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Greater Research Investments Needed to Address Refugee Health

Photo of Tala Al-Rousan, MD, MPH. Courtesy of The Herbert Wertheim School of Public Health and Human Longevity Science

A Q&A with Public Health Researcher Tala Al-Rousan, MD, MPH

One in 74 people in the world are forcibly displaced, which includes nearly 41 million refugees and asylum seekers. Over the past decade the number of refugees worldwide has more than doubled. The United States has historically resettled more refugees than any other country, with more than 3.5 million refugees since 1980.

Refugees suffer many health disparities that are poorly studied or intervened upon. They battle mental health trauma, interrupted access to care, disease epidemics and deterioration of chronic conditions while living with the stress of looking for a new and safe home.

In a cross-sectional study in the Jan. 10, 2024 online issue of JAMA Network Open, a multi-institutional team of researchers reported that 78 out of 1.7 million National Institutes of Health (NIH) grants funded refugee health research. As the largest public funder of biomedical research and development the NIH must increase its investments in comprehensive studies assessing the physical, mental and social well-being of an expanding refugee population, wrote the authors.

Corresponding author, Tala Al-Rousan, MD, MPH, assistant professor in the Herbert Wertheim School of Public Health and Human Longevity Science at UC San Diego, shares what the researchers learned from a secondary analysis of NIH-funded grants between 2000-2020.

Q: What is causing an increase in forced displacement around the world?
A: Multiple factors increasingly becoming more complex and intersectional are causing mass forced displacement. The current rate of forced displacement is unprecedented. The highest ever on record. The three major drivers of forced displacement are war or political unrest, global economic inequality and climate change. These all have been exacerbated by the COVID-19 pandemic. Wars are erupting in various parts of the world including most recently in Europe. Inequality is striking and affects more than 70 percent of the global population. Finally, climate change, an increasingly potent migration driver, could force 216 million people across six world regions to move within their countries by 2050.

Q: Why do refugees face health disparities?
A: The refugee experience typically involves exposure to trauma throughout the stages of pre-displacement, displacement and post-displacement. In their country of origin, before being displaced, refugees may undergo specific traumas related to war, such as mental and physical abuse directed at themselves or their family members. During displacement, many refugees endure challenging physical and psychological ordeals, including long journeys on foot and vulnerability to exploitation by smugglers or other perpetrators. Subsequently, refugees and asylum seekers often endure months to years of suboptimal living conditions as they await information about their resettlement destination.

Following resettlement, refugees confront additional challenges, including discrimination, the loss of social networks, and the need to construct an entirely new life while navigating unfamiliar social and health systems. This multifaceted experience significantly impacts their health, particularly as access to healthcare and medications may be disrupted at various stages of the migratory process. Additionally, the escalating political anti-refugee rhetoric not only contributes to the production or continued presence of refugees in perilous areas but also influences policies related to their resettlement and the allocation of resources for their well-being.

Despite the common notion that immigrants, in general, exhibit better health upon arrival in the United States compared to Americans, an extensive body of literature highlights a phenomenon known as the "healthy immigrant paradox." This paradox elucidates that the longer immigrants stay in the U.S., the poorer their health becomes due to acculturation to the American diet and lifestyle. Refugees, however, represent a distinct category of immigrants facing triple trauma and unmet needs. Furthermore, there is mounting evidence indicating that the trauma experienced by refugees can be transmitted to their children.

Q: Describe the findings of your analysis.
A: Our study represents the inaugural effort to dissect the National Institutes of Health's investment in refugee health over the past two decades. As the predominant global financier of biomedical research, the NIH plays a pivotal role. Recognizing the urgent necessity to address the substantial global public health challenge of forced displacement, our investigation delved into the specific details of which institute funded what type of refugee health research. We scrutinized the temporal aspects, funding mechanisms, geographical locations for project execution and the durations of these initiatives. A crucial comparative analysis was conducted against the annual resettlement numbers of refugees in the United States.

Among the 1.7 million NIH-funded grants spanning two decades, a mere 78 delved into refugee health research or incorporated refugees within their study populations. While grants were disbursed through various mechanisms, the predominant share (29 percent) comprised training grants, deviating from expectations for a more robust research grant program, particularly the R01 mechanism. This starkly underscores the dearth of knowledge generation regarding refugee health, highlighting the substantial lag in addressing the needs and understanding the health dynamics of the burgeoning displaced population.

Further scrutiny revealed conspicuous funding gaps in critical areas of research, particularly chronic conditions among refugees. The preponderance of current funding allocation is disproportionately skewed towards mental health studies, leaving a notable void in comprehensively addressing the broader spectrum of health challenges faced by the growing displaced population.

Q: What impact would an increase in research funding have on refugee health?
A: There is a pressing need for extensive research among refugees, which remains largely unmet due to insufficient funding. Allocating additional resources for refugee health research is not just a moral imperative, affirming our commitment to recognizing health as a universal human right irrespective of origin, but is also imperative for our collective survival in the face of significant threats to humanity, such as climate change, escalating violence and political instability. Increased funding for refugee health is essential in comprehending migration as a crucial social determinant of health. Research becomes pivotal in unraveling the intricate ways displacement impacts diverse health outcomes, including the incidence of diseases like cancer or dementia, health behaviors, the cross-border spread of infectious diseases, health service utilization and the effectiveness of community health programs.

Q: What type of research is needed most to address health disparities among this population?
A: There is an imperative for comprehensive refugee health research that delves into all dimensions of well-being, aligning with the World Health Organization's definition of health as a state of complete physical, mental and social well-being, beyond the mere absence of disease or infirmity. The scope of research must extend to understanding displacement across the entire life course and considering gender-specific impacts. To propel advancements in this critical field, funding programs and training grants are vital. These initiatives would pave the way for the next generation of trainees, healthcare providers, scientists and leaders to engage in a multidisciplinary approach. Such an approach fosters innovation and creativity, enabling the development of solutions to break the cycles of health disparities. The overarching goal is to empower refugees and their descendants to achieve their full potential and mitigate the impact of diseases that could otherwise lead to significant healthcare expenditures.

Q: How can public health researchers make a greater impact in reducing health disparities?
A: Prioritizing prevention and community-based research assumes paramount significance, given that many refugees depend on community organizations or federally qualified health centers for accessing health information. The key lies in leveraging the establishment of trustful relationships with community members and organizations and channeling efforts into dismantling systemic racism through community-partnered research. Such an approach holds the potential to propel advancements in establishing more longitudinal research in refugee health and enhancing participation in clinical trials and behavioral interventions — areas currently marked by insufficiency.

Public health researchers are strategically positioned to spearhead refugee health research, drawing inspiration from the successes witnessed during the COVID-19 pandemic. Embracing inclusivity across all communities, particularly those historically underrepresented in research, has proven effective. This approach aligns with the broader goal of fostering equity and sets the stage for a more comprehensive and impactful exploration of refugee health.

 — Yadira Galindo