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Planning for the health care of the Southeast Asian refugees, a review Ludwig, Barbara M. 1980

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PLANNING FOR THE HEALTH CARE OF THE SOUTHEAST ASIAN REFUGEES: A REVIEW by BARBARA M. LUDWIG B.N. McGill Univers i ty , 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE THE FACULTY OF Department of Health Program in Health in GRADUATE STUDIES Care and Epidemiology Services Planning We accept th is thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA December, 1980 (x) Barbara M. Ludwig 1980 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by the Head o f my Department or by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f The U n i v e r s i t y o f B r i t i s h Co lumbia 2075 Wesbrook Place Vancouver, Canada V6T 1WS Date &4 flpff ABSTRACT In 1979-80 the Canadian government accepted 50,000 refugees from Southeast Asia as landed immigrants. These new immigrants, known as "The Boat people", are part of the changing pattern of world migration and come from an area that i s d i f fe rent from Canada in terms of disease patterns, cu l tura l be l ie f s and customs- They are probably also affected by the i r experiences of prolonged warfare and subsequent f l i g h t . The question is raised about the e f fec t , i f any, the i r health status w i l l have on both the health of Canadians and/or the i r own future health. It i s postulated that both the i r own charac ter i s t i cs and those of Canadian society w i l l determine the problem and af fect the resolv ing of i t . Using the f i e l d s of anthropology, sociology, and h i s to ry , as well as those of medicine and health care, an extensive l i t e ra tu re search i s made to determine the charac ter i s t i cs of the refugee/immigrants and Canadian soc iety , and from th i s to del ineate the problems. The problems are seen to be the immediate and longer term problems of 1) the spread of infect ious diseases; 2) the importation of ' exo t i c ' diseases into Canada; and 3) the e f fec t of the l i f e experiences, migrat ion, and the process of adaptation to a new environment on the mental health of the immigrants. The resolut ion of the problems i s found to be affected by the i i att i tudes and be l ie fs of Canada and Canadians, inc luding the immigration, soc ia l and health po l i c i e s of governments; as well as by the cu l tura l be l i e f s and customs of the Southeast Asians. Recommendations are made on factors seen to af fect the effect iveness of health and soc ia l programs for immigrants. These include recommendations on the need for those planning and de l iver ing health care, espec ia l ly physic ians, publ ic health nurses and soc ia l workers, to be aware of the e f fec t of culture on health behaviour and the giv ing of health care; and for physicians to be knowledgeable about the epidemiology and diagnosis of the so-ca l led exot ic diseases. Recommendations are also made on the roles of the d i f fe rent levels of government and the voluntary agencies in the immigration process with regard to immigrant heal th. Thesis Supervisor i i i TABLE OF CONTENTS Page INTRODUCTION 1 Chapter 1. METHOD OF APPROACH 3 Chapter 2. MIGRATION: Causes and world patterns 8 Introduction 8 Why man migrates 8 Changes in the pattern of world. migration 9 Migration Post World War Two H Migration c l a s s i f i e d 12 Refugees 13 Voluntary migrants and refugees: 16 the i r s im i l a r i t i e s and differences The trend in migration patterns 17 Chapter 3. THE MIGRANT AND HIS NEEDS 19 Introduction 19 Basic needs: food, water and sleep 19 Shelter and secur i ty 21 The need to belong 21 The esteem of others 23 Se l f -ac tua l i za t i on 23 The immigrant adjustment process 24 The mental health of immigrants 24 Health problems 28 The e f fec t of war on health 31 Be l ie fs about health and sickness 33 Chapter 4. THE RECEIVING COUNTRIES AND THE CHANGING 36 PATTERNS OF MIGRATION i v Page Introduction 36 Economic stress 36 Social stress 37 Social problems and soc ia l service 38 Health problems and health services 39 Aid for immigrants 43 The e f fec t of culture and custom 43 on health care. Chapter 5. RECEIVING COUNTRIES: SOME EXPERIENCES WITH IMMIGRATION. 47 Introduction 47 Countries of permanent settlement 47 North west Europe 59 - Great B r i t a in 62 Chapter 6. CANADA AND IMMIGRATION 69 Introduction 69 1867-1918 69 1919-1945 72 1946-1960 73 1961 to the present 74 Canada's refugee po l i c ies 78 The Vietnamese in Canada 82 Chapter 7. THE 'BOAT PEOPLE' 83 Introduction 83 Human needs 83 Tradi t ional health and sickness 88 be l ie f s and pract ices v Page The e f fec t of co lonizat ion 90 The :effects of the war,. ' 91 Health problems in Viet-Nam 92 Post war 93 Experiences during f l i g h t 95 L i fe in the refugee camps 95 Chapter 8 HEALTH PROBLEMS EXPECTED WITH THE REFUGEES 98 Introduction 98 Indices of community health 98 The co l l ec t ion of internat ional -JQQ epidemiological data Factors in the spread of disease 101 Infectious diseases that may be transmitted to Canadians 103 Infectious diseases that are a threat to the ind iv idual refugee. 119 Diseases endemic in Viet-Nam that are un l ike ly to be a threat to e i ther Canadians or refugees 130 Other infect ious diseases 132 ^on-infectious diseases and conditions 133 Discussion 139 Chapter 9 PROBLEMS OF ADJUSTMENT AND MENTAL HEALTH 143 Introduction 143 The Vietnamese in the U.S.A., 1975-76 143 The Vietnamese in Canada 147 vi Paje Chapter 10. RECOMMENDATIONS AND CONCLUSIONS "155 Introduction 155 The character i s t i cs of the 'Boat people' 156 The Canadian character i s t i cs 157 The problems, and recommendations 159 Conclusion 168 v i i LIST OF TABLES Table Page Studies showing the number(%) of Indochinese chi ldren tested who were tubercul in pos i t ive > 10mm. 110 Rates of in fect ion with E h i s t o l y t i c a and G Iambiia in selected groups of Vietnamese refugees compared with those rates in the U.S.A. 118 Helminth in fect ion in selected groups of Indochinese refugees. 123 vi 11 LIST OF FIGURES Figure Page Diagram to i l l u s t r a t e the factors af fect ing the health status of the Southeast Asian refugees and a framework for solv ing problems ar i s ing from th i s . ' Map of Viet-Nam and part of Southeast Asia. 84 Summary of diseases that may be a problem with the resettlement of the Vietnamese refugees in Canada. 138 ix ACKNOWLEDGEMENTS I would l i k e to thank the members of my thesis committee for the i r help and patience. The Department of Health Care and Epidemiology, Faculty of Medicine, the Univers i ty of B r i t i s h Columbia: Dr M.M. Warner, Chairperson., (Director of the Program in Health Services Planning);Dr. J . Robinson; Dr. N. Waxier (formerly of the University of Sr i Lanka). I would also l i ke to thank the ind iv idua ls and organisat ions, too many to l i s t , who so generously gave of the i r time and information. x 1 INTRODUCTION On July 18 1979 the federal government announced Canada's decision to accept up to 50,000 refugees from Southeast Asia for resettlement in th is country.(1) These w i l l be added to the approximately 14,000 Vietnamese who have arr ived since the end of the Vietnam War in 1975, and w i l l be the largest group of refugees ever to be admitted to Canada. (2) It i s recognised that patterns of world migration are changing from the large scale movements between areas of s im i la r geography, race and cu l tu re , to a smaller movement between these areas and an increase in the migration between areas that are s i gn i f i c an t l y d i f fe rent . This voluntary movement i s complicated by a growing stream of involuntary migrants who have been uprooted for one reason or another and are looking for resettlement elsewhere. The involuntary migrants, or refugees from Southeast Asia are coming from an area of the world that i s s i gn i f i c an t l y d i f fe rent from Canada; and are known as 'The Boat people' . The changes in world migration patterns are causing unfamil iar problems in the countries receiving migrants: there may be a problem with ' v i s i b l e minor i t i es ' and rac ia l tension; the new immigrants may f ind i t d i f f i c u l t to adapt to a new environment; and there may be a r i s k of introducing diseases that 2 are a threat to the publ ic health and/or a challenge to the diagnostic and treatment capab i l i t i e s of the health serv ices. The questions asked are 1) what e f fec t w i l l the health status of these new immigrants have on the health of Canadians and/or the i r own future health, and 2) what factors determine the health status and af fect the resolut ion of any problems ar i s ing from this? This thesis w i l l explore both the factors determining the health status of the new immigrants and those seen to af fect the resolut ion of problems ar i s ing from th i s . While not prescr ib ing spec i f i c programs and services for the health care of the refugee/ immigrants, recommendations w i l l be made on factors seen to contribute to the success or f a i l u re of such programs. 3 CHAPTER 1 METHOD OF APPROACH The 'Boat people 1 are part of a large movement of refugees in Southeast As ia : t h i s , and the i r resettlement in Canada are seen as part of the changing patterns of migration across the world. S t a t i s t i c s show that over the las t decade a growing proportion of Canadian immigrants are coming from countries in As ia , Ind ia, and A f r i c a , and the same phenomenon i s happening to a d i f ferent degree in the U.S.A. and Aus t ra l i a . In those countries that have t r ad i t i ona l l y received large numbers of immigrants from Europe, the new immigrants are conspicuous because of colour, race, or custom. Because they come from areas of the world with d i f fe rent l i f e s t y l e s and standards of l i v i n g , there may be health problems associated with the move to a new environment. Over the las t three decades, Great B r i t a i n and Europe have been dealing with the soc ia l and health problems associated with large inflows of people from As ia , A f r i c a , the Caribbean, as well as from southern Europe. There i s concern that the health status of the Southeast Asian refugees on the i r a r r i va l in th i s country, w i l l threaten the health of Canadians; and that because of possible chronic health problems they w i l l be a burden on health services rather than becoming contr ibut ing members of soc iety. In view of 4 the changing patterns of world migrat ion, i t i s f e l t that by examining the s i tuat ion of the 'Boat people' in Canada some ind icat ion can be given of (any) changes required in the po l i c i e s , programs and services designed for the settlement of immigrants per se in th is country, espec ia l ly those in the area of health and health care. There are many factors involved in th is examination. The health status of the immigrant/refugees-will depend on the i r character i s t i cs as well as on the immigration po l i c i es of Canada. Human charac ter i s t i cs are a product of race, cu l ture, and soc ia l experience, as well as ind iv idua l s k i l l s and motivation. These in the i r turn are a product of geography and h i s tory . Human needs are met within th is framework and the health of the indiv idual i s a product of a l l of the above. Immigration, soc ia l and health po l i c i es are the product of the co l l ec t i ve wishes of a given country, which again are a product of geography, h is tory , and soc ia l experience. Immigration po l i c i es set the standard of health required for entry into a receiv ing country; and soc ia l and health po l i c i e s , programs and services w i l l have some impact on the health of an immigrant once he has se t t l ed . However, i t must be remembered that good health i s not so le ly dependent on the avai lab le health serv ices, buti. i s a function of personal cha rac te r i s t i c s , environment and l i f e experiences. 5 I t i s postulated that the health of the 'Boat people' i s determined by the i r own character i s t i cs and by Canadian immigration po l i c i e s . P o l i t i c a l and soc ia l values produce soc ia l and health po l i c i e s , not to mention immigration po l i c i e s . The att i tudes of Canadians w i l l a f fect the way these refugee/immigrants are welcomed; how they se t t l e down; and eventual ly how any health problems that might ar ise are resolved. I t i s postulated that the resolut ion of any health problems ar i s ing from the a r r i va l of 50,000 refugees from Southeast Asia w i l l be affected by the character i s t i cs of Canada and the Canadian people. This thes is w i l l approach the problem of the e f fec t that the health status of these new immigrants may have on the health of Canadians and themselves from these two perspectives: the charac ter i s t i cs of the *Boat people' as representative of the refugees; and the character i s t i cs of the receiv ing country, Canada. The process i s i l l u s t r a t ed in f igure 1. (page 7) The many facets of th is approach indicate the need to consult the d i sc ip l i nes of anthropology, sociology and h i s to ry , as well as those of medicine and health care. To., th is end an extensive l i t e ra tu re search w i l l be undertaken with the fol lowing framework. 6 World migration patterns w i l l f i r s t be reviewed and .the trends-:noted. As health i s a t least par t ly a resu l t of human needs being met, these and the health problems of migrants in general w i l l be examined. The e f fec t of the changing patterns of migration and migrant character i s t i cs on the receiving countries w i l l be explored. The experiences of selected receiving countries w i l l be reviewed before the development of Canadian immigration pol icy is examined. The charac ter i s t i cs of the'Boat people' w i l l be described, and the health problems that might ar ise with the i r a r r i va l in Canada defined. Recommendations w i l l then be made on factors seen to a f fect the outcomes of any programs and services designed to resolve these problems. INPUTS PROBLEM DESIRED OUTCOMES CHARACTERISTICS OF THE IMMIGRANT/REFUGEE Needs Experiences Culture S k i l l s Expectations Numbers Location Health 4 Status CHARACTERISTICS OF THE RECEIVING COUNTRY Risk of health status t o : 1. community 2. i n d i v i d u a l ~~ immigrant-refugee Needs Experiences Culture Expectations At t i tudes Immigration, s o c i a l and health p o l i c i e s , -* programs and serv ices 1. 2. to reduce the r i s k to the community to maximize the health o f the i n d i v i d u a l i mrni g ran t - re f u gee programs and serv ices needed to a t t a i n des i red outcomes recommendations Figure 1 Diagram to i l l u s t r a t e the factors a f f e c t i n g the health status of  Southeast Asian refugees and a framework, f o r s o l v i n g problems  a r i s i n g from t h i s . 8 CHAPTER 2 MIGRATION : CAUSES AND WORLD PATTERNS INTRODUCTION According to Lee, migration can be defined broadly as a permanent or semi-permanent change of residence, with no r e s t r i c t i on placed upon the distance of the move or upon the voluntary or involuntary nature of the act . ' (3) Human beings have been moving from one place to another, for one reason or another, since preh i s to r i c times; and the patterns of migration have changed over the centur ies. Migration can be e i ther voluntary or involuntary, and the problems of the movement-of refugees on a world-wide basis are growing. WHY MAN MIGRATES The causes of human migration are those natural impulses that f i r s t drove man, espec ia l ly pr imi t ive man, to emigrate in search of food and she l ter , to insure his protect ion, or merely to sa t i s fy his desire for movement. (4). Although we lack precise records of the ear ly migration of man, the evidence of legends and archeology indicate that people have moved from time immemorial. (5) The motivations for moving have remained constant through the ages. 9 Natural phenomena such as floods and eruptions have forced man to move; and sometimes he has l e f t an unproductive or overcrowded land in search of a better l i f e elsewhere. Examples of th is are the mass emigration from Ireland fol lowing the famines of the 1840s, the Puritans who l e f t England on the Mayflower in search of re l ig ious freedom, and the thousands of Jews who f l ed from eastern Europe at the end of the l as t century because of persecution. In h i s t o r i c a l times economic development has caused population movements from rural to urban areas; within regions; and between continents. (6) This i s not a recent phenomenon: Flemish weavers were enticed to England by Edward 111 so that England's wool could be processed at home instead of abroad; and the indust r ia l revolut ion in the late eighteenth and ear ly nineteenth centuries brought thousands into the new indust r ia l towns from the B r i t i s h countryside. In general, saysBeijer "migration i s a necessary element of normal population red i s t r ibu t ion and equi l ibr ium and an arrangement for making the maximum use of avai lab le manpower." (7) CHANGES IN THE PATTERN OF WORLD MIGRATION The patterns of migration changed dramatical ly with improvements in technology, espec ia l ly in transportat ion; with the rapid increase in the population of Europe; and with the discovery of the vast 'empty' spaces of both Americas, Oceania, and South A f r i c a . This transoceanic migration lasted from 1840 to 1914, 10 and besides the mass exodus from Europe there was considerable out-migration from China and Japan at the same time. "This period of mass emigration i s of considerable importance, since i t resulted in the creation of extra-European sections of the white race, in the expansion of the yel low race, and in the formation of the imperial ism of the great modern powers. 65 mi l l i on have crossed the oceans in one century to f ind a home elsewhere." (8) Unt i l the Second World War, migration was pr imar i ly for economic reasons: poor conditions at home 'pushed 1 , while the prospect of greater opportunity ' pu l l ed ' the emigrant. I t appeared to be the great remedy both for the d i f f i c u l t i e s of l i v i n g , and for the unemployment engendered f i r s t by the indust r ia l revolut ion and la ter by periods of economic stagnation. The freedom of internat ional migration which characterized the nineteenth century was part of the general ' l a i s s e z - f a i r e ' at t i tudes to soc ia l and economic matters. (9) In spi te of the 'open door' po l i c ies there was already ag i tat ion for r e s t r i c t i on of immigration before the end of the nineteenth century and th is affected the development of immigration po l i c ies in the major receiv ing countries such as Aus t ra l i a , U.S.A., and Canada. The rate of immigration slowed down in the period between the two world wars, but i t i s debatable whether th is was due to the r e s t r i c t i v e po l i c i es or to the economic slow-down of the 1920s and the 1930s. 11 MIGRATION POST WORLD WAR TWO The major goal of immigration since World War Two has been economic development, and the manpower needs of both the t rad i t i ona l receiv ing and sending countries are again changing the whole pattern of migrat ion. In fac t , rather than exporting surplus population, indust r ia l northwestern Europe has been importing foreign workers on a temporary basis because of a shortage of labour. (10) For both receiv ing and sending countries " . . . human cap i t a l , expressed not only, in numbers but also in s k i l l s , i s necessary for the i r economic development." (11) In exporting surplus unsk i l led labour, poorer countries often receive much needed foreign capi ta l in the money sent home by the i r emigrants. Thomas noted that "a s t r i k i ng features of the internat ional scene since the Second World War i s the high proportion of migrants who can be regarded as human cap i t a l , i . e . 'the profess iona l , technical and kindred grades." (12) He then examined the reasons for the so-ca l led 'brain dra in ' from the under-developed to the i ndus t r i a l i zed countries but hesitated to predict the continuation of th is trend into the future. However, Be i je r saw the composition and the d i rect ion of the voluntary migration stream changing. "In short, the streams of migrants w i l l no longer flow between areas of European settlement,but w i l l flow from the under-developed countries to the more developed ones in Europe and the countries of European settlement." (13) 12 The rebound of the European imper ia l i s t po l i c i es of the nineteenth and ear ly twentieth centuries has also affected world migration patterns since .the Second World War. The granting of independence to the i r former colonies has resulted in large inflows of repatr iates and refugees from the so-ca l led "Third World 1 countries into Great B r i t a i n , The Netherlands, France and Belgium. (14) Po l i c i es have had to be modified and programs and services expanded to cope with both "the v i s i b l e t ide of coloured immigrants", and the ensuing soc ia l unrest and po l i t i c a l ag i tat ion for the control of immigration. (15) In fac t , i t now seems that ". . .heavy immigration i s a thing of the past. Today, a country wishing to benef it from heavy immigration must be able to cope with the economic and soc ia l problems involved. In other words, i t must have a su f f i c i en t l y sound economic base to support the investments required, combined with adequate administrat ive machinery. I f th is structure is too weak, the ef fects of the investment that immigration i t s e l f can be expected to generate w i l l be problematic; simultaneously, there w i l l be a d i s t i n c t danger of disturbances, such as unemployment, lower wages and i n f l a t i o n . " (16) MIGRATION CLASSIFIED Migration may be c l a s s i f i e d as fo l lows: voluntary and temporary; voluntary and permanent; involuntary and temporary, and involuntary and permanent. Examples of voluntary but temporary migration are the movement of workers within the European Economic Community, and that of seasonal workers from Mexico and the Caribbean to the U.S.A. and Canada; while voluntary and permanent 13 migration i s i l l u s t r a t ed by the great population movements of the 19th and 20th centuries. Involuntary but temporary movement may be caused by natural d isaster or war, with theLmigrants intending and able to return home or f ind refuge elsewhere. Involuntary and permanent migration means the forced movement of people, for whatever reason, and who have no hope or intent ion of going back to the i r place of o r i g i n . Through the centur ies, the desire for re l i g i ous , p o l i t i c a l or soc ia l freedom has caused men to vo luntar i l y or invo lunta r i l y leave the i r homeland, but t ru ly involuntary movement:: "has not been planned, organized or part ic ipated in by ind iv idua ls or groups for the i r prefered reasons." (17) Slavery i s the c l a ss i ca l example, but th i s has been overshadowed in the 20th century by massive population movements caused by war, and po l i t i c a l and soc ia l change. REFUGEES The chief charac te r i s t i c of migratory currents since 1945 has been the s ize and importance of p o l i t i c a l , as dist inguished from economic migratory movements. " M i l l i o n s have been driven from the i r homes and the population structure of ent i re countries rad i ca l l y a l te red . Diplomacy and p o l i t i c a l upheavals involv ing redrawing of f ron t i e r s , transfers of sovereignty,, and changes in regime have forced ent i re populations into ex i l e and caused mass movements far greater than those normally resu l t ing from the world labour supply and demand." (18) 14 In Europe the involuntary t ransfer en masse of ethnic minor i t ies has been part of the scene since the ear ly 1900s, and " i t i s a sobering thought that the number of people expelled from one country to another in the decade af ter the Second World War i s about the same as the ent i re overseas migration from Europe in the 19th and the f i r s t decade of the 21th century." (19) Eight m i l l i on were helped to repatr iate or reset t le between 1944 and 1951 by several internat ional organizations inc luding UNRRA (United Nations Re l ie f and Rehabi l i tat ion Agency), and the IRO (Internat ional Refugee Organizat ion); and nearly two m i l l i on migrants and refugees were reset t led by ICEM (International Committee for European Migration) between 1952 and 1970. A large displacement of population has occurred in As ia , espec ia l ly between India and Pakistan; and continues in what was French IndoChina, and between The Peoples Republic of China and Hong Kong. There i s also a remarkable volume of movements developing within the Lat in American continent. Hoi born comments that i t should be recognized that often the only a l ternat ives facing some communities are ann ih i la t ion and refugee-migration: " . . . in i t s e a r l i e r .stages the refugee problem was seen as a temporary and l imi ted phenomenon, (but) i t has now. come to be acknowledged as universa l , continuing and recurr ing." (20) In response to the rea l i za t i on that the problem of . 15 refugees would not diminish, and a f ter two years of debate, the United Nations establ ished the Off ice of the United Nations High Commissioner for Refugees, UNHCR, to take e f fec t January 1951 and to replace the IRO. Most of i t s work i s not publ ic ized and i t i s thus more e f fec t ive in "its., single-minded humanitarian concern for the legal and material needs of the refugees themselves, whoever they may be and whereever they are found." (21) The United Nations Organization's de f i n i t i on of a refugee i s " . . . an indiv idual who owing to a well-founded fear of being persecuted for reasons of race, r e l i g i on , na t iona l i t y , membership of a par t i cu la r soc ia l group or po l i t i c a l opin ion, i s out-side the country of his na t iona l i t y and i s unable, or owing to such fear , unwi l l ing to ava i l himself of the protection of that country; or who, not having a nat iona l i t y and being outside the country of his former habitual residence as resu l t of such events i s unable, or owing to such fear, i s unwi l l ing to return to i t . " (revised 1951 U.N. Convention Relating to the Status of Refugees. A r t i c l e i . (2). ). Masel l i considers that th is de f i n i t i on , as s t r i c t l y re lated to the International Convention, i s no longer adequate for the present s i tuat ion in the world but should be more broadly interpreted. The problem of refugees w i l l always be with us, and "the internat ional community should recognize its., co l l e c t i ve respons ib i l i t y towards one of the most outstanding phenomena of a l l t imes." (22) Because both voluntary and involuntary migration 16 have profound effects upon everyone involved, i t i s important to recognise the differences and s im i l a r i t i e s between them, and the i r needs. VOLUNTARY MIGRANTS AND REFUGEES: THEIR SIMILARITIES AND DIFFERENCES. In both the e a r l i e r mass migrations and the present-day migration from under-developed countries to more techn ica l l y advanced countr ies, the migrants have tended to come from the re l a t i ve l y disadvantaged classes or groups who have less opportunity and fewer r i gh t s , e i ther economically, s o c i a l l y , or p o l i t i c a l l y . They have been able to take into consideration ethnic and cu l tura l k inships, which may have affected the place of resettlement i f not determining the i r decision to move. (23) The s k i l l e d migrants of today are also able to choose where they would l i k e to l i v e , depending on the demand for the i r s k i l l s . Both groups have tended to be in the prime of l i f e ; for instance, in 1967 almost three f i f t h s of immigrants into the U.S.A. were men and women between the ages 18 - 49 years, with chi ldren under 18 years of age accounting for less than one t h i r d , and one-ninth being 50 years and over. (24) Refugees have generally represented a l l classes of a given soc iety. Sometimes they may be only a segment of a population, e thn i ca l l y , r e l i g i ous l y , p o l i t i c a l l y or r a c i a l l y . Even then, they are a l l age groups, and a l l educational and occupational levels are 17 i n c l uded . Compared w i th vo lun ta ry migrants , who can p lan some.means o f f i n a n c i a l support f o r the t r a n s i t i o n a l pe r i od i n t h e i r new country and who recognise tha t rese t t l ement may be s t r e s s f u l , " A common f a c t o r among most refugees i s tha t they begin t h e i r f l i g h t w i th no means o f s ub s i s t an ce , and they d r i f t l e t h a r g i c a l l y . . . i n t o camps and hos te l s i n the country i n which they f i r s t r ece i ve a s y l um . . . they recogn ise t ha t they are f u g i t i v e s but most f a i l to recogn ise o r accept the consequences of t h i s f a c t , which i s a h inderence to t h e i r i n t e g r a t i o n ..and adjustment ." (25) THE-TREND IN MIGRATION PATTERNS The t rend i n m ig ra t i on pa t te rns i s seen as f o l l o w s : the vo lun ta ry movement o f s k i l l e d and u n s k i l l e d labour becoming more and more c o n t r o l l e d by the p o l i c i e s o f coun t r i e s r e q u i r i n g tha t l abour ; and the d i r e c t i o n o f the m ig ra t i on f low changing from that between areas o f European se t t l ement to t ha t from the ' T h i r d Wor ld 1 to areas o f i n d u s t r i a l development. Compl i ca t ing t h i s i s the con t i nu i ng (unplanned) f low o f refugees e i t h e r w i t h i n the ' T h i r d Wor ld ' coun t r i e s or between them and areas o f European se t t l ement . I f , as seen above, refugees have adjustment problems over and above those o f vo lun ta ry migrants , then i t cou ld be assumed tha t the r e c e i v i n g coun t r i e s w i l l have more problems w i th t h e i r rese t t l ement than w i th t h a t o f those who move v o l u n t a r i l y . In order to assess t h i s statement i t i s necessary to look at the ba s i c human and health needs of people per se, and to see i f the needs of immigrants and refugees d i f f e r from those of each othe 19 CHAPTER 3 THE MIGRANT AND HIS NEEDS INTRODUCTION The physical and psychological needs of human beings may be examined withinthe motivational framework out l ined by Maslow (a lbe i t without discussing the va l i d i t y of his theory) where needs are arranged and met in an ascending order of p r i o r i t i e s . ( 26 ) The basic needs for food, water and sleep are followed by the need for shel ter and secur i ty; the need to belong; the need for the esteem of others; and l a s t l y , the need for se l f - a c tua l i z a t i on . The immigrant adjustment process can be described in these terms, and f a i l u re to adapt can lead to mental health problems. There are other health problems associated with migrat ion, and these can be aggravated by warfare. Compounding a l l th i s are the be l ie f s and customs about health and sickness that w i l l a f fect the solving of health problems in the new environment. BASIC NEEDS: FOOD, WATER AND SLEEP The basic human needs are for food, water, and sleep. The need for sleep is se l f -explanatory, but sleep patterns are affected by other needs not being met. Geography determines the foods avai lab le and th i s in turn helps form dietary habits. For example, r i ce i s the staple in many parts of the world and wheat in others; f i sh i s the protein avai lab le to those l i v i n g by r ivers and seas, and meat to.those l i v i ng on grasslands. 20 A review of studies on food habits and nut r i t i ona l status by Freedman shows some ve r i f i c a t i on of the tenacity of food and eating patterns. Migrants, espec ia l l y those moving from and to areas of the world that are geographical ly and cu l t u ra l l y d i f f e ren t , experience 'cu l ture shock' in t ry ing to adapt to new food habi ts , and "quite often, due to a change in climate (they) may also experience subtle and/or overt changes in metabolism. These may in tu rn , cause palpable changes in biochemical patterns." (27) The in te r - re la t ionsh ip of re l ig ious tenets and food proscr ipt ions provides another example of the persistance of t rad i t i ona l d ietary patterns. L i t t l e sign of ass im i la t ion , that i s a change to English eating patterns, was found in the adult dietary pract ices of Moslem Pakistani fami l ies in Bradford, England. (28). The manner in which food i s prepared and eaten also d i f f e r s in various parts of the world. . In discussing ch i ld nu t r i t i on in the tropics and sub-tropics, J e l l i f f e and J e l l i f f e state that a l l communities have many nu t r i t i ona l l y related customs and that some may be harmless and can be ignored, and others are harmful and should be ac t i ve ly discouraged. (29) The need i s for food, but unfami l iar food cooked in an unfamil iar manner may not be accepted, with malnutr i t ion as the resu l t . 21 SHELTER AND SECURITY The second of Maslow's hierarchy of needs i s for shel ter and secur i ty , an environment free from fear , anxiety, or chaos. This includes a roof over the head, a job to support se l f and fami ly , and law and order. Again, housing i s related to cl imate and l i f e s t y l e : in the t rop ics i t i s open to the four winds and in the A rc t i c i t i s not. Di f ferent family sleeping arrangements means that the extended family in Asia actua l ly requires less space per person than does the nuclear family in North America. Bernard pointsout that the jobs ava i lab le to the migrant may not be the one for which he was t ra ined, and that he may be downgraded. Another economic aspect i s that of unemployment: i t i s often the most recently hired who are dismissed f i r s t , and they are general ly the newcomers to the community. (30) Law and order are taken for granted in most i ndus t r i a l i zed countr ies, but there have been attacks on immigrants conspicuous because of colour or custom in both B r i t a i n and The Netherlands and the knowledge of th i s can cause a sense of great insecur i ty in immigrants. (31) (32) THE NEED TO BELONG I f both physio logical and safety needs are f a i r l y wel l g ra t i f i ed then there emerges a need ' to belong' . In introducing the conclusions from his study of immigrant adaptation in I s r ae l , . Weinburg observed that: "Throughout th i s research i t has appeared that there ex is ts a remarkable s im i l a r i t y between the needs of the new immigrant with those of the newborn human being. The need for belonging, the need to be loved, understood: and supported, but not to be dominated, pampered or spo i led, these needs are s im i l a r to those enabling the ch i l d to develop to a sound, mature person, s a t i s f a c t o r i l y integrated in his fami ly, community, and soc iety ." (33) People need to belong to a group, be i t fami ly, f r iends , or the larger community. "Having roots i s not a question of an i nd i v i dua l ' value but rather of his relatedness." (34) Relationships with kin play an important part in promoting socia l integrat ion and avoiding feel ings of lonel iness,, (35) so i t would appear that se t t l i ng near one's own people i s an important factor in adjusting to a new environment. In order to belong, one must understand the re lat ionsh ips and values of the group and the a b i l i t y to speak the i r language opens 'points of contact 1 with that group. Without th i s s k i l l , migrants may also not acquire knowledge of the i r r ights and of services from which they might benef i t , and would have great d i f f i c u l t y in dealing with the complicated procedures that are so often necessary for the exercise of those r igh ts . (36) 'Belonging' also means being accepted by the receiving soc iety, and th i s is c lose ly related to Maslow's fourth need, to have the esteem of others. 23 THE ESTEEM OF OTHERS The feel ings of se l f -worth, se l f - respect , confidence, adequacy, and of being useful and necessary come from sensing the esteem of other people. The migrant is e i ther welcomed by the receptor networks or must deal with res istance, re jec t ion , prejudice and d iscr iminat ion. Prejudice and lack of economic opportunity const i tute barr iers to both accu l turat ion, i .e . the acceptance by the immigrant of the 'ways' of the major i ty, and to economic in tegrat ion. This prejudice may r e f l e c t the l im i t s of the absorb-at ive capacity of the receiv ing country as well as aspects of i t s cu l ture. (37) A good society must sa t i s f y these needs for 'belonging' i f i t i s to survive and be healthy. (38) Thwarting of the need of .'belong' and to having the esteem of others leads to maladjustment and pathology, to withdrawal, loss of hope, neurosis, or to psychotic breakdown. SELF-ACTUALIZATION F i na l l y , as the other needs are s a t i s f i e d , there i s the need for s e l f - a c tua l i z a t i on , or to develop f u l l y the person's unique charac ter i s t i cs and po ten t i a l . "A musician must make music, an a r t i s t must pa int , a poet must wr i te i f he i s to be ul t imately at peace with himself. What a man can be, he must be." (39) 24 THE IMMIGRANT ADJUSTMENT PROCESS. Adler uses Maslow's schema to describe the immigrant adjustment process. He sees immigration as a major d isrupt ion in the l i f e patterns of an i nd i v idua l , and in. the face of stress and f rus t ra t i on a regression to lower leve ls of the needs hierarchy may take place. "Adjustment can be seen as a recovery process in which the immigrant gradually moves back up the hierarchy towards se l f ac tua l i za t ion . This involves overcoming insecur i ty , overcoming lone l iness , overcoming se l f confusion; in other words recovering from a temporary state of d i s a b i l i t y known as culture shock." (40) A mentally healthy person i s one who i s adjusted to , or in harmony with his surroundings; and th i s is a function of many things including f u l f i l lmen t of physical and psychological needs. The stress of adapting to a new way of l i f e can cause depression and anxiety, i f not psychosis. THE MENTAL HEALTH OF IMMIGRANTS Studies on the mental health of migrants are found to be descr ipt ive rather than quant i ta t ive. Stress i s continuous when there i s an i n a b i l i t y to communicate with the immediate environment because of language d i f f i c u l t i e s , to meet even basic needs; (41) and adjustment becomes more d i f f i cu l t " with technology, urbanization and i ndus t r i a l i z a t i on . (42) This has been seen with the movement 25 of workers from rural areas of A f r i ca to France (43); from Cyprus to B r i t a in (44); and in immigrant chi ldren in Switzerland (45). For many immigrants into Israel the chasm between the dream and r ea l i t y brought shock, d is i l lus ionment , and b i t terness. (46) Sauna reviewed the l i t e r a tu re on migration and mental i l l n e s s with a special emphasis on schizophrenia, but concluded that hospital s t a t i s t i c s are var iables "too gross" for the examination r of th is re la t ionsh ip . (47) Burrowes concluded that there does not appear to be an except ional ly high incidence of mental i l l n e s s among immigrants of "coloured races" in B r i t a i n , but that there i s probably a vast amount of lone l iness , insecur i ty , b i t terness and anxiety which i s not adequately met. However, he suggests that there is a r e l a t i v e l y high incidence of mental i l l n e s s among immigrants from eastern Europe, and notes a s en s i t i v i t y to the i r status as immigrants "that may be due to the fact that they do not have the p o l i t i c a l attachment to th i s country (Br i ta in) that many other immigrants have." (48) Murphy raises the question of whether the associat ion between migration and mental disorder which researchers have found in the U.S.A. and Aust ra l ia i s a product of the cu l tura l set t ing with in which the migration is taking place. It has been found that immigrants are hospi ta l i zed for mental problems more frequently than the native-born populations. According to th i s study, the hosp i ta l i za t ion rates for immigrants in Canada were found to be lower when compared with those of the native-born population than those 26 rates in the U.S.A. and Aus t ra l i a . Both these countries have had the 'melting pot' at t i tude in which immigrants are expected to be assimi lated into the culture of the majority as quick ly as poss ib le , whereas in Canada the immigrant i s encouraged to maintain membership in a cu l tura l or ethnic group. (49) In another paper Murphy c i tes studies ind icat ing that the next generation can suffer psychological ly for the traumatic events endured by the i r parents while refugees. "Special attent ion would probably re l ieve these morbid s tates , but the average group (of immigrants) should not require i t . " (50) A study examining the d i f f i c u l t i e s in the adaptation to Canada of some of the refugees from Hungary in 1958 concluded that "one sees in Hungarian immigrants bas i ca l l y no d i f fe rent psycho-pathology from that of other groups . . . except that i t i s influenced by att i tudes common to the i r cu l tu re . " (51) Lack of knowledge and acceptance of psycho-therapeutic psychiatry caused many Hungarian refugees to resent re fe r ra l and treatment at that time. Some authors ra ise the question as to whether there should be a d i s t i n c t i on between voluntary and involuntary migrat ion, since emigration i s mostly the resu l t of an involuntary s i t ua t i on , i . e . a c on f l i c t . "Such a con f l i c t may be caused by external circumstances and pressures or by inner psychological factors resu l t ing from the personal i ty structure of the i nd i v i dua l . " (52) Psychological ly a voluntary migrant may be as much a refugee as an involuntary migrant. (53) In discussing the psychological charac ter i s t i cs of refugees and immigrants Bernard states that 27 there have been "too few" studies comparing the charac te r i s t i c s of these groups to determine i f refugees are actua l ly "worse o f f " . He notes that studies of patients in mental i n s t i t u t i ons show that migrants can be "adversely affected and psychological ly damaged" as a resu l t of migrat ion, but few studies have been concerned with whether the people examined were immigrants or refugees. "Perhaps the refugee i s more l i k e l y to be so, but the difference between his wounds and those of immigrants appear to be those of degree rather than type. It i s not that the refugee develops psychoses completely unknown to the immigrant. It i s jus t that he may acquire them more often, or perhaps more sharply." (54) Adaptation in the context of migration i s learning new ways of meeting basic human needs, and i t i s seen that th i s process can be s t r e s s f u l . The differences in the ef fect of th is stress on voluntary and involuntary migrants may be a matter of degree rather than of substance. Complicating th is i s the fact that the transfer of numbers of people from one area to another means that migrants are a group whose health i s a r i s k from causes other than s t ress . He may bring disease with him; and may meet diseases in the new environment to which he has no immunity or to which his new l i f e -s ty le may pre-dispose him. 28 HEALTH PROBLEMS Imported infect ious diseases. While typhus (ship fever) and typhoid were imported with the immigrants into North America in the l a t t e r ha l f of the l a s t century, internat ional travel regulations are intended to prevent the spread of disease by t rave l l e r s today. Today, tuberculosis and veneral disease are at the top of any l i s t of infect ious diseases among immigrants today. (55) "An immigrant groups in any community may experience a greater amount of tuberculosis than the permanently resident population i r respect ive of whether the immigrants come from areas of higher, lower, or approximately s imi la r leve ls of tubercu los is . " (56) If the overal l incidence of tuberculosis in the tota l population is increased by the a r r i va l of an immigrant group, then because the in fec t i ve pool of disease i s la rger , the potent ia l for spread i s greater. (57) In B r i s t o l , England, the percentage of new cases of tuberculosis which occurred in immigrants rose from 3.7% in 1960 to 19.2% in 1969 (58): however th i s i s d i f f i c u l t to evaluate in the absence of s t a t i s t i c s regarding the ra t i o of immigrants to tota l population over that per iod. Any migrant population i s prone to a high incidence of veneral disease, espec ia l ly when i t consists mainly of males. (59) One of the main epidemiological factors in th is increase i s "a recent in f lux of immigrants, who seldom introduce in fect ion but contract i t in disproport ionate numbers af ter a r r i v a l . " (60) The incidence of chanchroid, usual ly considered to be a venereal disease of the t rop i cs , 29 rose by more than f i v e - f o l d in Rotterdam during 1977-78 (61), showing that ' exot i c ' var iat ions on a disease may be imported. Rotterdam has a large immigrant population from t rop ica l and subtropical countries as well as being a major sea port. Immigrants may carry the i r parasites with them, espec ia l ly i f they come from areas of pr imi t ive san i ta t ion . Worms are common, but are of publ ic health importance only i f the i r developmental cycle can be completed in the new environment. (62) Otherwise they are of importance only to the indiv idual migrant and his physic ian. Malaria i s another pa ras i t i c disease that may cause chronic i l l - h e a l t h in the migrant but.be of l i t t l e publ ic health concern unless an appropriate mosquito vector, i s indigenous in the new environment. Non-infectious diseases. These have received far less pub l i c i t y than the infect ious diseases, and include the nu t r i t i ona l l y and genet ica l ly determined disorders. The World Health Organi-zat ion has found that the prote in/ca lor ie intake of many t rop ica l races i s sub-optimal, (63) lowering resistance of disease and the capacity to work. This w i l l be aggravated on moving to a colder cl imate where a s t i l l higher intake of protein and ca lor ies i s necessary jus t to cope with the c l imate. Avitaminosis has been found in coloured chi ldren in B r i t a i n where the production of vitamin D by the act ion of u l t r a - v i o l e t l i gh t on the skin i s diminished because of the lack of sunl ight . (64) 30 Some genet ica l ly transmitted diseases are seen more frequently in t rop ica l and subtropical countries than in temperate zones. These are not common and are not great"publ ic health importance, but may be of importance to the health of the ind i v idua l . Most frequently seen i s a group of condit ions where an abnormal haemoglobin molecule causes anaemia as the presenting symptom. (65) Primary adult hypolactasia ( lactose intolerance) i s genet ica l ly determined, and is more common in some races than in others. (66) The new environment. The immigrant may be at r i sk from various disorders in his new environment. A mild disease in one country may turn out to be severe in someone coming from an area where the disease i s not epidemic and where there has been l i t t l e or no opportunity to develop an appropriate immunity. 'New Commonwealth1 immigrants in B r i t a i n , for instance, may be at a greater r i sk of developing rube l l a , whooping cough, and measles than they were . 'at home',- as well as from the tuberculosis and venereal diseases mentioned above. (67) A number of diseases are charac te r i s t i c of modern c i v i l i z a t i o n , and are rare or unknown in communities whose way of l i f e has not changed much. A r i se in the frequency of these diseases occurs when Western customs are adopted. These include non-infectious diseases of the large bowel; diseases associated with cholestro l metabolism; venous disorders including pulmonary 31 embolism and CVA; obesity and diabetes, and others. (68) It may be surmised that these diseases wi l l appear and increase in an immigrant population as i t changes its l i f e style. Al l this adds to the stress of adapting to new ways of meeting needs. In considering the health status of refugees rather than that of voluntary migrants, i t must be remembered that they wil l probably have been uprooted by war, either c i v i l or international, and that this wil l have a further effect on their health. THE EFFECT OF WAR ON HEALTH Extensive warfare in any part of the world has always had the side effect of severe impairment of public health f a c i l i t i e s , and of disrupting normal l i f e patterns for c i v i l i a n population. (69) It is impossible to impose any effective public health measures on the general population at that time, and the uprooting and relocation of large numbers of people increases the poss ib i l i ty that many may come into contact with disease against which they have no immunity, either genetic or acquired. There is an increased risk of contact between animal reservoirs of disease, potential domestic animal carriers and humans. For instance, the plague cycle changed in Viet-Nam because the destruction of the forests by American bombing drove the 'wild' rats and their fleas - the reservoir of the disease -32 out into contact with the 'domestic' rats who were in contact with humans, and the incidence of plague in the population increased. (70) Because of the f l i g h t of c i v i l i a n populations, refugee camps and c i t i e s become overcrowded. The combination of increased population dens i t ies , poor san i ta t ion , and inadequate d i e t , increases the r i sk of epidemics. (71) The stress associated with re locat ion, lowered nut r i t iona l standards and changes in t rad i t i ona l l i f e patterns, a l l lower resistance to common diseases that can therefore become serious health hazards to the population; for example measles, tuberculosis and pneumonia. The stress can also lead to breakdown of the psychological coping mechanisms, and to neurosis and perhaps psychosis. The increased r i sk produced in such groups may l as t long af ter a return to normal condit ions.(72) These experiences of refugees are over and above the 'normal' stress of migrat ion. I f , as seen above, the health of themigrant/refugee i s at r i s k , then there i s a need for supervision and treatment of the problems that may appear sooner or l a te r in the i r new surroundings. Acceptance by the immigrant/refugee of the need for health surve i l lance and treatment w i l l depend on his conception of health and sickness; on the health care system to which he was o r i g i na l l y accustomed; and how he perceives the motives of the receiv ing country in demanding th is surve i l lance. 33 BELIEFS ABOUT HEALTH AND SICKNESS In a l l human groups, no matter the i r s ize or how technologica l ly advanced they are, there ex is ts a body of be l i e f s about the nature of disease, i t s . cause, and i t s : cure. There also ex i s t therapeutic and preventative measures against disease. Western medicine i s based on the knowledge of human anatomy and physiology; the 'germ' theory and the concept of prevention of disease as well as cure; and sophist icated medical and surgical technology. Many other parts of the world have other concepts of health and sickness. Hughes describes f i ve basic categories of events or s i tuat ions which, in fo lk e t io logy, are believed responsible for i l l n e s s : sorcery; breach of taboo; intrus ion of a disease object; intrus ion of a disease-causing s p i r i t ; and loss of sou l . (73) These can be a s ingle one or any combination. For example, "According to the Zulus any disease associated with laboured breathing, pains in the chest, loss of weight and coughing up blood-stained sputum i s at t r ibuted to the machinations of an i l l -w i s he r . " (74) The Spanish-Americans:attribute disease to an imbalance of hot and cold in the body, and that a cure must aim at restor ing the balance." (75) In Sr i Lanka and Maurit ius the people bel ieve that madness i s "supernatural ly caused and supernatural ly cured." (76) Yet in many instances modern medicine i s accepted with or without the acceptance of the 'germ' theory i f i t demonstrates greater effect iveness in the treatment and prevention of disease. 34 I t i s usual ly appl ied to sickness introduced by the Europeans, such as tubercu los is , measles and the l i k e . The diseases that are conceived to be unamenable to modern medical treatment are the t r ad i t i ona l l y endemic diseases, and espec ia l ly those ailments that have a large component of psychological or psycho-physiological involvement. (77) In describing health behaviour i n three cultures in Guatamala, Gonzalez observed that the way these groups u t i l i z e d the medical services almost exact ly para l le led the descr ipt ion in the l i t e ra tu re of the behaviour of persons in non-western cultures; elsewhere, and even that of members of the lower classes in England and the United States. "These groups are not interested in preventative measures, but ar r ive in droves to be cured; that they wait too long to seek professional care and often arr ive in the l a s t stages of a serious disease; that they r e s i s t hosp i ta l i za t ion and feel that th i s i s a condemnation to death; that they do not fol low prescr ipt ions and advice given which involves d i e t , res t , exercise e t c . , but demand p i l l s and in ject ions to re l ieve symptoms; that they do not return for check-ups as needed . . . and are often 'hard to reach 1 because of the i r indigenous be l ie fs concerning health and disease."(78) Also in discussing health behaviour, Read describes the tendency among natives of Alaska to depend on the i r k in groups in what they considered as i l l n e s s , which tendency was then transferred to a strong sense of dependence on government medical a i d . (79) 35 I f a migrant comes from an area with i t s own system of folk medicine that may or may not have been influenced by Western medicine, and i f the t r ad i t i ona l l y endemic diseases in that area are the ones which health author i t ies in the receiving country are concerned about in the i r immigrants, then the migrant may perceive those author i t ies as being meddling busibodies, or the i r behaviour as being i n su l t i ng . The success or f a i l u re of a health program is large ly governed by the way i t f i t s into the modes of thought and action of the rec ip ient population. (80) I t has been seen that human beings have basic needs, as well as those associated with health and sickness. The ways of meeting these needs are cu l t u ra l l y determined and are met with in a spec i f i c and familar environment. When people move, they take the i r conception of the ' r i gh t ' way of doing things with them; but they must adapt to new ways i f they are to survive in the new environment. This adaptation can be s t r e s s f u l . Two factors may add to the degree of stress experienced: when the move i s between areas that are geographically and cu l tu ra l l y d i f fe rent ; and when the migration i s involuntary. Besides s t ress , the migrant i s ' a t r i s k 1 in other aspects of heal th. The changes in migration patterns mean that countries receiv ing these new migrants w i l l be af fected. Having been accustomed to immigrants who have not d i f fered very much from the i r indigenous population and whose problems, including. those of health, have been s im i la r and fami lar , what might be the e f fec t of the changes? CHAPTER 4 36 THE RECEIVING COUNTRIES AND THE  CHANGING PATTERNS OF MIGRATION INTRODUCTION The e f f e c t o f the changing pa t te rns of m ig ra t i on may be examined under three headings: economic s t r e s s ; s o c i a l s t r e s s ; s o c i a l and hea l th problems, and the s e r v i c e s to deal w i th them. Aga in , c u l t u r e and custom, t h i s t ime of the r e c e i v i n g coun t ry , can a f f e c t the outcomes of s o c i a l and hea l th s e r v i c e s . ECONOMIC STRESS I t was seen e a r l i e r i n t h i s t h e s i s t ha t s i nce the Second World War vo lun ta ry m ig ra t i on has occured gene ra l l y dur ing per iods of economic expans ion. The immigrat ion p o l i c i e s of r e c e i v i n g coun t r i e s have been desc r ibed as a v i t a l component of manpower p o l i c i e s by being ab le to prov ide " r a the r q u i c k l y and r e l a t i v e l y e a s i l y , p a r t i c u l a r ca tego r i e s o f workers to help overcome labour sho r tages . " (81) However, Kubat sees immigrat ion p o l i c i e s as "the responses of na t ions and coun t r i e s faced w i th the consequences of steps taken on ly r e c e n t l y , to meet the needs of economic growth."(82) In o ther words, p o l i c i e s i n d i c a t e a t i g h t e r con t ro l o f immigrat ion i n what has been a r a the r l a i s s e z - f a i r e a t t i t u d e to economic p l ann i ng . 37 In the sense that the numbers and 'mix' of s k i l l s and education of immigrants are geared to manpower requirements, the acceptance of perhaps thousands of refugees at comparatively short notice i s unplanned and may cause economic, soc ia l and health problems for the country concerned. There w i l l be a s t ra in on the employment s i t ua t i on , housing and educational f a c i l i t i e s , as well as on the socia l and health serv ices. There may also be the need for d i rec t f inanc ia l assistance to the refugees un t i l they are se t t l ed . It i s not intended in th i s thesis to examine the economic costs of accepting a large group of refugees, but to look espec ia l l y at the health problems ar i s ing in th i s s i tua t i on . SOCIAL STRESS The re lat ionsh ip between a host population and i t s immigrant minor i t ies w i l l a f fect the adaptation per se, and the rate of adaptation of those immigrants. Unfortunately, o f f i c i a l po l i c i e s may be contradictory to att i tudes held in a country receiv ing immigrants. I t may be that governments state that they protect the immigrant population but administrat ive measures taken at the same time endanger the adaptation and welfare of the immigrants. Governments may o f f i c i a l l y encourage immigration but do l i t t l e to encourage acceptance of the newcomers by the indigenous population. (83) Jones concluded that the host i l e reactions to the three major waves of immigrants into 38 Br i t a in over the past 160 years were due to the i r being perceived as a threat to the "B r i t i sh way of l i f e " . (84) Discr iminat ion against 1 fore igners ' i s the outward manifestation of the resentment of the indigenous population towards those who are d i f f e ren t , or who are perceived as being a threat. This dicotomy of o f f i c i a l po l icy and publ ic att i tudes leaves the immigrant in an insecure and ambiguous s i tua t i on , leading perhaps to soc ia l and/or health problems. SOCIAL PROBLEMS AND SOCIAL SERVICES. Social and health problems are c lose ly l inked, as should be soc ia l and health serv ices. I t i s considered by several internat ional organizations interested in migrant welfare, that they should be included in expanded services rather than have separate services developed espec ia l ly for them. I f necessary, special services should be ava i lab le , but not in spec ia l i zed agencies. In discussing t h i s , Dumon also argues that soc ia l services for migrants have two funct ions; problem solv ing towards c l i e n t s , and problem formulating towards the au thor i t i es . (85) The increased demands on the soc ia l services caused by the immigration from d i f fe rent parts of the world w i l l be for assistance in the meeting of needs: programs may be necessary to help the immigrant and his family adapt to new foods, new ways of food preparation and housekeeping, and to new c lothing 39 and l i f e s t y l e because of the d i f fe rent climate. Housing i s a par t i cu la r problem for newcomers, and th is w i l l be aggrevated by larger family s ize and d i f fe rent customs. (86) Overcrowding and unsanitary l i v i n g conditions can lead to serious soc ia l and health problems. Social workers can also help integrate the newcomers into the loca l community - to explain each to the other. (87) Language t ra in ing for the whole family has already been seen as essent ia l for the acceptance of the community and immigrant by each other. These services may have to be expanded*as the charac ter i s t i cs of the immigrants change making adaptation more d i f f i c u l t than i t has been for the i r predecessors. I t may be that a sudden inf low of refugees w i l l need a sudden but temporary expansion of serv ices , including health care serv ices. HEALTH PROBLEMS AND HEALTH SERVICES The health problems of immigrants have received l i t t l e consideration apart from the medical examination required before the would-be migrant is allowed to enter the country. With the change in migration patterns, there is a possible r i sk to the indigenous population from imported diseases, as well as increased and d i f fe rent demands on the health serv ices. 40 ' Exot i c ' diseases. Maegraith defines an ' exo t i c ' disease as one normally acquired outside the area in which the doctor works, be i t in Europe, North America, or West A f r i c a . With more and more travel in and out of the t rop i cs , and with the speed of modern t r a ve l , "a person may be infected abroad with an exot ic disease and return before the incubation period i s completed so that the c l i n i c a l event begins some time af ter his return and w i l l have to be dist inguished from local disease." (88) Because of t h i s , many large urban centres already have hospital and medical f a c i l i t i e s to deal with exot ic diseases: for example, Toronto General Hospital Tropical Diseases C l i n i c , Canada-, The School of Tropical Medicine in L iverpool , England; and the Tulane Medical Center, New Orleans, in the U.S.A. These must act as re fer ra l centres for other areas. Medical p rac t i t i oners . Unusual demands in both numbers and s k i l l s w i l l be put on medical pract i t ioners by an in f lux of people from a d i f fe rent country, and perhaps with very d i f fe rent problems from those usual ly seen. Apart from the 'exot i c ' diseases, atypica l disease patterns may occur and the natural h istory of ailments may be modified by such factors as malnutr i t ion or the presence of i n tes t ina l paras i tes. Both malaria and diphtheria can show atyp ica l disease patterns. It has been noted in B r i t a i n that many people ar r ive from the tropics with sub-c l in i ca l scurvy, which i s a lack of vitamin C, that l a te r develops into c l i n i c a l scurvy with the change of l i f e s t y l e . (89) There may also be a need 41 for an interpreter where there i s a language bar r ie r , and th i s can cause problems. (90) Hospita ls. The a r r i va l of a few immigrants in a spec i f i c area presents no real problem in terms of numbers, but large concentrations w i l l require modif icat ion of services to allow for such factors as the age, sex, and family composition of the immigrants, as well as the i r country of o r i g i n . A high b i r thrate among some immigrant groups w i l l increase the demand for maternity beds (91), and large numbers of newly arr ived and newly born chi ldren w i l l create a greater demand for hospital beds espec ia l l y i f those chi ldren are prone to severe forms of what are normally mild childhood in fect ions . (92) Mental health problems may increase the demand for both in-pat ient and out-pat ient serv ices. (93) Publ ic health serv ices. There w i l l be an increase in the demand fo r , and scope of, publ ic health serv ices. Special arrangements may be required for the diagnosis and treatment of exot ic diseases as well as for a possible increase in the incidence of tuberculosis and enter ic diseases. (94) New immigrants often d r i f t into food serv ices, so supervision of food handlers becomes more important. (95) The rate of indus t r ia l accidents has been noted to be much higher among immigrants than in the work-force as a whole (96), and accidents happen more frequently in the home, espec ia l l y with small chi ldren. (97) These w i l l require supervision and education. 42 Maternal and ch i l d services w i l l be stretched. Advice on nu t r i t i on i s espec ia l l y hard to give because of language barr iers and d i f fe rent customs (98), as i s teaching hygeine where new ways of waste disposal are not understood. (99) Increased e f fo r ts may be necessary to achieve and maintain a sat i s factory level of immunization among both local and immigrant ch i ld ren. (100) School health programs w i l l be af fected. Poor nu t r i t i on , with possible parasites, af fects a c h i l d ' s performance in school; and the immigrant ch i l d is under a double s t ra in as adjustment to a strange school environment may be complicated by stress in his home environment. (101) (102). It has been suggested that there may be a delayed or cumulative ef fect of the stresses associated with the ch i l d immigrant, which indicates a possible long-term problem. (103) Some of these problems are common to a l l immigrants and are magnified by rac ia l and cu l tu ra l differences between them and the loca l population. As previously stated, i t i s only comparatively recently that much thought has been given to the help that can and should be given an immigrant to aid his adjustment to his new surroundings. 43 AID FOR IMMIGRANTS The most important charac te r i s t i c of help for immigrants seems to be that programs of assistance be planned. (104) (105) Dumon c i tes Rose's study of migrants in Europe in regard to problems of acceptance and adjustment (106), and the "amazing f i nd" that "the var iable that had most explanatory value, was not the degree of s im i l a r i t y or dif ference in cul ture between sending and receiv ing countr ies. The integrat ion and adjustment was most c l ea r l y related to the openness of programs, po l i c i e s and pract ices of immigrant countr ies." (107) However, before programs are planned, i t i s necessary that the ef fect of culture and custom on both the rec ip ients and providers of health care be considered. THE EFFECT OF CULTURE AND CUSTOM OF HEALTH CARE With the in f lux of a ' d i f f e ren t ' people, health care professionals w i l l meet the ef fect of culture and custom on medical and health care. For example, pre-natal care i s d i f f i c u l t i f women cannot be examined because of s t r i c t purdah. (108) The abandonment of breast feeding by Pakistani women in Bradford,. England was seen as part of the i r 'adaptat ion' to B r i t i s h customs, but which unfortunately had the ef fect of increasing the r i sk of gas t ro-enter i t i s among these babies as the process of mixing formulae was inadequately understood. (109) Advice on ch i l d care may be applied to the boys only in the family as the g i r l s 44 are considered to be a lesser status. (110) Intest ina l parasites may be considered 'normal' and as already suggested, health surve i l lance seen as gross interference. As already seen, hospitals are seen as a place in which to d ie, and i t may be very d i f f i c u l t to persuade an immigrant to go to hospital i f th i s i s needed. It can be seen that health program often f a i l , and for a mu l t i p l i c i t y of reasons. There are other reasons why programs f a i l . Patients many times misunderstand or ignore prescribed procedures, and th i s i s un iversa l . Others may choose not to use modern c l i n i c a l services but re ly instead on loca l remedies and curers. The way a treatment i s offered w i l l a lso af fect i t s acceptance. Leininger points out that the eth ica l and re l ig ious values of both c l i en t and health care professional impinge upon health care services and that "some ohealth providers act as i f r e l i g i on plays no ro le with c l i en t s in health care prac t i ces . " ( I l l ) In t a i l o r i ng health care to the needs of cu l tura l groups, she notes that one way of ' reaching' these people would be the a b i l i t y to converse in the i r language. Bernard fee ls that there are far too many soc ia l workers and counsel lors who know nothing about the cultures of other people nor do they speak the i r languages. He i s concerned that there are counsel lors "who do not know about other people well enough to be 45 able to in terpre t , and I don't mean jus t l i n g u i s t i c a l l y , to interpret the i r cu l tura l behaviour and the i r soc ia l problems as accurately and profoundly as they should." (112) There i s a great need for in terpretat ion of culture on a 'two-way s t r e e t ' . The culture and bureaucracy of s c i e n t i f i c health care can present serious obstacles to ef fect ive de l ivery of care. (113) Jones observed that "professional status in general seems to be a frequent j u s t i f i c a t i o n for the absence of any further t ra in ing on the subject of New Commonwealth immigration into B r i t a i n . " (114) Foster considers that "major barr ie rs" to improved health programs are found in the cultures of bureaucracies, the assumptions of the medical profess ion, and in the psychological makeup of the profes-sional in those programs. "This assumption, regretably, appears not to be widely accepted. In fact i t i s res is ted by many." (115) The att i tudes and knowledge of both rec ip ient and giver of health care w i l l a f fect the outcome of the care given, the giver in th is case being the health care system as well as the professional working in that system. I f the cu l tura l d i f ferences, i . e . a t t i tudes , are d i f fe rent then the problem may not be perceived in the same manner, and indeed i t may not be resolved unless the rec ip ient and giver rea l i se t h i s . From the l i t e ra tu re i t can be seen that soc ia l and health care professionals have recognised that there are problems associated with the inflow of large numbers of 46 immigrants who are r a c i a l l y and cu l t u r a l l y d i f f e ren t . The socia l and health care po l i c ies , programs, and services of a country, as well as the immigration po l i c i e s , are the product of the economic and cu l tura l experience of that country. As background for examining the development of Canada's immigration po l i c i e s and the possible ef fects of the a r r i va l of comparatively large numbers of Vietnamese refugees on the country, i t i s of in terest to look at the immigration experiences of selected countr ies, and to note the trends in immigration po l i c i e s , and the problems caused by the changing world migration patterns. 47 CHAPTER 5 RECEIVING COUNTRIES.:: SOME EXPERIENCES  WITH IMMIGRATION INTRODUCTION Countries receiv ing migrants may be c l a s s i f i e d according to the type of migrant they accept or prefer. Aus t ra l i a , the U.S.A. and Canada have t r ad i t i ona l l y received voluntary and permanent immigrants, while Israel has received permanent se t t l e r s in large numbers only since 1948. Since World War Two the indus t r i a l countries of Northwest Europe have recrui ted what they hoped were temporary migrant-workers as an answer to the i r chronic labour shortages. Along with Great B r i t a i n , they also gave c i t i zensh ip to people from the i r former colonies, and the resu l t ing inf low of these immigrants has caused complicated soc ia l problems. "/Many countries in Europe, A f r i ca and Asia have had experience with refugees ' i n t r ans i t ' and have been helped with aid from governments and voluntary agencies as well as from UNHCR, but th i s w i l l not be discussed here. COUNTRIES OF PERMANENT SETTLEMENT Immigration into Aus t ra l i a , the U.S.A. and Canada was v i r t u a l l y free unt i l the ser ies of 'gold-rushes' in those countries brought the Europeans face to face with the Chinese,-who were promptly blamed for a l l the soc ia l i l l s of those new countr ies. (116) 48 In response to publ ic ag i t a t i on , governments enacted l eg i s l a t i on r e s t r i c t i ng or excluding the in-f low of a l l races but the white: the U.S.A. in 1882, Canada in 1885, and Aust ra l ia in 1888. In a l l three countries th i s d iscr iminat ion on grounds of race continued unt i l a f ter World War Two. Also general ly excluded were "those whose physical and mental capaci t ies were beTieved.to make them publ ic charges or whose moral character was believed unwelcome."(117) Aus t ra l i a . Respons ib i l i ty for immigration rests with the central Austra l ian government, and i t s purpose has been to promote economic development and secur i ty . In l i ne with the 'White Aus t ra l i a ' po l icy that started with the exclusion of the Chinese, the preferred classes of immigrants have been those from Br i t a in and northern Europe; and the goal has been ass imi la t ion into the B r i t i sh -Aus t ra l i an society within one generation. To th i s end, there has been f i n anc i a l l y ass isted passage for selected immi-grants . The att i tudes of Austral ians towards immigrants in general has been ambivalent: while acknowledging the need to increase the population, they have f e l t the i r way of l i f e threatened by imported 'cheap' labour. Since World War Two, a change in immigration po l i c i es has seen more and moreimmigrants from countries of southern and eastern Europe, and the Middle East. This increase in the numbers of "foreign elements" has caused a certa in degree of tension and even fear for many Austra l ians. (118) 49 Once in the country, immigrants have been expected to make the i r own way. Many of these new immigrants are i l l i t e r a t e and have substant ia l l y d i f fe rent cu l tura l backgrounds. Night-school classes in the English language are a luxury for them as they struggle for f inanc ia l survival doing the d i r t y , poorly paid jobs that no-one else wants. (119) Services for immigrants are the respons ib i l i t y of States ' governments and voluntary organisations and these seem to have worked well together. However, services have been seen as inadequate. "Unt i l quite recently the Austra l ian governments, despite the i r anxiety to a t t rac t immigrants from a l l over Europe, have done very l i t t l e to help newcomers adapt to language, l i f e s t y l e , or workplace." (120) In the past few years there has been both publ ic c r i t i c i sm and c r i t i c a l discussion of the 'White Aus t ra l i a ' po l i cy , the size of the annual inflow of immigrants, and the amount and qua l i ty of the help offered them. (121) The tendency of immigrants to se t t l e near the i r compatriots ( for example there i s a large Greek community in Melbourne) has enabled them to keep a sense of cu l tura l i dent i t y and to develop p o l i t i c a l pressures for integrat ion rather than ass imi la t ion into the Austra l ian soc iety , and to press for improvements in immigrant serv ices . (122) After the gradual easing of the tota l exclusion of non-whites since 1945, Aust ra l ia abolished r e s t r i c t i on based on race 50 or colour, and immigration po l icy i s now based on a points system emphasizing s k i l l , education, and family re-union. A point to remember here, is that Aus t ra l i a ' s foreign po l icy has recognised the need for good re la t ions and trade with the countries of Southeast Asia and the Pac i f i c community, a l l of whom are r a c i a l l y and cu l t u ra l l y d i f fe rent from Aus t ra l i a , and from whom Aust ra l i a is now accepting ' se lected ' immigrants. The 1971 Pol icy Statement of the Austra l ian Labor Party (123)sets out major developments in services for immigrants, including research into chi ldmigrant education and language t ra in ing . Mu l t i - l ingua l welfare o f f i ce r s were being appointed to work in immigrant communities, and t ra in ing courses were being developed for those working in the immigration f i e l d . Financial help was being considered for the Good Neighbour Councils who co-ordinate the voluntary agencies of fer ing assistance to immigrants. (124) Since the change of government in 1974, however, these po l i c i e s have been modified with a movement back to ea r l i e r at t i tudes and po l i c i e s , with immigration 'preferred ' from Br i t a in and northern Europe. Aus t ra l i a ' s po l icy regarding the admission of refugees has been c r i t i c i s e d as being based large ly on s e l f - i n t e r e s t , (125) and i l l u s t r a t e s the i r ambivalence about immigration. The acceptance of refugee/immigrants from war-torn Europe was seen as a humanitarian gesture, as was the acceptance of refugees from Hungary (1956-7) 51 and Czechoslovakia (1968); but i t was only with much hes i tat ion that Aust ra l i a accepted 200 or so Indians expelled from Uganda in 1972. (126) Be late ly , 2500 Chileans were admitted in 1974, but through normal immigration procedures rather than through special arrangements for refugees. Families and voluntary agencies sponsoring refugees have been considered to be f u l l y responsible for them. The c r i t i c i sm i s that the majority of the refugees accepted would have been e l i g i b l e for entry under the normal se lect ion c r i t e r i a based on health and s k i l l s . "Acceptance of Vietnamese refugees i s an exception based perhaps on moral r espons ib i l i t y derived from Aus t ra l i a ' s involvement in the Vietnam war." (127) Although i t has been stated that Austral ians may feel threatened by immigrants who are r a c i a l l y or cu l t u ra l l y d i f f e ren t , there i s evidence that immigrants of mixed race from Southeast As ia , including India, have set t led successful ly since the immigration po l icy was relaxed. (128) The fee l ing appears to be that i f proceeded with slowly, integrat ion of ' d i f f e ren t ' immigrants can be done, but that perhaps programs are s t i l l needed to integrate those ' d i f f e ren t ' immigrants already in the country. The U.S.A. Like Aus t ra l i a , the trend in the U.S.A. has been to l i b e r a l i z e immigration po l i c i e s in terms of se lect ion by race or na t i ona l i t y , and to l ink them more to economic fac tors . Unt i l the F i r s t World War, the U.S.A. had an 'open door' po l icy for immigrants from Europe while excluding As i a t i c s . 52 Increasing publ ic h o s t i l i t y towards ' fore igners ' forced the enactment of more r e s t r i c t i v e po l i c i e s , and the quota system introduced in 1929 allowed immigration only in the proportions of the national groups already in the country. The reluctance to accept refugees from Nazi Germany in the late 1930s stemmed from these fee l ings and th i s l eg i s l a t i on . Changes came with World War Two. The Chinese Exclusion Act of 1882 was repealed in 1943,. with the decis ion probably influenced by foreign po l i cy ; and special l eg i s l a t i on allowed the in-migration of refugees from Europe af ter 1945. Although reaff i rming the quote system, the McCarran Walter Act of 1952 ins t i tu ted a preference system based on s k i l l s and close family re la t ionsh ip . (129) Discr iminat ion against As ia t i c s was o f f i c i a l l y abandoned, but the very small quota was an e f fec t ive barr ier against any increase in immigration from As ia . The Immigration Act of 1965 abolished the nationalorigins quota system and l inked immigration to the economic s i tuat ion and the re -un i f i ca t i on of fami l i e s , (130) and the preference system was s l i g h t l y revised in 1976. (131) Since the l eg i s l a t i on of 1965 there has been a s t r i k i ng global s h i f t in the national or ig ins of immigrants into the U.S.A. with a s i gn i f i can t growth in the numbers from As ia , Lat in America, and the Caribbean. With an eye to re lat ionships with other 53 countries and with the abandonment of the pol icy of ass im i l a t ion , "immigration pol icy i s obviously d i r e c t l y t ied into the image of the United States as a p l u r a l i s t i c soc iety ." (132) It has been recognised that the continuous infusion of d i f fe rent cultures has brought benefits to the country, but " i t i s by no means c lear that the fear of non-Western cultures i s a thing of the past or that the U.S.A. population w i l l accept and integrate the new groups created by the 1965 Act." (133) Under the American Const i tut ion immigration i s the respons ib i l i t y of the Federal Government, and there has been a long t r ad i t i on of the senior level of government's involvement with c i t i zensh ip education including language t ra in ing and .the teaching of American h is tory , with the goal of ass imi lat ing immigrants into the mainstream of American l i f e . Pract ica l help for immigrants has been provided by a network of voluntary organizat ions. Between 1880 and 1920 the U.S. governments did very l i t t l e to take care of the s ick and unemployed. This led to the emergence of powerful mutual benef it soc iet ies amongst almost a l l ethnic groups which, besides helping to preserve language and cu l tu re , helped to form the present-day network of voluntary organizat ions. (134) These groups are now co-ordinated by two large 'umbrel la ' organizat ions, the American Immigration and C i t i zensh ip Conference and the American Council for Nat iona l i t i es 54 Service, and these apparently have had good working re lat ions with government o f f i c i a l s and Congress. In t h i s , they appear to function somewhat l i k e the Good neighbour Councils in Aus t ra l i a , although the i r pattern of development has been d i f fe rent . In spite of some excel lent work being done, the pattern of services and assistance offered to the immigrants in the i r adjustment to American society i s under c r i t i c i sm as being inadequate. (135) The t rad i t i ona l process whereby voluntary agencies helped immigrants to f ind homes and jobs was used in rese t t l i ng the f i r s t wave of Vietnamese refugees to enter the U.S.A. in 1975-76. (136) I n i t i a l l y housed in former army camps, they were sponsored by groups and organisations across the country thus becoming i so la ted from one another. They have since been rese t t l i ng themselves out of the o r ig ina l areas into place where there are other Vietnamese. (137) I t appears that the need for the support of one's own people i s very strong. They have also formed the i r own se l f -he lp organizations with the aims of mutual ass istance, preserving the i r cu l tura l her i tage, and forming the basis for a Vietnamese-American culture of the future. With the a r r i va l of th i s large group of new immigrants came the opportunity to study the effects of migrat ion, f l i g h t , and adaptation; and the effect iveness of services designed to help resettlement. There i s a growing l i t e ra tu re on the health and 55 adaptation problems of these refugees. Studies undertaken in the 'holding camps' have a lerted the Public Health Services and the medical profession to possible health hazards as well as to diagnosis and treatment of ' exot i c ' diseases in immigrants from t rop ica l countr ies. Others have been reported in the Morbidity and Morta l i ty Weekly Reports from the Center for Disease Control .in At lanta. There have also been comments on the lack of co-ordination and co-operation of the voluntary agencies involved in the camps and camp l i f e , and the resettlement process. (138) (139) Developments immigration po l i c i es in Aust ra l ia and the U.S.A. appear to have been a ser ies of reactions to external events and internal soc ia l and economic pressures, and only comparatively recently has there been a perceived need for programs and services to help the immigrant adjust to his new environment. Both countries have attempted to ass imi late rather than integrate the newcomers into the i r soc iety . While the health of the immigrant on a r r i va l i s probably better than the average c i t i z en because of the s t r i c t medical examination required, not much concern seems to have been shown for his health thereafter. Israel has the same 'melt ing pot' at t i tude towards her immigrants but has from the beginning planned programs to help the immigrant adjust. I s rae l . Immigration i s a fundamental tenet of Zionism: the po l icy i s , and has been that every Jew has the r ight to 56 immigrate into the State of I s rae l . Only those who spe c i f i c a l l y act against the Jewish nation or who are considered a threat to the publ ic health or state secur i ty may be denied entry. (140) The resu l t of th is po l icy has been' to " f lood the land and a society not equipped to receive them with masses of variegated, t o t a l l y d i ss im i la r newcomers from a l l corners of the earth - and predominately from the more underprivi leged corners." (141) Apart from the moral commitment of the Jewish homeland, the urgent need has been for manpower for defence as well as economic development. Because of t h i s , immigrants are in a favoured pos i t ion in I s rae l i soc iety , receiv ing substant ia l f inanc ia l and socia l assistance with s e t t l i n g , inc luding free health insurance for s ix months and help with housing and employment. Unti l 1968, immigration and the absorption of immigrants was the exclusive respons ib i l i ty of the Jewish Agency, a non-governmental organizat ion. With the formation of the Ministry of Immigration and Absorption in 1968, the government became more involved with the co-ordination and operation of serv ices. In sp i te of a l l t h i s , there have been : housing and employment d i f f i c u l t i e s , and resentment of the newcomers by the native-born c i t i zens on account of the pr iv i leges they receive and the cu l tura l differences between them. There have been three 'waves' of immigrants into I s rae l : from Europe before 1948; from Asia and A f r i ca from then unt i l the 1960s; and from the Soviet Union in the 1970s. There has also 57 been a small but steady flow of immigrants from western Europe and North America. There are great differences between the way of l i f e of European and Oriental Jews: family structure and ro les , the level of education, the observance of the re l ig ious l i f e , and language have a l l made adaptation d i f f i c u l t . The need to change accustomed work roles was pa r t i cu l a r l y hard for Oriental Jews as the i r occupational "composition" was l i t t l e suited to meet the manpower needs of the young state . (142) There;have been special d i f f i c u l t i e s with the absorption of the Russian immigrants "who do not know what to expect from a free soc iety ." (143) No other country has studied the adjustment of immigrants or records the i r progress as care fu l l y .as I s rae l . I t i s pointed out to prospective immigrants that settlement i s not easy and in return for generous assistance the State requires an e f fo r t from the immigrant himself. The language i s not an easy one to learn: however, in 1973 about 61% of immigrants were ac t i ve ly studying Hebrew during the i r f i r s t year in I s rae l , which i s probably quite a high percentage when compared with other receiving countr ies. (144). Community organization are being encouraged to help with the socia l adjustment of immigrants, but in sp i te of great e f for ts to help them s e t t l e , there i s considerable disappointment as measured by the rate of out-migrat ion. (145) 58 With the acceptance of al lcomers, not every immigrant into Israel has been in optimal health. I t was observed very ear ly on that " although i t cannot be ve r i f i ed s t a t i s t i c a l l y , there i s good reason to bel ieve that abnormally low standards of health among some new immigrants great ly added to the d i f f i c u l t i e s of absorption. This appl ies to both physical and mental health and can be explained by the large per-centage of the new a r r i va l s who had gone through the ordeals of concentration camps and war, or who had come from backward countries where disease i s wide-spread, notions of hygeine are pr imi t ive and standards of nu t r i t i on among the poor are extremely low." (146) Health problems that would be a publ ic health hazard, such as act ive tubercu los is , have been treated where feas ib le in the country of o r ig in before the migrant has been allowed to travel to I s rae l . (147) Other problems such as poor nu t r i t i on and hygeine are dealt with in the process of settlement. Israel i s committed to immigration as a fundamental po l icy of populating the country, and has planned soc ia l and health services to ass imi late the newcomers into the I s rae l i community. In spite of t h i s , resettlement and adaptation have not been easy, with the process probably complicated by the internal economic s i tuat ion and the external p o l i t i c a l s i tuat ion in the Middle East. The goals of these three major receiv ing countries have been the growth of population by immigration, and the ass imi la t ion of those immigrants into a 'dominant' cu l ture. Unt i l comparatively recent ly , Aus t ra l i a and the U.S.A. have not paid much attent ion to the ef fect of th i s po l icy on the health of the immigrants af ter 59 the i r a r r i v a l . They have now recognised that mu l t i - cu l tura l soc iet ies have happened in sp i te of the i r 'melting pot' a t t i tudes , and that programs and services are indeed needed to help the integrat ion of the newcomers into the i r soc ie t ies . Israel has found that in sp i te of planning services to th is end, the process of adaptation has not been easy for her new c i t i z ens . In a l l three 1 countr ies, immigration po l i c i e s have been affected by outside events as well as the internal s i t ua t i on . Since the Second World War, countries of Northwest Europe have both recruited temporary labour from other countr ies, and admitted thousands of repatr iates from the i r former colonies -a l l c u l t u r a l l y , i f not r a c i a l l y d i f fe rent . They have had s im i la r problems with the integrat ion and adaptation of these immigrants. NORTHWEST EUROPE . France. Belgium, Luxemberg, and ; Germany d isc la im having been areas of settlement in the past despite evidence to the contrary: a l l have depended on immigration for both population growth and labour for the l as t 100 years. Economic expansion in the 1950s and 1960s encouraged the recruitment of temporary labour from the countries bordering the Mediterranean, and in the case of France, from North A f r i ca as we l l . At f i r s t these workers were s ingle males with compara-t i v e l y low educational and s k i l l s l eve l s , but in 1968 the European Economic Community asserted the r ight of fami l ies to migrate. U48) 60 The subsequent re jo in ing of fami l ies brought an increase in in-migration at the same time that pressure from the labour unions, welfare system o f f i c e r s , and po l i t i c i ans "hearing mumblings of discontent as to the v i s i b i l i t y of the new minor i t i es " , (149) was forc ing governments to r e s t r i c t recruitment of foreign workers. Aided by a down-swing in the economy, these controls were enforced in Belgium 1967; The Netherlands 1970; and France 1974. The countries of indust r ia l northwest Europe had never promised permanent settlement for the i r migrant workers and there seems to have been a decided ambivalence about integrat ing them into the host communities. The migrants and the i r fami l ies have been e l i g i b l e for the considerable health and welfare programs in the i r host countr ies; but otherwise the governments l e f t the i n i t i a t i v e for providing services to help the i r integrat ion to voluntary agencies, and only l a te r took over some of th is respons ib i l i t y themselves. Schooling for the migrant chi ldren has been compulsory within the loca l school systems, with varying amounts of ins t ruct ion in the i r mother tongues to maintain l inks with the i r own cu l ture. At home the chi ldren may not f ind much encouragement for the i r school ing, and as resu l t run the r i sk of becoming " i l l i t e r a t e s in two languages". (150) This could lead to a lack of a sense of ident i ty which in turn leads to delinquency; and w i l l ce r ta in ly 61 Pose a problem for the future in whichever country*they wi l I .find tnemselves. France is already grappling with the problems of integrat ing the second generation of immigrants into the French community. (151; A natural ghettoizat ion of foreign workers has made i t unnecessary for those with fami l ies to venture outside the c i r c l e of kin and f r iends. (152) The migrants themselves appear to be amb,;ivalent about integrat ing into the larger community, .(153) and opportunit ies for language t ra in ing are poorly u t i l i s ed . ( 154 ) x Yet they show no signs of wanting to go home. The issues raised by the s i tuat ion of the migrant workers are complicated by the fact that France, Belgium, and The Netherlands have also absorbed large numbers of refugees and repatr iates from the i r former colonies. Like the workers from southern Europe,- they are conspicuous minor i t ies by v i r tue of colour, race or cu l ture. However, unl ike the migrant workers, they immediately assumed a l l the r ights and respons ib i l i t i e s of c i t i z ensh ip , and great e f fo r ts were made to ass imi late them into the dominant culture - with varying degrees of success. L i t t l e attent ion seems to have been paid to possible health problems among a l l these immigrants, although they must have brought the i r parasites and diseases with them. They had a medical examination before being allowed to migrate, but the i r 62 l i v i n g condit ions in the new environment are not conducive to good health, e i ther physical or mental. This could be expected to contribute to an overloading of the socia l services, ' cause an increase in the cost of welfare s e r v i c e s a s well as adding to the delinquency of the children.. There has been a general f a i l u r e to integrate the workers and the i r fami l ies into soc iety; and the loca l population does not discr iminate between them and the repatr ia tes . There i s l i k e l y to be soc ia l tension between ' fore igners ' and'nat ives ' in periods of high unemployment (155). The overal l po l icy aims now, are to integrate those already in the country (s) and at the same time discourage any further in-migrat ion. GREAT BRITAIN•• - Br i ta in, also has a problem-in: t ha t ' s i gn i f i c an t minor i t ies are not being integrated into B r i t i s h soc iety. Although only one in three migrants since the war has been ' co loured ' , one of the remarkable features of the s i tuat ion in B r i t a in i s the almost universal equation of the term 'immigrant' with 'coloured person' . (156) There i s a considerable resentment against immigrants that has forced the government to enact l eg i s l a t i on for both the control of immigration per se, and the rampant d iscr iminat ion against them. Unt i l the ear ly 1900s B r i t i s h immigration po l i cy was ' l a i s s e z - f a i r e ' for "motives of both economic se l f - i n t e re s t and humanitarian concerns." (157) Around the turn of the century 63 there was po l i t i c a l ag i tat ion against the presence of large numbers of Jewish refugees from eastern Europe, with the resu l t that immigration was res t r i c ted by the Al iens Act (1905), (158) further l eg i s l a t i on in 1914 and 1919, and subsequent Orders in Counci l . Immigrants were not e l i g i b l e for the old age pensions introduced in 1908, nor for unemployment and health insurance in.1911: in fac t , popular sentiment was quite b latant ly anti-immigrant ( 159), and rac i s t (160). This antipathy towards foreigners ce r ta in l y affected the treatment of refugees from Nazi Germany in the late 1930s. Asylum was offered to Pol ish ex-servicemen who did not wish to go home at the end of the Second World War; and the Pol ish Resettlement Act of 1947 recognised that "resettlement had dimensions other than the economic and that i t embraces not only housing but health, welfare and education as we l l . " (161) However, the pr iv i leges of the Welfare State were not extended to the a l iens admitted under work permits from Europe at the same time; and those workers were also refugees l i k e the Poles. In 1948, The B r i t i s h Nat iona l i ty Act gave Commonwealth c i t i zens the pr iv i ledge of v i r t u a l l y free entry into B r i t a in to work and set t le , ' (162) and l i k e the Poles, they were en t i t l ed to the f u l l range of socia l secur i ty benef i ts . Because, of p o l i t i c a l ag i tat ion and act ive d iscr iminat ion against 'coloured' m inor i t i es , 64 the preferent ia l status of Commonwealth immigrants has been stead i ly whi t t led away by a ser ies of l eg i s l a t i v e and administrat ive measures culminating in the Immigration Act of 1971. (163) A permit i s now required to enter B r i t a in to work, except for pa t r i a l s (those who have spec i f i c family t i e s with Br i ta in) and nationals of E.E.C. countr ies. The Race Relations Act of 1976 (164) i s the la tes t in a ser ies of measures attempting to control rac ia l d iscr iminat ion in employment, housing, and in other serv ices. In 1980, the White Paper on Immigration proposed more res t r i c t i ons on immigration and on immigrants. (165) It has been a feature of recent h istory that no co-ordinated attempt has been made to help new minor i t ies integrate into B r i t i s h l i f e , with the exception of the Poles and to lesser extent the evacuees from Uganda. The Local Government Act of 1966 (166) and The Urban Program of 1968 (167) were promulgated to give f inanc ia l assistance to Local Author i t ies for extra services for immigrants, but use of the money made ava i lab le has been uneven across the country. Community Relations Counci ls , voluntary committees control led., by voluntary executives on which elected local government representatives of the major p o l i t i c a l part ies have been heavi ly represented, have attempted to involve ethnic minor i t ies in community educational and welfare schemes. A c t i v i t i e s and success have varied across the country, and with rare exceptions the i r impact on loca l p o l i t i c a l opinion about the real disadvantages 65 of the ethnic minor i t ies appears to have been t r i v i a l . "In retrospect, the explanation of these def ic ienc ies seems c l ea r l y p o l i t i c a l . " (168) The o f f i c i a l diagnosis of the educational problems posed by immigration has been made p r i n c i pa l l y in terms of problems for the host community rather than for the immigrants themselves. Rees comments that the proposal by the E.E.C. that ch i ldren be taught the i r 'mother tongue' during school hours does not appear to have been ser ious ly considered by the B r i t i s h Government, which i s s t i l l th inking on the l ines of rapid ass imi la t ion of immigrants into the B r i t i s h cu l ture . (169) One resu l t of th is thinking is that the low educational attainment and high unemployment among young Br i t i sh-born Blacks are fue l ing rac ia l tensions in the major c i t i e s . (170) Problems with immigrant health have also been documented. The 1962 Commonwealth Immigrants Act (171) s t ipu lates that immigrants from the Commonwealth are subject to a medical examination on a r r i v a l . Any medical procedure that however inc identa l l y seems to s ingle out "New Commonwealth' immigrants could be intepreted as d iscr iminatory; the. checks for typhoid are an example. Other problems appear to be centred on the charac ter i s t i cs of the immigrants themselves; the i r at t i tude to the health serv ice; the ignorance of both immigrants and health professionals of cu l tura l 66 dif ferences; and/or poor communication. Some Local Authority Health Departments and hospita ls have recrui ted s ta f f from the i r local minor i t ies in an attempt to overcome these in te rcu l tu ra l and communication problems, but Jones found that only two hospital management committees were current ly providing anything approximating race re la t ions br ie f ings for the i r s t a f f , and such provisions were for nurses and not for the doctors or the 'lower ranks ' . (173) There have- been-d i f f i cu l t i es ' based on colour and cu l tura l differences with pat ient/pat ient , pa t ien t /s ta f f , and s t a f f / s t a f f re la t ionsh ips . The t rad i t iona l B r i t i s h ' l a i s s e z - f a i r e ' a t t i tude to publ ic po l icy has only occasional ly been modif ied, and then in times o f ( in humanitarian terms) c r i s i s such as with the Po l i sh , Hungarian and Ugandan refugees. Only in recent years, and large ly because of fears of rac ia l tension, have any signs emerged of central government concern with the s i tuat ion of minor i t ies within a hos t i l e B r i t i s h soc iety. "The bitterness which resu l ts from the experience of rac ia l d iscr iminat ion does not disappear in a generation, and the s i tuat ion may be beyond repair in B r i t a i n . " (174) 67 Conclusion The trend in immigration po l i c i e s has been to remove the barr iers based on race or na t iona l i t y ; part ly in response to the changing internat ional p o l i t i c a l r e a l i t i e s and the changing world migration patterns, and part ly because of the need to l i nk immigration to economic needs. The exceptions being B r i t a i n , who by devious leg i s la t ion i s t ry ing to r e s t r i c t her 'coloured' immigration, and Israel who accepts a l l Jews who wish to migrate regardless of her internal economic s i tuat ion and external pressures. A l l have had problems with the integrat ion of immigrants into the i r respective soc ie t i es . Although the governments have o f f i c i a l l y encouraged immigration, with the exception of Israel they have not done much to prepare publ ic opinion or provide programs and services to help the newcomers to adapt to the i r new environment. The resu l t may have been to make i t d i f f i c u l t for them to meet the i r basic needs. Employment and housing may have been unsat isfactory or even unavailable because of indi f ference or h o s t i l i t y on the part of the loca l populat ion, and these att i tudes cer ta in ly do nothing to help the immigrants feel that they 'be long ' . When th is indi f ference is extended to the needs of the immigrant ch i ld ren, then soc ia l unrest may be expected when these chi ldren grow up and f ind themselves to be a disadvantaged segment of the population because of a lack of educational opportunit ies. 68 These countries have set basic standards of health for the i r immigrants, but again with the exception of I s r ae l , do not appear to have been too concerned with the i r health once they had se t t l ed . It has been seen ea r l i e r in th i s thesis that f a i l u r e to meet basic human needs may adversely af fect the health of immigrants; and i f they are involuntary migrants, then th is ef fect may be more detrimental as the i r health w i l l have already been affected by the i r experiences. With th i s in mind, i t i s intended to examine Canada's experience with immigration. 69 CHAPTER 6 CANADA AND IMMIGRATION INTRODUCTION Canada's experience with immigration has been somewhat s im i la r to both that of the U.S.A. and Aus t ra l i a . Although there was no del iberate 'melting pot 1 po l i cy , i t was hoped to bui ld a nation of people with s im i la r customs and ideals by se lect ive immigration. The ' f a c t ' of a mul t i cu l tura l society was accepted ea r l i e r by Canada; but the need for programs and services to help the adjustment of immigrants has only recently been recognised. 1867-1918 Before 1867, immigration was the respons ib i l i t y of the B r i t i s h government: with Confederation^ and under Section 95 of the B r i t i s h North America Act of 1867 i t became the j o i n t respon-s i b i l i t y the . federal and prov inc ia l governments.(174) The d iv i s ion of those re spons ib i l i t i e s was set out in the Immigration Act of 1869, (175) with the federal government being responsible for the se lect ion of immigrants and the i r welfare from point-of-departure to dest inat ion, and the provinces for the i r settlement. I n i t i a l l y , th i s was a l l rather l a i s s e z - f a i r e , but the quarantine stat ions set up by the federal author i t ies to prevent the importa-t ion of the infect ious diseases were the forerunners of publ ic health services for the whole population. The Immigration Aid 70 Societ ies Act of 1872 (176) was intended to regulate the functioning of the (voluntary) soc iet ies being set up across the country to aid the settlement of the newcomers. This Act i s s t i l l in force. The aim of immigration was the settlement of agr i cu l tura l land, and the 'preferred c lasses ' of immigrants were farmers, farm labourers, and domestic servants from B r i t a i n , selected European countr ies, and the U.S.A. When th i s f a i l ed to provide enough se t t l e r s for Canada's need, then large numbers were recrui ted from eastern Europe. The comparative i so l a t i on of the non-Anglo-Saxon communities that grew up on the pra i r i es meant the retention of the i r language and cu l ture: they were not ass imi lated. C l i f f o r d S i f ton as Min is ter of the Inter ior from 1896-1905 was responsible for immigration, and i s credited with the foundation of the concept of se lect ive immigration that remains the cornerstone of immigration po l icy today.(177) He was responsible for the 1902 amendment to the Immigration Act that excluded "diseased persons" as a measure of protect ion of the publ ic health.(178) Already excluded were those deemed undesirable on phys ica l , mental, or moral grounds. A rev is ion of the Immigration Act in 1910 gave the Canadian government power to make regulations rather than changing the Act i t s e l f in response to external and internal events and s i tuat ions that af fect the recruitment and settlement of immigrants. (179). 71 In spi te of the government's enthusiasm there was not unanimous publ ic approval of large scale immigration. The Province of Quebec feared the submersion of i t s - cu l ture; the trade unions campaigned against the a r r i va l of non-agricultural workers in the c i t i e s of the eastern provinces as i t caused unemployment; and publ ic ag i ta t ion in B r i t i s h Columbia led to increasing ( leg is la ted) d iscr iminat ion against Chinese immigrants by the imposition of a larger and larger head tax. There was already a head tax on immigrants to insure against the i r becoming a charge on the publ ic purse in the event of i l l ne s s or d i s a b i l i t y . This d iscr iminat ion on rac ia l grounds was extended to the Japanese and the Indians; although the problem was dealt with by an agreement with the Japanese government to r e s t r i c t the emigration of its,, c i t i z en s , and by the ' d i rec t passage' l eg i s l a t i on af fect ing the t r ave l l i ng route of the Indians. Services for immigrants were seen as perhaps necessary before, and during migration and were designed as much for the protect ion of Canada by excluding the undesirables as for the encouragement of the immigrant. There were voluntary soc ie t ies to a id the settlement of the immigrants, but neither prov inc ia l or federal governments appeared to take much interest in the i r welfare once they had arr ived at the i r dest inat ion. 72 By the end of th i s period land for settlement was becoming scarce, the publ ic were anti-immigrant, and l eg i s l a t i on was becoming more r e s t r i c t i v e . Immigration was p r a c t i a l l y stopped by the F i r s t World War. 1919-1945 The h o s t i l i t y towards certa in na t i ona l i t i e s and categories of people that was generated by the F i r s t World War, and the return of ex-servicemen to an economic recession with heavy unemployment, caused a slowdown in the rate of immigration in the 1920s. The decision to exclude immigrants from India was upheld by the Imperial Conference of 1919 thus sett ing a precedence for future pol icy regarding non-white B r i t i s h subjects; and the Chinese were t o t a l l y excluded in 1923. This xenophobic at t i tude para l le led that in the U.S.A. at that time, and continued unt i l a f ter the Second World War. As economic prosperity improved in the middle 1920s so immigration po l i c i e s became more ac t i ve , with land settlement s t i l l the major object ive. 1926 saw the beginning of a sponsorship scheme al lowing the re -un i f i ca t ion of fami l ies in Canada. At the same time services for immigrants were expanded: more o f f i ces were opened in B r i t a i n and Europe; passage assistance was generous; immigrants were welcomed at point-of-entry and helped with the evaluation and exp lo i ta t ion of (land) opportunit ies; and medical 73 examinations pr io r to departure were ins t i tu ted f i r s t in B r i t a in and then in Europe. It appears that once here, immigrants were expected to manage by themselves. Again, outside forces affected Canada's immigration program. The Stock Market crash of 1929 followed by the Depression of the 1930s, brought immigration to a v i r tua l s t ands t i l l that lasted unt i l 1945. 1946-1960 With the end of the World War Two, Canadian immigration po l icy evolved rap id ly , r e f l e c t i ng the swift pace of national development and the profound changes on the internat ional scene. In his statement to the House of Commons on May 1, 1947 Mr. MacKenzie King acknowledged that "the problem of immigration must be viewed in the l i gh t of the world s i tuat ion as a whole" and that po l icy should be related to the s o c i a l , p o l i t i c a l and economic circumstances resu l t ing from the war, and to the problem of the resettlement of d isplaced, homeless people, as well as to the future economic and population growth of the country. (181) Many of the immigrants accepted af ter the war were refugees from Europe, and many had tubercu los is . In 1946 the federal government accepted respons ib i l i t y for the medical care of indigent immigrants, and chest X-rays became compulsory. Later, these 74 arrangements were further developed with cost-sharing arrangements with the provinces who, under the B r i t i s h North American Act of 1867 are responsible for the health and welfare of the i r c i t i z en s . Apart from t h i s , immigrant services were s t i l l confined to the recruitment, screening, and transportat ion of immigrants. Between 1952 and 1960 the immigration flow was cont inual ly being adjusted to the country's labour requirements. However, the po l icy adopted with the 1952 Immigration Act did not give equal chances to a l l potent ia l newcomers.(181) The Chinese Exclusion Act of 1923 had been repealed in 1947 (182), but there was s t i l l e x p l i c i t d iscr iminat ion against immigrants from A f r i c a , Asia and the Caribbean. The ideal was s t i l l a nation of one culture . . . one race. At the same time there was a new emphasis on soc ia l and humanitarian considerations with sponsored immigration becoming a major phenomenon. This had the ef fect of bringing in large numbers of unsk i l led r e l a t i ve s , espec ia l l y from the countries of southern Europe. There seems to have been an increasing wi l l ingness on the part of the government to make exceptions to the rules in favour of ind iv idua ls and groups. 1961 to the present The problem in the 1960s was to f ind a way to end the discr iminatory features of immigration po l icy while bearing in 75 the mind the economic s i tua t ion and the changes in labour require-ments. Canada was fast becoming an indust r ia l country and needed highly s k i l l e d immigrants, and the formation in 1966 of the Department of Manpower and Immigration recognized the r e l a t i on -ship between economic needs and immigration. A new pol icy in 1962 made unsponsored immigrants from anywhere in the world admissible on the same c r i t e r i a - the education, t r a i n i ng , s k i l l s and other qua l i f i ca t i ons necessary to obtain employment or to set up the i r own enterpr ises. At the same time the sponsorship rules were changed to allow residents of Canada to sponsor certa in classes of re la t i ves regardless of na t i ona l i t y , while sponsorship of other classes of re la t ives was res t r i c ted to cer ta in countries of o r i g i n . (183) The regulat ions regarding sponsored immigrants were tightened in 1967, although the discr iminatory clause on country of o r ig in was removed. (184) This amendment to the Immigration Act also introduced a points system for independent and nominated immigrants based on education, knowledge of French and/or Engl ish, occupational s k i l l s and demand for those s k i l l s , age, and a personal assessment score. Although overt d iscr iminat ion on nat iona l i t y was f i n a l l y removed, the requirements of the points system tend to weigh against would-be immigrants from the poorer parts of the world who are more l i k e l y to be poorly educated, unsk i l l ed , and speak 76 neither English nor French. The removal of the l as t pieces of rac ia l d iscr iminat ion from Canada's immigration po l icy in 1967 may be compared with that in the U.S.A. - 1965, and Aust ra l ia -1973. Hawkins comments on the fact that th i s Canadian pol icy change was not in response to publ ic pressure as in the U.S.A. and l a te r to some extent in Aus t ra l i a ; in fact the Canadian publ ic was hardly aware that immigration po l icy was d iscr iminatory. The po l icy had become "d is tas te fu l and impracticable to the ru l ing groups in both major p o l i t i c a l par t ies" and was out -o f - l i ne with the role that Canada then wished to play in the internat ional community and Commonwealth, and with her role as a trading country espec ia l ly with the Caribbean and As ia . (185) The 1966 White Paper on Canadian Immigration Pol icy recognised the importance of services to help the adjustment of immigrants to Canadian l i f e . (186) In the same year, respons ib i l i t y for immigrant services at the federal l e v e l , previously borne en t i re l y by the Department of C i t i zensh ip and Immigration, was divided between the new Department of Manpower and Immigration and the Department of the Secretary of State. The former took respons ib i l i t y for the i n i t i a l needs of the immigrant - se lec t ion , counse l l ing, job placement; and the l a t t e r for the longer-term needs of adaptation to a new way of l i f e with emphasis on 77 programs rather than on indiv idual assistance. Social assistance services are the respons ib i l i t y of the provinces, and in th i s respect may be seen as the log ica l successors of the Department of Manpower and Immigration a f ter the l a t t e r has f a c i l i t a t e d the immigrants' i n i t i a l settlement.(187) Health insurance and health services f i t into th i s category. Hawkins has observed that there had been almost no consultat ion with the provinces in th i s area of common j u r i s d i c t i on and concern, and that l i t t l e thought seems to have been given to serious planning or to the development of adequate services beyond the basic welfare and medical needs of the immigrants for the f i r s t year a f ter a r r i v a l . (188) Richmond made the comment that when compared with services in Aus t ra l i a , and in B r i t a i n which has not encouraged immigration, "the quantity and qua l i ty of services to ass i s t immigrants in Canada has been low." (189) It has already been seen that in the las t decade those countries have considered the i r respective programs and services to be inadequate. There are voluntary agencies that have been interested in the welfare of immigrants af ter the i r a r r i va l in Canada, and these usual ly have cu l t u r a l , re l ig ious or ethnic a f f i l i a t i o n s . Being community based they should be well placed to ass i s t ind iv idua ls as well as encouraging and educating the community to understand and accept the needs of newcomers, and a l l leve ls of 78 governments maintain a l i a i son service with them. It has been commented that the i r programs do not reach enough immigrants and that no-one i s doing any planning, co-ordination and development in th i s f i e l d . "The voluntary sector in immigration i s , in f ac t , very d i f f i c u l t to c l a s s i f y and to describe because i t i s a scene of great d i ve r s i t y , very unequal performance and constant change and f l uc tua t i on . " (190) It i s p la in that these agencies have given considerable, and large ly unpaid, service to the government in the recept ion, welfare and adjustment of immigrants; but the consequences of the d i ve r s i t y and lack of planning mean very unequal treatment for the immigrants, and that there i s no way of knowing how many have benefited. CANADA'S REFUGEE POLICIES There has been frequent co-incidence between Canada's immigration requirements and the need of cer ta in groups of people for asylum. Doukhobors and Mennonites were admitted in 1899 as immigrants by Order- in-Counci l , rather than as the p o l i t i c a l -re l ig ious refugees they actua l ly were. At the same time, more than a thousand Mormon fami l ies set t led in what i s now southern Alberta as 'preferred ' immigrants in sp i te of the fact that they had f l ed from the U.S.A. for fear of persecution. 79 Mennonites and Doukhobors were denied entry in the ear ly 1920s during Canada's ear ly xenophobic period, but th i s regulat ion was rescinded in time to al low many thousands to leave Russia before the Russians 'closed the door' in 1926. Canada also accepted thousands of Roumanian Jews on humanitarian grounds in the 1920s. No modif icat ion of po l icy was made during the 1930s when "even refugees were rejected on economic grounds." (191) Some ind iv idual refugees with capi ta l or indust r ia l expert ise were admitted by Order-in-Council jus t pr io r to the war; otherwise refugees from Europe were interned as a l iens during the war jus t as they were in Aust ra l i a and B r i t a i n . "Overa l l , the Canadian publ ic has time af ter time f a i l ed to d i f f e ren t i a te between the immigrant and the refugee." (192) There was considerable pressure from the internat ional community on the t rad i t i ona l receiv ing countries to relax the i r immigration laws and give asylum to some of the mi l l i ons in Europe who had been uprooted by the war. Some of these refugees were admitted to Canada under special government author i ty; and many of them were bas i ca l l y healthy and had qua l i f i ca t i ons which would have made them e l i g i b l e under immigration standards. Canada's ear ly e f fo r ts concentrated on the admission of large numbers of those who could, with ass isted t ransportat ion, be 80 quickly rese t t l ed . (193) In other words, they had s k i l l s that Canada needed. Eventual ly, Canada admitted several thousand refugees from Europe, inc luding the unsk i l l ed , the s i ck , and the phys ica l ly and soc i a l l y handicapped. Canada's desired image abroad, and her fore ign-born 'po l i t i ca l jconst i tuents dictated the admission of immigrants not d i r e c t l y destined for the workforce.(194) Other refugee groups have been admitted under special programs in response to major internat ional c r i ses : 38,000 Hungarians, 1956-57; 12,000 Czechs, 1968; 228 Tibetans, 1970-whom the Province of B r i t i s h Columbia refused to accept; and 1200 Chi leans, 1973-74. In sp i te of the government contention that"the chief motive behind Canada's contr ibut ion to refugee resettlement has been the desire of the Canadian people to help" (195), Howard has commented that even as "genuinely humanitarian motives ex is t among many l eg i s l a to r s and c i v i l servants . . . (they) nevertheless f ind themselves obl igated to respond to a publ ic opinion which i s not uniformly in favour of admitting refugees."(196) Att i tudes towards minority groups appear to be improving but " i t cannot be assumed that these latent ant ipathies have altogether disappeared." (197). 81 Canada does not have a po l icy of p o l i t i c a l asylum, and suspicions have been voiced that there may be ideological factors in refugee pol icy. (198) (199) . I t may be noted that the majority of the refugees admitted since the 1950s have f led communist regimes. .While.taking cred i t for the admission-of Chileans f lee ing persecution from the i r r ight-wing government, the Canadian government has not f a c i l i t a t e d the i r migrat ion. There appears to be further d iscr iminat ion. " I t i s important that whatever numbers Canada al lows.. .refugees be selected according to the i r a b i l i t y to adapt to Canadian l i f e . " (200) The 1976 Immigration Act s tates , with regard to the se lect ion of immigrants: "Sec .6( l ) . Subject to th i s Act and the regulat ions, any immigrant inc luding a Convention refugee, a member of the family c l ass , and an independent immigrant, may be granted landing i f he is able to estab l i sh to the sa t i s fac t i on of an immigration o f f i c e r that he meets the se lect ion standards establ ished by the regulat ions for the purpose of determining whether or not an immigrant w i l l be able to become successful ly establ ished in Canada. (2) Any Convention refugee and any person who i s a member of a c lass designated by the Governor in Council as a c l ass , the admission of members of which would be in accordance with Canada's humanitarian t r ad i t i on with respect to the displaced and the persecuted, may be granted admission subject to such regulat ion as may be establ ished thereto and notwithstanding any other regulations made under th i s Act ." (201) The ind iv idual most in need of asylum may be the one who has suffered severe physical and/or psychological trauma, and who may well need extended medical care. Those disabled by torture have not 82 been admitted to Canada; and unless pr ivate ly sponsored, i l l i t e r a t e , unsk i l led peasants who speak neither French nor English have also had d i f f i c u l t y entering th i s country. (202) The Vietnamese in Canada There were several thousand Vietnamese already in Canada when the 'Boat people' sa i led over the horizon. They had been admitted as landed immigrants rather than as "refugees on parole, as the i r compatriots in the U.S. were."(203) The c r i t e r i a used to grant interviews/visas were good health, and re la t i ves in Canada or s k i l l s that Canada needed. As such, i t may be assumed that those accepted would have a good chance of adjust ing to a new environment. From the point of view of the government i t i s sound sense to admit only the most economically adaptable refugees to Canada -i t lessens publ ic h o s t i l i t y i f i t i s seen that they are not a publ ic charge. Low refugee costs are also a t t rac t i ve to.the provinces who must bear the cost of soc ia l services such as education and health care. At the same time the government can take c red i t for i t s 'humanitarian' a t t i tudes . The l eg i s l a t i on to admit 'the poor, the ha l t , and the lame' ex i s t s : i t remains to be seen i f i t i s used for the 'Boat-people' . 83 CHAPTER 7 THE 'BOAT PEOPLE' INTRODUCTION The 'Boat people' are only part of the vast population movements in present-day Southeast As ia; there are thousands of refugees from Kampuchea in Thailand, and from The People's Republic of China in Hong Kong. Wherever they are, in camps or otherwise, the i r needs must be met within an aTien environment. In add i t ion, there is the stress of an uncertain future; and once accepted for resettlement in another country the refugees are faced with making further adjustments. As a prelude to considering the health problems that may ar ise with the resettlement in Canada of some of the 'Boat people' i t i s necessary to look at the way needs are met within the Vietnamese cu l ture; at the ef fect of the war and the i r subsequent f l i g h t ; and from th i s to ident i fy possible health problems associated with the i r resettlement. HUMAN NEEDS As previously discussed, human needs are normally met within a spec i f i c cu l tura l se t t i ng , and in moving from one culture to another an indiv idual has to learn other ways of meeting his needs. In other words, he attempts to adapt. F i g u r e 2. Map o f Viet-Natn and p a r t o f S o u t h e a s t A s i a 85 A basic human need i s for food, and d iet and food preferences are par t ly governed by geography. Viet-Nam has been described as "two bags of r i ce on a pole"(204), as the t rop i ca l monsoon ensures the 'wet' cu l t i va t i on of r i ce on the two major r i ve r de l tas , the Songkoi (Black River) in the north and the Mekong in the south. The people do not consider that they have eaten i f there has not been r i ce at the meal, to which vegetables and f i s h , or occasional ly pork or chicken are added. Most ingredients fo r the i r accustomed d ie t w i l l be found in Canada, espec ia l ly in areas that have large concen-trat ions of Chinese people such as Vancouver, Toronto, and Montreal. Safety and secur i ty are supplied by fami l i a r surroundings. The Vietnamese people w i l l be used to a f l a t delta landscape where the majority of the population l i v e , and to a hot and humid cl imate which allows a great deal of out-door a c t i v i t y . The highlands are occupied by several h i l l t r ibes co l l e c t i v e l y known as the Montagnards and whose way of l i f e i s more pr imi t ive than that of the lowland Vietnamese. The change in cl imate alone w i l l mean that the 'Boat-people' w i l l have to adapt to heavier c lo th ing , and in many parts of Canada w i l l have to change to a l i f e - s t y l e spent mostly indoors during the winter. Housing in Viet-Nam ranges from the we l l - bu i l t masonry wal ls and t i l e d roofs of the wealthy to the wooden wa l l s , thatched 86 roofs and earthen f loors of the peasants. I f poss ib le , the furn i ture w i l l include the highly polished hardwood slabs used as beds. The most important room on the house contains the ' a l t a r of the ancestors' in Buddhist homes or a ' shr ine ' in Cathol ic homes, and th i s i s where the fami ly ' s re l ig ious observances take place and r i t e s honouring the ancestors are performed, espec ia l l y at the fes t i va l of Tet. . The family i s the basic unit of Vietnamese society and provides the chief source of i den t i t y , 'belongingness 1 and ' se l f -wor th ' for the ind iv idua l . The family takes precedence over the wishes or inc l ina t ions of the indiv idual and as th i s family s o l i d a r i t y i s not the 'norm' in North America where emphasis i s placed more on i nd i v i dua l i t y , i t i s possible that c on f l i c t may ar ise within Vietnamese fami l ies as the chi ldren become exposed to western values at school. Authority in the family rests with the senior male, and descent i s p a t r i l i n e a l . Unt i l recent ly , women have been considered i n f e r i o r with more duties than r i gh t s , however the economic changes caused by the war have meant that women have had to contribute!more f i nanc i a l l y to the family by working outside the home. There i s a strong sense of cont inui ty of the fami ly, pas t , present and future, and of i t s associat ion with the land. 87 "ancestor worshippers, the Vietnamese saw themselves as more than separate egos, (but) as part of th i s continuum of l i f e . To leave the land and the family forever was therefore to lose the i r place in the universe and to suffer a permanent, co l l e c t i ve death." It may be speculated that having to leave the land associated with the ancestors i s then a major psychological shock, although th is may be a delayed react ion. The family functions within a soc iety, and in Viet-Nam the t rad i t i ona l soc iety, bu i l t up over the past one thousand years, was based on the v i l l age as a socia l un i t . I t was an agrar ian, rather s t a t i c soc iety, s t r a t i f i e d according to wealth in land; ruled by an emperor and his royal fami ly; and governed by an i n te l l e c tua l e l i t e organized in a c i v i l bureaucracy. This soc ia l structure was more or less patterned on that of ancient China with whom the Vietnamese are e thn i ca l l y l inked. The teachings of the moral philosopher Confucius s t i l l inf luence values and a t t i tudes . As la te as 1945, rural communities s t i l l embraced more than ninety percent of the tota l population of the country, and th i s preponderance of the tota l population with i t s s t a t i c way of l i f e explains the existance in Vietnam of many old be l i e f s , t rad i t ions and supers t i t ions . (206) 88 TRADITIONAL HEALTH AND SICKNESS BELIEFS AND PRACTICES. In Viet-Nam the t rad i t i ona l be l ie f s and pract ices regarding health and sickness are widespread not only among the rural society but also among the educated urban fami l i es . These be l ie f s are related to and adapted from Chinese medicine with i ts concept of harmony with the universe. "There are three souls and nine v i t a l s p i r i t s which co l l e c t i v e l y sustain the l i v i n g body. When a l l souls and s p i r i t s are present the ind iv idual experiences a sense of well being, but i f one or a l l should depart, s ickness, insani ty or death could r e su l t . " (207) Popular be l ie f s a t t r i bu t ing the cause of disease to the entry of ev i l s p i r i t s into the body are common, espec ia l l y among the Montagnards. Some bel ieve that the s p i r i t can be induced to depart by sorcerers employing t rad i t iona l r i t e s , and others hope to keep the s p i r i t away by wearing charms or of fer ing sac r i f i c e s and pet i t i ons . Another set of be l ie f s i s that i l l n e s s can be caused by a sorcerer who possesses something belonging to the v i c t im, a piece of c lothing or a lock of hair for instance. Popular be l i e f s can often inter fere with diagnost ic and preventative procedures. A person who i s a f ra id that he will.become i l l i f someone, possibly a sorcerer, acquires something belonging to him i s l i k e l y to refuse to allow a blood sample to be 89. taken. Attempts to introduce publ ic health measures such as improved san i tat ion and personal hygeine have met with l i t t l e success when i t i s believed that sickness may be prevented by the appropriate r i t ua l s requesting protect ion from or prop i t i a t ing an ev i l or errant s p i r i t . The healers, therefore in t rad i t i ona l Vietnamese health pract ices are those who have the power to meet and exorcise ev i l s p i r i t s . (208). However, popular be l ie f s have not inter fered with acceptance of modern medical treatment. This acceptance i s based mostly on the e f fec t ive performance of Western drugs, espec ia l ly the an t i b i o t i c s , and s t r i k i ng surgical resu l t s . Reliance on Western medicine has been greatest in the c i t i e s , but was increasing in rural areas where people tended to see i t as an addit ional curat ive aid rather than a subst i tute for t rad i t i ona l remedies. It i s often believed that Western medicine i s unsuitable for the Vietnamese const i tut ion since Western drugs are 'hot ' and have a dehydrating ef fect on the humor and blood. It seems probable that the younger refugees at least w i l l accept Western medic ine,especia l ly i f they have come from the c i t i e s of Viet-Nam. Sensit ive and knowledgeable health services personnel w i l l ass i s t and ease th i s adaptation. Overlying th i s t rad i t i ona l society are the ef fects of the French co lon izat ion. 90 THE EFFECTS OF COLONIZATION The French imposed some changes on the t rad i t i ona l structures of the country: p o l i t i c a l subjugation; the introduct ion of French education; the beginnings of i ndus t r i a l i z a t i on in the north and of commercial agr icu l ture in the south; the growth of urban areas. These a l l made the i r impact on the socia l structure of Viet-Nam. In the c i t i e s there developed a new e l i t e consist ing of senior government o f f i c i a l s , m i l i t a r y o f f i c e r s , professional people and fami l ies engaged in commerce; a l l of whom spoke French and were at least part ly French educated. The new urban middle c lass consisted of c i v i l servants, school teachers, small merchants who, while not employing large amounts of labour did not themselves work with the i r hands - an a c t i v i t y they considered degrading. The urban lower class was made up of mainly unsk i l l ed , large ly uneducated labourers and petty tradesmen. An important factor in the p o l i t i c a l and cu l tura l h is tory of Viet-Nam has been the gradual inf low of Chinese people for permanent settlement as 'middlemen 1, t raders, and business men. (209) They contro l led banks, transport companies, insurance agencies, and the marketing of many basic foodstuffs . Most importantly, they establ ished a monopoly on the r i ce trade causing suffer ing and resentment on the part of the Vietnamese peasant. 91 They came o r i g i na l l y from southern China and "because of h i s tory , the proximity of China, the i r clannishness, entrepreneurial ta lents and opportunism, the 'Hoa' (as the Chinese l i v ing outside China were known) in Viet-Nam were to be inext r i cab ly caught up in the events of 1978-79 that caused the exodus. (210). THE EFFECTS OF THE WAR Because of the prolonged warfare i t i s d i f f i c u l t to separate culture and be l ie f s from the experiences of the population during that time. The safety and secur i ty of both rural and urban family and c lass re lat ionships in a l l of Viet-Nam were destroyed by the continuous warfare from the late 1930s unt i l the Americans withdrew in 1975. It was not always possible to keep the large extended fami l ies together when rese t t l i ng the refugees from the north in South Viet-Nam af ter the pa r t i t i on of the country in 1954; and later., the absence of physical secur i ty in the rural areas of the south forced the mass migration of peasants in the c i t i e s and 'safe areas ' . The huge labour surpluses caused by th i s migration were large ly absorbed by the needs of the Americans; in fac t , the c i t i e s became dependent for the i r economic survival on the prolongation of the war. (211) The socia l upheaval contributed to the breakdown of the t rad i t i ona l family l i f e , with widespread p ros t i t u t i on , an increase in juveni le delinquency, increased opium smoking, and an 92 increase in veneral disease. Family roles were reversed: farmers became unemployed because of re locat ion "while the wives and daughters could f ind work as pros t i tu tes , bar g i r l s , laundresses and maids . . . a l l war-created work, much of which . . . was re lated to the American presence." (212) Food was in short supply in both rural and urban areas. I t has been stated that malnutr i t ion was endemic in South Viet-Nam, and probably in North Viet-Nam as we l l , even before the destruct ion of crops, i . e . s tarvat ion, as a m i l i t a r y weapon by the Americans. (213) (214) The ef fect of a l l th is on the Vietnamese people was malnutr i t ion; an increased suscep t i b i l i t y to disease; and to the breakdown of psychological coping mechanisms. "I have never seen people so depressed, so t o t a l l y lacking in motivation . . . a t e r r i b l e sense of fat igue . . . enormous amounts of opium smoking . . . " (215). As Maslow points out " . . . the threat of chaos . . . produces a regression from higher needs." (216) HEALTH PROBLEMS IN VIET-NAM Attempts were made during the ten year truce, 1955-64, to improve the publ ic health services in the Democratic Republic of Viet-Nam (North Viet-Nam). "Having got r i d of many superst i t ions and bad habi ts , each family now has a double sept ic tank and a bathroom, and three or four fami l ies share a we l l . Bodi ly hygeine 93 . . . i s being improved. People take especial care to eat clean food and l i v e in clean dwel l ings." (217) This led to claims by the government of North Viet-Nam that malaria had been eradicated in several regions, as well as having improved the l i v i n g condit ions of the peasants: however a l l th i s must have been destroyed by the saturat ion bombing la te r in the war. Conditions in the South did not improve during th i s time. A malaria eradict ion program, which had begun to produce results,; was halted by the Viet Cong t e r r o r i s t attacks against the government teams working in the v i l l ages , and malaria is again endemic in Viet-Nam. (218) Plague was rampant with South Viet-Nam being the only country in the world with a plague problem. South Viet-Nam also had the highest rate of tuberculosis in any under-developed country; po l i o , leprosy and trachoma were common, and "everyone had in tes t ina l paras i tes ." (219) POST WAR On Apr i l 30th 1975 the war in Viet-Nam ended with tota l v ic tory for Hanoi. With the reconstruction of Vietnamese society by the new government, pr ivate property was abol ished, a new currency destroyed pr ivate holdings and hoarding, and the press was suppressed and books burned. The loss of pr ivate property and pr ivate holdings of money h i t the Chinese-dominated business 94 community espec ia l ly hard, as did th'e deter io r ia t ing p o l i t i c a l s i tuat ion between Viet-Nam and China. There was also persecution of Buddhists, Catho l ics , and the Cao Dai and Hoa Hao - two smaller re l ig ious groups. (220) There had been a continuous ' t r i c k l e ' of people leaving Viet-Nam by boat since the American evacuation of Saigon in 1975, but by ear ly 1979 th is had become a ' t o r r en t 1 . An invest igat ion of th i s phenomenon by the Austra l ian newspaper ,: the Melbourne 'Age' , documents the reasons for th i s outflow, and the experiences of the refugees and the countries of f i r s t asylum - Hong Kong, Thai land, Malaysia, Singapore, and Indonesia and the Ph i l l i p i n e s . They estimate that 65% of the main exodus of 163,000 people who l e f t between March 1978 and mid - 1979 were from Viet-Nam's Chinese minor i ty, and that in the same period about 250,000 Chinese l e f t for China. (221) . The 'Age' invest igat ion quotes a study made by the Hong Kong government in June 1979 on the ages of nearly 20,000 'boat people' that concluded that on an average boat about ha l f the passengers were ch i ld ren , women and old fo l k . "Of the 292,315 people who l e f t by boat from Viet-Nam, about 77,000 got to Hong Kong. Most of the rest - jus t over 200,000 - choose the sea-route leading southwest from Viet-Nam." (222) As Lord Carr ington, B r i t a i n ' s Secretary of State for Foreign and Commonwealth A f fa i r s is reported as saying to the 95 UNHCR Geneva Conference on July 20, 1979, "One can only conclude that they have l e f t because the po l i c i e s of the Vietnamese government made i t impossible for them to remain." (223) EXPERIENCES DURING FLIGHT Apart from shortages of water, food and fuel on the i r overcrowded, slow-moving, defenceless, and often unseaworthy.boats, the refugees leaving southern Viet-Nam were l i ab l e to attacks by pirates operating from por ts . in southern Thailand. U.S. refugee o f f i c i a l s interviewing victims of these attacks often wrote 'RPM1 in the i r notes, meaning rape, p i l l age and murder. An American o f f i c i a l estimated in June 1979 that 30% of a l l refugee boats leaving southern Viet-Nam had been ' h i t ' by p i ra tes ; of these about a th i rd suffered 'RPM'. (224) LIFE IN THE REFUGEE CAMPS From a l l the countries of f i r s t asylum the 'Age' invest igat ion documented some depressing common factors about the refugee camps. They were congested, f a c i l i t i e s were rudimentary, and above a l l , they were haunted by uncertainty. How long would the refugees have to wait for resettlement? Each camp had i t s own charac te r i s t i c s . From the descr ipt ion of one camp, Bidong in Malaysia, one gets the impression of a "dangerously congested slum" with rubbish ro t t ing 96 on the beach, and an overpowering stench of human-excrement. There was an acute shortage of water; the d i e t , UNHCR's standard rat ion pack, was inadequate; and there was a thr iv ing black market in everything inc luding food. There was widespread malnutr i t ion among the ch i ld ren , and many cases of tuberculosis for which they had an inadequate supply of drugs. There had been an outbreak of hepat i t i s in ear ly 1979, and some iso lated cases of typhoid and meningit is . In a population of 42,000 l i v i ng in an area of less than one square ki lometre, there were 28 cases of mental i l l n e s s "most of them 1RPM1 v i c t ims." There was a hosp i ta l , bu i l t and staffed by the refugees: and in spite of th is tragedy, the camp was described as an " indest ruct ib ly r e s i l i e n t world." (225) An eye-witness account of a refugee camp for Khymer (Cambodian) refugees described how the empty f i e l d designated as the camp was inundated with s ick and starving refugees before any shelter could be ra ised. Many were too weak to move when i t rained, and drowned. However, th i s camp soon "got i t s e l f organized." (226) At the other end of the spectrum, the 'Age' invest igat ion describes the most humane administrat ion of camp l i f e as being in Hong Kong where the government had progressively allowed the UNHCR to take over the running of most of the refugee centres. Most residents of the camps were allowed to come and go f ree ly except when they were about to f l y abroad for resettlement. A lso, because of a labour shortage in the Terr i tory they were encouraged, and helped, 97 to f ind employment. (227). This i s the world from which w i l l come the approximately 50,000 refugees to be reset t led in Canada. I t i s d i f f i c u l t to separate the 'normal' stresses of migration and adaptation from the 'abnormal' stress of deprivat ion and f l i g h t . In any case, the i r health w i l l have been affected by the i r experiences and the i r resistance to disease w i l l have been lowered. These w i l l include infect ious diseases that threaten the health of Canadians; and may include those indigenous to Southeast Asia that pose no threat to Canadians, as wel l as those common in the i r new environment against which they have no immunity. These w i l l be considered in the next chapter. The mental health aspects of the adaptation process w i l l be examined in the fol lowing chapter. 98 CHAPTER 8 HEALTH PROBLEMS EXPECTED WITH THE REFUGEES  INTRODUCTION Before considering the diseases that may be a threat to Canadians and/or the refugees themselves with the resettlement of the 'boat-people' in Canada, i t i s necessary to define concepts and terms used in descr ibing the health of a community. INDICES OF COMMUNITY HEALTH The usual measurement of the health of a community i s the frequency of disease, d i s a b i l i t y , or death in that community. I t may be simply measured by the number of people affected at a given time. However, most indicators current ly employed are based on the calculat ion., of rates that take into consideration the s ize of the population; e i ther the tota l number, or the parts that are susceptible or ' a t r i sk ' to certa in diseases or condit ions. For example, the morta l i ty rate indicates the number of deaths per 1000 population over a spec i f i c period of time. This crude rate i s l im i ted in its., usefulness as an ind icator of community health as i t merely states the number of deaths without reference to the composition of the population in terms of the age groups, or to a spec i f i c cause of death. I t may be ref ined as 'age-spec i f i c ' 99 and 'cause s p e c i f i c ' , but these rates s t i l l refer to deaths or diseases that cause death. Among the best indices of community health are the maternal and infant death rates because of the i r d i rec t re la t ion to soc ia l and environmental factors and to community serv ices. (228). The morbidity rate indicates the amount of a spec i f i c disease per 1000 population over a given period of time. Again th is is a crude measurement; and although :often unrel iable because of incomplete report ing, i s useful in a le r t ing the community to local outbreaks of infect ious diseases. The fol lowing are . more accurate indices of health/s ickness, and w i l l be used in th is thes is . The incidence rate indicates the number of new cases of a spec i f ied disease or condit ion occuring in a given period of time and i s expressed as N:100,000 to ta l population. The prevalence  rate indicates the number of ex i s t ing cases on a given date and may be expressed as N:100,000 population or as a percentage of the population. The case f a t a l i t y rate i s the number of deaths from a spec i f ied disease divided by the number of cases of that disease expressed .as N:100 population. 100 THE COLLECTION OF INTERNATIONAL EPIDEMIOLOGICAL DATA The problems of the r e l i a b i l i t y and comparabil ity of data on the internat ional d i s t r i bu t ion of disease are considerable. The more developed countries with the i r technology and extensive health care systems are able to co l l e c t more data, both qua l i t a t i ve l y and quant i ta t i ve ly , than are the more under-developed countr ies. The World Health Organization has made great s t r ides towards solv ing th i s problem by achieving recognit ion of the importance of uniform rules for processing health data and the use of a standard c l a s s i f i c a t i on of disease, in jury , and causes of death. (229) The problem of r e l i a b i l i t y remains: the World Health Organization rout inely co l lec ts data from indiv idual countr ies, and those judged re l a t i ve l y re l i ab l e are published pe r i od i ca l l y . (230) (231). However, caution i s required in in terpret ing differences between countries in publ ishing disease rates. There are no accurate and current epidemiological data about disease in Viet-Nam. The neglect of health care during the French co lonia l period was followed by prolonged warfare with the complete breakdown of soc ia l order. Sources of information on the possible health status of the Vietnamese refugees are the Centre fo r Disease Contro l , At lanta , U.S.A.; the l i t e r a tu re on the health problems of m i l i t a ry personnel a f ter service in 101 Viet-Nam; and the growing l i t e ra tu re on the health of the Vietnamese refugees admitted to the U.S.A. since 1975. FACTORS IN THE SPREAD OF DISEASE The reservoir of most diseases of man i s man himself , although he may become inc identa l l y infected with diseases where the reservoir i s in animals, such as Jungle Yellow Fever. The human reservoir consists of persons with both act ive and inact ive (quiescent) disease. A ' c a r r i e r ' i s defined as a person who i s not suf fer ing from c l i n i c a l symptoms of a disease but "who i s excret ing, or may from time to time excret, the agent to contaminate his environment or in fec t his associates." (232) The spread of disease may be by d i rec t transmission from man to man, as in coughing and sneezing; or i nd i r ec t , when the organism can remain viable outside the body and enter the body at a l a te r time. Some diseases require a 'vector ' for transmission, of which malaria i s an example as i t needs a mosquito ... to transmit the parasite causing the disease from man to man. Other diseases have an intermediate stage outside the human host in order to complete the developmental cyc le, e .g. hookworm. Certain c l imat i c conditions are necessary for the spread of some diseases, for instance malaria requires an average temperature 102 about 70°F for 10 consecutive days to enable the parasite to develop, the mosquito before i t can be transmitted to another person. In th is sense the global d i s t r i bu t ion of malaria canii be said to be geographically determined whereas measles knows no c l imat i c or geographical boundaries. Improvements in l i v i n g standards espec ia l ly in san i ta t ion , immunization, and treatment of communicable diseases, have lowered the incidence of many of the infect ious diseases of the past in countries of the ' F i r s t World ' . Travel lers today are subject to national and internat ional regulations aimed at preventing the spread of disease. (233) However, many of these diseases s t i l l pers i s t in the under-developed countries where reservoirs of i n fec t i on , the presence of spec i f i c vectors, and unsanitary conditions allow in fec t ion to spread. A low prevalence of an infect ious disease in a given area means that:much of,the population there ^will not have had the chance to acquire the appropriate immunity by contact with the disease-causing organism. Thus the movement of r e l a t i v e l y large numbers of people from areas with a high prevalence of a spec i f i c infect ious disease to areas where the prevalence i s low increases the s ize of the reservoir and subsequently the chances of the local population acquir ing the disease. I t can be seen that there may be a r i sk of introducing diseases into Canada from Viet-Nam 103 with the resettlement of large numbers of refugees in this country. Bearing in mind that imported diseases can threaten the health of Canadian as well as that of the individual refugee, these wi l l be considered under the following headings: 1. Infectious diseases that may be transmitted to Canadians. These may be caused by bacteria, viruses, or parasites; and thei.r transmission may be direct or indirect, by a vector, or through an intermediate host.* 2. Infectious diseases that are unlikely to be transmitted to Canadians, but remain a threat to the health of the individual refugee. 3. Infectious disease prevalent in Viet-Nam, but unlikely to be a problem for either Canadians or refugees. 4. Non-infectious diseases and conditions that may be seen in the refugees but are unfamiliar to Canadian health professionals. INFECTIOUS DISEASES THAT MAY BE TRANSMITTED TO CANADIANS Bacterial Diseases Bacterial enteric diseases. Enteric diseases caused by bacteria are a serious medical problem in Viet-Nam. Two studies in the Vietnamese population found Shigella to be the most often cultured. (234) (235) A study of Vietnamese refugee children found enteropathogens in 49% of 367 stools cultured, including E c o l i , Shigella, and Salmonella. (236) Some resistance of these organisms to chloramphenicol, tetracycline, and streptomycin was noted. * Unless otherwise indicated, the source of information on infectious diseases is Abram S. Benenson. ed. Control of Communicable Diseases in  Man. 12th ed. Washington, D . C ; The American Public Health Assoc. 1975. 104 Typhoid fever is endemic in Viet-Nam "and'from. 2. - 5% of cases become c a r r i e r s . : Typhoid b a c i l l i . t h a t are presumed to have come from that country may also-be chloramphenicol res is tant . (237) These diseases can be spread through food and water. Given the high standards of sani tat ion in Canada i t i s un l ike ly that they w i l l be spread through the water supply system; but as car r ie rs are asymptomatic, poor personal hygeine could spread the disease through the handling of food. As noted previously, newly arr ived immigrants tend to f ind employment in the poorer paid jobs of which food services i s an example. As no records are kept by the Department of Employment and Immigration on the jobs that new immigrants take, the degree of r i sk to the publ ic health from these diseases through food handlers cannot be estimated. Approximately 6000 Vietnamese refugee/immigrants had ( o f f i c i a l l y ) se t t led in Vancouver by the end of 1980, although the real number may be much greater. Vancouver has a large or ienta l populat ion, and i t has been estimated by S.U.C.C.E.S.S. (a voluntary agency o r i g i na l l y set up to a id the resettlement of Chinese immigrants) that there may be as many as 10,000 Vietnamese in Vancouver as they move from the places of or ig ina l settlement into an area of fami lar faces, language, and cul ture. In Vancouver, a special c l i n i c was set up by the 105 p r o v i n c i a l government i n ' Ch i na - t own ' , w i th s t a f f f l u e n t i n more than one o r i e n t a l language, Cantonese, Vietnamese, Mandar in, to look a f t e r the hea l th needs o f the Vietnamese immigrants. A spokesperson fo r t h a t c l i n i c s t a t ed tha t as f a r as he knew, no cases o f b a c t e r i a l e n t e r i c d isease had been repor ted among the new immigrants. However, i t must be remembered tha t these d iseases cou ld become a p ub l i c hea l th hazard. Gonorrhea. For convenience, t h i s d i s cu s s i on w i l l i n c l ude a l l s e xua l l y t r ansm i t t ed d i seases . I t has been repor ted t ha t p r e l im i na r y r e s u l t s o f s pe c i a l s tud ies t ha t screened refugee groups i n the U.S.A. f o r the presence o f s e xua l l y t r ansm i t t ed d iseases i n d i c a t e d tha t the preva lence i n these groups was low. The repor t a l s o noted tha t i s o l a t e s o f Ne i s s e r i a gonorrheae from Southeast As i a may be r e l a t i v e l y r e s i s t a n t to a v a r i e t y o f a n t i b i o t i c s . (238) The refugees accepted f o r rese t t l ement i n Canada w i l l have been screened f o r s y p h i l i s dur ing t h e i r p re - immigra t ion medical examinat ion . As they are a l s o mainly i n f am i l y groups (239) i t i s not expected tha t they w i l l add much to the problem o f con t ro l o f s e xua l l y t r ansm i t t ed d iseases i n t h i s country apa r t from the r e cogn i t i on and treatment o f d i sease a l ready present . Th is cou ld we l l i n c l ude the more e x o t i c v a r i e t i e s such as chanc ro i d , 106 Lymphopathia venerum, Granuloma venerum, and soft sore. A program screening adult Vietnamese immigrants in Vancouver has found no new cases of syph i l i s although i t i den t i f i ed 6 of 14 cases already known to have been treated pr io r to immigration. Tuberculosis. The reservoir of tuberculosis i s pr imar i ly man, and in some areas diseased ca t t l e . Infection, with Mycobacterium bovis (bovine tuberculosis) i s now rare in countries where dairy cows are regular ly tested for the presence of the disease. I t i s probably rare among the Vietnamese as there i s no t rad i t i on of dr inking milk a f ter weaning in that country. (240) The main source of in fec t ion from M tuberculosis i s sputum containing b a c i l l i , and transmission i s by d i rect contact; droplet nuc le i , which i s a true airbone in fec t i on ; or by ind i rec t droplet in fect ion where large par t i c les drop to the f l oo r and af ter drying become resuspended in the a i r . This bac i l lus causes pulmonary tuberculos is, and extra-pulmonary disease such as the tuberculosis of the lymph glands known as sc ro fu la . The re-act ivat ion of o ld pulmonary disease i s known to be a health problem among people with an already low resistance exacerbated by poor nu t r i t i on and l i v i n g condit ions. (241) Re-act ivat ion may also be tr iggered by s t ress , and i t has been recognised that rates of both new and re-act ivated tuberculosis 107 are higher in immigrants than in the Canadian-born population.(242) The Center for Disease Contro l , U.S.A., considers tuber-cu los is to be the most serious publ ic health problem with the present wave of Indochinese refugees. They report a survey in mid-1980 that showed a prevalence of 926 per 100,000 refugees based on the number of cases (act iv i ty unspecified)added to the tuberculosis reg isters in the par t i c ioa t ing areas. Of the 920 reported cases 47% had been recognised overseas, on the basis of X-ray abnormalit ies; 18% were known not to have been " ce r t i f i ed as having act ive or inact ive disease, and 35% were of unknown c e r t i f i c a t i o n status. (243) This means that 53% were diagnosed af ter the i r a r r i va l in the U.S.A. A s im i la r pattern could possibly develop with the refugees in Canada. The prevalence rate for tuberculosis in Canada in 1976 was 31.6/100,000 based on the number of patients under treatment on December 31st of that year.(244) This i s considerably lower than the rate for the Vietnamese population. Continual sens i t i za t ion by contact with the tubercle bac i l l us gives some resistance to the disease, and a decrease in exposure because of the dec l in ing number of act ive cases in the community means that more of the population become susceptible to that bac i l l u s . This has happened in Canada. The r i sk to the Canadian publ ic health i s from the increase in the s ize of the reservo i r of tuberculosis in the community with the inf low of r e l a t i v e l y large number of Vietnamese refugees, with the accompanying increase in exposure to the tubercle bac i l l u s . I t i s worth considering here some facts about tuberculosis in Viet-nam 108 and i n t h e V i e tnamese p e o p l e . The ma j o r p r o c edu r e s f o r t he d i a g n o s i s o f t u b e r c u l o s i s a r e t h e t u b e r c u l i n s k i n t e s t ; c h e s t X - r a y s ; and m i c r o s c o p i c e x a m i n a t i o n o f sputum and g a s t r i c w a s h i n g s , w i t h c u l t u r e o f t h e s e t o c o n f i r m the d i a g n o s i s and r e v e a l b a c i l l i t h a t d i d no t show* up w i t h t h e s t a i n i n g used i n t h e e x a m i n a t i o n o f d i r e c t smea r s . C e r t a i n p r o d u c t s o f M t u b e r c u l o s i s o r o f c u l t u r e e x t r a c t s ( t u b e r c u l i n s ) , when i n j e c t e d i n t o t h e s k i n , p r oduce a s p e c i f i c s e n s i t i v i t y r e a c t i o n . T h i s s k i n t e s t i s an i m p o r t a n t s c r e e n i n g d e v i c e f o r t h e i n d i v i d u a l s u s p e c t e d o f h a v i n g t h e d i s e a s e , as w e l l as b e i n g a s a f e and r e a s o n a b l y i n e x p e n s i v e t o o l f o r .the e p i d e m i o l o g i c a l s u r v e i l l a n c e o f t u b e r c u l o s i s p a t t e r n s i n t h e commun i ty . The Wo r l d H e a l t h O r g a n i z a t i o n has e s t a b l i s h e d an i n t e r n a t i o n a l s t a n d a r d f o r t he t u b e r c u l i n u s e d , PPD-S ( P u r i f i e d P r o t e i n D e r i v a t i v e - S t a n d a r d ) ( 2 4 5 ) , wh i c h s h o u l d a l l o w f o r a c c u r a t e c o m p a r i s i o n o f t h e r e s u l t s o f s c r e e n i n g i n d i f f e r e n t a r e a s i f t h i s s t a n d a r d i z e d t u b e r c u l i n i s u s ed . I f t h e c h i l d r e n i n a community show a h i g h p e r c e n t a g e o f p o s i t i v e r e a c t i o n s when s k i n t e s t e d , t h i s i n d i c a t e s t h a t t h e r e a r e s o u r c e s o f i n f e c t i o n i n t h a t community, i . e . p e r s on s who a r e o r have been e x c r e t i n g b a c i l l i i n t h e i r spu tum. R e g u l a r s c r e e n i n g o f t he c h i l d r e n i n a community ' a t r i s k ' i s t hu s a v a l u a b l e t o o l i n the s u r v e i l l a n c e o f t u b e r c u l o s i s ; b u t i t i s used i n Canada o n l y i n N a t i v e I n d i a n and I n u i t c ommun i t i e s where t h e p r e v a l e n c e o f 109 tuberculosis i s much higher than in the general population. Table 1 shows surveys of ch i ldren in Viet-Nam and in selected groups of Indochinese refugee chi ldren in the U.S.A. Although the numbers examined in the 1979 samples are smal l , the percentage of chi ldren with pos i t ive reactions in these i s larger than in the ea r l i e r groups. This could mean that overcrowding and under-nutr i t ion in the camps in Southeast Asia have helped to spread the disease. Attempts were made in the 1950s, 1960s, and ear ly 1970s, in both North and South Viet-Nam, to prevent the spread of th is disease, but they were neither consistent nor universa l . (246) . (247). In South Viet-Nam immunization of the chi ldren was attempted with the BCG (Bac i l lus Calmette Guerin): as th is often leaves no scar i t i s impossible to know how many chi ldren were vaccinated. This procedure can af fect the resul ts of the skin tes t s , although indurations of over 10mm are considered evidence of in fect ion rather than immunization. 110 Table 1 Studies showing the number [%) of Indochinese  chi ldren tested who were tubercul in pos i t i ve . >10mm. Study Ages Number examined Number {%) Pos i t i ve . 5-10mm 1. Viet-Nam 1967 0-14 2. Guam 1975 0-14 Refugees. 3. Washington 1979. 0T18 Refugees. 4. Utah 1979 0r l4 Refugees 5. San Francisco 1979 0-18 Refugees. 12,980 24,351 45 136 333 1 ,647 (18.2) >8mm 3,022 (12.4) 10 (22.0) 40 (29.4) 136 (41.0) Sources: 1. A Vennema. "Tuberculosis in Rural Vietnam." Tubercle 52 (1971):55. 2. "Update on Vietnamese Refugees Health Status." MMWR 24 (August 2 1975): 268. 3. "Health Screening of Resettled Indochinese Refugees." MMWR 29 (January 11. 1980): 9. 4. Ib id . p.10. * 5. "Health Status of Indochinese Refugees." MMWR 28 (August 24. 1979): 386. A study in the U. S. navy showed that the r i sk of breakdown of old tubercular disease is higher among Southeast Asians than in other population groups (248); and they may be more l i k e l y to have extra-pulmonary disease. (249). I t must be in remembered that these immigrant/refugees w i l l also be'at r i s k 1 from the breakdown of old tubercular disease and of having extra-pulmonary disease. Treatment of tuberculosis today i s with spec i f i c drugs used in various combinations for periods of one to two years. Drugs may also be used prophy lact i ca l ly where former treatment i s considered to have been inadequate, and with people who have been in close contact with an act ive case of tuberculosis and whose sk in- tests have subsequently changed from negative to pos i t i ve . In Southeast Asia a l l primary and secondary ant i - tubercu lar drugs are sold without prescr ip t ion . (250) A survey in Viet-Nam showed that 71% of M tuberculosis were res i s tant to streptomycin, 64% to INH, 27% to PAS, and 19% to a l l three drugs. (251) These are the drugs of f i r s t choice in the treatment of tuberculosis and the resistance of the organism isevidence of indiscr iminate use of drugs without supervis ion. Drugs s en s i t i v i t y w i l l be an important fact in the treatment of tuberculosis or ig inat ing from Viet-Nam. A major factor with tuberculosis in Canada due to th i s immigration i s the increased in the s ize of the reservo i r with the attendant increased r isk ' to the Canadian population. This i s complicated by the drug resistance of the organism, and the tendency of inact ive disease 112 to breakdown under s t ress . I t was seen ea r l i e r in th is thesis that migration can be s t r e s s f u l , and that involuntary migration more so. This i s de f i n i t e l y a publ ic health hazard. As the Southeast Asian refugees are being admitted to Canada as landed immigrants, they have been subject to the standard pre-immigration medical examination that includes a chest X-ray. Persons with tuberculosis that has been inact ive for one year may enter Canada on a Min i s te r ' s Permit that i s condit ional on continuing survei l lance (follow-up) and possible further treatment. There are 27 Vietnamese in B r i t i s h Columbia under th is Permit, and these are not considered to be a r i sk to Canadians because they are known. It is the unknown cases of the disease that are the problem. Because of the increased r i sk to the publ ic health inherent in the i n f l ux of large numbers of immigrants from an area with a high prevalence of tubercu los is , measures have been taken by the B r i t i s h Columbia prov inc ia l government to monitor the s i tua t i on . As mentioned ea r l i e r , there i s a special c l i n i c for these immigrants in Vancouver. A spokesperson for th is c l i n i c indicated that three cases of act ive tuberculosis have been discovered among approximately 6000 Vietnamese refugee/immigrants. One was a case of a 'wrong' chest X-ray f i lm at the medical examination in Hong Kong; and the others were two chi ldren in a 113 family with no other evidence of tuberculosis in the family members. These were found through a sk in- tes t screening program. This gives an incidence rate of new disease of 50/100,000 Vietnamese immigrants compared with a rate of 11.8/100,000 for Canada as a whole, and indicates that tuberculosis among these refugees could become a publ ic health hazard. Some 300-400.Vietnamese in Vancouver, with a tubercul in reaction (skin test) of diameter greater than 15mm, have been placed on prophylact ic drug therapy. However, there i s much discussion about the effect iveness of th i s . Against the obvious benefit of preventing the breakdown of quiescent disease, i t s .. presence indicated by the tubercul in react ion, must be weighed the po s s i b i l i t y that intermittent treatment resu l t ing from non-compliance with the drug regimen and/or poor supervis ion, w i l l produce a s t ra in of bacter ia res i s tant to one or more of the treatment drugs. There i s no question that there must be long-term surve i l l ance, for f ive years at leas t ; the question i s what i s the best way to accomplish this?. V i ra l diseases Hepat i t is B. A recent study has shown that the prevalence of asymptomatic Hepat i t is B antigenemia among the Vietnamese refugees is estimated at 13% while the prevalence of th i s antigen among 114 Canadians i s approximately 0.6% (252) The presence of t h i s antigen HB^ Ag means that the indiv idual i s a possible source of i n fec t i on . Man, and possibly chimpanzees, are the only known reservo i rs , and the incubation period i s from 50-180 days. The mode of transmission is by parenteral inoculat ion with infected human blood and blood products e i ther by contamination of wounds and lacerat ions, or by contaminated needles and syringes. There i s some evidence of non-parenteral spread with the antigen found in several body secretions and f l u i d s . (253) (254) (255). The people who are 'at r i s k 1 from th i s in fect ion are dent i s ts , doctors, and health care personnel who give d i rec t care to pat ients. The Department of Health and Welfare Canada pointed out on January 26, 1980 that over 300,000 immigrants from countries with unusually high prevalence of Hepat i t is B had entered Canada since 1972 "without causing an obvious resultant increase in morbidity." (256) S t a t i s t i c s issued by the same Department on November 8 1980 show an accumulated 840 cases of Hepat i t is B for 1980 compared with 690 on the same date in 1979, (257) an increase of 22%. No reason for th i s i s suggested; however, the above inf low of immigrants must have increased the reservoir of the disease in th i s country and so increased the r i sk to the Canadian pub l i c . Screening of the Vietnamese refugees in order to ident i fy those carrying the antigen was started in December 1979 af ter some lobbying by the dental profession. (258) It was intended that 115 information on the carriers; would be avai lab le at the provinc ia l departments of health.; however, there have been negative reactions from the provinces because of the need to process and store th i s information. Other groups in the Canadian population who have a high rate of in fect ion with Hepat i t is B are doctors and dent i s ts , and any s ing l ing out of Vietnamese refugees per se, as being a r i sk to health personnel could be construed as d iscr iminat ion on rac ia l grounds. • Prel iminary resu l ts of a screening project in Vancouver show that many of the Vietnamese who previously demonstrated the antigen HBgAg in the i r body have now produced the i r own ant ibodies, and are no longer a potent ia l source of in fec t ion . It may be that the prevalence of Hepat i t is B antigenemia in the Vietnamese w i l l eventual ly f a l l to that of Canada as a whole. However, precautions against the spread of the disease must be continued. Paras i t i c diseases Paras i t i c infect ions are almost universal in the people of-Southeast As ia , with 75% of rural and 56% of urban Vietnamese found to harbour one or more. (259) In countries of s im i la r problems 116 of sani tat ion over 50% of the population are infected. (260) The transmission of most parasites i s favoured by e i ther poor sani tat ion methods with promiscous defaecation and lack of personal hygeine, or a taste fo r uncooked foods. Many parasites are already present in Canada,-and there are r e l a t i v e l y few that could be transported from Viet-Nam and become establ ished here. However, Giardia lamblia and Entamoeba h i s t o l y t i c a could be a publ ic health problems. Infect ion with E h i s t o l y t i c a (amoebic dysentry) i s cosmopolitan but the prevalence rates vary from area to area. Epidemic spread i s usually by water contaminated with E h i s t o l y t i c a cysts; and endemic spread i s by f l i e s , vegetables contaminated with faeces containing cysts , and the so i led hands of food handlers. The reservoir i s usually an asymptomatic person who can excrete the cysts for years; and the incubation period i s from 2-4 weeks. The person with acute amoebiasis i s not highly infect ious due to the f r a g i l i t y of the trophozoites excrete at that time. Possible complications of in fect ion with E h i s t o l y t i c a are amoebic l i v e r abscess, and more rare ly amoebic pe r i c a rd i t i s . (261) G iard ias i s , in fect ion with G lambl ia, i s often asymptomatic although i t can produce gastro-enter ic symptoms. There i s a higher incidence in chi ldren than in adul ts , and a higher prevalence in areas of poor san i ta t ion . The diagnosis may be confused with many 117 others; and untreated, i t i s a deb i l i t a t i ng condit ion. There, are endemic foc i of amoebiasis and g ia rd ias i s in parts of Canada (262), which means that new foc i could s ta r t in other areas. It was also found that immigrants tend to keep the i r parasites (263) which could be due to the f am i l i a r i t y and acceptance of parasitemia as a fact of l i f e in the i r homeland; or to embarassment; or to resentment of perceived persecution by author i t ies in th i s country. It can be seen from Table 2 that the prevalence rates for E h i s t o l y t i c a in selected groups of Vietnamese are s im i la r to those in the U.S.A.; while the rates for G Iambiia are higher. Assuming that the Canadian prevalence rates for these infect ions are s im i la r to those in the U.S.A., then there may be a s l i gh t r i sk to Canadians from the increase in the s ize of the reservoir with the inf low of the refugees. The r i sk to the publ ic health can come from infected and unhygeinic food-handlers, and in i n s t i t u t i ons such as daycare centres and schools where ch i ldren are in close proximity. These condit ions w i l l need accurate diagnosis and treatment because of the i r deb i l i t a t i ng ef fects on the indiv idual rather than the r i sk of spreading the diseases. There has been one case of G lamblia reported among the Vietnamese refugees in Vancouver and no cases of E h i s t o l y t i c a , according to the spokesperson for Vancouver Health Department. 118 TABLE 2 Rates of in fec t ion with E h i s t o l y t i c a and  G Iambiia in selected groups of Vietnamese refugees compared with those rates in the U.S.A.* Group Number E h i s t o l y t i c a G lamblia examined number (%) number {%) 1. A l l ages. U.S.A. Refugees. Sept. 1975 2. A l l ages. Canada Refugees (volunteers) 1976-77. 3. A l l ages. U.S.A. Refugees. Feb. 1979 4. A l l ages. U.S.A. Refugees. 1979. 5. Children 0-18. U.S.A. Refugees 1979. 6. U.S.A. (estimated) 1077 75 165 356 31 - (2.2) - (8.2) 7 (9.3) 10(13.5) 3 (2.0) 29(18.0) 3 (1.0) 16( 4.0) - - — 6(19.0) (1.5-9.5) ( 5.0) * There are no national data for Canada: a National Data Bank for Paras i t i c Diseases i s in the process of being bu i l t . Sources: 1. " Intest ina l Parasites among IndoChinese Refugees." MMWR 24(January 22 1975): 398,403. 2. "Natural loss of in tes t ina l parasites of Vietnamese immigrants fol lowing entry to Canada." Can Pis Weekly Rep 2(Apr i l 24 1976) :65. 3. "Survey of Intest ina l Parasites - I l l i n o i s . " MMWR 28(July 27 1979):346. 4. "Health Screening of Resettled Refugees - Washington, D .C , Utah." MMWR 29 (January 11.. 1980): 10. 5. Ib id . p.9. 6. "Survey of Vietnamese Refugees for Intest ina l Parasites in the U.S.A." Can Pis Weekly Rep (March 27 1976):51. 119 INFECTIOUS DISEASES THAT ARE A THREAT TO THE INDIVIDUAL REFUGEE  Bac te r i a l . Hanson's Disease. Leprosy is a chronic and only mi ld ly communicable disease with a long incubation period probably averaging 3-5 years. Man i s the only known reservo i r , and the mode of transmission has not been de f i n i t e l y establ ished. Rel iable data about the prevalence of th i s disease in the world are lack ing, but i t s prevalence in Viet-Nam has been estimated at 300-500/ 100,000 (0.3-0.5%).(264). This may be compared with 0.37/100,000 in the U.S.A. in 1975.(265). Reported by WHO, with no data given but presumably in the mid-1970s, there were 64 registered cases in Canada (266) giv ing a prevalence rate of 0.3/100,000. (267) 39 de f in i te cases were found in 27,057 Vietnamese refugees examined in the U.S.A. in July 1976, with a prevalence rate of 144/100,000 (0.14%).(268) Three cases have been found in 10,000 Vietnamese refugees in B r i t i s h Columbia in 1980, and more may be expected dur ing the next decade because of the" long incubation per iod. Leprosy is great ly feared, and refugees'may deny symptoms or that .there is a family h istory of the disease for fear of deportat ion. It i s only mi ld ly contagious to close family contacts, and i s not considered to be a publ ic health hazard. However, the more act ive and contagious type, Lepromatous leprosy, needs treatment 120 to prevent disab.il i t y and disfigurement. The publ ic as. well as health, professionals need to be reminded that leprosy i s not highly contagious, as fear could provoke v io lent reactions against the Vietnamese in Canada. Me l io idos is . Endemic in Viet-Nam and extremely rare in the western hemisphere, th is i s a disease whose symptoms may simulate those of tuberculosis and which should be kept in mind " in any unexplained suppurative disease, espec ia l ly cav i tat ing pulmonary disease, in a patient l i v i n g or recently returned from Southeast As i a . " ("269) In some parts of Southeast Asia the prevalence of act ive and inact ive disease i s estimated to be as high as 30%.(270) The reservoir i s in animals, and in fect ion probably comes from contact with contaminated water and s o i l . The incubation period can be months or even years; and untreated, the morta l i ty rate i s high. Because secondary cases, i . e . d i rec t transmission from man to man, are exceedingly rare th i s would be a problem of diagnosis and treatment. I t appears that no cases have yet been seen among the Vietnamese refugee/immigrants in B r i t i s h Columbia. Yaws. Also caused by a spirochete, th i s chronic relapsing disease i s unevenly d is t r ibuted in the rural t rop ics and subtropics where there are low standards of hygeine. I t i s present in Southeast Asia in sp i te of attempts at e rad i c t ion , and "as the in fect ion rapid ly returns to high endemicity i f surve i l lance f a i l s " (27) i t may be assumed that the war has 121 encouraged i t s return. The reservoir i s man, and transmission i s ch ie f l y by d i rec t contact with exudates of ear ly skin lesions of infected persons. The incubation period is from two weeks to three months, and the period of communicability may extend intermi t tent ly over several years while moist lesions are present. Yaws is usual ly acquired in childhood, and thus cases could be seen among the refugees. This i s not a publ ic health hazard, and is eas i l y cured once diagnosed: apparently no cases have been recognised among the refugees in B r i t i s h Columbia. Paras i t i c Diseases. Helminths. Some in tes t ina l worms for example Strongyloides s te raco ra l i s , complete the i r l i f e - c y c l e in man. Because of the capacity for auto- in fect ion, th i s condit ion should be treated as soon as diagnosed as the worms can spread throughout the body causing acute as well as chronic i l l n e s s . Other helminths, such as Ascaris 1umbricoides, Tr ichur is t r i c hu r i a , and hookworm (Necator americanus and Ancylostoma duodenale in Southeast Asia) require a minimum of one to two weeks of incubation in the so i l before entering the human body through the skin to complete the i r l i f e - c y c l e . Man i s the reservo i r , and these parasites need the appropriate c l imat ic conditions with low standards of sani tat ion and hygeine to f a c i l i t a t e the i r spread. Only hookworm is known to spread in temperate c l imates. (272) 122 The incubation periods of these vary, but ca r r i e r s can excrete eggs or cysts; in the i r faeces for years; and although not usual ly fata l these condit ions can cause chronic i l l health in areas where re- in fec t ion is poss ib le. Studies in selected groups of Vietnamese refugees show that rates of in fect ion vary (see table 3). According to a spokesperson for the Vancouver Health Department, approximately 50% of the Vietnamese immigrants in Vancouver have helminth in fec t ions; with Ascaris lumbricoides and t r i chu r i s t r i chu r i a being most common, and with some hookworm diagnosed. With high standards of sani tat ion in th i s country, the c l imate, and the fact that Canadians do not usual ly go barefoot, there i s l i t t l e r i sk to Canadians from hookworm. As the developmental cycle for the other helminths cannot be completed in Canada, there is no chance of re - in fec t ion and parasitemia w i l l eventually die out among the Vietnamese. However, there i s the need to treat th i s condit ion when diagnosed. Protozoa. Leishmaniasis (Kala azar) i s a protozoal disease widely spread in the. t rop ica l and subtropical areas of the world. The known reservoirs include man, canines, cats , and wi ld rodents; the transmission i s by the bi te of an in fec t i ve sandf ly. Direct transmission from person to person by blood transfusion and sexual contact has been reported. The incubation period i s usual ly from 2-4 months but may range from 10 days to two years; and untreated, th is chronic and communicable disease i s usual ly highly f a t a l . The treatment drug i s highly tox i c , and must be Table 3 Helminth i n f e c t i o n in se lected groups of Indochinese refugees I n f e c t i o n s Group 1. A l l ages. 1975 2. A l l ages. 1979 3. A l l ages. 1979 Number  examined 1077 165 356 4. Chi ldren 0-18 31 1979 Ascar i s  Lumbricoides Number (%) 328 (30.5) 14 ( 9.0) 44 (12.0) 14 (45.0) Hookwork Number(%) 44 (4.1) 106(64.0) 25 (7.0) C h i o r i o r c h i s T r i c h u r i s s inens i s Number (%) 6(2.0) 1(3.0) t r i c h i u r a Number (%) 97 (9.0) 20 (12.0) 31 ( 9.0) 3 (10.0) Source: 1 " In tes t ina l Parasites among Indochinese Refugees." MMWR 24 (November 22 1975): 398, 403. 2. "Survey o f Intest ina l Paras i tes - I l l i n o i s . " MMWR 28~(July 27 1979):346. 3. "Health Screening of Resett led Refugees - Washington, D .C . , U t a h . , " MMWR 29 (January 11 1980):10. 4 . I b i d , p.9. ro 124 obtained from the Center for Disease Contro l , At lanta , U.S.A. With the absence of both a large reservoir of the parasites and the spec i f i c vector in Canada th is w i l l not be a publ ic health hazard but a problem of diagnosis and treatment. It has not been seen to date among the Vietnamese in B r i t i s h Columbia. Cutaneous Leishmaniasis (Oriental sore) does not occur in Southeast As ia . Flukes.' Schistosomiasis (B i l ha r z i as i s ) in Southeast Asia i s in fec t ion with Schistosoma japonicum, a blood f luke with both male and female worms l i v i n g in the veins of the host. Animals as well as men are epidemiological ly important hosts,a vector snai l . i s required, and transmission i s by contact with water contaminated with larva l forms (cercariae) that penetrate the sk in . S japonicum should not be confused with other schistosomes of birds and rodents in North America that may penetrate the human skin but do not mature in man - known as 'swimmer's i t c h 1 . S japonicum is not a publ ic health hazard in Canada as there are no vector sna i l s here for the species af fect ing man. This w i l l be a problem of diagnosis and treatment, and th i s f luke has not been seen to date among the Vietnamese in B r i t i s h Columbia. Paragonimiasis. The lung f luke , Paragonimus westermani, requires an intermediate host and ingest ion of raw or par t ly cooked freshwater crabs or crayf i sh containing encysted larvae for i t s spread. The reservoir i s man, and the parasite cannot be transmitted 125 d i r e c t l y from man to man. It i s endemic throughout Southeast As ia , and the problem in Canada w i l l be the d i f f i c u l t y of a de f i n i t i v e diagnosis as th is may be confused with tuberculos is . The spec i f i c treatment drug is Bithlonol which must be obtained from the Paras i t i c Drug Service in At lanta , U.S.A. I t has not been recognised to date among the Vietnamese refugees in B r i t i s h Columbia. Clonorchias is . This l i v e r f luke , Clonorchis s i nes i s , is endemic in Viet-Nam and requires the ingestion of contaminated f i sh for i t s spread. It cannot be transmitted d i r e c t l y from man to man, and the developmental cycle cannot be completed in Canada in the absence of the intermediate host snai l and the appropriate f i s h . This parasite w i l l not be a publ ic health hazard, but a problem of diagnosis. I t has not been diagnosed among the Vietnamese in B r i t i s h Columbia. Malar ia . This is also a paras i t i c disease: i t i s no longer endemic in temperate zone countries but is a major cause of i l l health in the tropics and subtropics. However, there i s concern in North America at the increasing number of cases appearing here. There are four types of th i s disease in humans: vivax or benign te r t i an malaria (Plasmodium v ivax); quartain malaria (P malar iae); falciparum or malignant te r t i an malaria (P falc iparum); and the less common ovale malaria (P ovale) seen only in West A f r i c a . Mixed in fect ion may occur in endemic areas and as the symptoms are 126 s imi la r for a l l types, a d i f f e ren t i a l diagnosis is. d i f f i c u l t without laboratory f a c i l i t i e s . Prompt diagnosis and treatment i s essent ia l as fa ta l complications may occur with P falciparum due to the rapid destruct ion of the red blood ce l l s as the gametoeytes develop and spread. The case f a t a l i t y rate for falciparum malaria among untreated chi ldren and non-immune adults exceeds 10%. This is complicated by the world-wide resistance of P falciparum to chloroquine which has been the treatment drug of f i r s t choice. Other drugs are being t r i e d . The reservoir is man and possibly the higher apes; and transmission requires a female vector mosquito. The mosquito becomes in fec t i ve by ingesting human blood containing Plasmodia in the gametocyte stage of development. The female and male gametoeytes unite in the mosquito's stomach and sporozoites develop there within 8-35 days depending on the species of parasite and the temperature to which the vector i s exposed. These sporozoites concentrate in the sa l i vary gland and are injected into man as the mosquito takes another blood meal. The incubation period varies from 12 to 30 days, again depending on the species of paras i te , but with P vivax th is may be 8-10 months. In the susceptible host, the gametoeytes usual ly appear in the blood within 3-14 days af ter the on-set of symptoms, according to the species of paras i te . The mosquito remains in fec t i ve for the rest of her l i f e - a few days or a month or so - and man i s in fec t i ve i nde f i n i t e l y with P malariae, one to three years with P vivax, 127 and approximately one year with. P falciparum. There are appropriate mosquito vectors and c l imat i c condit ions for the spread of malaria in parts of North America. The l as t de f in i te case of indigenous malaria in the U.S.A. was reported in 1957, [253) But there have been cases of malaria imported from the Punjab into parts of southern Ca l i fo rn ia in the 1970's, when i t was- suspected that the local mosquitoes became in fec t ive and spread the disease. (274) (275) Malaria has been diagnosed in servicemen returning from Viet-Nam, (276) (277) as well as in increasing numbers in t rave l l e r s returning from the tropics and subtropics. Malaria was endemic in parts of Ontario from about 1820-1880 but not above the summer isotherm of 70°F, and was apparently reported at one time in certa in (unstated) parts of the western provinces.(278) Given a large enough reservoir of the disease and the r ight c l imat i c condit ions, malaria could possibly become re-establ ished where there i s an appropriate vector. Malaria may also be spread through in jec t ion or transfusion of blood from an infected person, or by sharing needles during i l l i c i t drug use. (279) It has been reported from a Saigon prison that P falciparum was transmitted by the common use of needles and syringes among drug addicts who had not been in malarial areas. (280) P malariae is a r e l a t i v e l y uncommon disease which may become 128 chronic with a latency period of more than 30 years, and is thus more l i k e l y to be transmitted through a transfusion of blood from an infected person than are the species with a shorter l i f e - span . These, with P vivax, were c i ted in a discussion of t ransfus ion-induced malar ia. (281) The areas of Viet-Nam that are most heavi ly infected with malaria are the Central Highlands. The prevalence of malaria in the Vietnamese refugees in the U.S.A. was been found to be low, 0.09% in 1975 (282) and th i s may have been due to the fact that the majority of those refugees had come from the urban areas that are not infected. If th i s i s the case with 'the Boat-people 1 i t means that the new reservoir of the disease in Canada w i l l be smal l ; and further more, i t w i l l be d i luted by the spreading of the refugees across the country. The chances of a mosquito becoming in fec t i ve are further reduced by the fact that the areas of Canada that are plagued with mosquitoes have screened doors and windows which again reduce the opportunity for mosquitoes to take a blood meal from an infected person. There has been a s l i gh t increase in the incidence of malaria in Canada that i s thought to be due to Canadians t r ave l l i ng in infected areas without taking the prophylat ic drugs. The threat to the publ ic health i s more l i k e l y to come from the inadvertant. transmission of the disease through contaminated blood 129 products and needles and syringes, than from i t s re-e.stablls.bme.nt by vectors. Anyone with, a h istory of malaria i s never accepted as a blood donor by the Blood Transfusion Service of the Canadian Red Cross Society; and people who have come from or have l i ved in areas where malaria in endemic, and who may or may not have taken ant i -malar ia l drugs and have never had malar ia, are deferred from three years as donors and then only the plasma i s used. With the proper s t e r i l i z a t i o n of needles and syringes there should be no r i sk to the publ ic from th is source. The problem w i l l be the need for fast and accurate diagnosis of the species of parasite causing the symptoms in order to i n i t i a t e the appropriate treatment. DISEASES ENDEMIC IN VIET-NAM THAT ARE UNLIKELY TO BE  A TREAT TO EITHER CANADIANS OR REFUGEES. The fol lowing are included in th is chapter because of the pub l i c i t y given them. Cholera. This an acute diarrheal disease with a f a t a l i t y rate in untreated cases of over 50%. The reservoir i s man, and the mode of transmission i s through ingestion of water contaminated with faeces or vomitus of infected persons, and to a lesser extent through contaminated food, so i led hands, and f l i e s . I t i s widespread in Southeast As ia . The incubation 130 period is, from a few. hours to f i ve days., and i t has been reported in a refugee ' i n t r an s i t ' between Southeast Asia and Ca l i f o rn i a . (283) However, th i s has been an iso lated occurance, and cholera i s un l ike ly to become a problem with the refugees. Plague. Sy l va t i c , or wi ld rodent plague, i s known to ex i s t in the western th i rd of the U.S.A. as well as in large areas of the world including Southeast As ia . In the U.S.A. plague in man i s l imi ted and sporadic fo l lowing exposure to the rodents or the i r f l eas . It occurs in three c l i n i c a l forms, with untreated bubonic plague having a case f a t a l i t y rate of about 50% and untreated septocemic and pneumonic plague being usual ly f a t a l . Wild rodents are the natural reservoir of th is disease. Bubonic plague i s transmitted by the b i te of an in fec t ive (rat) f l e a , and pneumonic plague by the airborne route. The incubation period i s from 2-6 days. Since 1962 Southern Viet-Nam has experienced a marked increase in the incidence of plague. (284) International regulations require that pr ior to the i r departure from an area where there i s an epidemic of pulmonary plague, t rave l l e r s shal l be placed in quarantine for s ix days af ter l a s t exposure, and may be kept under survei l lance for not more than s ix days af ter a r r i va l at the i r dest inat ion. The refugees are coming from camps in Malaysia, Hong Kong, and Indonesia a f ter some months residence there. (285) No mention of plague in these areas has been found. Given these factors and the short incubation per iod, i t i s seen as un l ike ly that plague w i l l be a 131 problem with, the refugees. Certain ' exot i c ' diseases. I t i s possible that the i r incubation period of 5-15 days may allow certa in ' exot i c ' v i r a l diseases to produce symptoms af ter the a r r i va l of the refugees although th is i s un l i ke ly . They are Dengue; Japanese B encephal i t is which infects man only inc identa l l y but which i s associated with a morta l i ty rate of over 80%; scrub typhus; and Chikungunya (haemorrhagic disease). F i l i a r i a s i s i s the in fect ion with the nematode worm and m ic ro f i l a r i ae of Wucheria bancroft i or Brugea malayi in Southeast As ia . A long exposure and heavy parasit ism are required to produce symptoms. An epidemiological study of the prevalance of f i l a r i a s i s in South Viet-Nam f a i l ed to f ind in fect ion in residents of Saigon or in a d i s t r i c t of the Mekong Delta. (286) As the refugees are apparently coming from the urban areas of the lowlands th i s disease should not be a problem among them. Leptospiros is . Endemic in Southeast As ia , th i s spirochete only inc identa l l y infects man through his contact with water, s o i l , or vegetation contaminated with the urine of infected animals. The reservoir includes many farm animals, 132 rodents and other wi ld animals. The incubation period is 4-19 days so symptoms could manifest themselves af ter the a r r i va l of the refugees. Direct transmission from man to man i s neg l ig ib le , and untreated the morta l i ty rate i s 20%. This would be a problem of diagnosis and treatment, and no cases have been found among the refugees in B r i t i s h Columbia. OTHER INFECTIOUS DISEASES It has been pointed out that in the consideration of the 'exot i c ' the 'ordinary ' infect ious disease should not be overlooked. (287). Because of the malnutr i t ion and s t ress , and the ef fects of war and f l i g h t , the refugees may be more susceptible to infect ious diseases common in Canada. Measles can be pa r t i cu l a r l y devastating in a population with l i t t l e or no immunity to the disease; and diphtheria car r ie rs have been found among the refugees in the U.S.A. (288) It was found that of 45 refugee chi ldren screened within 10 days of the i r a r r i va l in Washington, D .C , less than hal f (44%) had any previous h istory of medical care, and immunization against the 'common' infect ious diseases was minimal. (289) Besides giv ing them protect ion, immunization of the refugee chi ldren w i l l reduce 133 the pool of susceptible chi ldren in Canada where the rate of immunization i s less than optimal, and thus help prevent the spread of these diseases. Overcrowding in the refugee camps in Southeast Asia w i l l have increased the spread of l i c e , scabies, and fungal skin in fes ta t ions . (290) (291) These w i l l l i k e l y have been cleared up before chi ldren go to school here, but th i s could become a problem where chi ldren are in close contact. NON-INFECTIOUS DISEASES AND CONDITIONS Malnutr i t ion. Malnutr i t ion was noted among Vietnamese chi ldren by Vennema in 1968 (292); and was observed in chi ldren evacuated to Aust ra l i a (27%), (293) and the U.S.A. (11%). (294) It may be assumed that i t i s widespread s t i l l in Viet-Nam as a . resu l t of the socia l upheaval since the war. Children are most susceptible to protein-energy malnutr i t ion which causes stunted growth and anemia. Other forms of malnutr i t ion may be vitamin def ic ienc ies causing scurvy due to lack of vitamin C; beri beri due to lack of vitamin B; and r i ckets due to lack of vitamin D. A survey of the nut r i t i ona l status of selected groups of Southeast Asian refugee ch i ld ren- in the U.S.A. has revealed anemia 134 and stunted growth to be the major nut r i t i on- re la ted problems. (295) The report suggested that there i s a need for awareness of the problems of acute under-nutr i t ion and anemia by health care workers, but comments that the i n i t i a l high prevalence of these condit ions may re f l e c t the impact of a d i f f i c u l t adjustment period for these chi ldren on American diets for the f i r s t time. Some of the Vietnamese chi ldren a r r i v ing in Vancouver during 1979-80 were observed to be rather tha in , but soon gained weight. No screening program was i n i t i a t e d . The babies born in th i s country are "a good s i ze" according to a spokesperson for/the Vancouver Health Department. Genet ical ly determined condit ions. More than 90% of Southeast Asians cannot digest lactose (milk sugar). (296) Gastro-enteric symptoms after, dr inking milk are" inev i tab le in subjects over nine years of age, with 50% of lac tose- in to lerant chi ldren under that age developing diarrhea. Six of 114 Vietnamese chi ldren evacuated to Aust ra l ia in 1975 and between the ages of one week and s ix years, were into lerant of lactose. (297) Awareness of th i s apparently cu l t u ra l l y determined condit ion is essent ia l for health personnel, espec ia l ly those concerned with nu t r i t i on and health education. 135 There has been no evidence of severe lactose intolerance among the refugees in Vancouver although the problem is known. Advice is given to fami l ies on the gradual introduct ion of milk into the i r d ie t s . The d i s t r i bu t i on of genet ica l ly determined red-ce l l defects is possibly l inked to the d i s t r i bu t ion of malaria in the world. The prevalence of Thalassaemia in Viet-Nam is estimated as 1-5%; of Haemoglobin E 2-8%; and 61ucose-6-phosphate dehydrogenage def ic iency (G6PD. def) as 2-6%. (298) These are not important per se, but people with G6PD def ic iency may experience mild to severe hemolysis during primaquine therapy for malar ia. (299) Haemolytic anaemia fol lowing administrat ion of trimethoprim-sulfamethorxazole (Bactr in and Septra) has been noted in some Asians with G6PD def ic iency. (300) This knowledge appears to be essent ia l for physicians who are or w i l l be t reat ing Vietnamese refugees, but information on the prevalence of these condit ions i s not ava i lab le . Tropical Sprue. This i s a primary mal-absorption syndrome of unknown and possibly mult ip le aet iology that i s not indigenous to North America but which has been seen in m i l i t a r y personnel returning from Viet-Nam. (301) Spontaneous cure i s common, but i f 136 untreated the morta l i ty rate may be as high as 30%. (302) This appears to be a problem of diagnosis and treatment. Malignancies. A tumour that i s rare in North America but i s "surpr i s ing ly prevalent" among people of Southeast Asia i s a primary l i v e r cancer, hepatoma. (303) Lung cancer may be more common in the Vietnamese and may manifest i t s e l f ear ly due to the pre-adolescent onset of c igarette smoking and a high prevalence of smoking in general. (304) No good data are ava i lab le on the above and i t remains to be seen what the actual incidence rates of these malignancies w i l l ' b e . It also remains to be seen i f the use of the defo l iant "Agent Orange" during the war w i l l have increased the r i sk of malignancies and deformed babies (305) among the Vietnamese people, of whom the refugees are a sample. Mi seellaneous. It i s reported that Southeast Asians have more rheumatic heart disease and more systemic lupus erythematosus than North Americans, although c lass i ca l rheumatoid a r t h r i t i s i s rare. (306) Otherwise i t may be assumed that there w i l l be a r i se in the incidence of the so-ca l led 'diseases of Western c i v i l i z a t i o n 1 such as ischemic cardiac disease and diabetes, as these non-Western people change the i r l i f e - s t y l e to that of North America. A cu l t u r a l l y determined condit ion that may be seen i s ' l i n ea r bru is ing ' that resembles trauma. The Vietnamese have a lay pract ice of coin-rubbing of several symptoms including fever and headaches -which could ra ise the spectre of ch i l d battering in western minds (307) This chapter may be summarized as fo l lows: 138 Publ ic health .L i t t le or no threat threat Threat to the publ ic health ind iv idual refugee Infectious diseases endemic in Viet-Nam Non-infectious diseases and conditions *bacter ia l enter ic disease *tuberculosis *hepat i t is B g ia rd ias i s amoebiasis cholera plague STD malaria (transfusion induced) l i c e , scabies, fungal skin infect ions bacter ia l enter ic disease tuberculosis hepat i t i s B Hanson's Disease helminths protozoa blood and t issue parasites l i c e , scabies, fungal skin infect ions 'common1 infect ions mel io idosis yaws malnutr i t ion genet ica l ly deter-mined diseases t rop ica l sprue rare malignancies * major threats. Figure 3 Summary of diseases that may be a problem  with the resettlement of the  Vietnamese refugees in Canada 139 DISCUSSION Even before the a r r i va l of these refugee/immigrants i t had been observed that there are special problems in Canada associated with the changing patterns of world migration (208) and these problems have been discussed in th i s thes i s . Apart from the fact that strained re lat ions between a host population and an immigrant minority can cause stress that u l t imately af fects health, i t i s the various aspects of the physical health problems that are of concern in th i s chapter. Because they are coming from an area of the world with d i f fe rent disease patterns, the a r r i va l of the Southeast Asians w i l l increase the s ize of the reservoir of tubercu los is , hepat i t i s B, and bacter ia l enter ic disease in the tota l Canadian population and thus increase the r i sk of Canadians acquir ing these diseases. Other diseases that are l i t t l e known in Canada and no threat to Canadians w i l l also be encountered among these refugees. Both infect ious and ' exo t i c ' diseases w i l l put a s t ra in on ex is t ing health care f a c i l i t i e s by increasing the demand for publ ic health survei l lance serv ices, and for diagnostic s k i l l s and laboratory f a c i l i t i e s . The federal Department of immigration i s responsible for the i n i t i a l health of immigrants, but the provinces are responsible for the i r health once se t t l ed , and there are problems ar i s ing from th i s s p l i t r espons ib i l i t y . Normally the prospective immigrant is medically examined in his country of o r i g i n , and any outstanding health problems are treated 140. there before an immigration visa is. granted. The examination includes chest X-ray for those over the age of eleven, and examination of blood, urine and s too l . The pol icy of family re -un i f i ca t ion means that on occasion a would-be immigrant is admitted to Canada on a 'M in i s te r ' s Permit' where landed immigrant status i s deferred and dependent on treatment and/or survei l lance fo r a spec i f i c disease. The aim of the medical examination as part of the immigration process i s to keep infect ious diseases out of Canada and to ensure that immigrants do not become a burden on the socia l and health programs and services of th i s country. Because of the unusual and emergency s i tuat ion in Southeast Asia the pre-immigration medical examination of the refugees was considered to be incomplete and was f in ished at the point-of-entry to th i s country. The health documents were then processed in the usual way with a copy going to the Department of Health and Welfare in Ottawa. Under the B r i t i s h North America Act of 1867 the provinces are responsible for the health of immigrants as part of the i r tota l population. I t i s the respons ib i l i t y of the federal Department of Health and Welfare to inform the appropriate provinc ia l departments of any health problems associated with a par t i cu la r immigrant, and th i s process is.known to be slow. Because the object ive of the immigration medical examination i s to (only) keep infect ious diseases out of Canada, information on the presence of inact ive disease that could be 141 a future source of in fect ion to the Canadian publ ic is. not recorded or passed on to the provinc ia l health departments. I t i s because of t h i s , that the provinc ia l health author i t ies have ins t i tu ted programs to re-screen a l l the refugee-immigrants from Southeast Asia in order to obtain baseline data for the continuing survei l lance for infect ious diseases. This process is complicated by the fact that the sponsorship program has scattered these refugee/immigrants across the country, and that they are l i k e l y to subsequently relocate themselves into areas where there are other Vietnamese. In large metropolitan areas such as Vancouver, i t i s comparatively easy to set up special programs for the survei l lance and health needs of these immigrants with s ta f f who are fami l i a r with the i r language and cu l ture. I t was found in th i s thesis that the culture of the 'g iver ' as well as that of the ' r ec ip ien t ' of health care w i l l a f fect the outcome of any health care program. One wonders how survei l lance for infect ious diseases i s accomplished in more remote areas where there are cu l tura l and language barr iers between health care personnel and the new immigrants? It has also been found in th is thesis that there i s a lack of knowledge about t rop ica l diseases on the part of health care professionals in countries with more temperate c l imates. In Canada th is is deemed to be the resu l t of i n su f f i c i en t attent ion being given in medical schools to the epidemiology and prevention of ' exo t i c ' as well as other diseases of the t rop i cs . (309) It could 142 also be a resu l t of the fact that paras i t i c disease has never been an important problem in Canada. A discussion with a member of the Faculty of Medicine at the Univers i ty of B r i t i s h Columbia brought the observation that work and travel in the t rop ics by medical students has increased the i r awareness of t rop ica l diseases, and th is has caused a (welcome?) increase in the i r interest in parasito logy. The problems seen to be associated with the a r r i va l of these refugee/immigrants are the continuing survei l lance of infect ious diseases such as tubercu los is , hepa t i t i s , and bacter ia l enter ic disease, for the protect ion of the publ ic health; the need for knowledge on the part of health professionals of diseases and condit ions that could cause symptoms and perhaps chronic i l l - h e a l t h in these new immigrants; and the need for knowledge of the ef fect of culture on the del ivery of health care. Factors seen to af fect the resolut ion of these problems are the d i f ferent objectives of the federal immigration po l i c i e s and the prov inc ia l Departments of Health, with a lack of inter-governmental co-ordination of health services for immigrants; and cur r i cu la for educating health care professionals that contain l i t t l e or no teaching on t rop ica l diseases or the ef fect of culture on the del ivery of health care. I f indeed the present pattern of world migration continues then the need for both of the above i s a t ru l y long-term prospect, and not jus t necessary to deal with the immediate phenomenon of 50,000 refugees from Southeast As ia . 143 CHAPTER 9 PROBLEMS OF ADJUSTMENT AND MENTAL HEALTH INTRODUCTION Adaptation to a new environment has been seen to be s t ress fu l in one way or another for a l l migrants, and th i s 'normal' stress may be aggrevated for the Vietnamese refugees by the i r experiences of war and f l i g h t . There i s a growing l i t e ra tu re on the adaptation and mental health of the f i r s t wave of refugees into the U.S.A. in 1975-76; but i t must be remembered that Canada has admitted the refugees from Southeast Asia as landed immigrants rather than as "refugees on parole, as the i r compatriots in the U.S. were." (310) This factor may have an ef fect on the adaptation problems of the Vietnamese in Canada. THE VIETNAMESE IN THE U.S.A., 1975-76. In her observations of the absorption of the f i r s t wave of refugees from Viet-Nam into American society in 1975-76, Kel ly noted that most of them had apparently thought l i t t l e about the soc ia l or cu l tura l consequences of leaving the i r home-land.(311) Housed i n i t i a l l y in ex-army camps, they had time on the i r hands to th ink, and while being 'processed' into America were s t i l l surrounded by Vietnamese cu l ture: a l l of which probably 144 caused ambivalent fee l ings , and contributed to depression, and anxiety about the future. Suic ida l attempts and psychotic depressive reactions were reported among some refugees in U.S. camps (312); and psychosomatic complaints such as headaches, stomach pains and insomnia were reported in another study.(313) Children expressed the i r d is t ress by somatic complaints, feeding disorders, sleep disturbances, developmental ar res t , tantrums, v io lent ant i - soc ia l behaviour and marked withdrawl; and the depth of the i r depression was i l l u s t r a t ed by the i r refusal to learn English.(314) This is the observable ' t i p of the iceberg' ind icat ing the presence of varying degrees of unhappiness with the i r s i tua t ion : however, no absolute f igures appear to be ava i lab le . These i n i t i a l reactions may have been avoided in Canada by the po l icy of a b r i e f period only at the Reception Centres set up for the Indochinese refugees in Edmonton and Montreal. Uncertainty about the future at th i s stage i s also avoided as the immigrants do not leave Southeast Asia un t i l they have a de f in i te dest inat ion in Canada, and are only" in t rans i t "a t the Reception Centres. Successful adaptation to a new environment appears to depend at least par t ly on how well needs are met. The a v a i l a b i l i t y of she l ter (housing), employment and f inanc ia l s t a b i l i t y are dependent on the economic s i t ua t i on , and North America has been in 145 an economic downswing for several years with high leve ls of unemployment. These are factors beyond the control of health services and personnel involved with the mental health of these new immigrants, but must be remembered as possibly contr ibut ing to maladjustment and unhappiness. I t was found that the Vietnamese refugees in the U.S.A. in 1975-76 found jobs and housing d i f f i c u l t to f i nd , and they were often under-employed in the sense that they were not able to use the s k i l l s and qua l i f i ca t ions they had. In add i t ion , the U.S. government po l icy was to scatter them across the country in an attempt to avoid concentration of Vietnamese in spec i f i c areas such as Ca l i f o rn i a . There was considerable publ ic opposit ion to rese t t l i ng the refugees in the U.S.A.; which was probably due to the overwhelming need to forget the Vietnam War, and the fear of unemployment due to the in f lux of thousands of new immigrants. There i s s t i l l ant i -Or ienta l feel ings in parts of the U.S.A. Even i f there was enough to eat and a roof over the i r heads, f u l f i l lmen t of the need 'to belong' and for ' s e l f esteem' would be denied the Vietnamese refugees in th is s i t ua t i on . The sense of a l i ena t i on , of fee l ing not being wanted by the American people, combined with soc i a l l y unacceptable employment (by Vietnamese standards) could lead to depression, anxiety, and may be psychotic reactions to th i s s t ress . 146 The resul ts of a two-year study of ' f i r s t wave' refugees in the U.S.A. based on the Cornell Medical Index, indicated a high and continuing level of physical and mental dysfunction pers is t ing into the second year. This was at t r ibuted to the i r refugee status rather than to cu l tura l fac tors . (315) The second part of th i s study of continuing changes in l i f e events gives some ind icat ion of the areas in which the refugees found i n s t a b i l i t y : work, f inances, spouse re la t ions and l i f e - s t y l e . (316) This could be restated as i n s t a b i l i t y in the process of meeting human needs. I t has been observed that the new habits and customs challenge Vietnamese t rad i t ions in painful ways beginning at the basis of Vietnamese l i f e - the fami ly. The e lder ly have become a burden rather than to be venerated; the i r wisdom is no longer app l icab le , and the i r a b i l i t y to adapt i s neg l ig ib le . The ro le of the chi ldren i s changing as adults become dependent on them for guides and in terpreters . They are at thesame time a source of pride and anxiety as they learn new ways, customs,and values that con f l i c t with those of t he i r parents.(317) It was seen ea r l i e r in th is thesis that the lack of a sense of ident i ty in immigrant chi ldren could lead to socia l problems as they grow up and t ry to resolve the i r c on f l i c t s . The Vietnamese are a persevering people, but to maintain th i s in the face of unemployment, under-employment, and low pay, i s not easy. 147 The po l icy of scatter ing them across the U.S.A. made the i r soc ia l and cu l tura l losses even harder to replace. It has been found that after one year in America, the refugees s t i l l had d i f f i c u l t y in accepting American values such as the dispersal of the extended family; numerical l im i t s on home occupancy; indi f ference and disrespect towards old people; absence of f r i end ly people with whom to soc i a l i z e in the daytime; the hect ic pace with few breaks in the workday; the distances that require vehicular t r a f f i c , rather than work, family and s o c i a b i l i t y being in one eas i l y • accessible locat ion; and value put on work and achievement rather than on interpersonal t i e s . (318) The f u l l impact of the break-up of the extended family, the westernization of the ch i ld ren , the widening of the generation gap, and the tug between t rad i t i ona l and western values may only be f e l t af ter some years, but the studies mentioned above have shown that there may be con f l i c t much ea r l i e r . This would indicate both immediate and long-term problems of adaptation, and the mental health problems that accompany t h i s . THE VIETNAMESE IN CANADA As mentioned e a r l i e r , the Vietnamese already in Canada were admitted in 1975-76 as landed immigrants having met immigration c r i t e r i a that would hopeful ly have enhanced the i r chances of adapting successfu l ly . However, i t has been observed 148 that they had problems s im i la r to those of the i r compatriots in U.S.A.; unemployment, cu l tura l adjustment, lone l iness , the language bar r i e r , a l l compounded by the weather. (319) Canada's pol icy regarding the resettlement of th is second wave of refugees from Southeast Asia has been to admit them as landed immigrants sponsored by community groups or organizat ions, with a matching formula by which the federal government sponsors an equal number to a to ta l of 50,000. The immigration c r i t e r i a are good health, and the motivation and s k i l l s to se t t l e successfu l ly in Canada. This i s a se lect ive process in that those with obvious health defects, e i ther physical or mental, w i l l have been 'screened out ' . The Canadian sponsors agree to provide food shel ter and f inanc ia l support as needed, unt i l the immigrants become se l f -supporting, or for one year. They are also expected to help the adjustment of the newcomers to the new l i f e - s t y l e , and to or ientate them to community and government serv ices. This i s a continuation of the unwritten po l icy of involv ing loca l communities and voluntary agencies in immigrant settlement; and with th i s scheme, the government has delegated moral and f inanc ia l r espons ib i l i t y for meeting the needs of these refugee/immigrants to the sponsors. There are o f f i c i a l l y about 6000 Vietnamese refugee/ immigrants in Vancouver, B r i t i s h Columbia. In an attempt to 149 assess what is being done to help the i r adaptation to the new environment, interviews were conducted with several community (voluntary) agencies and ind iv idua ls involved in th i s process. As stated e a r l i e r , the sponsors accepted respons ib i l i t y for a family un t i l they were set t led or for one year. One problem has been the acute shortage of housing in Vancouver, but th i s seems to have been overcome with several sponsors sharing the i r homes unt i l an apartment was found for the i r guests. There have been some humorous and not so humorous misunderstandings about food and its..; preparat ion, the use of western s ty le beds, and the d i f fe rent western and or ienta l concepts of time and the keeping of appointments. In western eyes being 45 minutes late means a cancel led appointment: in Vietnamese eyes i t i s po l i t e to arr ive 45 minutes af ter the appointment time. Another point of possible misunderstanding i s the d i f fe rent sty les of conversation: westerners f ind i t very d i f f i c u l t to accept the periods of s i l ence , and deep thought that the Vietnamese give to the i r answers. The concept of Sao You (scratch the wind) or coin-rubbing for various health problems has been met by health professionals and has raised the spectre of child-abuse in the i r minds. These seemingly small incidents are the everyday facts of c ross-cu l tura l in te rac t ion; and one wonders how much preparation was given the sponsors, and others working with the refugee/immigrants, in order to minimise the 150 i r r i t a t i o n and misunderstandings that can ar ise on both sides in th is s i t ua t i on . There are voluntary agencies with the expert ise to help sort out misunderstandings but no data to indicate who asks for what or in what quant i t ies . This supports the contention noted ea r l i e r in th is thesis that i t i s d i f f i c u l t to evaluate the part that voluntary agencies play in the resettlement of immigrants. Unfortunately, the co-ordinating body for the resettlement of the refugees in Vancouver, "The C i ty of Vancouver Task Force on Vietnamese Refugees", was disbanded in November 1980, so i t has not been possible to obtain e i ther an overview of the s i tuat ion or more spec i f i c data from th is source. Lack of knowledge of the English language has cer ta in ly been a bar r ie r to employment, and those who can speak English appear to be se t t l i ng down and obtaining employment much faster than those who do not know the language. Many are under-employed because of the language problem and/or because the i r professional and technical s k i l l s are not recognised in th is country. One comment heard was that professional and technical organizations could do more towards helping with th i s problem. There i s misunderstanding on the part of some employers of the immigrants' comparative slowness at completing tasks, in sp i te of the i r general wi l l ingness to work. A l l th is does not help the 'se l f -esteem'of these new immigrants. 151 Being able to communicate helps f i l l the need to 'belong' and English language classes are conducted by voluntary agencies as well as by the federal Department of Employment and Immigration - although there i s a two month wait ing l i s t for the l a t t e r . There is a weekly newspaper in three languages, Engl ish, Vietnamese and Chinese, supported by S.U.C.C.E.S.S. (United Chinese Community Enrichment Services Soc iety) , which f a c i l i t a t e s communication between community, sponsors and new immigrants. This i s the only multi-language newspaper in Canada for the South east Asian Refugees, and i s mailed across the country. One issue contained a r t i c l e s on nu t r i t i on , ch i l d development, and health; legal matters such as housing regulat ions; understanding Canada; and a l e t t e r from a sponsor expressing his/her feel ings on refugees! A major factor in the 'sense of belonging' in any culture is the ' soc ia l network' of fami l i a r faces, language, and a c t i v i t i e s . In the U.S.A the f irstwave Vietnamese soon ' r e se t t l ed ' themselves into areas where there were other Vietnamese. This would help them support each other in adjusting to the American way-o f - l i f e , and in forming a Vietnamese-American subculture.; I t ,has shown again that the po l i cy of d i rec t ass imi la t ion into the dominant cul ture does not work, and i t i s of in te res t . tha t i t was t r i e d in spite of the American recognit ion of the mul t i cu l tura l soc iety. 152 The large Chinese-Canadian community in Vancouver provides a ' soc i a l network1 for Chinese and Vietnamese immigrants, and th is i s a t t rac t ing the Vietnamese to ' r e se t t l e ' themselves here out of the i r o r ig ina l areas of settlement. S.U.C.C.E.S.S. estimates that the i r number in Vancouver alone i s now around 10,000. This 'network'with the special health c l i n i c in the area of 'Chinatown', w i l l help the adaptation of the Vietnamese to Canadian l i f e ; in fac t , they themselves have asked for spec i f i c programs at the c l i n i c , such as family planning. However, a l l th i s raises the question of what and how much help ( i f any) has been offered both sponsors and immigrants in the more remote areas of the country to aid the adjustment process? The overa l l fee l ing from the interviews and the news media i s that th i s resettlement scheme has been a success. But i s th is an Occidental view of a s i tuat ion where Oriental fee l ings are not expressed? I t i s of in terest to note here that nothing has been heard of possible react ion to RPM (Rape, P i l l age and Murder) or other experiences during the f l i g h t of the boat-people. Four of a possible 10,000 refugee/immigrants in the Greater Vancouver area have been admitted to psych iat r ic in-pat ient f a c i l i t i e s . Is th is the ' t i p of the iceberg'? What does i t mean for mental health programs - and professionals? 153 Prevention of the breakdown of coping mechanisms should be the objective of mental health programs, and recommendations on the creative aspects of this are beyond the scope of this thesis. Economic factors such as the high rate of unemployment and lack of housing are beyond the control of health services per-sonnel, although the effect of these on health must be remembered. Knowledge of Canada's o f f i c i a l policy of multiculturism is important for health care workers as this implies the acceptance and under-standing of 'different ways of doing things' . Planning and execution of programs for preventing the breakdown of coping mechanisms (mental health) is d i f f i c u l t i f the intended recipients perceive mental i l lness as caused by hostile agents outside the body. Understanding the effect of culture (ways of doing things) and l i f e experiences on the immigrant adaptation process wil l increase the sensit iv i ty of mental health workers when dealing with the psychological signs of maladaptation and stress. It was observed ear l ier in this thesis that social welfare personnel have a dual role; helping the c l ient(s) , and acting as an advocate for them to planners of social welfare programs. This could be applied equally well to a l l health care personnel, but implies an understanding of the effect that culture 154 and l i f e experiences including migrat ion, have on health and on the giv ing and receiv ing of health care. With perhaps 10,000 Vietnamese in Vancouver, th i s appears to be an ideal s i tua t ion for a study of the factors af fect ing the adaptation process of immigrants; espec ia l ly when i t i s remembered that patterns of world migration are changing, and Canada i s l i k e l y to receive more immigrants who are r a c i a l l y and cu l t u ra l l y d i f fe rent from the major i ty. Such research i s sadly lacking in Canada, and planning programs and services for immigrants per se i s point less without the information that th i s research would generate. 155 CHAPTER 10 RECOMMENDATIONS AND CONCLUSION INTRODUCTION The question posed in th is thesis is what e f f e c t , i f any, the health status of the Southeast Asian refugee/immigrants w i l l have on 1) the health of Canadians, and 2) the future health of the refugees themselves. I t was postulated that the factors underlying both the problem and i t s resolut ion would be the charac ter i s t i cs of the new immigrants and the country receiving them - Canada. This i s conceptualized in f igure 1. (page 7) It has been found that the health status of the new immigrants is determined by two factors: the immigration po l i c ies of the Canadian government, and the cu l tura l background and l i f e experiences of the refugee/immigrants themselves. The problems ar i s ing from th is are seen to be 1) the increased r i sk to Canadians from certa in in fect ious diseases, namely tubercu los is , hepa t i t i s , and bacter ia l enter ic disease; 2) the importation of ' exo t i c ' diseases that are not a great r i sk to Canadians but which may pose problems of diagnosis and treatment; and 3) mental health problems in the new immigrants a r i s ing from culture shock and possible d i f f i c u l t y in adapting to a new environment. The resolut ion of these problems is seen to be affected by the cu l tura l background and l i f e experiences of the new immigrants, 156 and by certa in Canadian charac te r i s t i c s . Besides the personal att i tudes of Canadians towards these immigrants, the l a t t e r includes a system in which respons ib i l i t y for various aspects of Canadian l i f e i s shared by d i f fe rent leve ls of government, and where po l i c i e s may be formulated at one level and programs and services provided at another. A factor found to contribute to the success or f a i l u re of programs and services designed for the . resettlement and health care of these immigrants is the knowledge of health care professionals about the e f fec t of culture on health and health care, and about the et io logy and epidemiology of t rop ica l diseases. The Character is t ics of the 'Boat people' . The 'Boat people 1 are a group representative of the large and continuing involuntary movement of people in Southeast Asia today. They appear to be mainly 'e thn ic ' Chinese f lee ing Viet-Nam because of in to lerab le l i v i n g condit ions, and have been l i v i n g for various periods of time in refugee camps in Thai land, Malaysia, and Hong Kong. The uncertainty of the i r refugee status has added to the accumulated stress of prolonged soc ia l upheaval and warfare and the i r experiences during f l i g h t . The process by which 50,000 of these refugees„were selected for resettlement in Canada means that overal l they have met the c r i t e r i a for immigrants per se. However, the environment 157 from which they have come means that there are some long-term health problems associated with the i r resettlement in th is country. Their cu l tura l background, espec ia l l y the i r be l ie f s and customs about health and sickness, w i l l a f fect the way in which these problems are solved. THE CANADIAN CHARACTERISTICS Under the B r i t i s h North American Act of 1867, immigration was to be the j o i n t respons ib i l i t y of the federal and prov inc ia l l eve l s . o f government. The evolut ion of the system has brought about the s i tua t ion whereby today the federal government alone makes immigration po l i cy . This i s aimed at preventing the spread of infect ious disease, as well as admitting immigrants who are healthy and who w i l l quickly se t t l e and become productive c i t i z ens . Settlement services such as language t ra in ing and employment counsel l ing are offered at the community level by the federal Departments of the Secretary of State and Employment and Immigration respect ive ly. These are supplemented through services offered by interested voluntary agencies and which are encouraged by the unwritten federal government po l icy of invo lv ing the community in immigrant settlement. The provinces are not involved in th is process per se; but they are involved in immigrant health problems in other ways, and i t appears that there i s a need for greater co-operation and co-ordinat ion between leve ls of government in th i s matter. 158 I t has been seen that immigrants may, through no fau l t of the i r own, make unusual demands on soc ia l and health programs. Again under the B r i t i s h North America Act of 1867, these are the respons ib i l i t y of the provinces - although the federal government can and does inf luence the formulation of health and welfare po l i c ies at th is l e v e l . The prov inc ia l governments delegate some of the planning and del ivery of programs and services to the local l e v e l , i . e . community Boards of Health and Health Units. The d iv i s ion of respons ib i l i t y for immigration and the welfare of landed immigrants across various leve ls and departments of government, and the voluntary sector, i s seen as leading to possible fragmentation of services and a lack of planning and co-ordination between o f f i c i a l and voluntary agencies. Other factors seen to contribute to the success or f a i l u re of programs and services offered in the context of the resettlement of these 50,000 refugees are the . att i tudes and knowledge of Canadian health care profess ionals. Att i tudes towards immigrants may be representative of soc ieta l values; but un t i l comparatively recently immigrants passed unnoticed into the mainstream of Canadian l i f e and the i r health and adaptation problems were not seen by the majority. This of course i s changing as immigrants are becoming more conspicuous by v ir tue of the i r race, colour and cu l ture. The previously homogeneous society means that Canadian health care professionals have not been educated in 159 the cross-cu l tura l aspects of health and sickness and the influence of th is on the del ivery of health care. Taking the health problems associated with the resettlement of the 'Boat people' one by one, recommendations w i l l be made on factors seen to af fect the i r reso lut ion, THE PROBLEMS The Risk bf the Spread of Infectious -Diseases One object ive of Canadian immigration pol icy i s the prevention of the spread of infect ious diseases? and as these new immigrants have had to pass a pre-immigration medical examination i t could be assumed that there would be no health problems associated with the i r resettlement in th is country. Obvious disease w i l l have been 'screened out' by th i s examination: however, i t i s known that tuberculos is , hepat i t i s and bacter ia l enter ic disease can l i e dormant, perhaps for years, and become act ive again at a l a t t e r date. Because of th is environment from which they come, and the i r experiences of war and f l i g h t , i t i s considered that the Vietnamese are susceptible to the breakdown of inact ive disease that had been acquired e a r l i e r , and can thus become a publ ic health hazard. Short-term programs were i ns t i tu ted by both federal and prov inc ia l governments to deal with th i s -problem as the immigrants a r r i ved , but these programs are now being'phased out . ' In future, 160 a l l immigrants from Southeast A s i a w i l l en te r Canada through r egu l a r immigrat ion channe ls ; and t h e i r hea l th care once they have a r r i v e d w i l l be the r e s p o n s i b i l i t y o f the p r o v i n c i a l governments and l o c a l hea l th u n i t s . The hea l th problems o f these f u tu re immigrants are expected to be s i m i l a r to those o f the Vietnamese re fugees . Programs and se r v i c e s f o r the p r o t e c t i on o f the p u b l i c ; hea l th are a l ready i n p l a ce . However, i t has been seen tha t the success o f any hea l t h program i s a t l e a s t p a r t l y dependent on how i t i s perce ived by the ' r e c i p i e n t ' , and h i s / h e r i n t e r a c t i o n w i th the ' g i v e r ' o f hea l th care who may see the problem from a d i f f e r e n t pe r spe c t i v e . These percept ions are c u l t u r a l l y determined, and the g rea te r the d i s t ance between those o f the ' r e c i p i e n t ' and ' g i v e r ' the g rea te r the r i s k o f program f a i l u r e . In t h i s i n s t an ce , i t cou ld mean the inc reased r i s k o f the spread o f i n f e c t i o u s d i seases . I t would appear t ha t both those respons ib l e f o r p lann ing programs and the hea l th care p r o f e s s i ona l s c a r r y i n g them out shou ld be aware o f the e f f e c t o f c u l t u r e on the g i v i n g o f hea l t h ca re . In the context o f the prevent ion of the spread o f i n f e c t i o u s d iseases t h i s i s seen to be p r i m a r i l y a r e s p o n s i b i l i t y o f the s e r v i c e l e v e l ; a l though the need f o r such knowledge shou ld be acknowledged a t the p o l i c y making l e v e l . 161 The professionals both planning and de l iver ing health care are seen to be physicians and publ ic health nurses; and the problem of acquir ing knowledge of the e f fec t of culture on health and sickness i s both immediate and long-term. The fol lowing recommendation i s made in order to solve the immediate problem. Recommendation. 1. That health care agencies, espec ia l ly those in the publ ic health f i e l d , provide material on the cross-cu l tura l aspects of working with the Vietnamese immigrants for the i r s ta f f . The a r r i va l of the Vietnamese refugee/immigrants has only highl ighted the fact that world migration patterns are changing and, that unless po l i c i es are d ra s t i c a l l y changed, Canada w i l l be admitting more immigrants from countries with d i f fe rent patterns of disease and d i f fe rent concepts of health and sickness. I t i s suggested that the need for understanding the e f fec t of culture on the del ivery of health care w i l l continue, i f not grow, and that courses on th i s subject should be included in the education of physicians and publ ic health nurses. These health care professionals are educated at un ivers i ty . . Professional l i cenc ing bodies ensure that basic standards are met in order to protect the publ ic; but apart from this function can only suggest that courses on certa in topics be 162 included in the univers i ty cu r r i cu l a . However, i t i s f e l t that i t i s a professional respons ib i l i t y to acknowledge the changes taking place in Canadian society and the e f fec t of th is on the del ivery of health care, and hence on the education of i t s members. Un ivers i t i es , as educational establishments, and the professional l i cenc ing bodies come under provinc ia l j u r i s d i c t i on . Separately, they have national associat ions that in teract with each other and government at the national l e v e l . With?-this .in mind the fol lowing recommendations are made. Recommendation. 2. That the medical.land nursing professional assoc iat ions, in conjunction with the appropriate un ivers i ty departments, explore ways of inc luding courses on the e f fec t of culture on health and sickness and the cross-cu l tura l aspects of the del ivery of health care, in the basic education of physicians and publ ic health nurses. I t i s further recommended that the d i sc ip l i nes of sociology and anthropology be involved in th is process. Continuing education i s also a professional r e spons ib i l i t y , and i t appears that these courses are i n i t i a t ed by interested professional ind iv idua l s . Recommendation 3. That the above professional associations encourage the i r members and the appropriate univers i ty departments (or community col leges) to plan continuing education courses in the cross-cu l tura l aspects of the del ivery of health care. The P r ob l em o f ' E x o t i c ' D i s e a s e s . 163 A p a r t f r om the r i s k t o t h e p u b l i c h e a l t h f r om i m p o r t e d i n f e c t i o u s d i s e a s e s such as t u b e r c u l o s i s , t h e r e i s t he p r ob l em o f d i s e a s e s t h a t a r e a t h r e a t t o t h e h e a l t h o f the i n d i v i d u a l r e f u g e e / imm i g r an t and wh i c h a r e pe rhaps l i t t l e o r unknown i n Canada . The r e c o g n i t i o n and t r e a t m e n t o f t h e s e d i s e a s e s , wh i c h i n c l u d e i n t e s t i n a l p a r a s i t e s , m a l a r i a , and H a n s e n ' s D i s e a s e , r e q u i r e s a l e v e l o f knowledge abou t t r o p i c a l d i s e a s e t h a t i s n o t common i n Canada , and wh i c h has no t been w i d e l y t a u g h t i n m e d i c a l s c h o o l s h e r e . There appea r s t o be a i n c r e a s i n g i n t e r e s t i n t r o p i c a l d i s e a s e s among m e d i c a l s t u d e n t s who a r e aware o f t h e e f f e c t o f s o c i a l change on t h e d i s t r i b u t i o n o f t h e s e d i s e a s e s i n t h e w o r l d : b u t a g a i n , t h i s a s p e c t o f m e d i c a l e d u c a t i o n i s seen as a p r o f e s s i o n a l r e s p o n s i b i l i t y . Recommendat ion . 4. Tha t the m e d i c a l p r o f e s s i o n , i n c o n j u n c t i o n w i t h t h e U n i v e r s i t y S c h o o l s o f M e d i c i n e , e n s u r e t h a t t e a c h i n g o f t h e e t i o l o g y and e p i d e m i o l o g y o f t r o p i c a l d i s e a s e s be expanded i n t he b a s i c e d u c a t i o n o f p h y s i c i a n s . A g a i n , c o n t i n u i n g e d u c a t i o n i s seen as a c o l l e c t i v e as w e l l as an i n d i v i d u a l r e s p o n s i b i l i t y o f h e a l t h c a r e p r o f e s s i o n a l s . I t was somewhat d i s t u r b i n g t o f i n d a t i m e - l a p s e o f two y e a r s between the announced a r r i v a l o f t h e V i e t namese r e f u g e e s i n Vancouve r and a ' p o s s i b l e ' c o u r s e on t r o p i c a l m e d i c i n e f o r p r a c t i c i n g p h y s i c i a n s a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . I t i s t h e r e f o r e recommended: 164 Recommendation. 5. That continuing education courses in t rop ica l medicine for physicians be i n i t i a t e d by the medical associations as well as by indiv idual p rac t i t i oners . Adaptation, and the Mental Health of Immigrants The other component of the health status of the 'Boat people' i s the mental stress caused by the process of adapting to a new environment. This is not a threat to the health of Canadians, but has ramif icat ions for mental health programs and serv ices. Those with obvious psychological d istress w i l l have been 'screened out' by the pre-immigration medical examination; however, loss of mental health can be an ins id ious process occuring over many years. Cultural be l ie f s and customs a f fec t the perception of th is problem and . i t s prevention and treatment, by both the Vietnamese and the western health care profess ionals. Adaptation is the learning of new ways of meeting needs, and i i t i s the i n a b i l i t y to deal with th i s that can lead to depression, anxiety, and desperation. I t has been seen that immigrants tend to have higher hosp i ta l i za t ion rates for mental disorders than the loca l ly-born populations, so i t would appear that ways of preventing th is should be explored. The federal government, with i t s respons ib i l i t y fo r immigration po l i c i e s , programs and serv ices , has r e l i ed heavi ly on the response of community groups and organizations for the operation 165 and success of the i r program for the resettlement of these refugees. This i s in l i ne with the i r unwritten po l i cy of involv ing the community in the immigrant resettlement process per se; and i t appears that by doing th is voluntary agencies and groups have given a great deal of unpaid help to the government. Many of the problems of adaptation can be handled by voluntary agencies with the in teres t and resources to do t h i s . Highly t ra ined, and highly paid, professionals are not needed; although there is a need for soc ia l workers to be aware of the special problems of immigrants and the ef fects of culture on the adaptation process, socia l welfare, and mental health. Therefore the fol lowing recommendation i s made. Recommendation. 6. That the professional associat ions of soc ia l workers, in conjunction with the appropriate univers i ty department explore ways of including courses on the e f fec t of culture on health and soc ia l welfare, and on the cross-cu l tura l aspects of the del ivery of care in these areas, in the education of the i r members. I f the coping mechanisms of the new immigrants do f a i l , then the knowledge of , and s ens i t i v i t y to , the pecul iar stresses of migration and adaptation by psych ia t r i s t s , psychologists, psych ia t r i c nurses, and soc ia l workers w i l l f a c i l i t a t e treatment and recovery. The actual numbers of immigrants requir ing help w i l l probably be smal l , so special programs may not be needed. There i s a need to sens i t i ze health care workers, inc luding the bureaucracy, to the 166 e f fec t of culture on mental health and to the eastern and western perceptions of a health problem and i t s reso lut ion. Again, th is is seen as a professional respons ib i l i t y and attent ion i s drawn to recommendations 1 and 2. I t has been observed that the evaluation of immigrant resettlement services is d i f f i c u l t because of the autonomy of the voluntary agencies involved in th is process, and an overal l lack of planning, co-ordination and accountabi l i ty . The need for the services has cer ta in ly been recognised by the federal government with the i r funding of the voluntary programs. I t would appear that the government has a respons ib i l i t y to the community i . e . the taxpayers, the agencies, and the immigrants themselves, in evaluating the way the money i s spent in terms of the type and quantity of services of fered, and to whom. Recommendation. 7. That a l l programs designed for the resettlement of the Vietnamese refugees be evaluated by the Department of Employment and Immigration. This.;is to include the sponsorship program, and the ro le of the voluntary agencies as well as that of the more formal soc ia l and health programs. In view of ;the probab i l i t y that immigration from countries that are s i gn i f i c an t l y d i f fe rent from Canada w i l l continue, the fol lowing recommendation i s made. 167 Recommendation 8. That these programs, redesigned i f necessary, and with an evaluation process bu i l t i n , be offered to a l l immigrants. I t i s d isturbing to note that in sp i te of the evidence that the resettlement problems of these new immigrants may continue for years, both senior levels of government appear to have reverted to the i r former ' l a i s s e z - f a i r e ' at t i tude to immigrants. The federal government has phased out the extra services that they supplied for the refugees; and the l eg i s l a t i on passed by the prov inc ia l government of B r i t i s h Columbia to provide the mechanism for funding services for the resettlement of refugees per se* does not seem to have been act ivated. The 'C i t y of Vancouver Task Force on Vietnamese Refugees' has been disbanded, leaving the e f for ts of voluntary agencies and sponsoring groups unco-ordinated. This 'Task Force' could have been used in an evaluating role for the programs and services offered to the refugees. Both voluntary and government programs and services are seen as contr ibut ing to the successful adaptation of a l l immigrants, not jus t to that of the Vietnamese; and the prevention of mental breakdown reduces the future cost to the community of immigrant i l l - h e a l t h . With a l l . t h i s in mind, a f ina l recommendation i s made. * B r i t i s h Columbia, Laws, Statutes, e tc . Refugee Settlement Act 1979, 28 E l i z . 2, ch 360. Revised Statutes of B r i t i s h Columbia 1979, 5, 1 ( s e c . l ) . 168 Recommendation 9. That both leve ls of senior government f a c i l i t a t e research into the factors that a f fect the immigrant adaptation process, and into immigrant health problems.in general. CONCLUSION Man has been migrating through time immemorial and although his motives have remained constant, the patterns.ofmovement across the globe have changed and quickened. World-wide soc ia l change means that there w i l l be more voluntary migration from areas that 'have not' to areas that 'have 1 ; and that the l a t t e r , for what ever reasons, w i l l feel obl iged to give asylum to those uprooted by war, natural d i saster , or p o l i t i c a l persecution. This has brought about new Canadian immigration po l i c i e s , with the resu l t that more and more Canadians w i l l be coming into everyday contact with people who are ' d i f f e r en t 1 . I t has been seen that the meeting of d i f fe rent races and cultures can produce some soc ia l s t ress . Immigrants in the future are l i k e l y to have health problems that w i l l bring them into ear ly contact with the health care system and i t s profess ionals . 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A Survey and Directory of Asia and the  Pa c i f i c . 11th ed. pp.1121-1130..London: Europe Publ icat ions Ltd., 1979. Su l l i van , Timothy, and nguyen Thi Nhu-Tuan. "Bacter ia l Enteropathoges in the Republic of South Vietnam." M i l i t a r y Medicine. 136 (January 1971): 1-6. Vennema, A. "Tuberculosis in Rural Vietnam" Tubercle. 52 (1971): 51-9. THE VIETNAMESE REFUGEES 1975-76: HEALTH PROBLEMS Ke l l y , Gail Paradise, From Vietnam to America. A Chronicle of  the Vietnamese Immigration to the United States. Boulder, Co.: Westview Press. 1977. L i u , Wil l iam, T. , and Murata, Maryanne L.A. Transi t ion to Nowhere. Vietnamese Refugees in America. Nashv i l le : Charter House Publishers Inc., 1.970. 205^  Goldsmith. Robert; S ta r le , Fred; Smith, Creed; Healy, George; Donegan, E l isabeth; Juchau, Vern; Stalcup, Alex. "Orphan A i r l i f t . " American Medical Associat ion Journal 235 (May 10. 1976): 2114-6. •".Hansen's Disease in Vietnamese Refugees." Mobidity and Morta l i ty  Weekly--Report-2-4 (January 3 1976): 455. Harding, Richard K. and Looney, John G. "Problems of Southeast Asian Children in a refugee camp". American Journal  of Psychiatry 134 (Apr i l 1977): 407-11. Hodson, El isabeth M., and Springthorpe, Barry J . "Medical Problems in Refugee Children evacuated from South Vietnam." Medical Journal of Aus t ra l i a 2(November 13 1976): 747-9. L in , K.M.; Tazuma, L; and Masuda, M. "Adaptational problems of Vietnamese refugees. 1. Health and mental health status." Archives of General Psychiatry. 26 (August 1979): 955-61. "Natural loss of i n tes t i na l parasites of Vietnamese immigrants fol lowing entry to Canada." Canada Diseases Weekly  Report 2 (Apr i l 24 1976): 65. Masuda, Minoru; L i n , Ken-Ming; and Tazuma, Laurie. "Adaptation Problems of Vietnamese Refugees. 11. L i fe Changes and Perception of L i fe Events." Archives of General  Psychiatry 37 (Apr i l 1980): 447-50. Mattson, R.A., and Ky, D.D. "Vietnamese refugee care. Psych iat r ic observations." Minnesota Medicine 61 (January 1978): 33-6. Rahe, R.H.; Looney, J .G . ; Ward, H.W.; Tung, T.M.; L iu , W.T. "Psych iat r i c consultat ion in a Vietnamese refugee camp." American Journal of Psychiatry. 135 (February 1978): 185-90. "Update on Vietnamese Refugees Health Status." Morbidity and  Morta l i ty Weekly Report 24 (August 2 1975): 267. Yeatman, Gentry W.; Shaw, Constance; Barlow Matthew J . ; and Ba r t l e t t , Glen. Pseudobattery in Vietnamese Chi ldren." Pediatr ics 58 (October 1976): 616-8. 206 THE VIETNAMESE REFUGEES, 1979-80: HEALTH PROBLEMS Breitenbucher, R.B. "Indo-Chinese Refugees. Medical Care of Southeast Asians-Compliance." Minnesota Medicine 63 (January 1980): 41-4. "Cholera in a Laotian Refugee - Ca l i f o rn i a . " Morbidity and  Morta l i ty Weekly Report 29 (Apr i l 25 1980): 191. Dahlberg, Keith. "Medical Care of Cambodian Refugees." American Medical Associat ion Journal 243 (March 14 1980): 1062-5. "Follow-up on Diphtheria in Indochinese Refugees from Thai land." Morbidity and Morta l i ty Weekly Report 28 (November 23 1959): 546., "Health Screening of Resettled Indochinese Refugees - Washington D.C., Utah." Morbidity and Morta l i ty Weekly Report 29 (January 11 1980): 4. "Health Status of Indochinese Refugees: Malaria and Hepat i t is B." Morbidity and Morta l i ty Weekly Report 28 (October 5 1979): 463. "Health Status of Indochinese Refugees." Morbidity and Morta l i ty  Weekly Report 28 (August 24. 1979): 395. "Hepat i t is Screening of Indochinese Refugees" Canada Diseases  Weekly Report 6 (January 26 1980): 14-5, 18-9. "Not i f iab le Diseases Summary." Canada Diseases Weekly Report 5 (November 8 1980): 224. "Nutr i t iona l Status of Southeast Asian Refugee Chi ldren." Morbidity and Morta l i ty Weekly Report 29 (October 3 1980): 477. Olness, Karen. "Indo-Chinese Refugees, Cultural Aspects of Working with Lao Refugees." Minnesota Medicine 62 (December 1979): 871-4. "Refugees w i l l be screened for Hepat i t is B. v i rus . " Journal of the Canadian Dental Associat ion 12 (December 1979): 638. 207 Tan, Joanna K., and Tan, Kenneth K. "Health Problems of the Vietnamese Refugees." Canadian Family Physician 26 (March 1980): 404-8 "Tuberculosis among Indochinese Refugees - United States, 1979" Morbidity and Morta l i ty Weekly Report. 29 (August 15 1980): 383. GOVERNMENT DOCUMENTS AND PUBLICATIONS CANADA Canada, Laws, Statutes, etc . The Immigration Act 1869 32-33 V ic t . c.10. Statutes of Canada 1867-68, 1869. Canada, Laws, Statutes etc. The Immigration Aid Societ ies Act 1872. 35 V ic t . c. 29. Statutes of Canada 1872. Canada, Laws, Statutes, etc . An Act to amend the Immigration  Act 1902, 2 Edw. VII , c.14. Statutes of Canada 1902. Canada, Laws, Statutes, e tc . The Immigration Act 1910, 9-10 Edw. VII , c.27. Statutes of Canada 1910. Canada, Parliament, Debates of the House of Commons, Session 1947, Vol. 3, (Apr i l 14 - May 12, 1947). Canada, Laws, Statutes, etc . The Immigration Act 1947. 11 Geo, VI. c.19. Statutes of Canada 1947. Vol.1 Canada, Laws, Statutes, e t c . . The Immigration Act 1952. 1 E l i z . 11. c.42. Statutes of Canada 1952, Vol . 1 Canada, Laws, Statutes, etc . Immigration Regulations Part 1. SOR/62-36, The Canada Gazette Part 11, Vol . 96. Canada, Off ice of the Minister of Manpower and Immigration. White Paper on Immigration 1966.Ottawa: Queen's P r in te r , 1966. Canada, Laws, Statutes, e t c . . Immigration Regulations, Part 1 amended. SOR/67-434. The Canada Gazette Part 11, Vol.101. 208 Canada, Royal Commission on B i l ingual i sm and B icu l tura l i sm. Report. Ottawa: Queen's P r in te r , 1969. Canada, Laws, Statutes, etc . The Immigration Act 1976, 25-26 E l i z 11, ch.52. Statutes of Canada 1976-77, Vol . 11. Canada, Department of Employment and Immigration, Press Release. "Notes for an Address by Bud Cul len, Min ister of  Employment and Immigration Canada, to the South Ottawa  Kiwanis Club; Ottawa, Ontario. Tuesday, January 16, 1979." Canada, Department of External A f f a i r s , Statements and Speeches, no. 79/12. "C r i s i s in Southeast As ia: humanitarian  and po l i t i c a l aspects can ' t be separated." A speech by the Secretary of State for External A f f a i r s , the Honourable Flora MacDonald, to the United Nations Conference on Refugees, Geneva, July 20, 1979. Canada, Department of Employment and Immigration, Publ ic A f fa i r s D iv i s ion , Newsletters. Indochinese Refugees. 1979-80. Canada, Tuberculosis S t a t i s t i c s . Morbidity and Morta l i ty 1977. Ottawa: S t a t i s t i c s Canada 1979. Canada Year Book 1978-79. Ottawa: S t a t i s t i c s Canada 1979. THE PROVINCE OF BRITISH COLUMBIA B r i t i s h Columbia, Laws, Statutes, etc . Refugee Settlement Act 1979, 28 E l i z . 2, ch 360, Revised Statutes of B r i t i s h Columbia 1979, Vol .5. THE EUROPEAN ECONOMIC COMMUNITY European Economic Community. 1968. Regulation No. 1612/68. October 15 209 GREAT BRITAIN Great B r i t a i n . The B r i t i s h North America Act 1867. 30 and 31 V i c t . c.3. Halsbury's Statutes of England (3rd ed . ) , Vol . IV Great B r i t a i n , Al iens Act 1905 5 Edw. 7, c.13. The Law Reports. Vol . XLIII . Great B r i t a i n , The B r i t i s h Nat iona l i ty Act 1948 11 and 12 Geo. 6, c.56. Halsbury's Statutes of England (3rd ed . ) , Vol.1 Great B r i t a i n , The Commonwealth Immigrants Act 1962. 10 and 11 E l i z . 2 c.21, Halsbury's Statutes of England (3rd ed . ) , Vol . IV. Great B r i t a i n , The Local Government Act 1966 1966 c.42, Halsbury's  Statutes of England (3rd ed . ) , Vol . 19. Great B r i t a i n , The Local Government Grants (Social Need) Act 1969 1969 c.2, Halsbury's Statutes of England (3rd ed . ) , Vol . 19. Great B r i t a i n , The Immigration Act 1971, 1971 c.77. Halsbury's  Statutes of England (3rd ed . ) , Vol. 41. Great B r i t a i n , The Race Relations Act 1976 1976 c.74. Halsbury's Statutes of England, (3rd ed.) Vol . 46. Great B r i t a i n , Parliament, House of Commons. Cmnd. 7750, Proposals for Revision of the Immigration Rules. November 1979. UNITED STATES OF AMERICA U.S. Congress, Immigration and Nat iona l i ty Act (McCarran Walter Act)  Statutes at Large, Vol. 66 (1952). U.S. Congress, Immigration and Nat iona l i ty Act, amendments.  Statutes at Large, Vol . 79 (1965). U.S., Department of Just ice , Immigrants and Natura l isat ion Services. Reports of Immigrants and Natura l isat ion  Services. S t a t i s t i c a l Bu l l e t i n . September 1968. 210 U.S. Congress, Immigration and Nat iona l i ty Act Amendments of 1976  Statutes at Large, Vol.90, (1976). — MISCELLANEOUS Maslow, Abraham H. Motivation and Personal i ty. 2nd ed. New York: Harper * 1970. 

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