1. Robertson, Cheryl L.
  2. Hoffman, Sarah J.

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We do not know where the adage "the wars of the 20th century were fought over oil, but the wars of the 21st century will be fought over water" comes from. However, its relevance to today's circumstance of conflict and scarcity of natural resources and the profound influence of these factors on human migration are undeniable. Moreover, although for a brief moment, the impact of these global circumstances did not appear to directly impact the universal human experience (at least not from the perspective of the global north), we now know differently. Let us consider this awareness a call to action for nurse scientists to expand our discipline's perspective on the science of health, in recognition of the ways the influence of policy, the state of environment, and the application of the human rights framework impress on the changing world. In particular, let us consider the ways these external issues contribute to health inequity; disparities; and the mental, physical, and psychosocial health consequences of forced migration.


The forced migration of families and communities is a complex phenomenon, driven by armed conflict, climate change, the allocation of scare, nonrenewable natural resources, and shifting patterns in the politics of globalization. On June 14, 2014, World Refugee Day, the United Nations High Commission for Refugees reported that the number of refugees, asylum seekers, and internally displaced people worldwide has, for the first time in the post-World War II era, exceeded 50 million people. As of 2014, in Syria, over 6.5 million people are internally displaced by the civil war (meaning they have fled their homes to seek protection but have not fled their country as refugees). In Colombia, 5.7 million people are internally displaced because of the decades-long conflict involving the international drug trade, political corruption, and armed resistance movements. In the Democratic Republic of Congo, nearly 3 million have been driven from their communities to escape the conflict caused by "Africa's world war" only to be faced with profound levels of disease and malnutrition. In Sudan, 2.4 million remain homeless because of the flight from human rights atrocities that have taken place since the start of their civil war. In Iraq, in addition to the regional instability caused by the Syrian conflict, tens of thousands have urgently fled cities to escape gender-based and religious persecution. In Somalia, 1.1 million people remain displaced because of violence, drought, and famine (Norwegian Refugee Council, 2013). In aggregate, these numbers reflect the massive issues faced globally, in terms of stability and public health. Considering each individual who has been forced to migrate because of fear, violence, or want, we recognize the challenge, from a human security perspective, of assuring each individual freedoms, dignity, and rights.


Internally displaced persons, refugees, and others under circumstances of forced migration such as victims of trafficking experience food insecurity, postmigration conflict, shifts in urbanization patterns, and human rights abuses. The loss of home and community impacts psychosocial and physical health, but these experiences tend to be overlooked as the trauma of events leading to migration is prioritized. Displacement drives changes in communities that result in disruptive culture transformation, dissolution of civil society, and diminished capacity for resilience. Fear breeds a culture of apathy where community rules, values, and cultural constructs are eroded and replaced by coarser and cruder norms that negatively affect determinants of health, further destabilizing communities themselves.


For example, refugees resettled in host countries face seemingly insurmountable challenges of navigating confusing and often fragmented systems. The refugee resettlement process in the United States is decentralized. Local resettlement agencies operate with limited resources. Refugees report challenges to integration that include poor housing options and inadequate experiences in education, employment, and healthcare sectors. Refugee housing tends to be concentrated in low-income apartment complexes located in high-crime areas. As a result, refugee families often experience urban violence and crowding. In addition, public school enrollment is tied to the home address. Therefore, the quality of housing and education are closely connected. The financial burden of supporting non-English-speaking students with a variety of unique needs falls to the schools, many of which operate under already strained financial models. A further threat is the approach to program evaluation adopted by federal bodies monitoring refugee resettlement, in partnership with states. Successful resettlement is not measured according to the resilience and thriving of individuals and communities, but primarily with a set of indicators targeting economic self-sufficiency. In turn, programs implemented to support new arrivals are focused on job readiness and rapid entry into the labor market. The mental, physical, and psychosocial health vulnerabilities of the individual are addressed at a lower priority level. The consequences of this approach place in jeopardy the full enjoyment of the right to the highest attainable standard of health, as we have interpreted from the United Nations Committee on Economic, Social and Cultural Rights, 2000.


Nearly all forced migrants seeking refuge across the globe have experienced losses, and many have experienced multiple traumatic experiences. Impairments of psychological functioning such as depression and anxiety disorders, including posttraumatic stress disorder, are common after migration and settlement. Despite this, most refugees with psychological problems do not access the clinical mental health system, and trends are likely similar for other types of forced migrants. Because conflict occurs within community contexts, it is logical that recovery from trauma and loss originates from within a social framework as well, with families gradually rebuilding relationships and individuals adapting to and adopting new routines and meaningful activities. The process of intergenerational memory transmission becomes a part of the collective healing process as families elicit meaning from their migration narrative.


Informed by epidemiologic science and social justice ethics, nurses pursue an approach to healing situated within a holistic framework and guided by the philosophy of health as a resource for life (World Health Organization, 2014). In partnership with communities experiencing forced migration, this perspective will support the expansion of the health agenda beyond the biomedical model to promote healing and reconnection with families and communities. However, there is nursing work to be done to reach this point. Through enhanced understanding of health status at all stages of life, coping, and resilience during and subsequent to migration, we can more intentionally connect the human rights framework with the actions of nursing and public health practitioners. This will both root and unite our approach to addressing the complex problems associated with displacement and resulting health inequities. Among the greatest assets in nursing is the application of appreciative inquiry to the critical assessment of circumstances like forced migration. As strengths inherent to individuals and communities impacted by forced migration emerge, the global community of nurse scientists must act urgently to use this information to build the intervention science around these observations.


In summary, within the forced migration context, families experience profound loss and trauma, and the community capacity to support healing is compromised through destroyed civil society, coarsened cultural norms, dismantled infrastructure, and eroded resilience. Nursing came of age in such environments-back when Florence Nightingale opened the windows in the Crimea. We have a storied history of engagement in the most complex of challenges. These roots keep us grounded and poised to promote healing among the chaos-to reintegrate individuals and families within healthy reconstructed communities.




Committee on Economic, Social and Cultural Rights. ( 2000). General Comment 14, The right to the highest attainable standard of health (22nd session, 2000), U.N. Doc. E/C.12/2000/4. Reprinted in Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI/GEN/1/Rev.6 at 85 (2003). Retrieved from[Context Link]


Norwegian Refugee Council. ( 2013). Global estimates 2012: People displaced by disasters. Retrieved from[Context Link]


World Health Organization. ( 2014). Health. Retrieved from[Context Link]