environmental migrant populations, notably women, children, indigenous and ethnic minority families, and the elderly. Greater efforts must be made now to educate the lay public, providers, policy makers, and political leaders about the “rising tide” of environmental migrants and the health burdens that they and their resettlement communities can experience, so that strategic planning activities can be undertaken, and resources can be positioned to meet these needs. Ultimately from a prevention standpoint, global efforts must be taken by all regions to meet the United Nations Sustainable Development Goal 13, which addresses climate change on the front-end, the root cause of forced, human-induced, environmental migration.
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