UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1981_A6_7 L94.pdf [ 8.24MB ]
Metadata
JSON: 831-1.0095108.json
JSON-LD: 831-1.0095108-ld.json
RDF/XML (Pretty): 831-1.0095108-rdf.xml
RDF/JSON: 831-1.0095108-rdf.json
Turtle: 831-1.0095108-turtle.txt
N-Triples: 831-1.0095108-rdf-ntriples.txt
Original Record: 831-1.0095108-source.json
Full Text
831-1.0095108-fulltext.txt
Citation
831-1.0095108.ris

Full Text

PLANNING FOR THE HEALTH CARE OF THE SOUTHEAST ASIAN REFUGEES: A REVIEW  by BARBARA M. LUDWIG B.N. McGill U n i v e r s i t y , 1972  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology Program in Health Services Planning  We accept t h i s 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  this  an a d v a n c e d  degree  the  shall  Library  I further for  scholarly  by h i s of  agree  this  written  thesis at  permission  purposes  for  freely  for  financial  is  of  British  2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1WS  &4  flpff  of  Columbia,  British  by  gain  Columbia  for  the  understood  of  The U n i v e r s i t y  of  extensive  may be g r a n t e d It  fulfilment  available  permission.  Department  Date  it  representatives. thesis  partial  the U n i v e r s i t y  make  that  in  shall  requirements  reference copying  Head o f  that  not  the  and  of my  copying  be a l l o w e d  I agree  that  study.  this  thesis  Department or  for  or  publication  without  my  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 f e r e n t from Canada in terms of disease patterns, c u l t u r a l b e l i e f s and customs-  They are  probably also affected by t h e i r experiences of prolonged warfare and subsequent f l i g h t .  The question i s raised about the e f f e c t , i f any,  t h e i r health status w i l l have on both the health of Canadians and/or t h e i r own future health. It i s postulated that both t h e i r own c h a r a c t e r i s t i c s and those of Canadian society w i l l determine the problem and a f f e c t the r e s o l v i n g of i t .  Using the f i e l d s of anthropology, sociology, and  h i s t o r y , as well as those of medicine and health care, an extensive l i t e r a t u r e search i s made to determine the c h a r a c t e r i s t i c s of the refugee/immigrants and Canadian s o c i e t y , and from t h i s to delineate the problems. The problems are seen to be the immediate and longer term problems of 1) the spread of i n f e c t i o u s diseases; 2) the importation of ' e x o t i c ' diseases i n t o Canada; and 3) the e f f e c t of the l i f e experiences, migration, and the process of adaptation to a new environment on the mental health of the immigrants. The r e s o l u t i o n of the problems i s found to be affected by the  i i  a t t i t u d e s and b e l i e f s of Canada and Canadians, i n c l u d i n g the immigration, s o c i a l and health p o l i c i e s of governments; as well as by the c u l t u r a l b e l i e f s and customs of the Southeast Asians. Recommendations are made on factors seen to a f f e c t the effectiveness of health and s o c i a l programs f o r immigrants.  These  include recommendations on the need f o r those planning and d e l i v e r i n g health care, e s p e c i a l l y physicians, p u b l i c health nurses and s o c i a l workers, to be aware of the e f f e c t of culture on health behaviour and the g i v i n g of health care; and f o r physicians to be knowledgeable about the epidemiology and diagnosis of the s o - c a l l e d e x o t i c diseases. Recommendations are also made on the roles of the d i f f e r e n t  levels  of government and the voluntary agencies in the immigration process with regard to immigrant h e a l t h .  Thesis Supervisor  ii i  TABLE OF CONTENTS Page  INTRODUCTION  1  Chapter 1.  METHOD OF APPROACH  3  Chapter 2.  MIGRATION: Causes and world patterns  8  Chapter 3.  Chapter 4.  Introduction  8  Why man migrates  8  Changes i n 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: t h e i r s i m i l a r i t i e s and differences  16  The trend i n migration patterns  17  THE MIGRANT AND HIS NEEDS  19  Introduction  19  Basic needs: food, water and sleep  19  S h e l t e r and s e c u r i t y  21  The need to belong  21  The esteem of others  23  Self-actualization  23  The immigrant adjustment process  24  The mental health of immigrants  24  Health problems  28  The e f f e c t of war on health  31  B e l i e f s about health and sickness  33  THE RECEIVING COUNTRIES AND THE CHANGING PATTERNS OF MIGRATION  i v  36  Page  Chapter 5.  Chapter 6.  Chapter 7.  Introduction  36  Economic stress  36  Social stress  37  Social problems and s o c i a l service  38  Health problems and health services  39  A i d f o r immigrants  43  The e f f e c t of culture and custom on health care.  43  RECEIVING COUNTRIES: SOME EXPERIENCES WITH IMMIGRATION.  47  Introduction  47  Countries of permanent settlement  47  North west Europe  59  - Great B r i t a i n  62  CANADA AND IMMIGRATION  69  Introduction  69  1867-1918  69  1919-1945  72  1946-1960  73  1961 to the present  74  Canada's refugee p o l i c i e s  78  The Vietnamese in Canada  82  THE 'BOAT PEOPLE'  83  Introduction  83  Human needs  83  T r a d i t i o n a l health and sickness b e l i e f s and practices  88  v  Page  Chapter 8  Chapter 9  The e f f e c t of c o l o n i z a t i o n  90  The :effects of the war,.'  91  Health problems i n Viet-Nam  92  Post war  93  Experiences during f l i g h t  95  L i f e in the refugee camps  95  HEALTH PROBLEMS EXPECTED WITH THE REFUGEES  98  Introduction  98  Indices o f community health  98  The c o l l e c t i o n of i n t e r n a t i o n a l epidemiological data  -JQQ  Factors in the spread of disease  101  Infectious diseases that may be transmitted to Canadians  103  Infectious diseases that are a threat to the i n d i v i d u a l refugee.  119  Diseases endemic in Viet-Nam that are u n l i k e l y to be a threat to e i t h e r Canadians or refugees  130  Other i n f e c t i o u s diseases  132  ^on-infectious diseases and conditions  133  Discussion  139  PROBLEMS OF ADJUSTMENT AND MENTAL HEALTH  143  Introduction  143  The Vietnamese in the U.S.A., 1975-76  143  The Vietnamese i n Canada  147  vi  Paje  Chapter 10.  RECOMMENDATIONS AND CONCLUSIONS Introduction  "155 155  The c h a r a c t e r i s t i c s of the 'Boat people'  156  The Canadian c h a r a c t e r i s t i c s  157  The problems, and recommendations  159  Conclusion  168  vii  LIST OF TABLES  Table  Page Studies showing the number(%) of Indochinese c h i l d r e n tested who were t u b e r c u l i n p o s i t i v e > 10mm.  110  Rates of i n f e c t i o n 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 i n f e c t i o n i n 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 a f f e c t i n g the health status of the Southeast Asian refugees and a framework f o r solving problems a r i s i n g from t h i s . Map of Viet-Nam and part of Southeast Asia. Summary of diseases that may be a problem with the resettlement of the Vietnamese refugees in Canada.  ix  ' 84  138  ACKNOWLEDGEMENTS  I would l i k e to thank the members of my thesis committee f o r t h e i r help and patience. The Department of Health Care and Epidemiology, Faculty of Medicine, the U n i v e r s i t y of B r i t i s h Columbia: Dr M.M. Warner, Chairperson., (Director of the Program i n Health Services Planning);Dr. J . Robinson; Dr. N. Waxier (formerly of the University of S r i Lanka). I would also l i k e to thank the i n d i v i d u a l s and o r g a n i s a t i o n s , too many to l i s t , who so generously gave of t h e i r time and information.  x  1  INTRODUCTION  On J u l y 18 1979 the federal government announced Canada's decision to accept up to 50,000 refugees from Southeast Asia f o r resettlement i n t h i s country.(1) These w i l l be added to the approximately 14,000 Vietnamese who have a r r i v e d since the end of the Vietnam War in 1975, and w i l l be the l a r g e s t group of refugees ever to be admitted to Canada. (2) I t i s recognised that patterns of world migration are changing from the large scale movements between areas of s i m i l a r geography, race and c u l t u r e , to a smaller movement between these areas and an increase in the migration between areas that are significantly different.  This voluntary movement i s complicated  by a growing stream of involuntary migrants who have been uprooted f o r one reason or another and are looking f o r resettlement elsewhere. The involuntary migrants, or refugees from Southeast Asia are coming from an area of the world that i s s i g n i f i c a n t l y  different  from Canada; and are known as 'The Boat people'. The changes in world migration patterns are causing unfamiliar problems in the countries receiving migrants: there may be a problem with ' v i s i b l e m i n o r i t i e s ' and r a c i a l tension; the new immigrants may f i n d 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 public health and/or a challenge to the diagnostic and treatment c a p a b i l i t i e s of the health s e r v i c e s . The questions asked are 1) what e f f e c t w i l l the health status of these new immigrants have on the health of Canadians and/or t h e i r own future h e a l t h , and 2) what factors determine the health status and a f f e c t the r e s o l u t i o n of any problems a r i s i n g from this? This thesis w i l l explore both the factors determining the health status of the new immigrants and those seen to a f f e c t the r e s o l u t i o n of problems a r i s i n g from t h i s .  While not p r e s c r i b i n g  s p e c i f i c programs and services f o r 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 r e of such programs.  3  CHAPTER 1 METHOD OF APPROACH  The 'Boat people refugees i n Southeast A s i a :  1  are part of a large movement of t h i s , and t h e i r resettlement i n  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 l a s t decade a  growing proportion of Canadian immigrants are coming from countries in A s i a , I n d i a , and A f r i c a , and the same phenomenon i s happening to a d i f f e r e n t degree in the U.S.A. and A u s t r a l i a . In those countries that have t r a d i t i o n a 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 f e r e n t 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 l a s t three decades, Great B r i t a i n and Europe have been dealing with the s o c i a l and health problems associated with large inflows of people from A s i a , 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 t h e i r a r r i v a l in t h 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 c o n t r i b u t i n g members of s o c i e t y .  In view of  4 the changing patterns of world migration, i t i s f e l t that by examining the s i t u a t i o n of the 'Boat people' i n Canada some i n d i c a t i o n can be given of (any) changes required i n the p o l i c i e s , programs and services designed f o r the settlement of immigrants per se in t h i s country, e s p e c i a l l y those in the area of health and health care. There are many factors involved in t h i s examination. The health status of the immigrant/refugees-will depend on t h e i r c h a r a c t e r i s t i c s as well as on the immigration p o l i c i e s of Canada. Human c h a r a c t e r i s t i c s are a product of race, c u l t u r e , and s o c i a l experience, as well as i n d i v i d u a l s k i l l s and motivation. These i n t h e i r turn are a product of geography and h i s t o r y . Human needs are met w i t h i n t h i s framework and the health of the i n d i v i d u a l i s a product of a l l of the above.  Immigration,  s o c i a l and health p o l i c i e s are the product of the c o l l e c t i v e wishes of a given country, which again are a product of geography, h i s t o r y , and s o c i a l experience. Immigration p o l i c i e s set the standard of health required f o r entry i n t o a receiving country; and s o c i a l and health p o 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 s e t t l e d .  However, i t  must be remembered that good health i s not s o l e l y dependent on the a v a i l a b l e health s e r v i c e s , buti. i s a function of personal c h a r a c t e 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 t h e i r own c h a r a c t e r i s t i c s and by Canadian immigration p o l i c i e s . P o l i t i c a l and s o c i a l values produce s o c i a l and health p o l i c i e s , not to mention immigration p o l i c i e s .  The a t t i t u d e s of  Canadians w i l l a f f e c t the way these refugee/immigrants are welcomed; how they s e t t l e down; and eventually how any health problems that might a r i s e are resolved. I t i s postulated that the r e s o l u t i o n of any health problems a r i s i n g from the a r r i v a l of 50,000 refugees from Southeast Asia w i l l be affected by the c h a r a c t e r i s t i c s of Canada and the Canadian people. This t h e s i s w i l l approach the problem of the e f f e c t that the health status of these new immigrants may have on the health of Canadians and themselves from these two perspectives: the c h a r a c t e r i s t i c s of the *Boat people' as representative of the refugees; and the c h a r a c t e r i s t i c s of the receiving country, Canada.  The process i s i l l u s t r a t e d in figure 1. (page 7) The many facets of t h i s approach i n d i c a t e the need to  consult the d i s c i p l i n e s of anthropology, sociology and h i s t o r y , as well as those of medicine and health care.  To., t h i s end an  extensive l i t e r a t u r e search w i l l be undertaken with the following 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 l e a s t p a r t l y a r e s u l t of human needs  being met, these and the health problems of migrants i n general w i l l be examined. The e f f e c t of the changing patterns of migration and migrant c h a r a c t e r i s t i c s 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 p o l i c y i s examined. The c h a r a c t e r i s t i c s of the'Boat people' w i l l be described, and the health problems that might a r i s e with t h e i r a r r i v a l Canada defined.  in  Recommendations w i l l then be made on factors seen  to a f f e c t the outcomes of any programs and services designed to resolve these problems.  PROBLEM  INPUTS  DESIRED OUTCOMES  CHARACTERISTICS OF THE IMMIGRANT/REFUGEE Needs Experiences Culture Skills Expectations Numbers Location  4  Health Status  Risk o f h e a l t h s t a t u s to: 1. community 2.  individual ~~ immigrant-refugee  1.  to reduce the r i s k t o the community  2.  to maximize the h e a l t h o f the i n d i v i d u a l i mrni g ran t - re f u gee  CHARACTERISTICS OF THE RECEIVING COUNTRY Needs Experiences Culture Expectations Attitudes  -*  programs and s e r v i c e s needed t o a t t a i n d e s i r e d outcomes  Immigration, s o c i a l and h e a l t h p o l i c i e s , programs and s e r v i c e s  recommendations  Figure 1  Diagram to i l l u s t r a t e the f a c t o r s a f f e c t i n g the h e a l t h s t a t u s o f Southeast A s i a n 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 o n placed upon the distance of the move or upon the voluntary or involuntary nature of the a c t . '  (3) Human beings  have been moving from one place to another, f o r one reason or another, since p r e h i s t o r i c times; and the patterns of migration have changed over the centuries.  Migration can be e i t h e r 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, e s p e c i a l l y p r i m i t i v e man, to emigrate in search of food and s h e l t e r , to insure his p r o t e c t i o n , or merely to s a t i s f y his desire f o r movement. (4).  Although we lack precise  records of the e a r l y migration of man, the evidence of legends and archeology i n d i c a t e 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  t h i s are the mass emigration from Ireland f o l l o w i n g the famines of the 1840s, the Puritans who l e f t England on the Mayflower in search of r e l i g i o u s freedom, and the thousands of Jews who f l e d from eastern Europe at the end o f the l a s 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; w i t h i n 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 i n d u s t r i a l revolution in the l a t e eighteenth and e a r l y nineteenth centuries brought thousands into the new i n d u s t r i a l towns from the B r i t i s h countryside.  In general, saysBeijer "migration i s a necessary  element of normal population r e d i s t r i b u t i o n and e q u i l i b r i u m and an arrangement for making the maximum use of a v a i l a b l e manpower." (7)  CHANGES IN THE PATTERN OF WORLD MIGRATION The patterns of migration changed dramatically with improvements i n technology, e s p e c i a l l y i n t r a n s p o r t a t i o n ; with the rapid increase in the population of Europe; and with the discovery of the vast 'empty' spaces of both Americas, Oceania, and South Africa.  This transoceanic migration l a s t e d 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 i n the creation of extra-European sections of the white race, i n the expansion of the yellow race, and in the formation of the imperialism of the great modern powers. 65 m i l l i o n have crossed the oceans in one century to f i n d a home elsewhere." (8) U n t i l the Second World War, migration was p r i m a r i l y f o r economic reasons:  poor conditions at home 'pushed , while the 1  prospect of greater opportunity ' p u l l e d ' the emigrant.  It  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 f o r the unemployment engendered f i r s t by the i n d u s t r i a l revolution and l a t e r by periods of economic stagnation.  The  freedom of i n t e r n a t i o n a l migration which characterized the nineteenth century was part of the general  'laissez-faire'  a t t i t u d e s to s o c i a l and economic matters. (9)  In s p i t e of the  'open door' p o l i c i e s there was already a g i t a t i o n for r e s t r i c t i o n of immigration before the end of the nineteenth century and t h i s affected the development of immigration p o l i c i e s i n the major r e c e i v i n g countries such as A u s t r a l i a , U.S.A., and Canada.  The  rate of immigration slowed down i n the period between the two world wars, but i t i s debatable whether t h i s was due to the r e s t r i c t i v e p o l i c i e s 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 r a d i t i o n a l receiving and sending countries are again changing the whole pattern of migration.  In f a c t , rather than exporting surplus population,  i n d u s t r i a l northwestern Europe has been importing foreign workers on a temporary basis because of a shortage of labour. (10)  For  both r e c e i v i n g and sending countries " . . . human c a p i t a l , expressed not only, in numbers but also i n s k i l l s , i s necessary for t h e i r economic development." (11)  In exporting surplus u n s k i l l e d labour,  poorer countries often receive much needed foreign c a p i t a l in the money sent home by t h e i r emigrants. Thomas noted that "a s t r i k i n g features of the i n t e r n a t i o n a l scene since the Second World War i s the high proportion of migrants who can be regarded as human c a p i t a l , i . e .  'the p r o f e s s i o n a l ,  technical and kindred grades." (12) He then examined the reasons for the s o - c a l l e d ' b r a i n d r a i n ' from the under-developed to the i n d u s t r i a l i z e d countries but hesitated to p r e d i c t the continuation of t h i s trend i n t o the future.  However, B e i j e r saw the composition  and the d i r e c t i o n of the voluntary migration stream changing. "In s h o r t , 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 i m p e r i a l i s t p o l i c i e s of the nineteenth and e a r l y twentieth centuries has also affected world migration patterns since .the Second World War.  The granting of  independence to t h e i r former colonies has resulted i n large inflows of repatriates and refugees from the s o - c a l l e d "Third World  1  countries into  Belgium. (14)  Great B r i t a i n , The Netherlands, France and  P o l i c i e s have had to be modified and programs and  services expanded to cope with both "the v i s i b l e t i d e of coloured immigrants", and the ensuing s o c i a l unrest and p o l i t i c a l for the control of immigration. (15)  agitation  In f a c t , i t now seems that  "...heavy immigration i s a thing of the past. Today, a country wishing to benefit from heavy immigration must be able to cope with the economic and s o c i a l problems involved. In other words, i t must have a s u f f i c i e n t l y sound economic base to support the investments required, combined with adequate administrative machinery. I f t h i s structure i s too weak, the e f f e c t s 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 inflation." (16) MIGRATION CLASSIFIED Migration may be c l a s s i f i e d as f o l l o w s : 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 e d by the great population movements of the 19th and 20th centuries.  Involuntary but temporary movement may  be caused by natural d i s a s t e r or war,  with theLmigrants intending  and able to return home or f i n d refuge elsewhere.  Involuntary  and permanent migration means the forced movement of people, f o r whatever reason, and who have no hope or i n t e n t i o n of going back to t h e i r place of o r i g i n . Through the c e n t u r i e s , the desire f o r r e l i g i o u s , p o l i t i c a l or s o c i a l freedom has caused men to v o l u n t a r i l y or i n v o l u n t a r i l y leave t h e i r homeland, but t r u l y involuntary movement  ::  "has not been planned, organized or p a r t i c i p a t e d in by  i n d i v i d u a l s or groups f o r t h e i r prefered reasons." (17) Slavery i s the c l a s s i c a l example, but t h i s has been overshadowed i n the 20th century by massive population movements caused by war, and p o l i t i c a l and s o c i a l change. REFUGEES The c h i e f c h a r a c t e r i s t i c of migratory currents since 1945 has been the s i z e and importance of p o l i t i c a l , as distinguished from economic migratory movements. " M i l l i o n s have been driven from t h e i r homes and the population structure of e n t i r e countries r a d i c a l l y a l t e r e d . Diplomacy and p o l i t i c a l upheavals i n v o l v i n g redrawing o f f r o n t i e r s , transfers of sovereignty,, and changes in regime have forced e n t i r e populations into e x i l e and caused mass movements f a r greater than those normally r e s u l t i n g from the world labour supply and demand." (18)  14  In Europe the involuntary t r a n s f e r en masse of ethnic m i n o r i t i e s has been part of the scene since the early 1900s, and " i t i s a sobering thought that the number of people expelled from one country to another in the decade a f t e r the Second World War i s about the same as the e n t i r e overseas migration from Europe i n the 19th and the f i r s t decade of the 21th century." (19)  Eight  m i l l i o n were helped to r e p a t r i a t e or r e s e t t l e between 1944 and 1951 by several i n t e r n a t i o n a l organizations i n c l u d i n g UNRRA (United Nations R e l i e f and R e h a b i l i t a t i o n Agency), and the IRO (International Refugee Organization); and nearly two m i l l i o n migrants and refugees were r e s e t t l e d by ICEM (International Committee f o r European Migration) between 1952 and 1970. A large displacement of population has occurred in A s i a , e s p e c i a l l y between India and Pakistan; and continues i n what was French IndoChina, and between The Peoples Republic of China and Hong Kong.  There i s also a remarkable volume of movements  developing w i t h i n the Latin American continent.  Hoi born comments  that i t should be recognized that often the only a l t e r n a t i v e s facing some communities are a n n i h i l a t i o n 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 i m i t e d phenomenon, (but) i t has now. come to be acknowledged as u n i v e r s a l , continuing and r e c u r r i n g . " (20) In response to the r e a l i z a t i o n that the problem of .  15  refugees would not d i m i n i s h , and a f t e r two years of debate, the United Nations established the O f f i c e of the United Nations High Commissioner for Refugees, UNHCR, to take e f f e c t January 1951 and to replace the IRO.  Most of i t s  work i s not p u b l i c i z e d and i t  i s thus more e f f e c t i v e 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 d e f i n i t i o n of a refugee is " . . . an i n d i v i d u a l who owing to a well-founded fear of being persecuted f o r reasons of race, r e l i g i o n , n a t i o n a l i t y , membership of a p a r t i c u l a r s o c i a l group or p o l i t i c a l o p i n i o n , i s out-side the country of his n a t i o n a l i t y and i s unable, or owing to such f e a r , u n w i l l i n g to a v a i l himself of the protection of that country; or who, not having a n a t i o n a l i t y and being outside the country of his former habitual residence as r e s u l t of such events i s unable, or owing to such f e a r , i s u n w i l l i n g 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). ). Maselli considers that t h i s d e f i n i t i o n , as s t r i c t l y r e l a t e d to the International Convention, i s no longer adequate f o r the present s i t u a t i o n i n the world but should be more broadly i n t e r p r e t e d . The problem of refugees w i l l always be with us, and "the i n t e r n a t i o n a l community should recognize its., c o l l e c t i v e r e s p o n s i b i l i t y towards one of the most outstanding phenomena of a l l times." (22)  Because both voluntary and involuntary migration  16  have profound e f f e c t s upon everyone involved, i t i s important to recognise the differences and s i m i l a r i t i e s between them, and t h e 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 t e c h n i c a l l y advanced countries, the migrants have tended to come from the r e l a t i v e l y disadvantaged classes or groups who have less opportunity and fewer r i g h t s , e i t h e r 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 c u l t u r a l k i n s h i p s , which may have affected the place of resettlement i f not determining t h e 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 f o r t h e i r  skills.  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 y e a r s , with c h i l d r e n under 18 years of age accounting f o r less than one t h i r d , and oneninth being 50 years and over. (24) Refugees have generally represented a l l classes of a given s o c i e t y .  Sometimes they may be only a segment of a population,  e t h n i c a l l y , r e l i g i o u s 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 l e v e l s are  17  included.  Compared w i t h v o l u n t a r y m i g r a n t s , who can p l a n some.means  of f i n a n c i a l  s u p p o r t f o r the t r a n s i t i o n a l  p e r i o d i n t h e i r new  c o u n t r y and who r e c o g n i s e t h a t r e s e t t l e m e n t may be s t r e s s f u l , " A common f a c t o r among most refugees i s t h a t t h e y begin t h e i r f l i g h t w i t h no means o f s u b s i s t a n c e , 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 h o s t e l s i n the c o u n t r y i n which they f i r s t r e c e i v e a s y l u m . . . they r e c o g n i s e t h a t they are f u g i t i v e s but most f a i l t o r e c o g n i s e o r a c c e p t the consequences o f t h i s f a c t , which i s a h i n d e r e n c e to t h e i r i n t e g r a t i o n ..and a d j u s t m e n t . " (25)  THE-TREND IN MIGRATION PATTERNS The t r e n d i n m i g r a t i o n p a t t e r n s i s seen as f o l l o w s :  the  v o l u n t a r y movement o f s k i l l e d and u n s k i l l e d l a b o u r 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 c o u n t r i e s  requiring that  l a b o u r ; and the d i r e c t i o n o f the m i g r a t i o n f l o w changing from t h a t between areas o f European s e t t l e m e n t t o t h a t from the ' T h i r d World  1  to areas o f i n d u s t r i a l  development.  Complicating  t h i s i s the c o n t i n u i n g (unplanned) f l o w o f refugees e i t h e r w i t h i n the ' T h i r d W o r l d ' c o u n t r i e s o r between them and areas o f European settlement. If,  as seen above, r e f u g e e s have a d j u s t m e n t problems  over  and above those o f v o l u n t a r y m i g r a n t s , then i t c o u l d be assumed t h a t the r e c e i v i n g c o u n t r i e s w i l l  have more problems w i t h  their  r e s e t t l e m e n t than w i t h t h a t o f those who move v o l u n t a r i l y .  In  o r d e r to a s s e s s t h i s statement i t i s n e c e s s a r y t o look a t the b a 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 o u t l i n e d by Maslow ( a l b e i t without discussing the v a 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 . ( 2 6 ) The basic needs f o r food, water and sleep are followed by the need f o r s h e l t e r and s e c u r i t y ; the need to belong; the need f o r the esteem of others; and l a s t l y , the need f o r s e l f - a c t u a l i z a t i o n .  The  immigrant adjustment process can be described in these terms, and f a i l u r e to adapt can lead to mental health problems.  There are  other health problems associated with migration, and these can be aggravated by warfare.  Compounding a l l t h i s are the b e l i e f s and  customs about health and sickness that w i l l a f f e c t the solving of health problems in the new environment. BASIC NEEDS:  FOOD, WATER AND SLEEP  The basic human needs are f o r food, water, and sleep. The need f o r sleep i s s e l f - e x p l a n a t o r y , but sleep patterns are affected by other needs not being met.  Geography determines the foods  a v a i l a b l e and t h i s in turn helps form d i e t a r y h a b i t s .  For example,  r i c e i s the staple in many parts of the world and wheat in others; f i s h i s the protein a v a i l a b l e to those l i v i n g by r i v e r s and seas, and meat to.those l i v i n g on grasslands.  20  A review of studies on food habits and n u t r i t i o n a l  status  by Freedman shows some v e r i f i c a t i o n of the t e n a c i t y of food and eating patterns.  Migrants, e s p e c i a l l y those moving from and to areas  of the world that are geographically and c u l t u r a l l y  different,  experience ' c u l t u r e shock' in t r y i n g to adapt to new food h a b i t s , and "quite o f t e n , due to a change i n climate (they) may also experience subtle and/or overt changes in metabolism.  These may  in t u r n , cause palpable changes in biochemical p a t t e r n s . " (27) The i n t e r - r e l a t i o n s h i p of r e l i g i o u s tenets and food p r o s c r i p t i o n s provides another example of the persistance of t r a d i t i o n a l patterns.  dietary  L i t t l e sign of a s s i m i l a t i o n , that i s a change to English  eating patterns, was found in the adult dietary practices of Moslem Pakistani f a m i l i e s 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 c h i l d n u t r i t i o n in the t r o p i c s and s u b - t r o p i c s , 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 n u t r i t i o n a l l y related customs and that some may be harmless and can be ignored, and others are harmful and should be a c t i v e l y discouraged. (29)  The need i s f o r food, but u n f a m i l i a r  food cooked in an unfamiliar manner may not be accepted, with m a l n u t r i t i o n as the r e s u l t .  21  SHELTER AND SECURITY  The second of Maslow's hierarchy of needs i s f o r s h e l t e r and s e c u r i t y , an environment free from f e a r , anxiety, or chaos.  This  includes a roof over the head, a job to support s e l f and f a m i l y , and law and order.  Again, housing i s related to climate and l i f e s t y l e :  in  the t r o p i c s i t i s open to the four winds and in the A r c t i c i t i s not. D i f f e r e n t family sleeping arrangements means that the extended family in Asia a c t u a l l y requires less space per person than does the nuclear family in North America. Bernard pointsout that the jobs a v a i l a b l e to the migrant may not be the one f o r which he was t r a i n e d , and that he may be downgraded.  Another economic aspect i s that of unemployment: i t  is  often the most recently hired who are dismissed f i r s t , and they are generally the newcomers to the community. (30)  Law and order are  taken f o r granted i n most i n d u s t r i a l i z e d c o u n t r i e s , but there have been attacks on immigrants conspicuous because of colour or custom i n both B r i t a i n and The Netherlands and the knowledge of t h i s can cause a sense of great i n s e c u r i t y in immigrants. (31) (32)  THE NEED TO BELONG I f both p h y s i o l o g i c a l and safety needs are f a i r l y well g r a t i f i e d then there emerges a need ' t o b e l o n g ' .  In introducing  the conclusions from his study of immigrant adaptation in I s r a e l , . Weinburg observed t h a t :  "Throughout t h i s research i t has appeared that there e x i s t s a remarkable s i m i l a r i t y between the needs of the new immigrant with those of the newborn human being. The need f o r belonging, the need to be loved, understood: and supported, but not to be dominated, pampered or s p o i l e d , these needs are s i m i l a r to those enabling the c h 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 f a m i l y , community, and s o c i e t y . " (33) People need to belong to a group, be i t f a m i l y , f r i e n d s , or the larger community.  "Having roots i s not a question of an i n d i v i d u a l '  value but rather of his relatedness." (34)  Relationships with kin  play an important part in promoting s o c i a l i n t e g r a t i o n and avoiding f e e l i n g s of loneliness,, (35) so i t would appear that s e t t l i n g near one's own people i s an important f a c t o r i n adjusting to a new environment. In order to belong, one must understand the r e l a t i o n s h i p s and values of the group opens 'points of contact  and the a b i l i t y to speak t h e i r language 1  with that group.  Without t h i s  skill,  migrants may also not acquire knowledge of t h e i r r i g h t s and of services from which they might b e n e f 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 f o r the exercise of those r i g h t s . (36) 'Belonging' also means being accepted by the receiving s o c i e t y , and t h i s i s c l o s e l y related to Maslow's fourth need, to have the esteem of others.  23 THE ESTEEM OF OTHERS The f e e l i n g s of s e l f - w o r t h , s e l f - r e s p e c t , confidence, adequacy, and of being useful and necessary come from sensing the esteem of other people.  The migrant i s e i t h e r welcomed by the  receptor networks or must deal with r e s i s t a n c e , r e j e c t i o n , prejudice and d i s c r i m i n a t i o n .  Prejudice and lack of economic opportunity  c o n s t i t u t e b a r r i e r s to both a c c u l t u r a t i o n , i . e . the acceptance by the immigrant of the 'ways' of the m a j o r i t y , and to economic integration.  This prejudice may r e f l e c t the l i m i t s of the absorb-  a t i v e capacity of the receiving country as well as aspects of i t s c u l t u r e . (37)  A good society must s a t i s f y these needs f o r  '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 n a l l y , as the other needs are s a t i s f i e d , there i s the need f o r s e l f - a c t u a l i z a t i o n , or to develop f u l l y the  person's  unique c h a r a c t e r i s t i c s and p o t e n t i a l . "A musician must make music, an a r t i s t must p a i n t , a poet must w r i t e i f he i s to be u l t i m a t e l y 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 i s r u p t i o n in  the l i f e patterns of an i n d i v i d u a l , and i n . t h e face of stress and f r u s t r a t i o n a regression to lower l e v e l s of the needs hierarchy may take place. "Adjustment can be seen as a recovery process i n which the immigrant gradually moves back up the hierarchy towards s e l f a c t u a l i z a t i o n . This involves overcoming i n s e c u r i t y , overcoming l o n e l i n e s s , overcoming s e l f confusion; in other words recovering from a temporary state of d i s a b i l i t y known as c u l t u r e shock." (40) A mentally healthy person i s one who i s adjusted t o , or in harmony with  his surroundings; and t h i s i s a function of many things  including f u l f i l l m e n 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 d e s c r i p t i v e rather than q u a n t i t a t i v e .  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 c u l t " with technology, urbanization and i n d u s t r i a l i z a t i o n . (42)  This has been seen with the movement  25  of workers from rural areas of A f r i c a to France (43); from Cyprus to B r i t a i n (44); and in immigrant c h i l d r e n in Switzerland (45). For many immigrants into Israel the chasm between the dream and r e a l i t y brought shock, d i s i l l u s i o n m e n t , and b i t t e r n e s s . (46) Sauna reviewed the l i t e r a t u r e 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 variables "too gross" f o r the examination r  of t h i s r e l a t i o n s h i p . (47)  Burrowes concluded that there does not  appear to be an e x c e p t i o n a l l y high incidence of mental  illness  among immigrants of "coloured races" in B r i t a i n , but that there i s probably a vast amount of l o n e l i n e s s , i n s e c u r i t y , b i t t e r n e s s and anxiety which i s not adequately met.  However, he suggests that  there i s 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 e n s i t i v i t y to t h e i r status as immigrants "that may be due to the f a c t that they do not have the p o l i t i c a l attachment to t h i s country ( B r i t a i n ) that  many  other immigrants have." (48) Murphy r a i s e s the question of whether the a s s o c i a t i o n between migration and mental disorder which researchers have found in the U.S.A. and A u s t r a l i a i s a product of the c u l t u r a l w i t h i n which the migration i s taking place.  setting  It has been found  that immigrants are h o s p i t a l i z e d f o r mental problems more frequently than the native-born populations.  According to t h i s study, the  h o s p i t a l i z a t i o n rates f o r 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 A u s t r a l i a .  Both these countries have had  the 'melting pot' a t t i t u d e in which immigrants are expected to be assimilated i n t o the c u l t u r e of the majority as q u i c k l y as p o s s i b l e , whereas in Canada the immigrant i s encouraged to maintain membership in a c u l t u r a l or ethnic group. (49) In another paper Murphy c i t e s studies i n d i c a t i n g that the next generation can s u f f e r p s y c h o l o g i c a l l y f o r the traumatic events endured by t h e i r parents while refugees.  "Special a t t e n t i o n would  probably r e l i e v e these morbid s t a t e s , 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 i n 1958 concluded that "one sees in Hungarian immigrants b a s i c a l l y no d i f f e r e n t psychopathology from that of other groups . . . except that i t i s influenced by a t t i t u d e s common to t h e i r c u l t u r e . " (51) Lack of knowledge and acceptance of psycho-therapeutic psychiatry caused many Hungarian refugees to resent r e f e r r a l and treatment at that time. Some authors r a i s e the question as to whether there should be a d i s t i n c t i o n between voluntary and involuntary m i g r a t i o n , since emigration i s mostly the r e s u l t of an involuntary s i t u a t i o n ,  i.e.  a c o n f l i c t . "Such a c o n f l i c t may be caused by external circumstances and pressures or by inner psychological factors r e s u l t i n g from the p e r s o n a l i t y structure of the i n d i v i d u a l . " (52)  Psychologically  a voluntary migrant may be as much a refugee as an involuntary migrant.  (53)  In discussing the psychological  c h a r a c t e r i s t i c s of refugees and immigrants Bernard states that  27  there have been "too few" studies comparing the c h a r a c t e r i s t i c s of these groups to determine i f refugees are a c t u a l l y "worse o f f " . He notes that studies of patients i n mental i n s t i t u t i o n s show that migrants can be "adversely affected and p s y c h o l o g i c a l l y damaged" as a r e s u l t of migration, 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 j u s t that he may acquire them more o f t e n , 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 t h i s process can be s t r e s s f u l .  The differences in the e f f e c t of t h i s stress on  voluntary and involuntary migrants may be a matter of degree rather than of substance.  Complicating t h i s i s the f a c t that the t r a n s f e r  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 r e s s . 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 t y l e may pre-dispose him.  28 HEALTH PROBLEMS Imported i n f e c t i o u s diseases.  While typhus (ship fever)  and typhoid were imported with the immigrants into North America in the l a t t e r h a l f of the l a s t century, i n t e r n a t i o n a l  travel  regulations are intended to prevent the spread of disease by t r a v e l l e r s today.  Today, tuberculosis and veneral disease are at the  top of any l i s t of i n f e c t i o u s 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 r e s p e c t i v e of whether the immigrants come from areas of higher, lower, or approximately s i m i l a r l e v e l s of t u b e r c u l o s i s . " (56)  If the o v e r a l l  incidence of tuberculosis in the t o t a l population i s increased by the a r r i v a l of an immigrant group, then because the i n f e c t i v e pool of disease i s l a r g e r , the potential f o r 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% i n 1960 to 19.2% in 1969 (58): however t h i s i s d i f f i c u l t to evaluate i n the absence of s t a t i s t i c s regarding the r a t i o of immigrants to t o t a l  population  over that period. Any migrant population i s prone to a high incidence of veneral disease, e s p e c i a l l y when i t consists mainly of males. (59) One of the main epidemiological factors i n t h i s increase i s "a recent i n f l u x of immigrants, who seldom introduce i n f e c t i o n but contract i n disproportionate numbers a f t e r a r r i v a l . " (60)  it  The incidence of  chanchroid, usually considered to be a venereal disease of the t r o p i c s ,  29 rose by more than f i v e - f o l d in Rotterdam during 1977-78 (61), showing that ' e x o t i c ' v a r i a t i o n s on a disease may be imported.  Rotterdam  has a large immigrant population from t r o p i c a l and subtropical countries as well as being a major sea port. Immigrants may carry t h e i r parasites with them, e s p e c i a l l y i f they come from areas of p r i m i t i v e s a n i t a t i o n . Worms are common, but are of public health importance only i f t h e i r developmental cycle can be completed in the new environment. (62)  Otherwise  they are of importance only to the i n d i v i d u a l migrant and his physician.  Malaria i s another p a r a s 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 public health concern unless an appropriate mosquito vector, i s indigenous in the new environment. Non-infectious diseases.  These have received f a r less  p u b l i c i t y than the i n f e c t i o u s diseases, and include the n u t r i t i o n a l l y and g e n e t i c a l l y determined d i s o r d e r s .  The World Health Organi-  zation has found that the p r o t e i n / c a l o r i e  intake of many t r o p i c a 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  climate where a s t i l l higher intake of protein and c a l o r i e s necessary j u s t to cope with the climate.  is  Avitaminosis has been  found in coloured c h i l d r e n i n B r i t a i n where the production of vitamin D by the action of u l t r a - v i o l e t l i g h t on the skin i s diminished because of the lack of s u n l i g h t .  (64)  30 Some g e n e t i c a l l y transmitted diseases are seen more frequently i n t r o p i c a l and subtropical countries than in temperate zones.  These are not common and are not great"public  health importance, but may be of importance to the health of the individual.  Most frequently seen i s a group  of conditions  where an abnormal haemoglobin molecule causes anaemia as the presenting symptom. (65)  Primary adult hypolactasia (lactose  intolerance) i s g e n e t i c a l l y determined, and i s more common i n some races than in others. (66) The new environment.  The immigrant may be at r i s k from  various disorders in his new environment.  A mild disease i n 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. Commonwealth  1  'New  immigrants in B r i t a i n , f o r instance, may be at a  greater r i s k of developing r u b e l l a , whooping cough, and measles than they were . ' a t home',- as well as from the tuberculosis and venereal diseases mentioned above. (67) A number of diseases are c h a r a c t e 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 s e in the frequency of these  diseases occurs when Western customs are adopted.  These include  non-infectious diseases of the large bowel; diseases associated with c h o l e s t r o l metabolism; venous disorders including pulmonary  31  embolism and CVA; obesity and diabetes, and others.  (68) It may  be surmised that these diseases w i l l appear and increase in an immigrant population as i t changes its  life  style.  A l 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 w i l l probably have been uprooted by war, either c i v i l or i n t e r n a t i o n a l , and that this w i l 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 e f f e c t 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 e f f e c t i v e public  health measures on the general population at that time, and the uprooting and relocation of large numbers of people increases the p o s s i b i l i t y that many may come into contact with disease against which they have no immunity, either genetic or acquired. There is an increased r i s k of contact between animal reservoirs of disease, humans.  potential domestic animal c a r r i e r s and  For instance, the plague cycle changed in Viet-Nam  because the destruction of the forests by American bombing drove the ' w i l d ' 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 d e n s i t i e s , poor s a n i t a t i o n , and inadequate d i e t , increases the r i s k of epidemics. (71)  The stress associated with  r e l o c a t i o n , lowered n u t r i t i o n a l standards and changes in t r a d i t i o n a l l i f e patterns, a l l lower resistance to common diseases that can therefore become serious health hazards to the population; f o r 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 s k produced in  such groups may l a s t long a f t e r a return to normal conditions.(72) These experiences of refugees are over and above the 'normal' stress of migration. I f , as seen above, the health of themigrant/refugee i s at r i s k , then there i s a need f o r supervision and treatment of the problems that may appear sooner or l a t e r i n t h e i r new surroundings. Acceptance by the immigrant/refugee of the  need f o r health  s u r v e i l l a n c e 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 n a l l y accustomed; and how he perceives the motives of the receiving country in demanding t h i s s u r v e i l l a n c e .  33 BELIEFS ABOUT HEALTH AND SICKNESS In a l l human groups, no matter t h e i r s i z e or how t e c h n o l o g i c a l l y advanced they are, there e x i s t s a body of b e l i e f s about the nature of disease, i t s . cause, and i t s : cure. There also e x 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 sophisticated medical and surgical technology.  Many other parts of the world have other  concepts of health and sickness.  Hughes describes f i v e basic  categories of events or s i t u a t i o n s which, in f o l k e t i o l o g y , are believed responsible f o r i l l n e s s : sorcery; breach of taboo; i n t r u s i o n of a disease object; i n t r u s i o n of a disease-causing s p i r i t ; and loss of s o u l . (73) combination.  These can be a s i n g l e one or any  For example, "According to the Zulus any disease  associated with laboured breathing, pains i n the chest, loss of weight and coughing up blood-stained sputum i s a t t r i b u t e d to the machinations of an i l l - w i s h e r . " (74)  The Spanish-Americans:attribute  disease to an imbalance of hot and cold in the body, and that a cure must aim at r e s t o r i n g the balance." (75) In S r i Lanka and Mauritius the people believe that madness i s  "supernaturally  caused and supernaturally 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 effectiveness i n the treatment and prevention of disease.  34 I t i s usually applied to sickness introduced by the Europeans, such as t u b e r c u l o s i s , measles and the l i k e .  The diseases  that are conceived to be unamenable to modern medical treatment are the t r a d i t i o n a l l y endemic diseases, and e s p e c i a l l y those ailments that have a large component of psychological or psychophysiological involvement. (77) In describing health behaviour i n three cultures i n Guatamala, Gonzalez observed that the way these groups u t i l i z e d the medical services almost e x a c t l y p a r a l l e l e d the description i n the l i t e r a t u r e of the behaviour of persons i n non-western cultures; elsewhere, and even that of members of the lower classes i n England and the United States. "These groups are not i n t e r e s t e d i n preventative measures, but a r r i v e i n droves to be cured; that they wait too long to seek professional care and often a r r i v e i n the l a s t stages of a serious disease; that they r e s i s t h o s p i t a l i z a t i o n and feel that t h i s i s a condemnation to death; that they do not follow prescriptions and advice given which involves d i e t , r e s t , exercise e t c . , but demand p i l l s and i n j e c t i o n s to r e l i e v e symptoms; that they do not return f o r check-ups as needed . . . and are often 'hard to reach because of t h e i r indigenous b e l i e f s concerning health and disease."(78) 1  Also in discussing health behaviour, Read describes the tendency among natives of Alaska to depend on t h e i r k i n groups i n 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 a d i t i o n a l l y endemic diseases i n that area are the ones which health a u t h o r i t i e s i n the receiving country are concerned about in t h e i r immigrants, then the migrant may perceive those a u t h o r i t i e s as being meddling busibodies, or t h e i r behaviour as being i n s u l t i n g .  The success o r f a i l u r e of a health program  i s l a r g e l y governed by the way i t f i t s i n t o the modes of thought and action of the r e c i p i e n t 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 c u l t u r a l l y determined and are met w i t h i n a s p e c i f i c and familar environment.  When people move, they take  t h e i r conception of the ' r i g h 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 .  to the degree of stress experienced:  Two factors may add  when the move i s between  areas that are geographically and c u l t u r a l l y d i f f e r e n t ; and when the migration i s involuntary. 'at risk  1  Besides s t r e s s , the migrant i s  in other aspects of h e a l t h . The changes in migration patterns mean that countries  r e c e i v i n g these new migrants w i l l be a f f e c t e d .  Having been  accustomed to immigrants who have not d i f f e r e d very much from t h e i r indigenous population and whose problems, including. those of h e a l t h , have been s i m i l a r and f a m i l a r , what might be the e f f e c t of the changes?  36 CHAPTER 4  THE RECEIVING COUNTRIES AND THE CHANGING PATTERNS OF MIGRATION  INTRODUCTION The e f f e c t o f the changing p a t t e r n s o f m i g r a t i o n may be examined under t h r e e h e a d i n g s : economic s t r e s s ; s o c i a l social  stress;  and h e a l t h p r o b l e m s , and the s e r v i c e s t o deal w i t h them.  A g a i n , c u l t u r e and custom, t h i s time o f the r e c e i v i n g c o u n t r y , can a f f e c t the outcomes o f s o c i a l and h e a l t h  services.  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 h a t s i n c e the Second World War v o l u n t a r y m i g r a t i o n has o c c u r e d g e n e r a l l y d u r i n g o f economic e x p a n s i o n .  The i m m i g r a t i o n p o l i c i e s o f  periods  receiving  c o u n t r i e s have been d e s c r i b e d as a v i t a l component o f manpower p o l i c i e s by being a b l e t o p r o v i d e " r a t h e r q u i c k l y and easily,  relatively  p a r t i c u l a r c a t e g o r i e s o f workers t o h e l p overcome l a b o u r  shortages."  (81)  However, Kubat sees i m m i g r a t i o n p o l i c i e s as  "the  responses o f n a t i o n s and c o u n t r i e s f a c e d w i t h the consequences o f s t e p s taken o n l y r e c e n t l y , t o meet the needs o f economic In o t h e r 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 control of  growth."(82)  immigration  i n what has been a r a t h e r l a i s s e z - f a i r e a t t i t u d e t o economic p l a n n i n g .  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, s o c i a l and health problems f o r the country concerned.  There w i l l be a s t r a i n  on the employment s i t u a t i o n , housing and educational f a c i l i t i e s , as well as on the s o c i a l and health s e r v i c e s .  There may also be the  need f o r d i r e c t f i n a n c i a l assistance to the refugees u n t i l they are settled.  It i s not intended in t h i s t h e s i s to examine the economic  costs of accepting a large group of refugees, but to look e s p e c i a l l y at the health problems a r i s i n g i n t h i s s i t u a t i o n .  SOCIAL STRESS The r e l a t i o n s h i p between a host population and i t s  immigrant  m i n o r i t i e s w i l l a f f e c t the adaptation per se, and the rate of adaptation of those immigrants. Unfortunately, o f f i c i a l p o l i c i e s may be contradictory to a t t i t u d e s held in a country r e c e i v i n g immigrants.  I t may be  that governments state that they protect the immigrant population but administrative 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 h o s t i l e reactions to the three major waves of immigrants into  38  B r i t a i n over the past 160 years were due to t h e i r being perceived as a threat to the " B r i t i s h way of l i f e " . (84) Discrimination against  1  f o r e i g n e r s ' i s the outward manifestation  of the resentment of the indigenous population towards those who are d i f f e r e n t , or who are perceived as being a t h r e a t .  This  dicotomy of o f f i c i a l p o l i c y and public a t t i t u d e s leaves the immigrant i n an insecure and ambiguous s i t u a t i o n , leading perhaps to s o c i a l and/or health problems. SOCIAL PROBLEMS AND SOCIAL SERVICES. Social and health problems are c l o s e l y l i n k e d , as should be s o c i a l and health s e r v i c e s .  I t i s considered by several  i n t e r n a t i o n a l organizations interested in migrant w e l f a r e , that they should be included in expanded services rather than have separate services developed e s p e c i a l l y f o r them.  I f necessary,  special services should be a v a i l a b l e , but not in s p e c i a l i z e d agencies.  In discussing t h i s , Dumon also argues that s o c i a l  services f o r migrants have two functions; problem s o l v i n g towards c l i e n t s , and problem formulating towards the a u t h o r i t i e s . (85) The increased demands on the s o c i a l services caused by the immigration from d i f f e r e n t parts of the world w i l l be f o r 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 l o t h i n g  39  and l i f e s t y l e because of the d i f f e r e n t climate. Housing i s a p a r t i c u l a r problem f o r newcomers, and t h i s w i l l be aggrevated by l a r g e r family s i z e and d i f f e r e n t customs. (86)  Overcrowding and  unsanitary l i v i n g conditions can lead to serious s o c i a l and health problems. Social workers can also help integrate the newcomers i n t o the l o c a l community - to explain each to the other. (87) Language t r a i n i n g f o r the whole family has already been seen as e s s e n t i a l f o r the acceptance of the community and immigrant by each other.  These services may have to be expanded*as the c h a r a c t e r i s t i c s  of the immigrants change making adaptation more d i f f i c u l t than i t has been f o r t h e i r predecessors.  I t may be that a sudden inflow  of refugees w i l l need a sudden but temporary expansion of s e r v i c e s , including health care s e r v i c e s .  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 i s allowed to enter the country.  With the  change in migration patterns, there i s a possible r i s k to the indigenous population from imported diseases, as well as increased and d i f f e r e n t demands on the health s e r v i c e s .  40  ' E x o t i c ' diseases.  Maegraith defines an ' e x o 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  t r a v e l in and out of the t r o p i c s , and with the speed of modern t r a v e l , "a person may be infected abroad with an exotic 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 a f t e r his return and w i l l have to be distinguished from l o c a l 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 exotic diseases: f o r example, Toronto General Hospital Tropical Diseases C l i n i c , Canada-,  The School of Tropical Medicine i n L i v e r p o o l ,  England; and the Tulane Medical Center, New Orleans, i n the U.S.A. These must act as r e f e r r a l centres f o r other areas. Medical p r a c t i t i o n e r s .  Unusual demands in both numbers  and s k i l l s w i l l be put on medical p r a c t i t i o n e r s by an i n f l u x of people from a d i f f e r e n t country, and perhaps with very d i f f e r e n t problems from those u s u a l l y seen. atypical  Apart from the ' e x o t i c '  diseases,  disease patterns may occur and the natural h i s t o r y of  ailments may be modified by such factors as m a l n u t r i t i o n or the presence of i n t e s t i n a l p a r a s i t e s .  Both malaria and diphtheria can  show  It has been noted i n B r i t a i n  a t y p i c a l disease patterns.  that many people a r r i v e from the t r o p i c s with s u b - c l i n i c a l  scurvy,  which i s a lack of vitamin C, that l a t e 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  f o r an i n t e r p r e t e r where there i s a language b a r r i e r , and t h i s can cause problems. (90) Hospitals.  The a r r i v a l of a few immigrants in a s p e c i f i c  area presents no real problem in terms of numbers, but large concentrations w i l l require modification of services to allow f o r such factors as the age, sex, and family composition of the immigrants, as well as t h e i r country of o r i g i n .  A high b i r t h r a t e  among some immigrant groups w i l l increase the demand f o r maternity beds (91), and large numbers of newly a r r i v e d and newly born c h i l d r e n w i l l create a greater demand f o r hospital beds e s p e c i a l l y i f those c h i l d r e n are prone to severe forms of what are normally mild childhood i n f e c t i o n s . (92)  Mental health problems may  increase the demand f o r both i n - p a t i e n t and out-patient s e r v i c e s . (93) Public health s e r v i c e s .  There w i l l be an increase in the  demand f o r , and scope of, public health s e r v i c e s .  Special  arrangements may be required f o r the diagnosis and treatment of e x o t i c diseases as well as f o r a possible increase i n the incidence of tuberculosis and e n t e r i c diseases. (94)  New immigrants often  d r i f t i n t o food s e r v i c e s , so supervision of food handlers becomes more important. (95)  The rate of i n d u s t r i a l accidents has been  noted to be much higher among immigrants than i n the work-force as a whole (96), and accidents happen more frequently in the home, e s p e c i a l l y with small c h i l d r e n . (97) supervision and education.  These w i l l  require  42 Maternal and c h i l d services w i l l be stretched.  Advice  on n u t r i t i o n i s e s p e c i a l l y hard to give because of language b a r r i e r s and d i f f e r e n t customs (98), as i s teaching hygeine where new ways of waste disposal are not understood. (99)  Increased e f f o r t s may  be necessary to achieve and maintain a s a t i s f a c t o r y l e v e l of immunization among both l o c a l and immigrant c h i l d r e n . (100) School health programs w i l l be a f f e c t e d .  Poor n u t r i t i o n ,  with possible parasites, a f f e c t s a c h i l d ' s performance in school; and the immigrant c h i l d i s under a double s t r a i n 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 e f f e c t of the stresses associated with the c h 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 r a c i a l and c u l t u r a l differences between them and the l o c a l population.  As previously s t a t e d , 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 c h a r a c t e r i s t i c of help f o r immigrants seems to be that programs of assistance be planned. (104)  (105)  Dumon c i t e s Rose's study of migrants in Europe in regard to problems of acceptance and adjustment (106), and the "amazing f i n d " that "the v a r i a b l e that had most explanatory value, was not the degree of s i m i l a r i t y or difference in c u l t u r e between sending and receiving c o u n t r i e s . The i n t e g r a t i o n and adjustment was most c l e a r l y related to the openness of programs, p o l i c i e s and practices of immigrant c o u n t r i e s . " (107) However, before programs are planned, i t i s necessary that the e f f e c t of c u l t u r e  and custom on both the r e c i p i e n t s and providers  of health care be considered. THE EFFECT OF CULTURE AND CUSTOM OF HEALTH CARE With the i n f l u x of a ' d i f f e r e n t ' people, health care professionals w i l l meet the e f f e c t of c u l t u r e and custom on medical and health care.  For example, pre-natal care i s  difficult  i f women cannot be examined because of s t r i c t purdah. (108)  The  abandonment of breast feeding by Pakistani women i n Bradford,. England was seen as part of t h e i r 'adaptation' to B r i t i s h customs, but which unfortunately had the e f f e c t of increasing the r i s k of g a s t r o - e n t e r i t i s among these babies as the process of mixing formulae was inadequately understood. (109)  Advice on c h 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 l e s s e r status. (110) I n t e s t i n a l parasites may be considered 'normal' and as already suggested, health s u r v e i l l a n c e seen as gross i n t e r f e r e n c e .  As already seen,  hospitals are seen as a place i n which to d i e , 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 t h i s i s needed.  It can be seen that health program often f a i l , and f o r  a m u 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 t h i s i s universal.  Others may choose not to use modern c l i n i c a l  but r e l y instead on l o c a l remedies and curers. i s offered w i l l also a f f e c t i t s  services  The way a treatment  acceptance.  Leininger points out that the e t h i c a l and r e l i g i o u s values of both c l i e n t and health care professional impinge upon health care services and that "some health providers act as i f o  r e l i g i o n plays no r o l e with c l i e n t s in health care p r a c t i c e s . "  (Ill)  In t a i l o r i n g health care to the needs of c u l t u r a l groups, she notes that one way of 'reaching' these people would be the a b i l i t y to converse in t h e i r language. Bernard f e e l s that there are f a r too many s o c i a l workers and counsellors who know nothing about the cultures of other people nor do they speak t h e i r languages.  He i s concerned that there are  counsellors "who do not know about other people well enough to be  45 able to i n t e r p r e t , and I don't mean j u s t l i n g u i s t i c a l l y ,  to  i n t e r p r e t t h e i r c u l t u r a l behaviour and t h e i r s o c i a l problems as accurately and profoundly as they should." (112) There i s a great need f o r i n t e r p r e t a t i o n of c u l t u r e on a 'two-way s t r e e t ' . The c u l t u r e and bureaucracy of s c i e n t i f i c health care can present serious obstacles to e f f e c t i v e d e l i v e r y 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 f o r the absence of any f u r t h e r t r a i n i n g on the subject of New Commonwealth immigration into B r i t a i n . " (114) Foster considers that "major b a r r i e r s " to improved health programs are found in the cultures of bureaucracies, the assumptions of the medical p r o f e s s i o n , and in the psychological makeup of the professional in those programs.  "This assumption, regretably, appears  not to be widely accepted. The a t t i t u d e s and  In f a c t i t i s r e s i s t e d by many." (115) knowledge of both r e c i p i e n t and giver  of health care w i l l a f f e c t the outcome of the care given, the giver in t h i s case being the health care system as well as the professional working in that system.  I f the c u l t u r a l d i f f e r e n c e s , i . e .  attitudes,  are d i f f e r e n t then the problem may not be perceived i n the same manner, and indeed i t may not be resolved unless the r e c i p i e n t and giver r e a l i s e t h i s .  From the l i t e r a t u r e i t can be seen that  s o c i a 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 c u l t u r a l l y d i f f e r e n t .  The s o c i a l  and health care p o l i c i e s , programs, and services of a country, as well as the immigration p o l i c i e s , are the product of the economic and c u l t u r a l experience of that country.  As background f o r examining  the development of Canada's immigration p o l i c i e s and the possible e f f e c t s of the a r r i v a l of comparatively large numbers of Vietnamese refugees on the country, i t i s of i n t e r e s t to look at the immigration experiences of selected c o u n t r i e s , and to note the trends in immigration p o 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 receiving migrants may be c l a s s i f i e d according to the type of migrant they accept or prefer.  A u s t r a l i a , the U.S.A.  and Canada have t r a d i t i o n a l l y received voluntary and permanent immigrants, while Israel has received permanent s e t t l e r s i n large numbers only since 1948.  Since World War Two the i n d u s t r i a l  countries of Northwest Europe have r e c r u i t e d what they hoped were temporary migrant-workers as an answer to t h e i r chronic labour shortages.  Along with Great B r i t a i n , they also gave c i t i z e n s h i p  to people from t h e i r former c o l o n i e s , and the r e s u l t i n g inflow of these immigrants has caused complicated s o c i a l problems. "/Many countries in Europe, A f r i c a and Asia have had experience with refugees ' i n t r a n s i t ' and have been helped with aid from governments and voluntary agencies as well as from UNHCR, but t h i s w i l l not be discussed here. COUNTRIES OF PERMANENT SETTLEMENT Immigration into A u s t r a l i a , the U.S.A. and Canada was v i r t u a l l y free u n t i l the series of 'gold-rushes' i n those countries brought the Europeans face to face with the Chinese,-who were promptly blamed f o r a l l the s o c i a l i l l s o f those new countries. (116)  48  In response to public a g i t a t i o n , governments enacted l e g i s l a t i o n r e s t r i c t i n g or excluding the i n - f l o w of a l l races but the white: the U.S.A. in 1882, Canada in 1885, and A u s t r a l i a in 1888.  In a l l  three countries t h i s d i s c r i m i n a t i o n on grounds of race continued u n t i l a f t e r World War Two.  Also generally excluded were "those  whose physical and mental c a p a c i t i e s were beTieved.to make them public charges or whose moral character was believed unwelcome."(117)  Australia.  R e s p o n s i b i l i t y f o r immigration rests with  the central A u s t r a l i a n government, and i t s  purpose has been to  promote economic development and s e c u r i t y .  In l i n e with the  'White A u s t r a l i a ' p o l i c y that started with the exclusion of the Chinese, the preferred classes of immigrants have been those from B r i t a i n and northern Europe; and the goal has been a s s i m i l a t i o n into the B r i t i s h - A u s t r a l i a n society w i t h i n one generation. To t h i s end, there has been f i n a n c i a l l y a s s i s t e d passage f o r selected immigrants . The a t t i t u d e s of A u s t r a l i a n s towards immigrants in general has been ambivalent: while acknowledging the need to increase the population, they have f e l t t h e i r way of l i f e threatened by imported 'cheap' labour.  Since World War Two, a change in immigration  p o l i c i e s 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 c e r t a i n degree of tension and even fear f o r many A u s t r a l i a n s . (118)  49 Once in the country, immigrants have been expected to make t h e i r own way.  Many of these new immigrants are i l l i t e r a t e  and have s u b s t a n t i a l l y d i f f e r e n t c u l t u r a l backgrounds.  Night-  school classes in the English language are a luxury f o r them as they struggle f o r f i n a n c i a l survival doing the d i r t y , poorly paid jobs that no-one else wants. (119)  Services f o r immigrants are  the r e s p o n s i b i l i t y of States' governments and voluntary organisations and these seem to have worked well together. have been seen as inadequate.  However, services  " U n t i l quite recently the A u s t r a l i a n  governments, despite t h e i r anxiety to a t t r a c 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 public c r i t i c i s m and c r i t i c a l discussion of the 'White A u s t r a l i a '  policy,  the size of the annual inflow of immigrants, and the amount and q u a l i t y of the help offered them. (121)  The tendency of immigrants  to s e t t l e near t h e i r compatriots ( f o r example there i s a large Greek community in Melbourne) has enabled them to keep a sense of c u l t u r a l i d e n t i t y and to develop p o l i t i c a l pressures f o r i n t e g r a t i o n rather than a s s i m i l a t i o n into the A u s t r a l i a n s o c i e t y , and to press f o r improvements in immigrant s e r v i c e s . (122) A f t e r the gradual easing of the t o t a l exclusion of nonwhites since 1945, A u s t r a l i a abolished r e s t r i c t i o n based on race  50 or colour, and immigration p o l i c y i s now based on a points system emphasizing s k i l l , education, and family re-union.  A  point to remember here, i s that A u s t r a l i a ' s foreign p o l i c y has recognised the need f o r good r e l a t i o n s and trade with the countries of Southeast Asia and the P a c i f i c community, a l l of whom are r a c i a l l y and c u l t u r a l l y d i f f e r e n t from A u s t r a l i a , and from whom A u s t r a l i a i s now accepting ' s e l e c t e d ' immigrants. The 1971 P o l i c y Statement of the A u s t r a l i a n Labor Party (123)sets out major developments i n services f o r immigrants, including research into childmigrant education and language training.  M u l t i - l i n g u a l welfare o f f i c e r s were being appointed  to work in immigrant communities, and t r a i n i n g courses were being developed f o r those working in the immigration f i e l d .  Financial  help was being considered f o r the Good Neighbour Councils who co-ordinate the voluntary agencies o f f e r i n g assistance to immigrants. (124)  Since the change of government in 1974,  however, these p o l i c i e s have been modified with a movement back to e a r l i e r a t t i t u d e s and p o l i c i e s , with immigration ' p r e f e r r e d ' from B r i t a i n and northern Europe. A u s t r a l i a ' s p o l i c y regarding the admission of refugees has been c r i t i c i s e d as being based l a r g e l y on s e l f - i n t e r e s t , and i l l u s t r a t e s t h e i r ambivalence about immigration.  (125)  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 h e s i t a t i o n that A u s t r a l i a accepted 200 or so Indians expelled from Uganda in 1972. (126)  B e l a t e l y , 2500 Chileans were admitted in 1974,  but through normal immigration procedures rather than through special arrangements f o r refugees.  Families and voluntary agencies  sponsoring refugees have been considered to be f u l l y responsible f o r them.  The c r i t i c i s m i s that the majority of the refugees accepted  would have been e l i g i b l e f o r entry under the normal s e l e c t i o n 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 e s p o n s i b i l i t y derived from A u s t r a l i a ' s involvement in the Vietnam war." (127) Although i t has been stated that Australians may feel threatened by immigrants who are r a c i a l l y or c u l t u r a l l y  different,  there i s evidence that immigrants of mixed race from Southeast A s i a , including India, have s e t t l e d s u c c e s s f u l l y since the immigration p o l i c y was relaxed. (128)  The f e e l i n g appears to be  that i f proceeded with slowly, i n t e g r a t i o n of  'different'  immigrants can be done, but that perhaps programs are s t i l l to integrate those ' d i f f e r e n t ' The U.S.A.  needed  immigrants already in the country.  Like A u s t r a l i a , the trend in the U.S.A. has  been to l i b e r a l i z e immigration p o l i c i e s i n terms of s e l e c t i o n by race or n a t i o n a l i t y , and to l i n k them more to economic f a c t o r s . U n t i l the F i r s t World War, the U.S.A. had an 'open door' p o l i c y f o r immigrants from Europe while excluding A s i a t i c s .  52  Increasing public h o s t i l i t y towards ' f o r e i g n e r s ' forced the enactment of more r e s t r i c t i v e p o l i c i e s , and the quota system introduced i n 1929 allowed immigration only i n the proportions of the national groups already in the country.  The reluctance  to accept refugees from Nazi Germany in the l a t e 1930s stemmed from these f e e l i n g s and t h i s l e g i s l a t i o n . Changes came with World War Two.  The Chinese Exclusion  Act of 1882 was repealed in 1943,. with the decision probably influenced by foreign p o l i c y ; and special l e g i s l a t i o n allowed the in-migration of refugees from Europe a f t e r 1945. Although reaffirming the quote system, the McCarran Walter Act of 1952 i n s t i t u t e d a preference system based on s k i l l s and close family r e l a t i o n s h i p . (129)  Discrimination against  A s i a 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 f e c t i v e b a r r i e r against any increase in immigration from A s i a . The Immigration Act of 1965 abolished the nationalorigins quota system and linked immigration to the economic s i t u a t i o n and the r e - u n i f i c a t i o n of f a m i 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 e g i s l a t i o n of 1965 there has been a s t r i k i n g global s h i f t i n the national o r i g i n s of immigrants into the U.S.A. with a s i g n i f i c a n t growth in the numbers from A s i a , Latin America, and the Caribbean.  With an eye to r e l a t i o n s h i p s with other  53  countries and with the abandonment of the p o l i c y of a s s i m i l a t i o n , "immigration p o l i c y i s obviously d i r e c t l y t i e d into the image of the United States as a  p l u r a l i s t i c s o c i e t y . " (132) It has been  recognised that the continuous i n f u s i o n of d i f f e r e n t cultures has brought benefits to the country, but " i t i s by no means c l e a r 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 A c t . " (133) Under the American C o n s t i t u t i o n immigration i s the r e s p o n s i b i l i t y of the Federal Government, and there has been a long t r a d i t i o n of the senior level of government's involvement with c i t i z e n s h i p education including language t r a i n i n g and .the teaching of American h i s t o r y , with the goal of a s s i m i l a t i n g immigrants i n t o the mainstream of American l i f e .  P r a c t i c a l help  f o r immigrants has been provided by a network of voluntary organizations. Between 1880 and 1920 the U.S. governments did very l i t t l e to take care of the s i c k and unemployed.  This led to the  emergence of powerful mutual benefit s o c i e t i e s amongst almost a l l ethnic groups which, besides helping to preserve language and c u l t u r e , helped to form the present-day network of voluntary organizations. (134)  These groups are now co-ordinated by two  large 'umbrella' o r g a n i z a t i o n s , the American Immigration and C i t i z e n s h i p Conference and  the American Council f o r N a t i o n a l i t i e s  54  Service, and these apparently have had good working r e l a t i o n s 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 A u s t r a l i a , although t h e i r pattern of development has been d i f f e r e n t .  In s p i t e of some  e x c e l l e n t work being done, the pattern of services and assistance offered to the immigrants in t h e i r adjustment to American society i s under c r i t i c i s m as being inadequate. (135) The t r a d i t i o n a l process whereby voluntary agencies helped immigrants to f i n d homes and jobs was used i n r e s e t t l i n g 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 s o l a t e d from one another.  They have since been r e s e t t l i n g themselves out  of the o r i g i n a l areas into place where there are other Vietnamese. (137) I t appears that the need f o r the support of one's own people i s very strong. They have also formed t h e i r own s e l f - h e l p organizations with the aims of mutual a s s i s t a n c e , preserving t h e i r c u l t u r a l  heritage,  and forming the basis f o r a Vietnamese-American culture of the future. With the a r r i v a l of t h i s large group of new immigrants came the opportunity to study the e f f e c t s of migration, f l i g h t , and adaptation; and the effectiveness of services designed to help resettlement.  There i s a growing l i t e r a t u r e on the health and  55  adaptation problems of these refugees. Studies undertaken i n the 'holding camps' have a l e r t e d the Public Health Services and the medical profession to possible health hazards as well as to diagnosis and treatment of ' e x o t i c ' diseases i n immigrants from t r o p i c a l countries.  Others have been reported in the Morbidity and M o r t a l i t y  Weekly Reports from the Center  f o r Disease Control .in A t l a n t a . 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) D e v e l o p m e n t s immigration p o l i c i e s in A u s t r a l i a and the U.S.A. appear to have been a series of reactions to external events and i n t e r n a l s o c i a l and economic pressures, and only comparatively recently has there been a perceived need f o r programs and services to help the immigrant adjust to his new environment.  Both countries have attempted to a s s i m i l a t e  rather than integrate the newcomers into t h e i r s o c i e t y .  While  the health of the immigrant on a r r i v a l i s probably better than the average c i t i z e n because of the s t r i c t medical examination required, not much concern seems to have been shown for his health t h e r e a f t e r . Israel has the same 'melting pot' a t t i t u d e towards her immigrants but has from the beginning planned programs to help the immigrant adjust. Israel.  Immigration i s a fundamental tenet of Zionism:  the p o l i c y i s , and has been that every Jew has the r i g h t to  56 immigrate into the State of I s r a e l .  Only those who s p e c i f i c a l l y  act against the Jewish nation or who are considered a threat to the public health or state s e c u r i t y may be denied entry. (140) The r e s u l t of t h i s p o l i c y has been' to " f l o o d the land and a society not equipped to receive them with masses of variegated, t o t a l l y d i s s i m i l a r newcomers from a l l corners of the earth - and predominately from the more underprivileged corners." (141) Apart from the moral commitment of the Jewish homeland, the urgent need has been f o r manpower f o r defence as well as economic development.  Because of t h i s , immigrants are in a  favoured p o s i t i o n in I s r a e l i s o c i e t y , r e c e i v i n g s u b s t a n t i a l  financial  and s o c i a l assistance with s e t t l i n g , i n c l u d i n g free health insurance f o r s i x months and help with housing and employment.  Until 1968,  immigration and the absorption of immigrants was the exclusive r e s p o n s i b i l i t y of the Jewish Agency, a non-governmental o r g a n i z a t i o n . With the formation of the M i n i s t r y of Immigration and Absorption i n 1968, the government became more involved with the co-ordination and operation of s e r v i c e s . In s p i t e 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 z e n s on account of the p r i v i l e g e s they receive and the c u l t u r a l differences between them. There have been three 'waves' of immigrants i n t o I s r a e l : from Europe before 1948; from Asia and A f r i c a from then u n t i l the 1960s; and from the Soviet Union i n 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 r o l e s , the level of education, the observance of the r e l i g i o u s 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 p a r t i c u l a r l y hard for Oriental Jews as t h e i r occupational "composition" was l i t t l e suited to meet the manpower needs of the young s t a t e . (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 s o c i e t y . "  (143)  No other country has studied the adjustment of immigrants or records t h e i r progress as c a r e f u l l y . a s I s r a e l .  I t i s pointed  out to prospective immigrants that settlement i s not easy and in return f o r generous assistance the State requires an e f f o r t from the immigrant himself.  The language i s not an easy one  to l e a r n : however, in 1973 about 61% of immigrants were a c t i v e l y studying Hebrew during t h e i r f i r s t year i n I s r a e l , which i s probably quite a high percentage when compared with other receiving c o u n t r i e s . (144).  Community organization are being encouraged to  help with the s o c i a l adjustment of immigrants, but i n s p i t e of great e f f o r t s to help them s e t t l e , there i s considerable disappointment as measured by the rate of out-migration. (145)  58  With the acceptance of allcomers, not every immigrant into Israel has been in optimal health.  I t was observed very e a r l y on that  " although i t cannot be v e r i f i e d s t a t i s t i c a l l y , there i s good reason to believe that abnormally low standards of health among some new immigrants greatly added to the d i f f i c u l t i e s of absorption. This applies to both physical and mental health and can be explained by the large percentage of the new a r r i v a 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 p r i m i t i v e and standards of n u t r i t i o n among the poor are extremely low." (146) Health problems that would be a public health hazard, such as a c t i v e t u b e r c u l o s i s , have been treated where f e a s i b l e in the country of o r i g i n before the migrant has been allowed to t r a v e l to I s r a e l . (147)  Other  problems such as poor n u t r i t i o n and hygeine are dealt with in the process of settlement. Israel i s committed to immigration as a fundamental p o l i c y of populating the country, and has planned s o c i a l and health services to a s s i m i l a t e the newcomers into the I s r a e l i community.  In s p i t e  of t h i s , resettlement and adaptation have not been easy, with the process probably complicated by the i n t e r n a l economic s i t u a t i o n and the external p o l i t i c a l s i t u a t i o n i n the Middle East. The goals of these three major receiving countries have been the growth of population by immigration, and the a s s i m i l a t i o n of those immigrants into a 'dominant' c u l t u r e .  Until  comparatively  r e c e n t l y , A u s t r a l i a and the U.S.A. have not paid much a t t e n t i o n to the e f f e c t of t h i s p o l i c y on the health of the immigrants a f t e r  59  their a r r i v a l .  They have  now recognised that m u l t i - c u l t u r a l  s o c i e t i e s have happened in s p i t e of t h e i r 'melting pot'  attitudes,  and that programs and services are indeed needed to help the i n t e g r a t i o n of the newcomers into t h e i r s o c i e t i e s .  Israel has  found that in s p i t e of planning services to t h i s end, the process of adaptation has not been easy f o r her new c i t i z e n s .  In a l l three  1  c o u n t r i e s , immigration p o l i c i e s have been affected by outside events as well as the i n t e r n a l s i t u a t i o n . Since the Second World War, countries of Northwest Europe have both r e c r u i t e d temporary labour from other c o u n t r i e s , and admitted thousands of r e p a t r i a t e s from t h e 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 f e r e n t .  They have had s i m i l a r  problems with the i n t e g r a t i o n and adaptation of these immigrants. NORTHWEST EUROPE .  France. Belgium, Luxemberg, and ;  Germany d i s c l a i m having been areas of settlement in the past despite evidence to the contrary: a l l have depended on immigration f o r both population growth and labour f o r the l a s 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 c a as w e l l . At f i r s t these workers were single males with comparat i v e l y low educational and s k i l l s l e v e l s , but i n 1968 the European Economic Community asserted the r i g h t of f a m i l i e s to migrate.  U48)  60 The subsequent r e j o i n i n g of f a m i l i e s 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 p o l i t i c i a n s "hearing mumblings of discontent as to the v i s i b i l i t y of the new m i n o r i t i e s " , (149) was f o r c i n g 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 i n d u s t r i a l northwest Europe had never promised permanent settlement f o r t h e i r migrant workers and there seems to have been a decided ambivalence about i n t e g r a t i n g them into the host communities.  The migrants and t h e i r f a m i l i e s  have been e l i g i b l e f o r the considerable health and welfare programs in t h e i r host c o u n t r i e s ; but otherwise the governments l e f t the i n i t i a t i v e f o r providing services to help t h e i r i n t e g r a t i o n to voluntary agencies, and only l a t e r took over some of t h i s r e s p o n s i b i l i t y themselves. Schooling f o r the migrant c h i l d r e n has been compulsory w i t h i n the l o c a l school systems, with varying amounts of i n s t r u c t i o n in t h e i r mother tongues to maintain l i n k s with t h e i r own c u l t u r e . At home the c h i l d r e n may not f i n d much encouragement f o r t h e i r schooling, and as r e s u l t run the r i s k 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 i d e n t i t y which in turn leads to delinquency; and w i l l  certainly  61 Pose a problem f o r the future in whichever country*they w i l I .find tnemselves.  France i s already grappling with the problems of  i n t e g r a t i n g the second generation of immigrants into the French community. (151; A natural g h e t t o i z a t i o n of foreign workers has made i t unnecessary f o r those with f a m i l i e s to venture outside the c i r c l e of kin and f r i e n d s . (152)  The migrants themselves appear to be  amb,;ivalent about integrating into the larger community, .(153) and opportunities f o r language t r a i n i n g are poorly u t i l i s e d . ( 1 5 4 ) Yet they show no signs of wanting to go home. The issues raised by the s i t u a t i o n of the migrant workers are complicated by the f a c t that France, Belgium, and The Netherlands have also absorbed large numbers of refugees and r e p a t r i a t e s from t h e i r former c o l o n i e s .  Like the workers from  southern Europe,- they are conspicuous m i n o r i t i e s by v i r t u e of c o l o u r , race or c u l t u r e .  However, unlike the migrant workers,  they immediately assumed a l l the r i g h t s and r e s p o n s i b i l i t i e s of c i t i z e n s h i p , and great e f f o r t s were made to a s s i m i l a t e them into the dominant culture - with varying degrees of success. L i t t l e a t t e n t i o n seems to have been paid to possible health problems among a l l these immigrants, although they must have brought t h e i r parasites and diseases with them.  They had  a medical examination before being allowed to migrate, but t h e i r  x  62  l i v i n g conditions in the new environment are not conducive to good h e a l t h , e i t h e r physical or mental.  This could be expected to  contribute to an overloading of the social services,' cause an increase i n 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 t h e i r f a m i l i e s into s o c i e t y ; and the l o c a l population does not discriminate between them and the r e p a t r i a t e s .  There i s l i k e l y to  be s o c i a l tension between ' f o r e i g n e r s ' and'natives' in periods of high unemployment (155).  The o v e r a l l p o l i c y aims now, are to integrate  those already in the country (s) and at the same time discourage any f u r t h e r i n - m i g r a t i o n . GREAT BRITAIN•• -  B r i t a i n , also has a problem-in: t h a t ' s i g n i f i c a n t  m i n o r i t i e s are not being integrated into B r i t i s h s o c i e t y . Although only one in three migrants since the war has been ' c o l o u r e d ' , one of the remarkable features of the s i t u a t i o n in B r i t a i n 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 e g i s l a t i o n f o r both the control of immigration per se, and the rampant d i s c r i m i n a t i o n against them. U n t i l the e a r l y 1900s B r i t i s h immigration p o l i c y was ' l a i s s e z - f a i r e ' f o r "motives of both economic s e l f - i n t e r e s t and humanitarian concerns." (157)  Around the turn of the century  63 there was p o l i t i c a l a g i t a t i o n against the presence of large numbers of Jewish refugees from eastern Europe, with the r e s u l t that immigration was r e s t r i c t e d by the A l i e n s Act (1905), (158) f u r t h e r l e g i s l a t i o n in 1914 and 1919, and subsequent Orders in C o u n c i l .  Immigrants were not e l i g i b l e f o r the old age pensions  introduced in 1908, nor f o r unemployment and health insurance in.1911: in f a c t , popular sentiment was quite b l a t a n t l y anti-immigrant ( 159), and r a c i s t (160).  This antipathy towards foreigners c e r t a i n l y  affected the treatment of refugees from Nazi Germany in the l a t e 1930s. Asylum was offered to P o l i s h ex-servicemen who did not wish to go home at the end of the Second World War; and the P o l i s h Resettlement Act of 1947 recognised that "resettlement had dimensions other than the economic and that i t embraces not only housing but h e a l t h , welfare and education as w e l l . " (161)  However,  the p r i v i l e g e s of the Welfare State were not extended to the a l i e n s 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 N a t i o n a l i t y Act gave Commonwealth c i t i z e n s the p r i v i l e d g e of v i r t u a l l y free entry into B r i t a i n to work and s e t t l e , ' (162) and l i k e the Poles, they were e n t i t l e d to the f u l l range of s o c i a l s e c u r i t y b e n e f i t s .  Because, of p o l i t i c a l  a g i t a t i o n and a c t i v e d i s c r i m i n a t i o n against 'coloured' m i n o r i t i e s ,  64 the p r e f e r e n t i a l status of Commonwealth immigrants has been s t e a d i l y w h i t t l e d away by a series of l e g i s l a t i v e and administrative measures culminating in the Immigration Act of 1971. (163)  A permit  i s now required to enter B r i t a i n to work, except f o r p a t r i a l s (those who have s p e c i f i c family t i e s with B r i t a i n ) and nationals of E.E.C. c o u n t r i e s .  The Race Relations Act of 1976 (164) i s the  l a t e s t in a series of measures attempting to control  racial  d i s c r i m i n a t i o n in employment, housing, and in other s e r v i c e s . In 1980, the White Paper on Immigration proposed more r e s t r i c t i o n s on immigration and on immigrants. (165) It has been a feature of recent h i s t o r y that no co-ordinated attempt has been made to help new m i n o r i t i e s 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 i n a n c i a l assistance to Local A u t h o r i t i e s f o r extra services f o r immigrants, but use of the money made a v a i l a b l e has been uneven across the country.  Community Relations C o u n c i l s , voluntary committees  controlled., by voluntary executives on which elected l o c a l government representatives of the major p o l i t i c a l p a r t i e s have been heavily represented, have attempted to involve ethnic m i n o r i t i e s 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 t h e i r impact on l o c a l p o l i t i c a l opinion about the real disadvantages  65  of the ethnic m i n o r i t i e s appears to have been t r i v i a l .  "In  retrospect, the explanation of these d e f i c i e n c i e s seems c l e a r l y political."  (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 p a l l y in terms of problems f o r the host community rather than f o r the immigrants themselves. Rees comments that the proposal by the E.E.C. that c h i l d r e n be taught t h e i r 'mother tongue' during school hours does not appear to have been s e r i o u s l y considered by the B r i t i s h Government, which i s s t i l l thinking on the l i n e s of rapid a s s i m i l a t i o n of immigrants into the B r i t i s h c u l t u r e . (169)  One r e s u l t of t h i s thinking i s  that the low educational attainment and high unemployment among young B r i t i s h - b o r n Blacks are f u e l i n g r a c i a l tensions in the major cities.  (170) Problems with immigrant health have also been documented.  The 1962 Commonwealth Immigrants Act (171) s t i p u l a t e s that immigrants from the Commonwealth are subject to a medical examination on a r r i v a l .  Any medical procedure that however i n c i d e n t a l l y seems  to single out "New Commonwealth' immigrants could be intepreted as d i s c r i m i n a t o r y ; the. checks f o r typhoid are an example.  Other  problems appear to be centred on the c h a r a c t e r i s t i c s of the immigrants themselves; t h e i r a t t i t u d e to the health s e r v i c e ; the ignorance of both immigrants and health professionals of c u l t u r a l  66 d i f f e r e n c e s ; and/or poor communication. Some Local Authority Health Departments and h o s p i t a l s have r e c r u i t e d s t a f f from t h e i r l o c a l m i n o r i t i e s in an attempt to overcome these i n t e r c u l t u r a l and communication problems, but Jones found that only two hospital management committees were c u r r e n t l y providing anything approximating race r e l a t i o n s b r i e f i n g s f o r t h e i r s t a f f , and such provisions were f o r nurses and not f o r the doctors or the 'lower r a n k s ' . (173) There have- b e e n - d i f f i c u l t i e s ' based on colour and c u l t u r a l differences with p a t i e n t / p a t i e n t , p a t i e n t / s t a f f , and s t a f f / s t a f f  relationships.  The t r a d i t i o n a l B r i t i s h ' l a i s s e z - f a i r e ' a t t i t u d e to public p o l i c y has only o c c a s i o n a l l y been modified, and then in times o f ( i n humanitarian terms) c r i s i s such as with the P o l i s h , Hungarian and Ugandan refugees.  Only in recent years, and l a r g e l y  because of fears of r a c i a l t e n s i o n , have any signs emerged of central government concern with the s i t u a t i o n of m i n o r i t i e s w i t h i n a hostile B r i t i s h society.  "The bitterness which r e s u l t s from the  experience of r a c i a l d i s c r i m i n a t i o n does not disappear in a generation, and the s i t u a t i o n may be beyond r e p a i r in B r i t a i n . " (174)  67  Conclusion The trend in immigration p o l i c i e s has been to remove the b a r r i e r s based on race or n a t i o n a l i t y ; p a r t l y in response to the changing i n t e r n a t i o n a l 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 p a r t l y because of the need to l i n k immigration to economic needs.  The exceptions being B r i t a i n , who  by devious l e g i s l a t i o n i s t r y i n g 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 i n t e r n a l economic s i t u a t i o n and external pressures. A l l have had problems with the i n t e g r a t i o n of immigrants into t h e i r respective s o c i e t i e s .  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 public opinion or provide programs and services to help the newcomers to adapt to t h e i r new environment. The r e s u l t may have been to make i t d i f f i c u l t them to meet t h e i r basic needs.  for  Employment and housing may have  been u n s a t i s f a c t o r y or even unavailable because of i n d i f f e r e n c e or h o s t i l i t y on the part of the l o c a l population, and these a t t i t u d e s c e r t a i n l y do nothing to help the immigrants feel that they ' b e l o n g ' .  When t h i s i n d i f f e r e n c e i s extended to the needs of  the immigrant c h i l d r e n , then s o c i a l unrest may be expected when these c h i l d r e n grow up and f i n d themselves to be a disadvantaged segment of the population because of a lack of educational opportunities.  68  These countries have set basic standards of health f o r t h e i r immigrants, but again with the exception of I s r a e l , do not appear to have been too concerned with t h e i r health once they had s e t t l e d .  It has been seen e a r l i e r in t h i s thesis that f a i l u r e  to meet basic human needs may adversely a f f e c t the health of immigrants; and i f they are involuntary migrants, then t h i s e f f e c t may be more detrimental as t h e i r health w i l l have already been affected by t h e i r experiences. With t h 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 i m i l a r to both that of the U.S.A. and A u s t r a l i a . was no d e l i b e r a t e 'melting pot  1  Although there  p o l i c y , i t was hoped to b u i l d a  nation of people with s i m i l a r customs and i d e a l s by s e l e c t i v e immigration.  The ' f a c t ' of a m u l t i c u l t u r a l society was accepted  e a r l i e r by Canada; but the need f o r programs and services to help the adjustment of immigrants has only recently been recognised.  1867-1918 Before 1867, immigration was the r e s p o n s i b 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 responsibility  the . federal and p r o v i n c i a l governments.(174)  The  d i v i s i o n of those r e s p o n s i b i l i t i e s was set out i n the Immigration Act of 1869, (175)  with the federal government being responsible  f o r the s e l e c t i o n of immigrants and t h e i r welfare from p o i n t of-departure to d e s t i n a t i o n , and the provinces f o r t h e i r settlement. I n i t i a l l y , t h i s was a l l rather l a i s s e z - f a i r e , but the quarantine s t a t i o n s set up by the federal a u t h o r i t i e s to prevent the importat i o n of the i n f e c t i o u s diseases were the forerunners of public health services f o r the whole population.  The Immigration Aid  70  S o c i e t i e s Act of 1872 (176) was intended to regulate the functioning of the (voluntary) s o c i e t i e s being set up across the country to aid the settlement of the newcomers.  This Act i s  still  in f o r c e . The aim of immigration was the settlement of a g r i c u l t u r a l land, and the 'preferred c l a s s e s ' of immigrants were farmers, farm labourers, and domestic servants from B r i t a i n , selected European c o u n t r i e s , and the U.S.A.  When t h i s f a i l e d to provide enough s e t t l e r s  f o r Canada's need, then large numbers were r e c r u i t e d from eastern Europe.  The comparative i s o l a t i o n of the non-Anglo-Saxon  communities that grew up on the p r a i r i e s meant the retention of t h e i r language and c u l t u r e :  they were not a s s i m i l a t e d .  Clifford  S i f t o n as M i n i s t e r of the I n t e r i o r from 1896-1905 was responsible f o r immigration, and i s credited with the foundation of the concept of s e l e c t i v e immigration that remains the cornerstone of immigration p o l i c y today.(177)  He was responsible f o r the 1902  amendment to the Immigration Act that excluded "diseased persons" as a measure of protection of the public health.(178) Already excluded were those deemed undesirable on p h y s i c a l , mental, or moral grounds.  A r e v i s i o n 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 i n t e r n a l events and s i t u a t i o n s that a f f e c t the recruitment and settlement of immigrants. (179).  71 In s p i t e of the government's enthusiasm there was not unanimous public approval of large scale immigration.  The Province  of Quebec feared the submersion of i t s - c u l t u r e ; the trade unions campaigned against the a r r i v a l of non-agricultural workers in the c i t i e s of the eastern provinces as i t caused unemployment; and public a g i t a t i o n in B r i t i s h Columbia led to increasing  (legislated)  d i s c r i m i n a t i o n against Chinese immigrants by the imposition of a l a r g e r and l a r g e r head tax.  There was already a head tax on  immigrants to insure against t h e i r becoming a charge on the public purse in the event of i l l n e s s or d i s a b i l i t y .  This d i s c r i m i n a t i o n  on r a c i a 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 e n s , and by the ' d i r e c t passage' l e g i s l a t i o n a f f e c t i n g the t r a v e l l i n g route of the Indians. Services f o r immigrants were seen as perhaps necessary before, and during migration and were designed as much f o r the protection of Canada by excluding the undesirables as f o r the encouragement of the immigrant.  There were voluntary s o c i e t i e s  to a i d the settlement of the immigrants, but neither p r o v i n c i a l or federal governments appeared to take much i n t e r e s t in t h e i r welfare once they had a r r i v e d at t h e i r d e s t i n a t i o n .  72 By the end of t h i s period land f o r settlement was becoming scarce, the p u b l i c were anti-immigrant, and l e g i s l a t i o n 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 c e r t a i n n a t i o n a 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 i n the 1920s.  The  decision to exclude immigrants from India was upheld by the Imperial Conference of 1919 thus s e t t i n g a precedence f o r future p o l i c y 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 a t t i t u d e p a r a l l e l e d  that in the U.S.A. at that time, and continued u n t i l a f t e r the Second World War. As economic prosperity improved in the middle 1920s so immigration p o l i c i e s became more a c t i v e , with land settlement s t i l l the major o b j e c t i v e .  1926 saw the beginning of a sponsorship  scheme allowing the r e - u n i f i c a t i o n of f a m i l i e s in Canada.  At the  same time services f o r immigrants were expanded: more o f f i c e s were opened i n B r i t a i n and Europe; passage assistance was generous; immigrants were welcomed at p o i n t - o f - e n t r y and helped with the evaluation and e x p l o i t a t i o n of (land) o p p o r t u n i t i e s ; and medical  73 examinations p r i o r to departure were i n s t i t u t e d f i r s t in B r i t a i n 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 t u a l s t a n d s t i l l  that  lasted u n t i l 1945.  1946-1960 With the end of the World War Two, Canadian immigration p o l i c y evolved r a p i d l y , r e f l e c t i n g the swift pace of national development and the profound changes on the i n t e r n a t i o n a l  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 i n the l i g h t of the world s i t u a t i o n as a whole" and that p o l i c y should be related to the s o c i a l , p o l i t i c a l and economic circumstances r e s u l t i n g from the war, and to the problem of the resettlement of d i s p l a c e d , homeless people, as well as to the future economic and population growth of the country. (181) Many of the immigrants accepted a f t e r the war were refugees from Europe, and many had t u b e r c u l o s i s .  In 1946 the federal  government accepted r e s p o n s i b i l i t y f o r 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 f o r the health and welfare of t h e i r c i t i z e n s . Apart from t h i s , immigrant services were s t i l l confined to the recruitment, screening, and transportation of immigrants. Between 1952 and 1960 the immigration flow was c o n t i n u a l l y being adjusted to the country's labour requirements.  However, the  p o l i c y adopted with the 1952 Immigration Act did not give equal chances to a l l p o t e n t i a 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 i s c r i m i n a t i o n against immigrants from A f r i c a , Asia and the Caribbean. one race.  The ideal was s t i l l a nation of one c u l t u r e  ...  At the same time there was a new emphasis on s o c i a l  and humanitarian considerations with sponsored immigration becoming a major phenomenon.  This had the e f f e c t of bringing in large  numbers of u n s k i l l e d r e l a t i v e s , e s p e c i a l l y from the countries of southern Europe.  There seems to have been an increasing w i l l i n g n e s s  on the part of the government to make exceptions to the rules i n favour of i n d i v i d u a l s and groups.  1961 to the present The problem in the 1960s was to f i n d a way to end the d i s c r i m i n a t o r y features of immigration p o l i c y while bearing in  75  the mind the economic s i t u a t i o n and the changes in labour r e q u i r e ments.  Canada was f a s t becoming an i n d u s t r i a 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 o n ship between economic needs and immigration. A new p o l i c y 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 n g , s k i l l s and other q u a l i f i c a t i o n s necessary to obtain employment or to set up t h e i r own e n t e r p r i s e s .  At  the same time the sponsorship rules were changed to allow residents of Canada to sponsor c e r t a i n classes of r e l a t i v e s regardless of n a t i o n a l i t y , while sponsorship of other classes of r e l a t i v e s was r e s t r i c t e d to c e r t a i n countries of o r i g i n . (183) The regulations regarding sponsored immigrants were tightened in 1967, although the d i s c r i m i n a t o r y clause on country of o r i g i n was removed. (184) This amendment to the Immigration Act also introduced a points system f o r independent and nominated immigrants based on education, knowledge of French and/or E n g l i s h , occupational s k i l l s and demand f o r those s k i l l s , age, and a personal assessment score.  Although overt d i s c r i m i n a t i o n on n a t i o n a 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, u n s k i l l e d , and speak  76  neither English nor French.  The removal of the l a s t pieces of  r a c i a l d i s c r i m i n a t i o n from Canada's immigration p o l i c y in 1967 may be compared with that i n the U.S.A. - 1965, and A u s t r a l i a 1973. Hawkins comments on the f a c t that t h i s Canadian p o l i c y change was not in response to public pressure as in the U.S.A. and l a t e r to some extent i n A u s t r a l i a ; in f a c t the Canadian public was hardly aware that immigration p o l i c y was d i s c r i m i n a t o r y . The p o l i c y had become " d i s t a s t e f u l and impracticable to the r u l i n g groups in both major p o l i t i c a l p a r t i e s " and was o u t - o f - l i n e with the role that Canada then wished to play in the i n t e r n a t i o n a l community and Commonwealth, and with her role as a trading country e s p e c i a l l y with the Caribbean and A s i a . (185) The 1966 White Paper on Canadian Immigration P o l i c y recognised the importance of services to help the adjustment of immigrants to Canadian l i f e . ( 1 8 6 )  In the same year,  responsibility  f o r immigrant services at the federal l e v e l , previously borne e n t i r e l y by the Department of C i t i z e n s h i p and Immigration, was divided between the new Department of Manpower and Immigration and the Department of the Secretary of State.  The former took  r e s p o n s i b i l i t y f o r the i n i t i a l needs of the immigrant - s e l e c t i o n , c o u n s e l l i n g , job placement; and the l a t t e r f o r the longer-term needs of adaptation to a new way of l i f e with emphasis on  77 programs rather than on i n d i v i d u a l assistance.  Social assistance  services are the r e s p o n s i b i l i t y of the provinces, and in t h i s respect may be seen as the l o g i c a l successors of the Department of Manpower and Immigration a f t e r 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 i n t o t h i s category. Hawkins has observed that there had been almost no consultation with the provinces i n t h i s area of common j u r i s d i c t i o n 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 f o r the f i r s t year a f t e r a r r i v a l . (188)  Richmond made the comment that when  compared with services in A u s t r a l i a , and in B r i t a i n which has not encouraged immigration, "the quantity and q u a l i t y of services to a s s i s t immigrants in Canada has been low." (189)  I t has already  been seen that in the l a s t decade those countries have considered t h e i r respective programs and services to be inadequate. There are voluntary agencies that have been interested i n the welfare of immigrants a f t e r t h e i r a r r i v a l in Canada, and these u s u a l l y have c u l t u r a l , r e l i g i o u s or ethnic a f f i l i a t i o n s . Being community based they should be well placed to a s s i s t i n d i v i d u a l s as well as encouraging and educating the community to understand and accept the needs of newcomers, and a l l l e v e l s of  78 governments maintain a l i a i s o n service with them. It has been commented that t h e i r programs do not reach enough immigrants and that no-one i s doing any planning, co-ordination and development in t h i s f i e l d .  "The voluntary sector in immigration  i s , in f a c 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 v e r s i t y , very unequal performance and constant change and f l u c t u a t i o n . " (190)  It i s p l a i n that these  agencies have given considerable, and l a r g e l y unpaid, service to the government in the reception, welfare and adjustment of immigrants; but the consequences of the d i v e r s i t y and lack of planning mean very unequal treatment f o r 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 c e r t a i n groups of people f o r asylum.  Doukhobors and Mennonites were admitted in 1899 as  immigrants by O r d e r - i n - C o u n c i l , rather than as the p o l i t i c a l r e l i g i o u s refugees they a c t u a l l y were.  At the same time, more  than a thousand Mormon f a m i l i e s s e t t l e d i n what i s now southern Alberta as ' p r e f e r r e d ' immigrants in s p i t e of the had f l e d from the U.S.A. f o r fear of persecution.  f a c t that they  79  Mennonites and Doukhobors were denied entry in the e a r l y 1920s during Canada's e a r l y xenophobic period, but t h i s regulation was rescinded in time to allow 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 modification of p o l i c y was made during the 1930s when "even refugees were rejected on economic grounds." (191) Some i n d i v i d u a l refugees with c a p i t a l or i n d u s t r i a l expertise were admitted by Order-in-Council j u s t p r i o r to the war; otherwise refugees from Europe were interned as a l i e n s during the war j u s t as they were i n A u s t r a l i a and B r i t a i n .  " O v e r a l l , the Canadian  public has time a f t e r time f a i l e d to d i f f e r e n t i a t e between the immigrant and the refugee." (192) There was considerable pressure from the i n t e r n a t i o n a l community on the t r a d i t i o n a l receiving countries to relax t h e i r immigration laws and give asylum to some of the m i l l i o n s Europe who had been uprooted by the war.  in  Some of these refugees  were admitted to Canada under special government a u t h o r i t y ; and many of them were b a s i c a l l y healthy and had q u a l i f i c a t i o n s which would have made them e l i g i b l e under immigration standards. Canada's e a r l y e f f o r t s concentrated on the admission of large numbers of those who could, with a s s i s t e d t r a n s p o r t a t i o n , be  80  quickly resettled. Canada needed.  (193)  In other words, they had s k i l l s that  Eventually, Canada admitted several thousand  refugees from Europe, i n c l u d i n g the u n s k i l l e d , the s i c k , and the p h y s i c a l l y and s o c i a l l y handicapped. Canada's desired image abroad, and her f o r e i g n - b o r n ' p o l i t i c a l j c o n s t i t u e n t s dictated the admission of immigrants not d i r e c t l y destined f o r the workforce.(194) Other refugee groups have been admitted under special programs in response to major i n t e r n a t i o n a l c r i s e s : 38,000 Hungarians, 1956-57; 12,000 Czechs, 1968; 228 Tibetans, 1970whom the Province of B r i t i s h Columbia refused to accept; and 1200 Chileans, 1973-74. In s p i t e of the government contention that"the c h i e f motive behind Canada's c o n t r i b u t i o n to refugee resettlement has been the desire of the Canadian people to help" (195), Howard has commented that even as "genuinely humanitarian motives e x i s t among many l e g i s l a t o r s and c i v i l s e r v a n t s . . .  (they)  nevertheless f i n d themselves obligated to respond to a public opinion which i s not uniformly i n favour of admitting refugees."(196) A t t i t u d e s towards minority groups appear to be improving but " i t cannot be assumed that these l a t e n t antipathies have altogether disappeared." (197).  81 Canada does not have a p o l i c y of p o l i t i c a l asylum, and suspicions have been voiced that there may be i d e o l o g i c a l i n refugee p o l i c y . (198) (199) .  I t may be noted that  factors  the majority  of the refugees admitted since the 1950s have f l e d communist regimes. .While.taking c r e d i t for the admission-of Chileans f l e e i n g persecution from t h e i r right-wing government, the Canadian government has not f a c i l i t a t e d t h e i r migration. There appears to be f u r t h e r d i s c r i m i n a t i o n . " I t i s important that whatever numbers Canada a l l o w s . . . r e f u g e e s be selected according to t h e i r a b i l i t y to adapt to Canadian l i f e . " ( 2 0 0 ) The 1976 Immigration Act s t a t e s , with regard to the s e l e c t i o n of immigrants: " S e c . 6 ( l ) . Subject to t h i s Act and the r e g u l a t i o n s , any immigrant i n c l u d i n g a Convention refugee, a member of the family c l a s s , and an independent immigrant, may be granted landing i f he i s able to e s t a b l i s h to the s a t i s f a c t i o n of an immigration o f f i c e r that he meets the s e l e c t i o n standards established by the regulations f o r the purpose of determining whether or not an immigrant w i l l be able to become s u c c e s s f u l l y established in Canada. (2) Any Convention refugee and any person who i s a member of a c l a s s designated by the Governor in Council as a c l a s s , the admission of members of which would be i n accordance with Canada's humanitarian t r a d i t i o n with respect to the displaced and the persecuted, may be granted admission subject to such regulation as may be established thereto and notwithstanding any other regulations made under t h i s A c t . " (201) The i n d i v i d u a l most i n 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 t o r t u r e have not  82  been admitted to Canada; and unless p r i v a t e l y sponsored, i l l i t e r a t e , u n s k i l l e d peasants who speak neither French nor English have also had d i f f i c u l t y entering t h i s country. (202)  The Vietnamese i n Canada There were several thousand Vietnamese already in Canada when the 'Boat people' s a i l e d over the horizon.  They  had been admitted as landed immigrants rather than as "refugees on parole, as t h e i r compatriots in the U.S. were."(203) The c r i t e r i a used to grant i n t e r v i e w s / v i s a s were good h e a l t h , and r e l a t i v e s 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 adjusting 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 p u b l i c h o s t i l i t y i f i t i s seen that they are not a public charge.  Low refugee costs are also a t t r a c t i v e to.the  provinces who must bear the cost of s o c i a l services such as education and health care. take c r e d i t f o r i t s  At the same time the government can  'humanitarian' a t t i t u d e s .  The l e g i s l a t i o n  to admit 'the poor, the h a l t , and the lame' e x i s t s : i t remains to be seen i f i t i s used f o r 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 A s i a ; 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, t h e i r needs must be met w i t h i n an aTien environment. In a d d i t i o n , there i s the stress of an uncertain f u t u r e ; and once accepted f o r resettlement in another country the refugees are faced with making f u r t h e r adjustments.  As a prelude to  considering the health problems that may a r i s e with the resettlement in Canada of some of the 'Boat people' i t i s necessary to look at the way needs are met w i t h i n the Vietnamese c u l t u r e ; at the e f f e c t of the war and t h e i r subsequent f l i g h t ; and from t h i s to i d e n t i f y possible health problems associated with t h e i r resettlement. HUMAN NEEDS As previously discussed, human needs are normally met w i t h i n a s p e c i f i c c u l t u r a l s e t t i n g , and in moving from one c u l t u r e to another an i n d i v i d u a l 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  of  Southeast  Asia  85  A basic human need i s f o r food, and d i e t and food preferences are p a r t l y governed by geography.  Viet-Nam has been  described as "two bags of r i c e on a pole"(204), as the t r o p i c a l monsoon ensures the 'wet' c u l t i v a t i o n of r i c e on the two major r i v e r d e l t a s , the Songkoi (Black River) in the north and the Mekong i n the south.  The people do not consider that they have  eaten i f there has not been r i c e at the meal, to which vegetables and f i s h , or o c c a s i o n a l l y pork or chicken are added. Most ingredients f o r t h e i r accustomed d i e t w i l l be found in Canada, e s p e c i a l l y in areas that have large concent r a t i o n s of Chinese people such as Vancouver, Toronto, and Montreal. Safety and s e c u r i t y are supplied by f a m i l i a r surroundings. The Vietnamese people w i l l be used to a f l a t d e l t a landscape where the majority of the population l i v e , and to a hot and humid climate 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 i b e s c o 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 p r i m i t i v e than that of the lowland Vietnamese.  The change i n climate alone  w i l l mean that the 'Boat-people' w i l l have to adapt to heavier c l o t h i n g , 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 w e l l - b u i l t masonry w a l l s and t i l e d roofs of the wealthy to the wooden w a l l s , thatched  86  roofs and earthen  f l o o r s of the peasants.  I f p o s s i b l e , the  f u r n i t u r e w i l l include the highly polished hardwood slabs used as beds.  The most important room on the house contains the  of the ancestors' in Buddhist homes  'altar  or a ' s h r i n e ' in Catholic homes,  and t h i s i s where the f a m i l y ' s r e l i g i o u s observances take place and r i t e s honouring the ancestors are performed, e s p e c i a l l y at the f e s t i v a l of Tet. . The family i s the basic unit of Vietnamese society and provides the c h i e f source of i d e n t i t y , ' s e l f - w o r t h ' f o r the i n d i v i d u a l .  'belongingness  1  and  The family takes precedence  over the wishes or i n c l i n a t i o n s of the i n d i v i d u a l and  as t h 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 n d i v i d u a l i t y , i t i s possible that c o n f l i c t may a r i s e within Vietnamese f a m i l i e s as the c h i l d r e n 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 .  Until  recently,  women have been considered i n f e r i o r with more duties than r i g h t s , however the economic changes caused by the war have meant that women have had to contribute!more f i n a n c i a l l y to the family by working outside the home. There i s a strong sense of c o n t i n u i t y of the f a m i l y , p a s t , present and f u t u r e , and of i t s  association with the land.  87 "ancestor worshippers, the Vietnamese saw themselves as more than separate egos, (but) as part of t h i s continuum of l i f e . To leave the land and the family forever was therefore to lose t h e i r place in the universe and to s u f f e r a permanent, c o l l e c t i v e death." It may be speculated that having to leave the land associated with the ancestors i s then a major psychological shock, although t h i s may be a delayed r e a c t i o n . The family functions w i t h i n a s o c i e t y , and in Viet-Nam the t r a d i t i o n a l s o c i e t y , b u i l t up over the past one thousand years, was based on the v i l l a g e as a s o c i a l u n i t .  I t was an a g r a r i a n ,  rather s t a t i c s o c i e t y , s t r a t i f i e d according to wealth in land; ruled by an emperor and his royal f a m i l y ; and governed by an i n t e l l e c t u a l e l i t e organized in a c i v i l bureaucracy.  This s o c i a l structure was  more or less patterned on that of ancient China with whom the Vietnamese are e t h n i c a l l y l i n k e d . The teachings of the moral philosopher Confucius still  influence values and a t t i t u d e s .  As l a t e as 1945, rural  communities s t i l l embraced more than ninety percent of the t o t a l population of the country, and t h i s preponderance of the t o t a l population with i t s s t a t i c way of l i f e explains the existance i n Vietnam of many old b e l i e f s , t r a d i t i o n s and s u p e r s t i t i o n s .  (206)  88 TRADITIONAL HEALTH AND SICKNESS BELIEFS AND PRACTICES. In Viet-Nam the t r a d i t i o n a l b e l i e f s and practices regarding health and sickness are widespread not only among the rural society but also among the educated urban f a m i l i e s .  These  b e l i e f s are related to and adapted from Chinese medicine with its 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 c o 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 i n d i v i d u a l experiences a sense of well being, but i f one or a l l should depart, sickness, i n s a n i t y or death could r e s u l t . " (207) Popular b e l i e f s a t t r i b u t i n g the cause of disease to the entry of e v i l s p i r i t s into the body are common, e s p e c i a l l y among the Montagnards.  Some believe that the s p i r i t can be  induced to depart by sorcerers employing t r a d i t i o n a l r i t e s , and others hope to keep the s p i r i t away by wearing charms or o f f e r i n g s a c r i f i c e s and p e t i t i o n s .  Another set of b e l i e f s  is  that i l l n e s s can be caused by a sorcerer who possesses something belonging to the v i c t i m , a piece of c l o t h i n g or a lock of h a i r f o r instance. Popular b e l i e f s can often i n t e r f e r e with diagnostic and preventative procedures. will.become i l l  A person who i s a f r a i d that he  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 public health measures such as  improved s a n i t a t i o n and personal hygeine have met with  little  success when i t i s believed that sickness may be prevented by the appropriate r i t u a l s requesting protection from or p r o p i t i a t i n g an e v i l or errant s p i r i t .  The healers, therefore in t r a d i t i o n a l  Vietnamese health practices are those who have the power to meet and exorcise e v i l s p i r i t s .  (208).  However, popular b e l i e f s have not i n t e r f e r e d with acceptance of modern medical treatment.  This acceptance i s  based mostly on the e f f e c t i v e performance of Western drugs, e s p e c i a l l y the a n t i b i o t i c s , and s t r i k i n g s u r g i c a l  results.  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 a d d i t i o n a l curative aid rather than a s u b s t i t u t e f o r t r a d i t i o n a l remedies.  It i s often believed that Western medicine  i s unsuitable f o r the Vietnamese c o n s t i t u t i o n since Western drugs are 'hot' and have a dehydrating e f f e c t on the humor and blood. It seems probable that  the younger refugees at l e a s t  will  accept Western medicine,especially i f they have come from the c i t i e s of Viet-Nam.  S e n s i t i v e and knowledgeable health services  personnel w i l l a s s i s t and ease t h i s adaptation. Overlying t h i s t r a d i t i o n a l society are the e f f e c t s of the French c o l o n i z a t i o n .  90  THE EFFECTS OF COLONIZATION The French imposed some changes on the t r a d i t i o n a l structures of the country:  p o l i t i c a l subjugation; the introduction  of French education; the beginnings of i n d u s t r i a l i z a t i o n in the north and of commercial a g r i c u l t u r e in the south; the growth of urban areas.  These a l l made t h e i r impact on the s o c i a l  structure  of Viet-Nam. In the c i t i e s there developed a new e l i t e c o n s i s t i n g 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 f a m i l i e s engaged in commerce; a l l of whom spoke French and were at l e a s t p a r t l y French educated. The new urban middle c l a s s 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 t h e i r hands - an a c t i v i t y they considered degrading.  The urban lower class was made up of mainly u n s k i l l e d ,  l a r g e l y uneducated labourers and petty tradesmen. An important f a c t o r in the p o l i t i c a l and c u l t u r a l  history  of Viet-Nam has been the gradual inflow of Chinese people f o r permanent settlement as 'middlemen , t r a d e r s , and business men. 1  (209)  They c o n t r o l l e d banks, transport companies, insurance  agencies, and the marketing of many basic f o o d s t u f f s .  Most  importantly, they established a monopoly on the r i c e trade causing s u f f e r i n g and resentment on the part of the Vietnamese peasant.  91 They came o r i g i n a l l y from southern China and "because of h i s t o r y , the proximity of China, t h e i r clannishness, entrepreneurial  talents  and opportunism, the 'Hoa' (as the Chinese l i v i n g outside China were known) in Viet-Nam were to be i n e x t r i c a b l y 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 c u l t u r e and b e l i e f s from the experiences of the population during that time. The safety and s e c u r i t y of both rural and urban family and c l a s s r e l a t i o n s h i p s i n a l l of Viet-Nam were destroyed by the continuous warfare from the l a t e 1930s u n t i l the Americans withdrew in 1975.  It was not always possible to keep the large extended  f a m i l i e s together when r e s e t t l i n g the refugees from the north in South Viet-Nam a f t e r the p a r t i t i o n of the country i n 1954; and later., the absence of physical s e c u r i t y in the rural areas of the south forced the mass migration of peasants in the c i t i e s and 'safe a r e a s ' . The huge labour surpluses caused by t h i s migration were l a r g e l y absorbed by the needs of the Americans; in f a c t , the c i t i e s became dependent f o r t h e i r economic survival on the prolongation of the war. (211)  The s o c i a l upheaval contributed to the breakdown of  the t r a d i t i o n a l family l i f e , with widespread p r o s t i t u t i o n , an increase in j u v e n i l e delinquency, increased opium smoking, and an  92  increase in veneral disease.  Family roles were reversed: farmers  became unemployed because of r e l o c a t i o n "while the wives and daughters could f i n d work as p r o s t i t u t e s , bar g i r l s ,  laundresses  and maids . . . a l l war-created work, much of which . . . was r e l a t e d to the American presence." (212) Food was in short supply in both rural and urban areas. I t has been stated that m a l n u t r i t i o n was endemic i n South Viet-Nam, and probably i n North Viet-Nam as w e l l , even before the destruction of crops, i . e . s t a r v a t i o n , as a m i l i t a r y weapon by the Americans. (213) (214) The e f f e c t of a l l t h i s on the Vietnamese people was m a l n u t r i t i o n ; an increased s u s c e p 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 fatigue . . . 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 t r u c e , 1955-64, to improve the public health services in the Democratic Republic of Viet-Nam (North Viet-Nam). "Having got r i d of many s u p e r s t i t i o n s and bad h a b i t s , each family now has a double s e p t i c tank and a bathroom, and three or four f a m i l i e s share a w e l l . Bodily hygeine  93 . . . i s being improved. People take especial care to eat clean food and l i v e in clean d w e l l i n g s . " (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 conditions of the peasants: however a l l t h i s must have been destroyed by the saturation bombing l a t e r in the war. Conditions in the South did not improve during t h i s time.  A malaria e r a d i c t i o n program, which had begun to produce  results,; was halted by the V i e t Cong t e r r o r i s t attacks against the government teams working in the v i l l a g e s , and malaria i s 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; p o l i o , leprosy and trachoma were common, and "everyone had i n t e s t i n a l p a r a s i t e s . " (219) POST WAR On A p r i l 30th 1975 the war in Viet-Nam ended with t o t a l v i c t o r y f o r Hanoi.  With the reconstruction of Vietnamese society  by the new government, p r i v a t e property was abolished, a new currency destroyed private holdings and hoarding, and the press was suppressed and books burned.  The loss of private property  and private holdings of money h i t the Chinese-dominated business  94  community e s p e c i a l l y hard, as did th'e d e t e r i o r i a t i n g s i t u a t i o n between Viet-Nam and China.  political  There was also persecution  of Buddhists, C a t h o l i c s , and the Cao Dai and Hoa Hao - two smaller r e l i g i o u s 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 e a r l y 1979 t h i s had become a ' t o r r e n t . 1  An i n v e s t i g a t i o n of  t h i s phenomenon by the A u s t r a l i a n newspaper , the Melbourne ' A g e ' , :  documents the reasons f o r t h i s outflow, and the experiences of the refugees and  the countries of f i r s t asylum - Hong Kong, Thailand,  Malaysia, Singapore, and Indonesia and the P h i l l i p i n e s . estimate that 65% of the  They  main exodus of 163,000 people who l e f t  between March 1978 and mid - 1979 were from Viet-Nam's Chinese m i n o r i t y , and that in the f o r China. (221)  same period about 250,000 Chinese l e f t  .  The 'Age' i n v e s t i g a t i o n 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 h a l f the passengers were c h i l d r e n , women and old f o 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  r e s t - j u s t over 200,000 - choose the sea-route leading southwest from Viet-Nam." (222) As Lord Carrington, B r i t a i n ' s Secretary of State f o r Foreign and Commonwealth A f f a i r s i s 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 p o l i c i e s of the Vietnamese government made i t impossible f o r them to remain." (223) EXPERIENCES DURING FLIGHT Apart from shortages of water, food and fuel on t h e i r overcrowded, slow-moving, defenceless, and often unseaworthy.boats, the refugees leaving southern Viet-Nam were l i a b l e to attacks by p i r a t e s operating from p o r t s . i n southern Thailand. U.S. refugee o f f i c i a l s interviewing victims of these attacks often wrote 'RPM in t h e i r notes, meaning rape, p i l l a g e and murder.  1  An American  o f f i c i a l estimated i n June 1979 that 30% of a l l refugee boats leaving southern Viet-Nam had been ' h i t ' by p i r a t e s ; of these about a t h i r d suffered 'RPM'. (224)  LIFE IN THE REFUGEE CAMPS From a l l the countries of f i r s t asylum the 'Age' i n v e s t i g a t i o n 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 f o r resettlement? Each camp had i t s  own c h a r a c t e r i s t i c s .  From the  d e s c r i p t i o n of one camp, Bidong in Malaysia, one gets the impression of a "dangerously congested slum" with rubbish r o t t i n g  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 r a t i o n pack, was inadequate; and there was a t h r i v i n g black market in everything i n c l u d i n g food.  There was widespread m a l n u t r i t i o n  among the c h i l d r e n , and many cases of tuberculosis f o r which they had an inadequate supply of drugs.  There had been an outbreak  of h e p a t i t i s in early 1979, and some i s o l a t e d cases of typhoid and m e n i n g i t i s .  In a population of 42,000 l i v i n g in an area of  less than one square kilometre, there were 28 cases of mental i l l n e s s "most of them RPM v i c t i m s . " 1  1  There was a h o s p i t a l , b u i l t  and staffed by the refugees: and in s p i t e of t h i s tragedy, the camp was described as an " i n d e s t r u c t i b l y r e s i l i e n t w o r l d . " (225) An eye-witness account of a refugee camp f o r Khymer (Cambodian) refugees described how the empty f i e l d designated as the camp was inundated with sick and starving refugees before any s h e l t e r could be r a i s e d . and drowned.  Many were too weak to move when i t rained,  However, t h i s camp soon "got i t s e l f organized." (226)  At the other end of the spectrum, the 'Age'  investigation  describes the most humane administration 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 r e e l y except when they were about to f l y abroad f o r resettlement. A l s o , because of a labour shortage in the T e r r i t o r y they were encouraged, and helped,  97 to f i n d employment. (227). This i s the world from which w i l l come the approximately 50,000 refugees to be r e s e t t l e d 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 o f deprivation and f l i g h t .  In any case,  t h e i r health w i l l have been affected by t h e i r experiences and t h e i r resistance to disease w i l l have been lowered.  These w i l l include i n f e c t i o u s diseases that threaten the health of Canadians; and may include those indigenous to Southeast Asia that pose no threat to Canadians, as well as those common in t h e 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 following 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 i n describing 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  i n that community.  may be simply measured by the number of people affected at a given time.  However, most i n d i c a t o r s c u r r e n t l y employed are based on  the calculation., of rates that take i n t o consideration the s i z e of the population;  e i t h e r the t o t a l number, or the parts that are  susceptible or ' a t r i s k '  to c e r t a i n diseases or conditions.  For  example, the m o r t a l i t y rate indicates the number of deaths per 1000 population over a s p e c i f i c period of time.  This crude rate i s  l i m i t e d i n its., usefulness as an i n d i c a t o r 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 s p e c i f i c cause of death.  I t may be refined as ' a g e - s p e c i f i c '  It  99 and 'cause s p e c i f i c ' , but these rates s t i l l diseases that cause death.  r e f e r to deaths or  Among the best indices of community  health are the maternal and i n f a n t death rates because of t h e i r d i r e c t r e l a t i o n to s o c i a l and environmental factors and to community s e r v i c e s . (228). The morbidity rate indicates the amount of a s p e c i f i c disease per 1000 population over a given period of time. Again t h i s i s a crude measurement; and although :often u n r e l i a b l e because of incomplete r e p o r t i n g , i s useful i n a l e r t i n g the community to l o c a l outbreaks of i n f e c t i o u s diseases.  The following a r e . more  accurate indices of health/sickness, and w i l l be used i n t h i s thesis. The incidence rate indicates the number of new cases of a s p e c i f i e d disease or condition occuring i n a given period of time and i s expressed as N:100,000 t o t a l population. The prevalence rate indicates the number of e x i s t i n g 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 s p e c i f i e d 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 comparability of data on the i n t e r n a t i o n a l d i s t r i b u t i o n of disease are considerable. The more developed countries with t h e i r technology and extensive health care systems are able to c o l l e c t more data, both q u a l i t a t i v e l y and q u a n t i t a t i v e l y , than are the more under-developed countries. The World Health Organization has made great s t r i d e s towards s o l v i n g t h i s problem by achieving recognition of the importance of uniform rules f o r processing health data and the use of a standard c l a s s i f i c a t i o n of disease, i n j u r y , and causes of death. (229)  The problem of  r e l i a b i l i t y remains: the World Health Organization r o u t i n e l y c o l l e c t s data from i n d i v i d u a l countries, and those judged r e l a t i v e l y r e l i a b l e are published p e r i o d i c a l l y .  (230)  (231).  However, caution i s required i n i n t e r p r e t i n g differences between countries in publishing disease rates. There are no accurate and current epidemiological data about disease i n Viet-Nam.  The neglect of health care during the  French c o l o n i a l period was followed by prolonged warfare with the complete breakdown of s o c i a l order.  Sources of information on  the possible health status of the Vietnamese refugees are the Centre f o r Disease C o n t r o l , A t l a n t a , U.S.A.; the l i t e r a t u r e on the health problems of m i l i t a r y personnel a f t e r service i n  101 Viet-Nam; and the growing l i t e r a t u r e on the health of the Vietnamese refugees admitted to the U.S.A. since 1975.  FACTORS IN THE SPREAD OF DISEASE  The r e s e r v o i r of most diseases of man i s man himself, although he may become i n c i d e n t a l l y i n f e c t e d with diseases where the r e s e r v o i r i s in animals, such as Jungle Yellow Fever.  The  human r e s e r v o i r consists of persons with both a c t i v e and i n a c t i v e (quiescent) disease. A ' c a r r i e r '  i s defined as a person who i s not  s u f f e r i n g from c l i n i c a l symptoms of a disease but "who i s e x c r e t i n g , or may from time to time e x c r e t , the agent to contaminate his environment or i n f e c t his a s s o c i a t e s . " (232) The spread of disease may be by d i r e c t transmission from man to man, as i n coughing and sneezing; or i n d i r e c t , when the organism can remain viable outside the body and enter the body at a l a t e r time.  Some diseases require a ' v e c t o r '  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 i n order to complete the developmental c y c l e , e . g . hookworm. Certain c l i m a t i c conditions are necessary f o r the spread of some diseases, for instance malaria requires an average temperature  102  about 70°F f o r 10 consecutive days to enable the parasite to develop, the mosquito before i t can be transmitted to another person. In t h i s sense the global d i s t r i b u t i o n of malaria canii be s a i d to be geographically determined whereas measles knows no c l i m a t i c or geographical boundaries. Improvements in l i v i n g standards e s p e c i a l l y in s a n i t a t i o n , immunization, and treatment of communicable diseases, have lowered the incidence of many of the i n f e c t i o u s diseases of the past i n countries of the ' F i r s t W o r l d ' .  T r a v e l l e r s today are subject to  national and i n t e r n a t i o n a l regulations aimed at preventing the spread of disease. (233) However, many of these diseases  still  p e r s i s t in the under-developed countries where reservoirs of i n f e c t i o n , the presence of s p e c i f i c vectors, and unsanitary conditions allow i n f e c t i o n to spread. A low prevalence of an i n f e c t i o u s disease i n 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 s p e c i f i c i n f e c t i o u s disease to areas where the prevalence i s low increases the s i z e of the r e s e r v o i r  and subsequently the chances of the  l o c a l population acquiring the disease. I t can be seen that there may be a r i s k 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 w i 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 i n d i r e c t , 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 , S h i g e l l a , and Salmonella. (236)  Some resistance of these organisms  to chloramphenicol, t e t r a c y c l i n e , 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 i s 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 resistant.  (237) These diseases can be spread through food and water. Given  the high standards of s a n i t a t i o n i n Canada i t i s u n l i k e l y that they w i l l be spread through the water supply system; but as c a r r i e r s are asymptomatic, poor personal hygeine could spread the disease through the handling of food.  As noted previously, newly a r r i v e d  immigrants tend to f i n d 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 s k to the p u b l i c 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 ) s e t t l e d i n Vancouver  by the end of 1980, although  the real number may be much greater.  Vancouver has a large  o r i e n t a l population, and i t has been estimated by S.U.C.C.E.S.S. (a voluntary agency o r i g i n a l l y set up to a i d the resettlement of Chinese immigrants) that there may be as many as 10,000 Vietnamese in Vancouver as they move from the places of o r i g i n a l settlement into an area of familar faces, language, and c u l t u r e . In Vancouver, a special c l i n i c  was set up by the  105  provincial  government i n  than one o r i e n t a l  ' C h i n a - t o w n ' , w i t h s t a f f f l u e n t i n more  l a n g u a g e , Cantonese, Vietnamese, M a n d a r i n , to  look a f t e r the h e a l t h needs o f the Vietnamese i m m i g r a n t s .  A  spokesperson f o r t h a t c l i n i c s t a t e d t h a 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 i s e a s e had been r e p o r t e d among the new i m m i g r a n t s .  However, i t must be remembered t h a t these  diseases  c o u l d become a p u b l i c h e a l t h h a z a r d .  Gonorrhea. all  For c o n v e n i e n c e , t h i s d i s c u s s i o n w i l l  sexually transmitted  include  diseases.  I t has been r e p o r t e d t h a t p r e l i m i n a r y r e s u l t s o f  special  s t u d i e s t h a t s c r e e n e d refugee groups i n the U . S . A . f o r the presence o f s e x u a l l y t r a n s m i t t e d d i s e a s e s i n d i c a t e d t h a t the p r e v a l e n c e these groups was low.  The r e p o r t a l s o noted t h a t i s o l a t e s  N e i s s e r i a gonorrheae from S o u t h e a s t A s i a may be r e l a t i v e l y to a v a r i e t y o f a n t i b i o t i c s . The  of resistant  (238)  r e f u g e e s a c c e p t e d f o r r e s e t t l e m e n t i n Canada w i l l  have been s c r e e n e d f o r s y p h i l i s medical e x a m i n a t i o n .  during t h e i r  pre-immigration  As they are a l s o m a i n l y i n f a m i l y groups  i t i s not e x p e c t e d t h a t they w i l l  (239)  add much t o the problem o f  control of sexually transmitted diseases i n t h i s country from the r e c o g n i t i o n and t r e a t m e n t o f d i s e a s e a l r e a d y This could well  in  apart  present.  i n c l u d e the more e x o t i c v a r i e t i e s such as c h a n c r o i d ,  106  Lymphopathia venerum, Granuloma venerum, and s o f t sore. A program screening adult Vietnamese immigrants i n Vancouver has found no new cases of s y p h i l i s although i t  identified  6 of 14 cases already known to have been treated p r i o r to immigration. Tuberculosis.  The r e s e r v o i r of tuberculosis i s p r i m a r i l y  man, and i n some areas diseased c a t t l e . Infection, with Mycobacterium bovis (bovine t u b e r c u l o s i s ) i s now rare i n countries where dairy cows are r e g u l a r l y tested f o r the presence of the disease.  It is  probably rare among the Vietnamese as there i s no t r a d i t i o n of drinking milk a f t e r weaning in that country. (240) The main source of i n f e c t i o n from M tuberculosis i s sputum containing b a c i l l i , and transmission i s by d i r e c t contact; droplet n u c l e i , which i s a true airbone i n f e c t i o n ; or by i n d i r e c t droplet i n f e c t i o n where large p a r t i c l e s drop to the f l o o r and a f t e r drying become resuspended in the a i r .  This b a c i l l u s causes  pulmonary t u b e r c u l o s i s , and extra-pulmonary disease such as the tuberculosis of the lymph glands known as s c r o f u l a . The r e - a c t i v a t i o n of o l d pulmonary disease i s known to be a health problem among people with an already low resistance exacerbated by poor n u t r i t i o n and l i v i n g conditions.  (241)  Re-activation may also be t r i g g e r e d by s t r e s s , and i t has been recognised that rates of both new and r e - a c t i v a t e d tuberculosis  107  are higher in immigrants than in the Canadian-born population.(242) The Center f o r Disease C o n t r o l , U.S.A., considers tuberc u l o s i s to be the most serious public health problem with the present wave of Indochinese refugees.  They report a survey i n  mid-1980 that showed a prevalence of 926 per 100,000 refugees based on the number of cases ( a c t i v i t y unspecified)added to the tuberculosis r e g i s t e r s in the p a r t i c i o a t i n g areas.  Of the 920 reported cases 47%  had been recognised overseas, on the basis of X-ray abnormalities; 18% were known not to have been " c e r t i f i e d as having active or i n a c t i v e disease, and 35% were of unknown c e r t i f i c a t i o n status. (243) that 53% were diagnosed a f t e r t h e i r a r r i v a l in the U.S.A.  This means  A similar  pattern could possibly develop with the refugees in Canada. The prevalence rate f o r 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 f o r  the Vietnamese population.  Continual s e n s i t i z a t i o n by contact with the  tubercle b a c i l l u s gives some resistance to the disease, and a decrease in exposure because of the d e c l i n i n g number of a c t i v e cases in the community means that more of the population become susceptible to that b a c i l l u s . This has happened in Canada.  The r i s k to the Canadian public  health i s from the increase in the s i z e of the r e s e r v o i r of tuberculosis in the community with the inflow 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 b a c 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 Vietnamese  people.  The m a j o r p r o c e d u r e s the t u b e r c u l i n  skin  test;  for  chest  the d i a g n o s i s  X-rays;  o f sputum and g a s t r i c w a s h i n g s , w i t h diagnosis  and r e v e a l  i n the examination or of culture  the d i s e a s e , tool  smears.  (tuberculins),  sensitivity  screening device as w e l l  an i n t e r n a t i o n a l (Purified  for accurate areas  if  this  If positive  are sources  Derivative  This  - Standard)  skin  results  in  tested, that in  the c h i l d r e n  i n a community  'at  surveillance  of tuberculosis;  I n d i a n and I n u i t  the  test  is  an  suspected of  used,  skin,  having  inexpensive patterns  established  PPD-S  (245), which should of screening  is  in  allow  different  used.  i n a c o m m u n i t y show a h i g h p e r c e n t a g e  when s k i n  of infection  the  this  indicates  community, i . e .  their risk'  but i t  sputum. is is  thus  used  of M tuberculosis  of tuberculosis  the t u b e r c u l i n  of the  the c h i l d r e n  confirm  into  H e a l t h O r g a n i z a t i o n has  have been e x c r e t i n g b a c i l l i  Native  products  when i n j e c t e d  reaction.  standardized tuberculin  reactions  Certain  surveillance  standard for  comparision  examination  of these to  as b e i n g a s a f e a n d r e a s o n a b l y  The W o r l d  Protein  culture  f o r the i n d i v i d u a l  f o r .the e p i d e m i o l o g i c a l  i n the community.  and m i c r o s c o p i c  are  t h a t d i d n o t show* up w i t h t h e s t a i n i n g  of d i r e c t  extracts  produce a s p e c i f i c important  bacilli  of tuberculosis  that  of  there  p e r s o n s who a r e  or  Regular screening  of  a valuable  tool  used i n Canada o n l y  communities where t h e p r e v a l e n c e  of  in in  the  109 tuberculosis i s much higher than i n the general population.  Table 1  shows surveys o f c h i l d r e n i n Viet-Nam and i n selected groups of Indochinese refugee children in the U.S.A.  Although the numbers  examined i n the 1979 samples are s m a l l , the percentage of children with p o s i t i v e reactions in these i s l a r g e r than in the e a r l i e r groups.  This could mean that overcrowding and under-nutrition  in the camps i n Southeast Asia have helped to spread the disease. Attempts were made i n the 1950s, 1960s, and e a r l y 1970s, in both North and South Viet-Nam, to prevent the spread of t h i s disease, but they were neither consistent nor u n i v e r s a l . (246) . (247). In South Viet-Nam immunization of the children was attempted with the BCG ( B a c i l l u s Calmette Guerin): as t h i s often leaves no scar i t i s impossible to know how many children were vaccinated. procedure can a f f e c t the r e s u l t s of the skin t e s t s , although indurations of over 10mm are considered evidence of i n f e c t i o n rather than immunization.  This  110  Studies showing the number [%) of Indochinese c h i l d r e n tested who were t u b e r c u l i n p o s i t i v e . >10mm.  Table 1  Study  Ages  Number examined  Number {%) P o s i t i v e . 5-10mm  1.  Viet-Nam 1967  0-14  12,980  1 ,647 (18.2) >8mm  2.  Guam 1975 Refugees.  0-14  24,351  3,022 (12.4)  3.  Washington 1979. Refugees.  0T18  45  10 (22.0)  4.  Utah 1979 Refugees  0rl4  136  40 (29.4)  5.  San Francisco 1979 Refugees.  0-18  333  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. I b i d . 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 s k of breakdown of old tubercular disease i s higher among Southeast Asians than i n 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 b e ' a t 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 s p e c i f i c drugs used in various combinations f o r periods of one to two years. Drugs may also be used p r o p h y l a c t i c a l l y where former treatment i s considered to have been inadequate, and with people who have been in close contact with an a c t i v e case of tuberculosis and whose s k i n - t e s t s have subsequently changed from negative to p o s i t i v e .  In Southeast  Asia a l l primary and secondary a n t i - t u b e r c u l a r drugs are sold without p r e s c r i p t i o n . (250)  A survey in Viet-Nam showed that 71% of M  tuberculosis were r e s i s t a n t 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  i n the treatment of tuberculosis and the resistance of the organism isevidence of i n d i s c r i m i n a t e use of drugs without supervision. Drugs s e n s i t i v i t y w i l l be an important f a c t in the treatment of tuberculosis o r i g i n a t i n g from Viet-Nam. A major f a c t o r with tuberculosis in Canada due to t h i s immigration i s the increased i n the s i z e of the r e s e r v o i r with the attendant increased r i s k ' to the Canadian population. This i s complicated by the drug resistance of the organism, and the tendency of i n a c t i v e disease  112 to breakdown under s t r e s s .  I t was seen e a r l i e r i n t h i s thesis that  migration can be s t r e s s f u l , and that involuntary migration more so. This i s d e f i n i t e l y a public 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 i n a c t i v e f o r one year may enter Canada on a M i n i s t e r ' s Permit that i s conditional on continuing s u r v e i l l a n c e (follow-up) and possible f u r t h e r treatment. There are 27 Vietnamese in B r i t i s h Columbia under t h i s Permit, and these are not considered to be a r i s k to Canadians because they are known.  I t i s the unknown cases of the disease that are the  problem. Because of the increased r i s k to the public health inherent in the i n f l u x of large numbers of immigrants from an area with a high prevalence of t u b e r c u l o s i s , measures have been taken by the B r i t i s h Columbia p r o v i n c i a l government to monitor the situation.  As mentioned e a r l i e r , there i s a special c l i n i c f o r  these immigrants in Vancouver.  A spokesperson f o r t h i s  clinic  indicated that three cases of active tuberculosis have been discovered among approximately 6000 Vietnamese refugee/immigrants. One was a case of a 'wrong' chest X-ray f i l m at the medical examination in Hong Kong; and the others were two children i n a  113  family with no other evidence of tuberculosis in the family members. These were found through a s k i n - t e s 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 f o r Canada as a whole, and indicates that tuberculosis among these refugees could become a public health hazard. Some 300-400.Vietnamese in Vancouver, with a t u b e r c u l i n reaction (skin t e s t ) of diameter greater than 15mm, have been placed on prophylactic drug therapy.  However, there i s much  discussion about the effectiveness of t h i s . Against the obvious benefit of preventing the breakdown of quiescent disease, i t s .. presence indicated by the tuberculin r e a c t i o n , must be weighed the p o s s i b i l i t y that i n t e r m i t t e n t treatment r e s u l t i n g from noncompliance with the drug regimen and/or poor s u p e r v i s i o n , w i l l produce a s t r a i n of bacteria r e s i s t a n t to one or more of the treatment drugs. There i s no question that there must be longterm s u r v e i l l a n c e , f o r f i v e years at l e a s t ; the question i s what i s the best way to accomplish this?.  V i r a l diseases H e p a t i t i s B. A recent study has shown that the prevalence of asymptomatic H e p a t i t i s B antigenemia among the Vietnamese refugees i s estimated at 13% while the prevalence of t h 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 i n d i v i d u a l i s a possible source of i n f e c t i o n . Man, and possibly chimpanzees, are the only known r e s e r v o i r s , and the incubation period i s from 50-180 days.  The mode of transmission  i s by parenteral inoculation with infected human blood and blood products e i t h e r by contamination of wounds and l a c e r a t i o n s , 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 ' a t r i s k  1  from t h i s i n f e c t i o n are d e n t i s t s , doctors, and health care personnel who give d i r e c t care to p a t i e n t s . 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 H e p a t i t i s B had entered Canada since 1972 "without  causing an obvious r e s u l t a n t 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 H e p a t i t i s B f o r 1980 compared with 690 on the same date in 1979, (257) an increase of 22%.  No reason  f o r t h i s i s suggested; however, the above inflow of immigrants must have increased the r e s e r v o i r of the disease in t h i s country and so increased the r i s k to the Canadian p u b l i c . Screening of the Vietnamese refugees in order to i d e n t i f y those carrying the antigen was started in December 1979 a f t e r some lobbying by the dental profession. (258)  I t was intended that  115  information on the carriers; would  be a v a i l a b l e at the p r o v i n c i a l  departments of health.; however, there have been negative reactions from the provinces because of the need to process and store t h i s information. Other groups in the Canadian population who have a high rate of i n f e c t i o n with H e p a t i t i s B are doctors and d e n t i s t s , and any s i n g l i n g out of Vietnamese refugees per se, as being a r i s k to health personnel could be construed as d i s c r i m i n a t i o n on r a c i a l grounds. • Preliminary r e s u l t s of a screening project in Vancouver show that many of the Vietnamese who previously demonstrated the antigen HBgAg in t h e i r body have now produced t h e i r own antibodies, and are no longer a potential source of i n f e c t i o n .  It may be  that the prevalence of H e p a t i t i s B antigenemia in the Vietnamese w i l l eventually f a l l to that of Canada as a whole.  However,  precautions against the spread of the disease must be continued.  P a r a s i t i c diseases P a r a s i t i c i n f e c t i o n s are almost universal in the people of-Southeast A s i a , with 75% of rural and 56% of urban Vietnamese found to harbour one or more. (259)  In countries of s i m i l a r problems  116  of s a n i t a t i o n over 50% of the population are i n f e c t e d . (260) The transmission of most parasites i s favoured by e i t h e r poor s a n i t a t i o n methods with promiscous defaecation and lack of personal hygeine, or a taste f o r uncooked foods.  Many parasites are already  present i n Canada,-and there are r e l a t i v e l y few that could be transported from Viet-Nam and become established here.  However,  Giardia lamblia and Entamoeba h i s t o l y t i c a could be a p u b l i c health problems. Infection 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 c y s t s ; and endemic spread i s by f l i e s , vegetables contaminated with faeces containing c y s t s , and the s o i l e d hands of food handlers. The r e s e r v o i r i s usually  an asymptomatic person who can excrete the  cysts f o r years; and the incubation period i s from 2-4 weeks. The person with acute amoebiasis i s not highly i n f e c t i o u s due to the f r a g i l i t y of the trophozoites excrete  at that time. Possible  complications of i n f e c t i o n with E h i s t o l y t i c a are amoebic l i v e r abscess, and more r a r e l y amoebic p e r i c a r d i t i s .  (261)  G i a r d i a s i s , i n f e c t i o n with G l a m b l i a , i s often asymptomatic although i t can produce g a s t r o - e n t e r i c symptoms.  There i s a higher  incidence in children than in a d u l t s , and a higher prevalence in areas of poor s a n i t a t i o n .  The diagnosis may be confused with many  117 others; and untreated, i t i s a d e b i l i t a t i n g c o n d i t i o n . There, are endemic f o c i of amoebiasis and g i a r d i a s i s parts of Canada (262), other areas.  in  which means that new f o c i could s t a r t in  It was also found that immigrants tend to keep  t h e i r parasites (263) which could be due to the f a m i l i a r i t y and acceptance of parasitemia as a f a c t of l i f e in t h e i r homeland; or to embarassment; or to resentment of perceived persecution by a u t h o r i t i e s in t h i s country. It can be seen from Table 2 that the prevalence rates f o r E h i s t o l y t i c a in selected groups of Vietnamese are s i m i l a r to those in the U.S.A.; while the rates f o r G Iambiia are higher. Assuming that the Canadian prevalence rates f o r these i n f e c t i o n s are s i m i l a r to those in the U.S.A., then there may be a s l i g h t r i s k to Canadians from the increase in the s i z e of the r e s e r v o i r with the inflow of the refugees.  The r i s k to the public health can come from  infected and unhygeinic food-handlers, and in i n s t i t u t i o n s such as daycare centres and schools where c h i l d r e n are i n close proximity. These conditions w i l l need accurate diagnosis and treatment because of t h e i r d e b i l i t a t i n g e f f e c t s on the i n d i v i d u a l rather than the r i s k 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 f o r Vancouver Health Department.  118 TABLE 2 Rates of i n f e c t i o n 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  1. A l l ages. U.S.A. Refugees. Sept. 1975 2. A l l ages. Canada Refugees (volunteers) 1976-77.  Number examined 1077  E histolytica number (%) -  G lamblia number {%)  (2.2)  -  (8.2)  75  7  (9.3)  10(13.5)  3. A l l ages. U.S.A. Refugees. Feb. 1979  165  3  (2.0)  29(18.0)  4. A l l ages. U.S.A. Refugees. 1979.  356  3  (1.0)  16( 4.0)  31  --  5. Children 0-18. U.S.A. Refugees 1979. 6. U.S.A. (estimated)  —  (1.5-9.5)  6(19.0) ( 5.0)  * There are no national data f o r Canada: a National Data Bank f o r P a r a s i t i c Diseases i s in the process of being b u i l t .  Sources: 1.  " I n t e s t i n a l Parasites among IndoChinese Refugees." MMWR 24(January 22 1975): 398,403.  2.  "Natural loss of i n t e s t i n a l parasites of Vietnamese immigrants following entry to Canada." Can Pis Weekly Rep 2 ( A p r i l 24 1976) :65.  3.  "Survey of I n t e s t i n a 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. I b i d . p.9. "Survey of Vietnamese Refugees f o r I n t e s t i n a l Parasites in the U.S.A." Can Pis Weekly Rep (March 27 1976):51.  5. 6.  119  INFECTIOUS DISEASES THAT ARE A THREAT TO THE INDIVIDUAL REFUGEE Bacterial. Hanson's Disease.  Leprosy i s a chronic and only m i l d l y  communicable disease with a long incubation period probably averaging 3-5 years.  Man i s the  only known r e s e r v o i r , and the mode  of transmission has not been d e f i n i t e l y e s t a b l i s h e d . data about the but i t s  Reliable  prevalence of t h i s disease i n the world are l a c k i n g ,  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 i n Canada (266) g i v i n g a prevalence rate of 0.3/100,000. (267) 39 d e f i n i t e 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 d u r i n g the next decade because of the" long incubation p e r i o d . Leprosy i s g r e a t l y feared, and refugees'may deny symptoms or that .there i s a family h i s t o r y of the disease f o r fear of deportation.  It i s only m i l d l y contagious to close family contacts,  and i s not considered to be a public health hazard.  However, the  more a c t i v e and contagious type, Lepromatous leprosy, needs treatment  120 to prevent disab.il i t y and disfigurement.  The public as. well as  health, professionals need to be reminded that leprosy i s not highly contagious, as fear could provoke v i o l e n t reactions against the Vietnamese in Canada. Melioidosis.  Endemic in Viet-Nam and extremely rare in the  western hemisphere, t h i s i s a disease whose symptoms may simulate those of tuberculosis and which should be kept in mind "in any unexplained suppurative disease, e s p e c i a l l y c a v i t a t i n g pulmonary disease, in a patient l i v i n g or recently returned from Southeast A s i a . " ("269)  In some parts of Southeast Asia the prevalence of  a c t i v e and i n a c t i v e disease i s estimated to be as high as 30%.(270) The r e s e r v o i r i s in animals, and i n f e c t i o n probably comes from contact with contaminated water and s o i l .  The incubation period can be months  or even years; and untreated, the m o r t a l i t y rate i s high.  Because  secondary cases, i . e . d i r e c t transmission from man to man, are exceedingly rare t h 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, t h i s chronic relapsing disease i s unevenly d i s t r i b u t e d in the rural  tropics  and subtropics where there are low standards of hygeine. I t i s present in Southeast Asia in s p i t e of attempts at e r a d i c t i o n , and "as the i n f e c t i o n r a p i d l y returns to high endemicity i f s u r v e i l l a n c e f a i l s " (27) i t may be assumed that the war has  121 encouraged i t s r e t u r n .  The r e s e r v o i r i s man, and transmission i s  c h i e f l y by d i r e c t contact with exudates of early skin lesions of infected persons.  The incubation period i s from two weeks to  three months, and the period of communicability may extend i n t e r m i t t e n t l y over several years while moist lesions are present. Yaws i s usually acquired in childhood, and thus cases could be seen among the refugees. This i s not a public health hazard, and i s e a s i l y cured once diagnosed: apparently no cases have been recognised among the refugees in B r i t i s h Columbia.  P a r a s i t i c Diseases.  Helminths.  Some i n t e s t i n a l worms f o r example Strongyloides  s t e r a c o r a l i s , complete t h e i r l i f e - c y c l e in man.  Because of the  capacity f o r a u t o - i n f e c t i o n , t h i s condition should be treated as soon as diagnosed as the worms can spread throughout the body causing acute as well as chronic  illness.  Other helminths, such as Ascaris 1umbricoides, T r i c h u r i s t r i c h u 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 s o i l before entering the human body through the skin to complete t h e i r l i f e - c y c l e .  Man i s the r e s e r v o i r , and  these parasites need the appropriate c l i m a t i c conditions with low standards of s a n i t a t i o n and hygeine to f a c i l i t a t e t h e i r spread. Only hookworm i s known to spread in temperate climates. (272)  122  The incubation periods of these vary, but c a r r i e r s can excrete eggs or cysts; in t h e i r faeces f o r years; and although not usually f a t a l these conditions can cause chronic i l l health in areas where r e - i n f e c t i o n is possible. Studies in selected groups of Vietnamese refugees show that rates of i n f e c t i o n vary (see table 3).  According to a spokesperson f o r  the Vancouver Health Department, approximately 50% of the Vietnamese immigrants in Vancouver have helminth i n f e c t i o n s ; with Ascaris lumbricoides and t r i c h u r i s t r i c h u r i a being most common, and with some hookworm diagnosed. With high standards of s a n i t a t i o n i n t h i s country, the c l i m a t e , and the f a c t that Canadians do not usually go barefoot, there i s l i t t l e r i s k to Canadians from hookworm.  As the developmental  cycle f o r the other helminths cannot be completed in Canada, there i s no chance of r e - i n f e c t i o n and parasitemia w i l l eventually die out among the Vietnamese.  However, there i s the need to t r e a t t h i s  condition when diagnosed. Protozoa. Leishmaniasis (Kala azar) i s a protozoal disease widely spread in t h e . t r o p i c a l and subtropical areas of the world.  The known reservoirs include man, canines, c a t s , and w i l d  rodents; the transmission i s by the b i t e of an i n f e c t i v e sandfly. Direct transmission from person to person by blood transfusion and sexual contact has been reported.  The incubation period i s  usually from 2-4 months but may range from 10 days to two years; and untreated, t h i s chronic and communicable disease i s usually highly f a t a l .  The treatment drug i s highly t o x i c , and must be  Table 3  Helminth i n f e c t i o n i n s e l e c t e d groups o f Indochinese  refugees  I n f e c t i o n s Group  Number examined  Ascaris Lumbricoides Number (%)  Hookwork Number(%)  1. A l l a g e s . 1975  1077  328 (30.5)  44 ( 4 . 1 )  2. A l l a g e s . 1979  165  14 ( 9.0)  106(64.0)  3. A l l a g e s . 1979  356  44  4.  C h i l d r e n 0-18 1979  31  (12.0)  14 (45.0)  25 ( 7 . 0 )  Chioriorchis sinensis Number (%)  Trichuris trichiura Number (%)  97  (9.0)  20 (12.0)  6(2.0)  31 ( 9 . 0 )  1(3.0)  3 (10.0)  Source: 1 " I n t e s t i n a l P a r a s i t e s among Indochinese Refugees." MMWR 24 (November 22 1975): 398, 403. 2. "Survey o f I n t e s t i n a l P a r a s i t e s - I l l i n o i s . " MMWR 28~(July 27 1979):346. 3. " H e a l t h Screening of R e s e t t l e d 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 f o r Disease C o n t r o l , A t l a n t a , U.S.A. With the absence of both a large r e s e r v o i r of the parasites and the s p e c i f i c vector in Canada t h i s w i l l not be a public health hazard but a problem of diagnosis and treatment.  It has not been  seen to date among the Vietnamese i n B r i t i s h Columbia.  Cutaneous  Leishmaniasis (Oriental sore) does not occur in Southeast A s i a . Flukes.'  Schistosomiasis ( B i l h a r z i a s i s ) in Southeast  Asia i s i n f e c t i o n with Schistosoma japonicum, a blood f l u k e with both male and female worms l i v i n g in the veins of the host.  Animals  as well as men are epidemiologically important hosts,a vector s n a i l . i s required, and transmission i s by contact with water contaminated with l a r v a l forms (cercariae) that penetrate the s k i n .  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 i s not a public  health hazard in Canada as there are no vector s n a i l s here f o r the species a f f e c t i n g man.  This w i l l be a problem of diagnosis and  treatment, and t h i s f l u k e has not been seen to date among the Vietnamese i n B r i t i s h Columbia. Paragonimiasis.  The lung f l u k e , Paragonimus westermani,  requires an intermediate host and ingestion of raw or p a r t l y cooked freshwater crabs or c r a y f i s h containing encysted larvae f o r i t s spread. The r e s e r v o i r i s man, and the parasite cannot be transmitted  125 d i r e c t l y from man to man.  I t i s endemic throughout Southeast A s i a ,  and the problem i n Canada w i l l be the d i f f i c u l t y of a d e f i n i t i v e diagnosis as t h i s may be confused with t u b e r c u l o s i s .  The  s p e c i f i c treatment drug i s Bithlonol which must be obtained from the P a r a s i t i c Drug Service i n A t l a n t a , U.S.A.  I t has not been  recognised to date among the Vietnamese refugees in B r i t i s h Columbia. Clonorchiasis.  This l i v e r f l u k e , Clonorchis s i n e s i s , i s  endemic in Viet-Nam and requires the ingestion of contaminated f i s h f o r 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 s n a i l and the appropriate f i s h . This parasite w i l l not be a public 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. M a l a r i a . This i s also a p a r a s i t i c disease: i t i s no longer endemic in temperate zone countries but i s a major cause of ill  health in the t r o p i c s and subtropics.  However, there i s concern  in North America at the increasing number of cases appearing here. There are four types of t h i s disease in humans: vivax or benign t e r t i a n malaria (Plasmodium v i v a x ) ; quartain malaria (P malariae); falciparum or malignant t e r t i a n malaria (P falciparum); and the less common ovale malaria (P ovale) seen only i n West A f r i c a . Mixed i n f e c t i o n may occur in endemic areas and as the symptoms are  126 s i m i l a r for a l l types, a d i f f e r e n 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  essential as f a t a l complications may occur with P falciparum due to the rapid destruction of the red blood c e l l s as the gametoeytes develop and spread.  The case f a t a l i t y rate f o r falciparum malaria among  untreated c h i l d r e n and non-immune adults exceeds 10%. This i s 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 r e s e r v o i r i s man  and possibly the higher apes; and transmission requires a female vector mosquito.  The mosquito becomes i n f e c t i v e 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 w i t h i n 8-35 days depending on the species of parasite and the temperature to which the vector i s exposed.  These sporozoites concentrate in the s a l i v a r y gland and  are i n j e c t e d into man as the mosquito takes another blood meal.  The  incubation period varies from 12 to 30 days, again depending on the species of p a r a s i t e , but with P vivax t h i s may be 8-10 months. In the susceptible host, the gametoeytes usually appear in the blood w i t h i n 3-14 days a f t e r the on-set of symptoms, according to the species of p a r a s i t e . The mosquito remains i n f e c t i v e f o r the rest of her l i f e - a few days or a month or so - and man i s  infective  i n d e 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 i m a t i c conditions f o r the spread of malaria in parts of North America. The l a s t d e f i n i t e 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 C a l i f o r n i a in the 1970's, when i t was- suspected that the l o c a l mosquitoes became i n f e c t i v e 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 r a v e l l e r s returning from the t r o p i c s 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 c e r t a i n (unstated) parts of the western provinces.(278) Given a large enough r e s e r v o i r of the disease and the r i g h t c l i m a t i c c o n d i t i o n s , malaria could possibly become r e - e s t a b l i s h e d where there i s an appropriate vector. Malaria may also be spread through i n j e c t i o n or transfusion of blood from an infected person, or by sharing needles during drug use. (279)  illicit  I t 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 i n malarial areas. (280) P malariae i s 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 i s 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 - s p a n . These, with P vivax, were c i t e d in a discussion of t r a n s f u s i o n induced m a l a r i a . (281) The areas of Viet-Nam that are most heavily 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% i n 1975 (282) and t h i s may have been due to the f a c t that the majority of those refugees had come from the urban areas that are not infected.  If t h i s i s the case with 'the Boat-people  1  i t means that  the new r e s e r v o i r of the disease i n Canada w i l l be s m a l l ; and further more, i t w i l l be d i l u t e d by the spreading of the refugees across the country. The chances of a mosquito becoming i n f e c t i v e are further reduced by the f a c t that the areas of Canada that are plagued with mosquitoes have screened doors and windows which again reduce the opportunity f o r mosquitoes to take a blood meal from an infected person. There has been a s l i g h t increase in the incidence of malaria in Canada that i s thought to be due to Canadians t r a v e l l i n g i n i n f e c t e d areas without taking the prophylatic drugs.  The  threat to the public 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 i s t o r y 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 v e d in areas where malaria in endemic, and who may or may not have taken a n t i - m a l a r i a l drugs and have never had m a l a r i a , 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 s k to the public from t h i s source. The problem w i l l be the need f o r f a s t 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 following are included in t h i s chapter because of the p u b 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 r e s e r v o i r 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 l e s s e r extent through contaminated food, s o i l e d hands, and flies.  I t i s widespread in Southeast A s i a .  The incubation  130 period is, from a few. hours to f i v e days., and i t has been reported in a refugee ' i n t r a n s i t ' between Southeast Asia and C a l i f o r n i a . (283)  However, t h i s has been an i s o l a t e d occurance, and cholera  i s u n l i k e l y to become a problem with the refugees. Plague.  S y l v a t i c , or w i l d rodent plague, i s known to  e x i s t in the western t h i r d of the U.S.A. of the world including Southeast A s i a .  as well as in large areas In the U.S.A. plague in  man i s l i m i t e d and sporadic f o l l o w i n g exposure to the rodents or t h e i r f l e a s .  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 usually f a t a l . are the natural r e s e r v o i r of t h i s disease.  Wild rodents  Bubonic plague i s  transmitted by the b i t e of an i n f e c t i v e (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 p r i o r to t h e i r departure from an area where there i s an epidemic of pulmonary plague, t r a v e l l e r s s h a l l be placed in quarantine f o r s i x days a f t e r l a s t exposure, and may be kept under s u r v e i l l a n c e f o r not more than s i x days a f t e r a r r i v a l at t h e i r d e s t i n a t i o n .  The refugees  are coming from camps in Malaysia, Hong Kong, and Indonesia a f t e r some months residence there. (285) in these areas has been found.  No mention of plague  Given these factors and the short  incubation period, i t i s seen as u n l i k e l y that plague w i l l be a  131  problem with, the refugees.  Certain ' e x o t i c ' diseases.  I t i s possible that t h e i r  incubation period of 5-15 days may allow c e r t a i n ' e x o t i c '  viral  diseases to produce symptoms a f t e r the a r r i v a l of the refugees although t h i s i s u n l i k e l y .  They are Dengue; Japanese  B e n c e p h a l i t i s which i n f e c t s man only i n c i d e n t a l l y but which i s associated with a m o r t a l i t y rate of over 80%; scrub typhus; and Chikungunya (haemorrhagic disease).  F i l i a r i a s i s i s the i n f e c t i o n with the nematode worm and m i c r o f i l a r i a e of Wucheria bancrofti or Brugea malayi in Southeast A s i a .  A long exposure and heavy parasitism 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 e d to f i n d i n f e c t i o n in residents of Saigon or in a d i s t r i c t of the Mekong D e l t a . (286) As the refugees are apparently coming from the urban areas of the lowlands t h i s disease should not be a problem among them.  Leptospirosis.  Endemic in Southeast A s i a , t h i s  spirochete only i n c i d e n t a l l y i n f e c t s man through his contact with water, s o i l , or vegetation contaminated with the urine of infected animals.  The r e s e r v o i r includes many farm animals,  132  rodents and other w i l d animals.  The incubation period i s  4-19 days so symptoms could manifest themselves a f t e r the a r r i v a l of the refugees.  Direct transmission from man to man  i s n e g l i g i b l e , and untreated the m o r t a l i t y 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 ' e x o t i c ' the ' o r d i n a r y ' i n f e c t i o u s disease should not be overlooked. (287). Because of the m a l n u t r i t i o n and s t r e s s , and the e f f e c t s of war and f l i g h t , the refugees may be more susceptible to i n f e c t i o u s diseases common in Canada.  Measles can be  p a r t i c u l a r l y devastating in a population with l i t t l e or no immunity to the disease; and diphtheria c a r r i e r s have been found among the refugees in the U.S.A. (288) It was found that of 45 refugee children screened w i t h i n 10 days of t h e i r a r r i v a l in Washington, D . C , less than h a l f (44%) had any previous h i s t o r y of medical care, and immunization against the 'common' i n f e c t i o u s diseases was minimal. (289)  Besides giving  them p r o t e c t i o n , immunization of the refugee c h i l d r e n w i l l reduce  133 the pool of susceptible c h i l d r e n 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 i n f e s t a t i o n s . (290) (291)  These w i l l l i k e l y have been cleared up  before c h i l d r e n go to school here, but t h i s could become a problem where c h i l d r e n are in close contact.  NON-INFECTIOUS DISEASES AND CONDITIONS  Malnutrition.  M a l n u t r i t i o n was noted among Vietnamese  c h i l d r e n by Vennema in 1968 (292); and was observed in children evacuated to A u s t r a l i a (27%), (293) and the U.S.A. (11%).  (294)  I t may be assumed that i t i s widespread s t i l l  in Viet-Nam as a .  r e s u l t of the s o c i a l upheaval since the war.  Children are most  susceptible to protein-energy m a l n u t r i t i o n which causes stunted growth and anemia.  Other forms of m a l n u t r i t i o n may be vitamin  d e f i c i e n c i e s causing scurvy due to lack of vitamin C; beri beri due to lack of vitamin B; and r i c k e t s due to lack of vitamin D.  A survey of the n u t r i t i o n a l status of selected groups of Southeast Asian refugee c h i l d r e n - i n the U.S.A. has revealed anemia  134  and stunted growth to be the major n u t r i t i o n - r e l a t e d problems. (295)  The report suggested that there i s a need f o r awareness of  the problems of acute under-nutrition and anemia by health care workers, but comments that the i n i t i a l high prevalence of these conditions may r e f l e c t the impact of a d i f f i c u l t adjustment period f o r these c h i l d r e n on American d i e t s f o r the f i r s t time.  Some of the Vietnamese c h i l d r e n a r r i v i n g i n Vancouver during 1979-80 were observed to be rather t h a i n , but soon gained weight.  No screening program was i n i t i a t e d .  The babies born in  t h i s country are "a good s i z e " according to a spokesperson for/the Vancouver Health Department.  G e n e t i c a l l y determined c o n d i t i o n s .  More than 90% of  Southeast Asians cannot digest lactose (milk sugar). (296) Gastro-enteric symptoms after, drinking milk a r e " i n e v i t a b l e in subjects over nine years of age, with 50% of l a c t o s e - i n t o l e r a n t c h i l d r e n under that age developing diarrhea.  Six of 114 Vietnamese  c h i l d r e n evacuated to A u s t r a l i a in 1975 and between the ages of one week and s i x y e a r s , were i n t o l e r a n t of l a c t o s e . (297) Awareness of t h i s apparently c u l t u r a l l y determined condition i s e s s e n t i a l f o r health personnel, e s p e c i a l l y those concerned with n u t r i t i o n and health education.  135  There has been no evidence of severe lactose intolerance among the refugees in Vancouver although the problem i s known. Advice i s given to f a m i l i e s on the gradual introduction of milk into t h e i r d i e t s . The d i s t r i b u t i o n of g e n e t i c a l l y determined r e d - c e l l defects i s possibly linked to the d i s t r i b u t i o n of malaria in the world.  The prevalence of Thalassaemia in Viet-Nam i s estimated  as 1-5%; of Haemoglobin E 2-8%; and 61ucose-6-phosphate dehydrogenage d e f i c i e n c y (G6PD. def) as 2-6%. (298)  These  are not important per se, but people with G6PD d e f i c i e n c y may experience mild to severe hemolysis during primaquine therapy f o r malaria. (299)  Haemolytic anaemia f o l l o w i n g administration of  trimethoprim-sulfamethorxazole  (Bactrin and Septra) has been  noted i n some Asians with G6PD d e f i c i e n c y . (300)  This  knowledge appears to be e s s e n t i a l f o r physicians who are or w i l l be t r e a t i n g Vietnamese refugees, but information on the prevalence of these conditions i s not a v a i l a b l e .  Tropical Sprue.  This i s a primary mal-absorption syndrome  of unknown and possibly multiple aetiology 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 m o r t a l i t y 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 " s u r p r i s i n g l y 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 e a r l y due to the pre-adolescent onset of c i g a r e t t e smoking and a high prevalence of smoking in general. (304)  No good data are a v a i l a b l e 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 d e f o l i a n t "Agent Orange" during the war w i l l have increased the r i s k 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 l a s s i c a l rheumatoid a r t h r i t i s rare. (306)  is  Otherwise i t may be assumed that there w i l l be a r i s e  in the incidence of the s o - c a l l e d '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 t h e i r l i f e - s t y l e to that of North America. c u l t u r a l l y determined condition that  A  may be seen i s ' l i n e a r b r u i s i n g '  that resembles trauma.  The Vietnamese have a lay p r a c t i c e of  coin-rubbing of several symptoms including fever and headaches which could r a i s e the spectre of c h i l d battering in western minds (307)  This chapter may be summarized as f o l l o w s :  138 Public health threat  Infectious diseases endemic in Viet-Nam  *bacterial enteric disease  . L i t t l e or no public health threat cholera plague STD  Threat to the individual refugee bacterial enteric disease  *tuberculosis  tuberculosis  *hepatitis B  hepatitis B Hanson's Disease  giardiasis amoebiasis malaria (transfusion induced) l i c e , scabies, fungal skin i n f e c t i o n s  helminths protozoa blood and t i s s u e parasites l i c e , scabies, fungal skin infections 'common i n f e c t i o n s 1  melioidosis yaws Non-infectious diseases and conditions  malnutrition g e n e t i c a l l y determined diseases t r o p i c a 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 v a 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 t h i s t h e s i s .  Apart from the f a c t that strained  r e l a t i o n s between a host population and an immigrant minority can cause stress that u l t i m a t e l y a f f e c t s h e a l t h , i t i s the various aspects of the physical health problems that are of concern in t h i s chapter. Because they are coming from an area of the world with d i f f e r e n t disease patterns, the a r r i v a l of the Southeast Asians w i l l increase the s i z e of the r e s e r v o i r of t u b e r c u l o s i s , h e p a t i t i s B, and b a c t e r i a l e n t e r i c disease in the t o t a l Canadian population and thus increase the r i s k of Canadians acquiring 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 i n f e c t i o u s and  ' e x o t i c ' diseases w i l l put a s t r a i n on e x i s t i n g health care f a c i l i t i e s by increasing the demand f o r public health s u r v e i l l a n c e s e r v i c e s , and f o r 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 f o r the i n i t i a l health of immigrants, but the provinces are responsible f o r t h e i r health once s e t t l e d , and there are problems a r i s i n g from t h i s s p l i t  responsibility.  Normally the prospective immigrant i s 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 f o r those over the age of eleven, and examination of blood, urine and s t o o l .  The p o l i c y of family r e - u n i f i c a t i o n means that on  occasion a would-be immigrant i s admitted to Canada on a ' M i n i s t e r ' s Permit' where landed immigrant status i s deferred and dependent on treatment and/or s u r v e i l l a n c e f o r a s p e c i f i c disease.  The aim of the  medical examination as part of the immigration process i s to keep i n f e c t i o u s diseases out of Canada and to ensure that immigrants do not become a burden on the s o c i a l and health programs and services of t h i s country. Because of the unusual and emergency s i t u a t i o n in Southeast Asia the pre-immigration medical examination of the refugees was considered to be incomplete and was f i n i s h e d at the p o i n t - o f - e n t r y to t h i s country.  The health documents were then processed i n 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 f o r the health of immigrants as part of t h e i r t o t a l population.  I t i s the r e s p o n s i b i l i t y of the federal Department of  Health and Welfare to inform the appropriate p r o v i n c i a l departments of any health problems associated with a p a r t i c u l a r immigrant, and t h i s process is.known to be slow.  Because the objective of the immigration  medical examination i s to (only) keep i n f e c t i o u s diseases out of Canada, information on the presence of i n a c t i v e disease that could be  141 a future source of i n f e c t i o n to the Canadian public is. not recorded or passed on to the p r o v i n c i a l health departments.  I t i s because  of t h i s , that the p r o v i n c i a l health a u t h o r i t i e s have i n s t i t u t e d programs to re-screen a l l the refugee-immigrants from Southeast Asia in order to obtain baseline data f o r the continuing s u r v e i l l a n c e f o r i n f e c t i o u s diseases.  This process i s complicated by the f a c t  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 f o r the s u r v e i l l a n c e and health needs of these immigrants with s t a f f who are f a m i l i a r with t h e i r language and culture.  I t was found in t h i s thesis that the c u l t u r e of the  ' g i v e r ' as well as that of the ' r e c i p i e n t ' of health care w i l l the outcome of any health care program.  affect  One wonders how s u r v e i l l a n c e  f o r i n f e c t i o u s diseases i s accomplished in more remote areas where there are c u l t u r a l and language b a r r i e r s between health care personnel and the new immigrants? It has also been found in t h i s thesis that there i s a lack of knowledge about t r o p i c a l diseases on the part of health care professionals in countries with more temperate climates.  In Canada  t h i s i s deemed to be the r e s u l t of i n s u f f i c i e n t a t t e n t i o n being given i n medical schools to the epidemiology and prevention of ' e x o t i c ' as well as other diseases of the t r o p i c s . (309) It could  142 also be a r e s u l t of the f a c t that p a r a s 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 U n i v e r s i t y of B r i t i s h Columbia brought the observation that work and t r a v e l in the t r o p i c s by medical students has increased t h e i r awareness of t r o p i c a l diseases, and t h i s has caused a (welcome?) increase in t h e i r i n t e r e s t in parasitology. The problems seen to be associated with the a r r i v a l of these refugee/immigrants are the continuing s u r v e i l l a n c e of i n f e c t i o u s diseases such as t u b e r c u l o s i s , h e p a t i t i s , and b a c t e r i a l e n t e r i c disease, f o r the protection of the public health; the need f o r knowledge on the part of health professionals of diseases and conditions that could cause symptoms and perhaps chronic  ill-health  in these new immigrants; and the need f o r knowledge of the e f f e c t of culture on the d e l i v e r y of health care.  Factors seen to a f f e c t  the r e s o l u t i o n of these problems are the d i f f e r e n t objectives of the federal immigration p o l i c i e s and the p r o v i n c i a l Departments of Health, with a lack of inter-governmental co-ordination of health services f o r immigrants; and c u r r i c u l a f o r educating health care professionals that contain l i t t l e or no teaching on t r o p i c a l diseases or the e f f e c t of c u l t u r e on the d e l i v e r y of health care. I f indeed the present pattern of world migration continues then the need f o r both of the above i s a t r u l y long-term prospect, and not j u s t necessary to deal with the immediate phenomenon of 50,000 refugees from Southeast A s i a .  143 CHAPTER 9 PROBLEMS OF ADJUSTMENT AND MENTAL HEALTH  INTRODUCTION Adaptation to a new environment has been seen to be s t r e s s f u l in one way or another f o r a l l migrants, and t h i s 'normal' stress may be aggrevated f o r the Vietnamese refugees by t h e i r experiences of war and f l i g h t .  There i s a growing l i t e r a t u r e  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 p a r o l e , as t h e i r compatriots in the U.S. were." (310) This f a c t o r may have an e f f e c t on the adaptation problems of the Vietnamese i n 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 i n t o American society in 1975-76, K e l l y noted that  most of them had apparently thought  little  about the s o c i a l or c u l t u r a l consequences of leaving t h e i r homeland.(311)  Housed i n i t i a l l y in ex-army camps, they had time on  t h e i r hands to t h i n k , and while being 'processed' into America were s t i l l surrounded by Vietnamese c u l t u r e : a l l of which probably  144 caused ambivalent f e e l i n g s , and contributed to depression, and anxiety about the f u t u r e . S u i c i d a l attempts and psychotic depressive reactions were reported among some refugees i n U.S. camps (312); and psychosomatic complaints such as headaches, stomach pains and insomnia were reported in another study.(313)  Children expressed t h e i r d i s t r e s s  by somatic complaints, feeding d i s o r d e r s , sleep disturbances, developmental a r r e s t , tantrums, v i o l e n t a n t i - s o c i a l behaviour and marked withdrawl; and the depth of t h e i r depression was i l l u s t r a t e d by t h e i r refusal to learn English.(314)  This i s the  observable ' t i p of the iceberg' i n d i c a t i n g the presence of varying degrees of unhappiness with t h e i r s i t u a t i o n : however, no absolute figures appear to be a v a i l a b l e . These i n i t i a l reactions may have been avoided in Canada by the p o l i c y of a b r i e f period only at the Reception Centres set up f o r the Indochinese refugees in Edmonton and Montreal.  Uncertainty  about the future at t h i s stage i s also avoided as the immigrants do not leave Southeast Asia u n t i l they have a d e f i n i t e d e s t i n a t i o n in Canada, and are o n l y " i n t r a n s i t " a t the Reception Centres. Successful adaptation to a new environment appears to depend at l e a s t p a r t l y on how well needs are met.  The a v a i l a b i l i t y  of s h e l t e r (housing), employment and f i n a n c i a l s t a b i l i t y are dependent on the economic s i t u a t i o n , and North America has been in  145  an economic downswing f o r several years with high l e v e l s 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 c o n t r i b u t i n g 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 n d , and they were often under-employed in the sense that they were not able to use the s k i l l s and q u a l i f i c a t i o n s they had.  In a d d i t i o n ,  the U.S. government p o l i c y was to s c a t t e r them across the country in an attempt to avoid concentration of Vietnamese i n s p e c i f i c areas such as C a l i f o r n i a .  There was considerable public opposition  to r e s e t t l i n g 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 i n f l u x of thousands of new immigrants. There i s s t i l l a n t i - O r i e n t a l f e e l i n g s i n parts of the U.S.A. Even i f there was enough to eat and a roof over t h e i r heads, f u l f i l l m e n t of the need 'to belong' and f o r ' s e l f esteem' would be denied the Vietnamese refugees i n t h i s s i t u a t i o n .  The  sense of a l i e n a t i o n , of f e e l i n g not being wanted by the American people, combined with s o c i a l l y unacceptable employment (by Vietnamese standards) could lead to depression, anxiety, and may be psychotic reactions to t h i s s t r e s s .  146  The r e s u l t s 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 l e v e l of physical and mental dysfunction p e r s i s t i n g into the second year.  This was a t t r i b u t e d to t h e i r refugee status  rather than to c u l t u r a l f a c t o r s . (315) The second part of t h i s study of continuing changes i n l i f e events gives some i n d i c a t i o n of the areas in which the refugees found i n s t a b i l i t y : work, finances, spouse r e l a t i o n s and l i f e - s t y l e . ( 3 1 6 )  This could be  restated as i n s t a b i l i t y i n the process of meeting human needs. I t has been observed that the new habits and customs challenge Vietnamese t r a d i t i o n s in painful ways beginning at the basis of Vietnamese l i f e - the family.  The e l d e r l y have become  a burden rather than to be venerated; t h e i r wisdom i s no longer a p p l i c a b l e , and t h e i r a b i l i t y to adapt i s n e g l i g i b l e .  The r o l e  of the c h i l d r e n i s changing as adults become dependent on them f o r guides and i n t e r p r e t e r s .  They are at thesame time a source of  pride and anxiety as they learn new ways, customs,and values  that  c o n f l i c t with those of t h e i r parents.(317) It was seen e a r l i e r in t h i s thesis that the lack of a sense of i d e n t i t y i n immigrant c h i l d r e n could lead to s o c i a l problems as they grow up and t r y to resolve t h e i r c o n f l i c t s . The Vietnamese are a persevering people, but to maintain t h i s in the face of unemployment, under-employment, and low pay, i s not easy.  147  The p o l i c y of s c a t t e r i n g them across the U.S.A. made t h e i r s o c i a l and c u l t u r a l losses even harder to replace.  It has been found that  a f t e r 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 i m i t s on home occupancy; i n d i f f e r e n c e and disrespect towards old people; absence of f r i e n d l y people with whom to s o c i a l i z e in the daytime; the h e c t i c pace with few breaks i n 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 e a s i l y •  accessible l o c a t i o n ; 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 c h i l d r e n , the widening of the generation gap, and the tug between t r a d i t i o n a l and western values may only be f e l t a f t e r some years, but the studies mentioned above have shown that there may be c o n f l i c t much e a r l i e r .  This would  i n d i c a t e 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 hopefully have enhanced t h e i r chances of adapting s u c c e s s f u l l y .  However, i t has been observed  148  that they had problems s i m i l a r to those of t h e i r compatriots in U.S.A.; unemployment, c u l t u r a l adjustment, l o n e l i n e s s , the language b a r r i e r , a l l compounded by the weather. (319) Canada's p o l i c y regarding the resettlement of t h i s second wave of refugees from Southeast Asia has been to admit them as landed immigrants sponsored by community groups or o r g a n i z a t i o n s , with a matching formula by which the federal government sponsors an equal number to a t o t a l of 50,000.  The immigration c r i t e r i a  are good h e a l t h , and the motivation and s k i l l s to s e t t l e s u c c e s s f u l l y in Canada.  This i s a s e l e c t i v e process  in that  those with obvious health d e f e c t s , e i t h e r physical or mental, w i l l have been 'screened o u t ' . The Canadian sponsors agree to provide food s h e l t e r and f i n a n c i a l support as needed, u n t i l the immigrants become s e l f supporting, or f o r 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 orientate them to community and government s e r v i c e s .  This i s a continuation  of the unwritten p o l i c y of i n v o l v i n g l o c a l communities and voluntary agencies in immigrant settlement; and with t h i s scheme, the government has delegated moral and f i n a n c i a l  responsibility  f o r 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 i n Vancouver, B r i t i s h Columbia.  In an attempt to  149  assess what i s being done to help t h e i r adaptation to the new environment, interviews were conducted with several community (voluntary) agencies and i n d i v i d u a l s involved in t h i s process. As stated e a r l i e r , the sponsors accepted r e s p o n s i b i l i t y f o r a family u n t i l they were s e t t l e d or f o r one year.  One problem  has been the acute shortage of housing i n Vancouver, but t h i s seems to have been overcome with several sponsors sharing t h e i r homes u n t i l an apartment was found f o r t h e i r guests. There have been some humorous and not so humorous misunderstandings about food and its..; preparation, the use of western s t y l e beds, and the d i f f e r e n t western and o r i e n t a l concepts of time and the keeping of appointments. In western eyes being 45 minutes l a t e means a cancelled appointment: in Vietnamese eyes i t i s p o l i t e to a r r i v e 45 minutes a f t e r the appointment time.  Another point of possible misunderstanding i s  the d i f f e r e n t s t y l e s of conversation: westerners f i n d i t very d i f f i c u l t to accept the periods of s i l e n c e , and deep thought that the Vietnamese give to t h e i r answers.  The concept of Sao You  (scratch the wind) or coin-rubbing f o r various health problems has been met by health professionals and has raised the spectre of child-abuse in t h e i r minds. are the everyday  These seemingly small  incidents  facts of c r o s s - c u l t u r a l i n t e r a c t i o n ; and one  wonders how much preparation was given the sponsors, and others working with the refugee/immigrants, i n order to minimise the  150 i r r i t a t i o n and misunderstandings that can a r i s e on both sides in this situation. There are voluntary agencies with the expertise to help sort out misunderstandings but no data to indicate who asks f o r what or in what q u a n t i t i e s .  This supports the contention noted e a r l i e r  in t h i s 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 f o r the  resettlement of the  refugees in Vancouver, "The C i t y of Vancouver Task Force on Vietnamese Refugees", was disbanded in November 1980, so i t has not been possible to obtain e i t h e r an overview of the s i t u a t i o n or more s p e c i f i c data from t h i s source. Lack of knowledge of the English language has c e r t a i n l y been a b a r r i e r to employment, and those who can speak English appear to be s e t t l i n g down and obtaining employment much f a s t e r than those who do not know the language.  Many are under-employed  because of the language problem and/or because t h e i r professional and technical s k i l l s are not recognised in t h i s country. One comment heard was that professional and technical organizations could do more towards helping with t h i s problem.  There i s misunderstanding  on the part of some employers of the immigrants' comparative slowness at completing t a s k s , in s p i t e of t h e i r general w i l l i n g n e s s to work. A l l t h i s does not help the ' s e l f - e s t e e m ' o f 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 waiting l i s t f o r the latter.  There i s a weekly newspaper in three languages, E n g l i s h ,  Vietnamese and Chinese, supported by S.U.C.C.E.S.S. (United Chinese Community Enrichment Services S o c i e t y ) , 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 f o r the South east Asian Refugees, and i s mailed across the country.  One issue  contained a r t i c l e s on n u t r i t i o n , c h i l d development, and health; legal matters such as housing r e g u l a t i o n s ; understanding Canada; and a l e t t e r from a sponsor expressing his/her f e e l i n g s on refugees! A major f a c t o r in the 'sense of belonging' i n any c u l t u r e i s the ' s o c i a l network' of f a m i l i a r faces, language, and a c t i v i t i e s . In the U.S.A the firstwave Vietnamese soon ' r e s e t t l e d ' themselves into areas where there were other Vietnamese.  This would help  them support each other in adjusting to the American w a y - o f - l i f e , and i n forming a Vietnamese-American s u b c u l t u r e . ; I t  ,has shown  again that the p o l i c y of d i r e c t a s s i m i l a t i o n into the dominant c u l t u r e does not work, and i t i s of i n t e r e s t . t h a t i t was t r i e d in s p i t e of the American recognition of the m u l t i c u l t u r a l  society.  152 The large Chinese-Canadian community in Vancouver provides a ' s o c i a l network  1  f o r Chinese and Vietnamese immigrants,  and t h i s i s a t t r a c t i n g the Vietnamese to ' r e s e t t l e ' themselves here out of t h e i r o r i g i n a l areas of settlement.  S.U.C.C.E.S.S.  estimates that t h e 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 f a c t , they themselves have asked f o r s p e c i f i c programs at the c l i n i c , such as family planning.  However, a l l  this  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 o v e r a l l f e e l i n g from the interviews and the news media i s that t h i s resettlement scheme has been a success. i s t h i s an Occidental view of a s i t u a t i o n where Oriental are not expressed?  But  feelings  I t i s of i n t e r e s t to note here that nothing  has been heard of possible reaction to RPM (Rape, P i l l a g e 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 i n the Greater Vancouver area have  been admitted to p s y c h i a t r i c  in-patient  f a c i l i t i e s . Is t h i s the ' t i p of the iceberg'? What does i t mean f o r 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 t h i s are beyond the scope of this t h e s i s . Economic factors such as the high rate of unemployment and lack of housing are beyond the control of health services personnel, although the effect of these on health must be remembered. Knowledge of Canada's o f f i c i a l  policy o f multiculturism is important  for health care workers as this implies the acceptance and understanding of ' d i f f e r e n t ways of doing t h i n g s ' .  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  as caused by hostile agents outside the body.  illness  Understanding the  effect of culture (ways of doing things) and l i f e experiences on the immigrant adaptation process w i l l  increase the s e n s i t i v i t y of mental  health workers when dealing with the psychological signs of maladaptation and stress. It was observed e a r l i e r in this thesis that social welfare personnel have a dual r o l e ;  helping the c l i e n t ( 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 migration, have on health  and on  the g i v i n g and r e c e i v i n g of health care. With perhaps 10,000 Vietnamese in Vancouver, t h i s appears to be an ideal  situation  f o r a study of the factors a f f e c t i n g the adaptation process of immigrants; e s p e c i a l l y 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 c u l t u r a l l y d i f f e r e n t from the majority.  Such research i s sadly lacking i n Canada, and planning  programs and services f o r immigrants per se i s p o i n t l e s s without the information that t h i s research would generate.  155 CHAPTER 10 RECOMMENDATIONS AND CONCLUSION INTRODUCTION The question posed in t h i s 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 r e s o l u t i o n would be the c h a r a c t e r i s t i c s of the new immigrants and the country receiving them - Canada.  This i s  conceptualized in figure 1. (page 7) I t has been found that the health status of the new immigrants i s determined by two f a c t o r s : the immigration p o l i c i e s of the Canadian government, and the c u l t u r a l background and l i f e experiences of the refugee/immigrants themselves. The problems a r i s i n g from t h i s are seen to be 1) the increased r i s k to Canadians from c e r t a i n i n f e c t i o u s diseases, namely t u b e r c u l o s i s , h e p a t i t i s , and b a c t e r i a l e n t e r i c disease; 2) the importation of  'exotic'  diseases that are not a great r i s k to Canadians but which may pose problems of diagnosis and treatment; and 3) mental health problems in the new immigrants a r i s i n g from culture shock and possible d i f f i c u l t y in adapting to a new environment. The r e s o l u t i o n of these problems is seen to be affected by the c u l t u r a l background and l i f e experiences of the new immigrants,  156 and by c e r t a i n Canadian c h a r a c t e r i s t i c s .  Besides the personal  a t t i t u d e s of Canadians towards these immigrants, the l a t t e r includes a system in which r e s p o n s i b i l i t y f o r various aspects of Canadian l i f e i s shared by d i f f e r e n t l e v e l s of government, and where p o l i c i e s may be formulated at one level and programs and services provided at another. A f a c t o r found to contribute to the success or f a i l u r e of programs and services designed f o r the . resettlement and health care of these immigrants i s the knowledge of health care professionals about the e f f e c t of culture on health and health care, and about the e t i o l o g y and epidemiology of t r o p i c a l  diseases.  The C h a r a c t e r i s t i c s 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 t h n i c ' Chinese f l e e i n g Viet-Nam because of i n t o l e r a b l e l i v i n g c o n d i t i o n s , and have been l i v i n g f o r various periods of time in refugee camps i n Thailand, Malaysia, and Hong Kong. The uncertainty of t h e i r refugee status has added to the accumulated stress of prolonged s o c i a l upheaval and warfare  and t h e i r  experiences during f l i g h t . The process by which 50,000 of these refugees„were selected f o r resettlement in Canada means that o v e r a l l they have met the c r i t e r i a f o r immigrants per se.  However, the environment  157 from which they have come means that there are some long-term health problems associated with t h e i r resettlement i n t h i s country. Their c u l t u r a l background, e s p e c i a l l y t h e i r b e l i e f s and customs about health and sickness, w i l l a f f e c t 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 r e s p o n s i b i l i t y of the federal and p r o v i n c i a l l e v e l s . o f government.  The evolution of the system has brought  about the s i t u a t i o n whereby today the federal government alone makes immigration p o l i c y .  This i s aimed at preventing the  spread of i n f e c t i o u s disease, as well as admitting immigrants who are healthy and who w i l l quickly s e t t l e and become productive c i t i z e n s . Settlement services such as language t r a i n i n g and employment counselling are offered at the community level by the federal Departments of the Secretary of State and Employment and Immigration r e s p e c t i v e l y .  These are supplemented through services  offered by i n t e r e s t e d voluntary agencies and which are encouraged by the unwritten federal government p o l i c y of i n v o l v i n g the community in immigrant settlement. The provinces are not involved in t h i s process per se; but they are involved in immigrant health problems in other ways, and i t appears that there i s a need f o r greater co-operation and co-ordination between l e v e l s of government in t h i s matter.  158 I t has been seen that immigrants may, through no f a u l t of t h e i r own, make unusual demands on s o c i a l and health programs. Again under the B r i t i s h North America Act of 1867, these are the r e s p o n s i b i l i t y of the provinces - although the federal government can and does influence the formulation of health and welfare p o l i c i e s at t h i s l e v e l . The p r o v i n c i a l governments delegate some of the planning and d e l i v e r y of programs and services to the l o c a l l e v e l , i . e . community Boards of Health and Health Units. The d i v i s i o n of r e s p o n s i b i l i t y f o r immigration and the welfare of landed immigrants across various l e v e l s and departments of government, and the voluntary s e c t o r , 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 r e of programs and services offered in the context of the resettlement of these 50,000 refugees are t h e . a t t i t u d e s and knowledge of Canadian health care p r o f e s s i o n a l s . Attitudes towards immigrants may be representative of s o c i e t a l values; but u n t i l comparatively recently immigrants passed unnoticed i n t o the mainstream of Canadian l i f e and t h e 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 i r t u e of t h e i r race, colour and c u l t u r e .  The previously homogeneous society means  that Canadian health care professionals have not been educated i n  159  the c r o s s - c u l t u r a l aspects of health and sickness and the influence of t h i s on the d e l i v e r y 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 a f f e c t t h e i r r e s o l u t i o n ,  THE PROBLEMS The Risk bf the Spread of Infectious  -Diseases  One objective of Canadian immigration p o l i c y i s the prevention of the spread of i n f e c t i o u s 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 t h e i r resettlement in t h i s country. Obvious disease w i l l have been 'screened out' by t h i s examination: however, i t i s known that t u b e r c u l o s i s , h e p a t i t i s and b a c t e r i a l e n t e r i c disease can l i e dormant, perhaps f o r years, and become active again at a l a t t e r date.  Because of t h i s environment from which they come, and t h e i r  experiences o f war and f l i g h t , i t i s considered that the Vietnamese are susceptible to the breakdown of i n a c t i v e disease that had been acquired e a r l i e r , and can thus become a p u b l i c health hazard. Short-term programs were i n s t i t u t e d by both federal and p r o v i n c i a l governments to deal with t h i s -problem as the immigrants a r r i v e d , but these programs are now being'phased o u t . '  In f u t u r e ,  160 all  immigrants from S o u t h e a s t A s i a w i l l e n t e r Canada through  r e g u l a r i m m i g r a t i o n c h a n n e l s ; and t h e i r h e a l t h care once they have a r r i v e d w i l l and l o c a 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  health units.  The h e a l t h problems o f these  governments  future  immigrants are e x p e c t e d t o be s i m i l a r t o those o f the Vietnamese refugees.  Programs and s e r v i c e s f o r the p r o t e c t i o n o f the h e a l t h are a l r e a d y i n p l a c e .  public;  However, i t has been seen t h a t the  s u c c e s s o f any h e a 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 p e r c e i v e d by the ' r e c i p i e n t ' , 'giver'  and h i s / h e r i n t e r a c t i o n w i t h the  o f h e a l t h c a r e who may see the problem from a d i f f e r e n t  perspective.  These p e r c e p t i o n s are c u l t u r a l l y d e t e r m i n e d , and the  g r e a t e r the d i s t a n c e between those o f the ' r e c i p i e n t ' g r e a t e r the r i s k o f program f a i l u r e .  and ' g i v e r '  In t h i s i n s t a n c e , i t  mean the i n c r e a s e d r i s k o f the spread o f i n f e c t i o u s  the  could  diseases.  I t would appear t h a t both those r e s p o n s i b l e f o r  planning  programs and the h e a l t h c a r e p r o f e s s i o n a l s c a r r y i n g them o u t s h o u l d 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 h e a l t h c a r e . In the c o n t e x t o f the p r e v e n t i o n o f the s p r e a d o f diseases t h i s  infectious  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 t h o u g h the need f o r such knowledge s h o u l d be acknowledged a t the p o l i c y making l e v e l .  161 The professionals both planning and d e l i v e r i n g health care are seen to be physicians and p u b l i c health nurses; and the problem of acquiring knowledge of the e f f e c t of culture on health and sickness i s both immediate and long-term.  The following  recommendation i s made i n order to solve the immediate problem.  Recommendation.  1.  That health care agencies, e s p e c i a l l y those i n the p u b l i c health f i e l d , provide material on the c r o s s - c u l t u r a l aspects of working with the Vietnamese immigrants f o r t h e i r s t a f f .  The a r r i v a l of the Vietnamese refugee/immigrants has only h i g h l i g h t e d the f a c t that world migration patterns are changing and, that unless p o l i c i e s are d r a s t i c a l l y changed, Canada w i l l be admitting more immigrants from countries with d i f f e r e n t patterns of disease and d i f f e r e n t concepts of health and sickness.  It is  suggested that the need f o r understanding the e f f e c t of culture on the d e l i v e r y  of health care w i l l continue, i f not grow, and that  courses on t h i s subject should be included i n the education of physicians and p u b l i c health nurses. These health care professionals are educated at university.  . Professional l i c e n c i n g bodies ensure that basic  standards are met i n order to protect the p u b l i c ; but apart from t h i s function can only suggest that courses on c e r t a i n topics be  162 included in the u n i v e r s i t y c u r r i c u l a .  However, i t i s f e l t that i t  i s a professional r e s p o n s i b i l i t y to acknowledge the changes taking place in Canadian society and the e f f e c t of t h i s on the d e l i v e r y of health care, and hence on the education of i t s members. U n i v e r s i t i e s , as educational establishments, and the professional l i c e n c i n g bodies come under p r o v i n c i a l j u r i s d i c t i o n . Separately, they have national associations that i n t e r a c t with each other and government at the national l e v e l . With?-this .in mind the following recommendations are made.  Recommendation. 2.  That the medical.land nursing professional a s s o c i a t i o n s , i n conjunction with the appropriate u n i v e r s i t y departments, explore ways of i n c l u d i n g courses on the e f f e c t of culture on health and sickness and the c r o s s - c u l t u r a l aspects of the d e l i v e r y of health care, i n the basic education of physicians and p u b l i c health nurses. I t i s f u r t h e r recommended that the d i s c i p l i n e s of sociology and anthropology be involved in t h i s process. Continuing education i s also a professional  r e s p o n s i b i l i t y , and i t appears that these courses are i n i t i a t e d by i n t e r e s t e d professional  individuals.  Recommendation 3.  That the above professional associations encourage t h e i r members and the appropriate u n i v e r s i t y departments (or community colleges) to plan continuing education courses i n the c r o s s - c u l t u r a l aspects of the d e l i v e r y of health care.  163 The P r o b l e m o f  Apart infectious diseases  diseases  risk  intestinal  s u c h as t u b e r c u l o s i s ,  parasites,  about t r o p i c a l  t o be a i n c r e a s i n g  medical  students  distribution  of  is  is  from  individual  that  Disease,  is  in  tropical  aware o f t h e e f f e c t  of  requires  diseases social  a  level  Canada,  here.  in the world: but again,  s e e n as a p r o f e s s i o n a l  The  include  n o t common i n schools  of  refugee/  o r unknown i n C a n a d a .  in medical  interest  imported  the problem  d i s e a s e s , which  disease  these diseases  education  there  and H a n s e n ' s  taught  appears  who a r e  little  these  malaria,  has n o t b e e n w i d e l y  health  t o the h e a l t h o f the  and t r e a t m e n t o f  knowledge  medical  to the p u b l i c  and w h i c h a r e perhaps  recognition  which  from the  t h a t are a t h r e a t  immigrant  of  'Exotic'Diseases.  and  There among  c h a n g e on t h e this  aspect  responsibility.  Recommendation. That the medical 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 the U n i v e r s i t y Schools o f Medicine, ensure that teaching of 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 the b a s i c e d u c a t i o n of p h y s i c i a n s .  4.  Again, well  continuing education  as an i n d i v i d u a l  responsibility  I t was somewhat d i s t u r b i n g the announced a r r i v a l a 'possible' at  of  s e e n as a c o l l e c t i v e health care  to f i n d a time-lapse  o f the Vietnamese  c o u r s e on t r o p i c a l  the U n i v e r s i t y  is  of British  medicine  Columbia.  refugees  professionals.  o f two y e a r s i n Vancouver  for practicing It  is  as  therefore  between and  physicians recommended:  of  164  Recommendation. 5.  That continuing education courses in t r o p i c a l medicine f o r physicians be i n i t i a t e d by the medical associations as well as by i n d i v i d u a l p r a c t i t i o n e r s .  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  r a m i f i c a t i o n s for mental health programs and s e r v i c e s .  Those with  obvious psychological d i s t r e s s w i l l have been 'screened out' by the pre-immigration medical examination; however, loss of mental health can be an i n s i d i o u s process occuring over many years.  Cultural  b e l i e f s and customs a f f e c t the perception of t h i s problem and . i t s prevention and treatment, by both the Vietnamese and the western health care p r o f e s s i o n a l s . Adaptation i s 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 t h i s that can lead to depression, anxiety, and desperation.  I t has been seen that immigrants tend  to have higher h o s p i t a l i z a t i o n rates f o r mental disorders than the l o c a l l y - b o r n populations, so i t would appear that ways of preventing t h i s should be explored. The federal government, with i t s r e s p o n s i b i l i t y f o r immigration p o l i c i e s , programs and s e r v i c e s , has r e l i e d heavily on the response of community groups and organizations f o r the operation  165 and success of t h e i r program f o r the resettlement of these refugees. This i s in l i n e with t h e i r unwritten p o l i c y of i n v o l v i n g the community in the immigrant resettlement process per se; and i t appears that by doing t h i s 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 i n t e r e s t and resources to do t h i s . Highly t r a i n e d , and highly p a i d , professionals are not needed; although there i s a need f o r s o c i a l workers to be aware of the special problems of immigrants and the e f f e c t s of culture on the adaptation process, s o c i a l w e l f a r e , and mental health. Therefore the f o l l o w i n g recommendation i s made. Recommendation. 6.  That the professional associations of s o c i a l workers, in conjunction with the appropriate u n i v e r s i t y department explore ways of including courses on the e f f e c t of culture on health and s o c i a l welfare, and on the crossc u l t u r a l aspects of the d e l i v e r y of care i n these areas, in the education of t h e i r members. I f the coping mechanisms of the new immigrants do f a i l ,  then the knowledge o f , and s e n s i t i v i t y t o , the p e c u l i a r stresses of migration and adaptation by p s y c h i a t r i s t s , psychologists,  psychiatric  nurses, and s o c i a l workers w i l l f a c i l i t a t e treatment and recovery. The actual numbers of immigrants r e q u i r i n g help w i l l probably be s m a l l , so special programs may not be needed.  There i s a need to  s e n s i t i z e health care workers, i n c l u d i n g the bureaucracy, to the  166 e f f e c t of culture on mental health and to the eastern and western perceptions of a health problem and i t s r e s o l u t i o n .  Again, t h i s is  seen as a professional r e s p o n s i b i l i t y and attention 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 t h i s process, and an o v e r a l l lack of planning, co-ordination and a c c o u n t a b i l i t y . The need f o r the services has c e r t a i n l y been recognised by the federal government with t h e i r funding of the voluntary programs. I t would appear that the government has a r e s p o n s i b 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 o f f e r e d , and to whom.  Recommendation. 7.  That a l l programs designed f o r the resettlement of the Vietnamese refugees be evaluated by the Department of Employment and Immigration. This.;is to include the sponsorship program, and the r o l e of the voluntary agencies as well as that of the more formal s o c i a l and health programs. In view of ;the p r o b a b i l i t y that immigration from countries  that are s i g n i f i c a n t l y d i f f e r e n t from Canada w i l l continue, the f o l l o w i n g recommendation i s made.  167 Recommendation 8.  That these programs, redesigned i f necessary, and with an evaluation process b u i l t i n , be offered to a l l immigrants. I t i s d i s t u r b i n g to note that in s p i t e of the evidence  that the resettlement problems of these new immigrants may continue f o r years, both senior l e v e l s of government appear to have reverted to t h e i r former ' l a i s s e z - f a i r e ' a t t i t u d e to immigrants. The federal government has phased out the extra services that they supplied f o r the refugees; and the l e g i s l a t i o n passed by the p r o v i n c i a l government of B r i t i s h Columbia to provide the mechanism f o r funding services f o r the resettlement of refugees per se* does not seem to have been a c t i v a t e d .  The ' C i t y of Vancouver Task Force on  Vietnamese Refugees' has been disbanded, leaving the e f f o r t s of voluntary agencies and sponsoring groups unco-ordinated. This 'Task Force' could have been used in an evaluating role f o r the programs and services offered to the refugees.  Both voluntary and government  programs and services are seen as c o n t r i b u t i n g to the successful adaptation of a l l immigrants, not j u s 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 i n a l recommendation i s made. * B r i t i s h Columbia, Laws, Statutes, e t c . 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 l e v e l s of senior government f a c i l i t a t e research into the factors that a f f e c t 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 s o c i a l  change means that there w i l l be more voluntary migration from areas that 'have not' to areas that ' h a v e ; and that the l a t t e r , f o r what 1  ever reasons, w i l l feel obliged to give asylum to those uprooted by war, natural d i s a s t e r , or p o l i t i c a l  persecution.  This has brought about new Canadian immigration p o l i c i e s , with the r e s u 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 e n t . 1  I t has been seen  that the meeting of d i f f e r e n t races and cultures can produce some social stress. Immigrants in the future are l i k e l y to have health problems that w i l l bring them into e a r l y contact with the health care system and i t s p r o f e s s i o n a l s .  Planners of health care services should be  aware of the f a c t that s e n s i t i v e and informed professionals can ensure successful outcomes to these c r o s s - c u l t u r a l contacts i n the health care f i e l d , and u l t i m a t e l y contribute to making the concept of a m u l t i c u l t u r a l Canada a r e a l i t y .  169 REFERENCES 1.  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 A s i a : Humanitarion and P o l i t i c a l Aspects Can't be Separated." A speech by the Secretary of State f o r External A f f a i r s , the Honourable Flora MacDonald, to the United Nations Conference on Refugees, Geneva, July 20, 1979.  2. . '.Canada, Department of Employment and Immigration. Newsletter Indochinese Refugees. 1 (July 16 1979): 4. 3.  Everett S. Lee. "A Theory of Migration" in Migration ed: J . A . Lackson. (Cambridge: The U n i v e r s i t y Press 1969), p.285.  4.  Louis D o l l o t . Race and Human Migration. Trans. S y l v i a and George Leeson. (New York: Walker and Company, 1964), p.2.  5.  Franklin D. Scott, ed. World Migration i n Modern Times. (Englewood C l i f f s , N.J.I Prentice-Hall I n c . , 1968), p.1.  6.  J . A. Jackson ed. M i g r a t i o n . (Cambridge : The U n i v e r s i t y Press 1969), p . l .  7.  G. B e i j e r . "Modern Patterns of International Migratory Movements" in Migration ed: J.A. Jackson (Cambridge: The U n i v e r s i t y Press, 1969), p.14.  8.  Pol l e t Race and Human M i g r a t i o n , 31.  9.  Anthony M. Richmond "Sociology of Migration i n I n d u s t r i a l and Post I n d u s t r i a l Societies'.' i n Migration ed: J . A . Jackson . (Cambridge:- The U n i v e r s i t y Press.. 1969), p.240.  10.  Anthony T. Bouscaren. European Economic Community Migrations. (The Hague: Martinus N i j h o f f , 1969), p.5.  11.  Beijer  12.  Brindey Thomas, Migration and Economic Growth, 2nd ed. (Cambridge: The U n i v e r s i t y Press 1973), p.306.  1.3.  Beijer  14.  Anthony T. Bouscaren. International Migrations since 1945. (New York: Frederick A. Praeger 1963), p. 154.  Modern Patterns, 26.  Modern Patterns, 28.  170 15.  Richmond  Sociology of M i g r a t i o n , 239.  16.  Bouscaren  17.  William S. Bernard. "Immigrants and Refugees: Their S i m i l a r i t i e s , Differences and Needs" International Migration XIV (1976): 267.  18.  Bouscaren International Migrations, 3.  19.  B e i j e r Modern Patterns, 20.  20.  Louise W. Holborn. "Refugee Migration i n the Twentieth Century," in World Migration i n Modern Times, ed: Franklin D. Scott. (Englewood C l i f f s , N . J . : P r e n t i c e - H a l l I n c . , 1968), p. 153.  21.  Louise N. Holborn. Refugees: A Problem of Our Time. (Metuchen, N . J . : The Scarecrow Press Inc. 1975), p.1428.  22.  G. M a s e l l i . "World Population Movements" International Migration 9 (1971): 120.  23.  Bernard 'Immigrants and Refugees, 268.  24.  U.S., Department of J u s t i c e , Immigrants.and N a t u r a l i z a t i o n Services. Reports of U.S. Immigrants and N a t u r a l i z a t i o n Services. S t a t i s t i c a l B u l l e t i n . September 1968.  25.  Beijer  26.  Abraham H. Marlow. Motivation and P e r s o n a l i t y . 2nd ed. (New York: Harper and Row 1970), p. 35.  27.  Robert L. Freedman. " N u t r i t i o n Problems and Adaptation of Migrants i n a New Cultural Environment" International Migration. XI (1973): 17.  28.  W.R. Aykroyd, M.A. Hossain "Diet and State of N u t r i t i o n of Pakistani Families in Bradford, Yorkshire." Br Med /J 1 (1967): 44. (January 7, 1967).  29.  D.B. J e l l i f f e Children" i n 3rd ed. eds: (Publishers)  International Migrations, 152.  Modern Patterns, 18.  and E.F. Patrice J e l l i f f e "Feeding of Infants and Diseases of Children in the Subtropics and Tropics D.B. J e l l i f f e and J . P . S t a n f i e l d . (Edward Arnold L t d . 1978), p. 194.  171 30.  Bernard  Immigrants and Refugees, 271.°  31.  C. Bagley. The Dutch Plural Society: A Comparative Study in Race Relations. (London: Oxford Press 1973), p.184.  32.  I b i d , p. 185.  33.  Abraham A. Weinburg. Migration and Belonging. A Study of Mental Health and Persona.! Adjustment in I s r a e l . (The Hague: Martinus N i j h o f f 1961), p.242.  34.  Charles Zwingmann and Maria P f i s t e r - Ammende. eds: Uprooting and A f t e r . . . (New York : Springer - Verlag 1973), p.14.  35.  Anthony M. Richmond. Migration and Race Relations in an English C i t y . A Study in B r i s t o l . (London: Oxford U n i v e r s i t y Press 1973), p.270.  36.  Bouscaren  37.  Eugene B. Brody ed. Behavior i n New Environments. Adaptation of Migrant Populations"! (Beverly H i l l s , C a l . : Sage Publications 1969), p. 18.  38.  Maslow M o t i v a t i o n , 43.  39.  I b i d , p.46  40.  Seymour Adler. "Maslow s Reed Hierarchy and the Adjustment of Immigrants." International Migration Review 11 (1977): 446.  41.  C h r i s t i n e Markopoulou. "A Project of Social Work with Cypriot Immigrants i n London" International M i g r a t i o n . XII (1974): 8.  42.  William S. Bernard "Orientation and Counselling. Their nature and r o l e in the adaptation and i n t e g r a t i o n of permanent immigrants". International Migration XII (1974): 182.  43.  S. Diarra "African Workers in France and Problems of Adaptation" in Uprooting and A f t e r . . . e d s . Charles Zwingmann and Maria P f i s t e r - Ammende. (New York: Springer - Verlag 1973), p.121.  44.  Markopoulou  45.  R. Rodriguez. " D i f f i c u l t i e s of Adjustment i n Immigrant Children in Geneva" in Uprooting and A f t e r . . . e d s : Charles Zwingmann and Maria P f i s t e r -Ammende. (New York: Springer Verlag 1973), p.134.  European Migrations, 135.  1  A Project of Social Work, 8.  172 46.  Hal Lehrman. " I s r a e l ; The Beginning and Tomorrow" in World Migration in Modern Times, ed: Franklin D. Scott. (Englewood C l i f f s , N . J . : Prentice-Hall Inc. 1968), p.163.  47.  V i c t o r D. Sanua"Immigration, Migration and Mental I l l n e s s : A Review of the L i t e r a t u r e with special emphasis on Schizophrenia" in Behaviour in New Environment, ed: Eugene B. Brody. (Beverly H i l l s , C a l . : Sage P u b l i c a t i o n s 1970), p.341.  48.  H.P. Burrowes. "The Migrant and Mental Health" in The F i e l d Worker in Immigrant Health, e d . : J . S . Dodge. (London: Staples Press 1969), p.73.  49.  H.B.M. Murphy. "Migration and the Major Mental Disorders: A Reappraisal" in Uprooting and A f t e r . . . e d . Charles Zwingmann and Maria P f i s t e r -Ammende (New York: Springer - Verlag 1973), p.218.  50.  H.B.M. Murphy. "Mental Health Guidelines f o r Immigration P o l i c y " International M i g r a t i o n . XII (1974): 345.  51.  E.K. Koranyi, A. Kerenyi, and G . J . Sarwer - Foner. "On adaptive D i f f i c u l t i e s of some Hungarian Immigrants. A s d c i o - p s y c h i a t r i c study." Med Ser J 14 (.1958): 403.  52.  Zwingmann and P f i s t e r - Ammende Uprooting, 1.  53.  A.A. Weinburg "Mental Health Aspects of Voluntary M i g r a t i o n . " Ment Hyg 39 (1955): 450.  54.  Bernard Immigrants and Refugees, 271.  55.  K. Schwarz. "Public Health Aspects of Migration" in Immigration.Medical and Social Aspects, eds: G.E.W. Wolsenholme and M.O'Connor. (London: J.A. C h u r c h i l l , Ltd. 1966), p.28.  56.  V.H. Springett. "Tuberculosis" in Immigration. Medical and Social Aspects, eds: G.E.W. Wolsenholme and M.O'Connor. (London: J . A . C h u r c h i l l , Ltd. 1966), p.56.  57.  J . S . Dodge, ed. The F i e l d Worker in Immigrant Health. (London: Staples Press, 1969), p.23.  58.  J . F . Skone. Public Health Aspects of Immigration. 2nd ed. (London: Community Relations Commission 1970), p.14.  173  59.  Schwarz  Public Health Aspects, 28.  60.  Dodge The F i e l d Worker, 142.  61.  K.C. Nayyar, E. S t o l z , M.F. Michel. "Rising Incidence of Chancroid in Rotterdam" Br J of Ven. Pis 55 (1979): 439  62.  P.M. Archer, F.N. Bamford, and E. Lees. "Helminth Infestations in Immigrant C h i l d r e n . " Br Med J : 2(Pecember 25, 1965): 1517.  63.  "Protein Requirements" WHO Chronicle 19 (1965): 288.  64.  W.D. Dolton. "The Health and Welfare of the Immigrant" Royal Society of Health J • 86 (1966): 23.  65.  Dodge  66.  Robert D. McCracken. "Lactase Deficiency: An example of d i e t a r y e v o l u t i o n . " Current Anthropology, 12 (1971): 500.  67.  Schwarz  68.  Denis P. Burkett. "Some Diseases C h a r a c t e r i s t i c of Modern Western C i v i l i z a t i o n " i n Health and the Human Condition ed: Micheal H. Logan and Edward E. Hunt. (North S c i t u a t e , Mass.:) Duxbury Press 1978), p. 137.  69.  Alexander A l l a n d . "War and Disease: An Anthropological Natural H i s t o r y . 76 (1967): 60.  70.  Thomas Bodenheimer and George Roth. "Health and Death in Vietnam" i n Ecocide in Indochina, ed: Bary Weisberg. (San Francisco: Canfield Press 1970), p. 164.  71  "Emergency Care in Natural D i s a s t e r s . " (1980): 97.  72.  Harold G. Wolfe. "Stresses as a Cause of Disease i n Man" in Stress and P s y c h i a t i c Disorders, ed. J.M. Tanner. (Oxford: Blackwell S c i e n t i f i c P u b l i c a t i o n s 1958), p. 29.  73.  Charles C. Hughes. "Medical Care; etho-medicine." in Health and the Human Condition. Perspectives on Medical Anthropology, eds: Michael H. Logan and Edward E. Hunt. (North S c i t u a t e , Mass.: Durbury Press 1978), p.151.  ..  The F i e l d Worker, 22.  Public Health Aspects, 2 8 .  Perspective.  WHO Chronicle 34  174  74.  John Cassel. "A Comprehensive Health Program among South A f r i c a n Zulus." in Health, Culture and Community, ed: Benjamin D. Paul. (New York, Russell Sage Foundation 1955), p.30.  75.  Richard L. C u r r i e r . "The Hot-Cold Syndrome and Symbolic Balance in Mexican and Spanish - American Folk Medicine." Ethnology 5 (1966): 251.  76.  Nancy E. Waxier "Social Change and P s y c h i a t r i c I l l n e s s in Ceylon: T r a d i t i o n a l and Modern Conceptions of Disease and Treatment." in Culture-bound Syndromes, Ethnopsychiatry and A l t e r n a t i v e Therapies, ed: William P. Lebra. (Honolulu: U n i v e r s i t y of Hawaii Press 1976), p.222.  77.  Hughes  78.  NancieSolien Gonzalez. "Health Behaviour i n Cross-Cultural Perspective: A Guatemalan Example]' Human Organization. 25 (1966): 123.  79.  Margaret Read. C u l t u r e , Health and Disease.(London: Tavistock Publications 1966), p.117.  80.  Benjamin D. Paul. "Anthropological Perspectives on Medicine and Public Health" in The Cross-Cultural Approach to Health Behavior, ed: L. Riddick Ly.ch. (Cranbury, N . J . : Associated U n i v e r s i t y Presses, Inc. 1969), p.31.  81.  Louis P a r a i . The Economic Impact of Immigration. (Ottawa: Information Canada 1974), p.4. '  82.  Daniel Kubat. ed. The P o l i t i c s of Migration P o l i c i e s . (New York: Center f o r Migration Studies 1979), p. XVIII.  83.  I. Gelinek "The Role of Social Work and the Contribution of Voluntary Social Agencies." International Migration XV (1977): 127.  84.  Catherine Jones. Immigration and Social P o l i c y in B r i t a i n . (London T a v i s t o c k P u b l i c a t i o n s 1977), p.3.  85.  W.A. Dumon. "The A c t i v i t y of Voluntary Agencies and National Associations in Helping Immigrants to Overcome I n i t i a l Problems." International Migration XV (1977): 119.  Medical Care, 157.  175  86.  Gelinek The Role of Social Work', 130.  87.  I b i d . p.133  88.  Brian Maegraith. Exotic Diseases in P r a c t i c e . (London: Wm. Heinemann Medical Books L t d . 1965), p.3.  89.  N. Schwarz Public Health Aspects, 127.  90.  L.M. Cathcart, P. Berger, and B. Knazan. "Medical Examination of t o r t u r e victims applying f o r refugee s t a t u s . " Can Med J 121 (July 21, 1979): 183.  91.  Gunther Beyer. "The Benelux Countries: Belgium, the Netherlands, Luxemberg," in The P o l i t i c s of Migration P o l i c i e s ed: Daniel Kubat. (New York: Center f o r Migration Studies 1979), p.109.  92.  Dodge  93.  F. Hashmi. "Mores,Migration and Mental I l l n e s s . " in Immigration Medical and Social Aspects, ed: G.E.W. Wolsenholme and M.O'Connor. (London: J . A . C h u r c h i l l Ltd. 1966), p.50.  94.  E.J.Y. Aujaleu. "Protecting and Promoting the Health of Migrant Workers" Migration News (May-June 1974): 40.  95.  Dodge  96.  Aujaleu Protecting and Promoting, 3.  97.  Schwarz Public Health Aspects, 31.  98.  F.N. Bamford. " N u t r i t i o n of Immigrant Children" in The F i e l d Worker in Immigrant Health, ed: J . S . Dodge. (London: Staples Press 1969), p. 89.  99.  J . S . Dodge and K.M. Lumb. "Culture and Custom" in The F i e l d Worker in Immigrant Health, ed: J . S . Dodge (London: Staples Press. 1969) p.32.  100. Dodge  The F i e l d Worker, 107.  The F i e l d Worker, 128.  The F i e l d Worker, 128.  101. I b i d , p.103. 102. Ursula Mehrlander. "Federal Republic of Germany" in The P o l i t i c s of Migration P o l i c i e s , ed: Daniel Kubat. (New York: Center f o r Migration Studies 1979), p.158.  176 103. Ronald T a f t . "A Comparative Study of the I n i t i a l Adjustment of Immigrant School Children i n A u s t r a l i a . " International Migration Review. 13 (1979): 78. 104. Henry P. David. "Involuntary International Migration in Behavior in New Environments, ed: Eugene B. Brody. (Beverly H i l l s , C a l . : Sage P u b l i c a t i o n 1969) p.86. 105. Dumon  The Acturty of Voluntary Agencies, 118.  106. A. Rose. Migrants in Europe. Problems of Acceptance and Adjustment. Minneapolis: U n i v e r s i t y of Minnesota Press 1959. 107. Dumon  The A c t i v i t y of Voluntary Agencies, 113.  108. Dodge and Lumb  Culture and Custom, 32.  109. Aykroyd and Hossain Diet and State of N u t r i t i o n , 42. 110. Jones Immigration and Social P o l i c y , 202. 111. Madeleine Leininger. "Humanism, Health and Cultural Values" in Health Care Issues, eds: Madeleine Leininger and Gary Buck. ( P h i l a d e l p h i a : F.A. Davis Co. 1974), p.53. 112. William S. Bernard "How to Influence the Public f o r a Better Understanding of the Problems of Immigrant Families and Social Welfare Measures needed i n order to f a c i l i t a t e a Better Integration of the Newcomers." International Migration XIV (1976): 87. 113. Michael H. Logan and Edward E. Hunt. eds. Health and the Human Condition. Perspectives on Medical Anthropology. (North S c i t u a t e . Mass.: Durbury Press 1978), p.299. 114. Jones Immigration and Social Policy. 201. 115. George M. Foster. "Medical Anthropology and International Health Planning." in Health and the Human Condition, eds: Micheal H. Logan and Edward E. Hunt. (North S c i t u a t e , Mass.: Surdbury Press 1978), p.303.  177 116.  Charles P r i c e . The Great White Walls are B u i l t . (Canberra: The A u s t r a l i a n I n s t i t u t e of Internal A f f a i r s 1974), p.261.  117.  Kubat  118.  Michael T. Sculley " A u s t r a l i a ' s Immigration Program: an evaluation of i t ' s e f f e c t i v e n e s s . " International Migration XV (1977): 27.  119.  I b i d . p,32  120.  Wendy Lowenstein and Morag Loh. The Immigrants. (Melbourne: Hyland House Publishing Pty Ltd. 1977) p.11.  121.  Freda Hawkins. Immigration P o l i c y and Management in Selected Countries. (Ottawa: Information Canada, 1974), p.29.  122.  I.H. Burnley "Immigrant Absorption in the A u s t r a l i a n C i t y " International Migration Review. IX(1975): 330.  123.  The 1971 P o l i c y Statement of the A u s t r a l i a n Labor Party, c i t e d by Freda Hawkins in Immigration p o l i c y and management in selected c o u n t r i e s . Canadian immigration and population study. (Ottawa: Information Canada 1974), p.21.  124.  Hawkins  125.  Peter J . B r a i n , Rhonda L. Smith and Gerard P. Schuyers. Population, Immigration and the A u s t r a l i a n Economy. (London: Croom Helm 1979), p. 39.  126.  Charles P r i c e . " A u s t r a l i a " in The P o l i t i c s of Migration P o l i c i e s ex: Daniel Kubat. (New York: Center for Migration Studies 1979), p. 10.  127.  B r a i n , Smith and Schuyers A u s t r a l i a n Economy, 39.  128.  Kenneth R i v e t t ed. A u s t r a l i a and the Non-White Migrants. (Melbourne: Melbourne U n i v e r s i t y Press 1975), p. 205.  129.  U.S. Congress, Immigration and N a t i o n a l i t y Act. (McCarran Walter A c t ) , Statutes at Large, 66 sec. 201, 175; sec. 205, 180, sec. 212 (14); 183 (1952).  130.  U.S., Congress, Immigration and N a t i o n a l i t y A c t , Amendments, Statutes at Large, 79, sec. 201 ( e ) , 911 (1965).  The P o l i t i c s of Migration P o l i c i e s , 23.  P o l i c y and Management, 33.  Population, Immigration, and the  178 131.  U.S., Congress, Immigration and N a t i o n a l i t y Act Amendments of 1976. Statutes at Large, 90 sec. 5. 2705 (1976).  132.  Charles Keely. "The United States of America" in The P o l i t i c s of Migration P o l i c i e s , ed: Daniel Kubat. (New York: Center f o r Migration Studies 1979), p.64.  133.  Ibid,  134.  Charles P r i c e . "Immigration and Group Settlement" in The Cultural Integration of Immigrants, ed. W.D. B o r r i e . ( P a r i s : UNESCO 1959), p. 267".  135.  Hawkins  136.  Donald G. Hohl. "The Indo-Chinese Refugee: The Evolution of United States Policy." International Migration Review 12 (Spring 1978): 128.  137.  Gail Paradise K e l l y . From Vietnam to America. A Chronicle of the Vietnamese Immigration to the United States. (Boulder, C o l . : West View Press 1977), p.201.  138.  I b i d , p.66.  139.  R.H. Rahe et a l . "Psychiat Consultation in a Vietnamese refugee camp." Am J Pschiat. 135 (February 1978): 187.  140.  Hawkins  Immigration Policy, and Management, 39.  141.  Lehrman  I s r a e l , The Beginning and Tomorrow, 160.  142.  J . Isaac "Israel - A New Melting Pot?" in The C u l t u r a l Integration of Immigrants, ed:: W.D. B o r r i e . ( P a r i s : UNESCO, 1959), p. 245.  143.  Hawkins  144.  Ibid,  145.  I b i d , p. 49-  146.  Isaac  147.  Lehrman  148.  European Economic Community. Regulation No. 1612/68, October 15, 1968.  p.64.  Immigration. P o l i c y and Management, 14.  Immigration P o l i c y and Management, 51.  p.50.  Melting Pof, 245. I s r a e l , The Beginning and Tomorrow, 161.  179 149.  Kubat  The P o l i t i c s of Migration P o l i c i e s , XXVI.  150.  Mehrlander Germany, 160.  151.  Yann Moulier and Georges Tapinos. "France" in The P o l i t i c s of Migration P o l i c i e s , ed: Daniel Kubat. (New York: Center f o r Migration Studies 1979), p.143.  152.  MerTander  153.  Ernst Kreuzaler. "The Federal Republic of Germany as Host Country to Foreign Guest workers and t h e i r Dependents." I n t e r n a t i o n a l ' Migration XV (1977): 139  154.  Beyer  155.  Reinhard Lohrmann "European Migration: Recent Developments and Future Prospects" International Migration XIV (1976): 233.  156.  Richmond  157.  Tom Rees. "The United Kingdom" in The P o l i t i c s of Migration P o l i c i e s , ed:,- Daniel Kubat. (New York: Center f o r Migration Studies 1979), p.71.  158.  Great B r i t a i n , Laws, S t a t u t e s , e t c . A l i e n s Act. 1905 5 Edw.7.c.l3. The Law Reports X L I I I , 22-7. (Pt. 1, sec. 3).  159.  Jones Immigration and Social P o l i c y , 117.  160.  Rees . The United Kingdom, 71.  161.  I b i d , p. 73.  162.  Great B r i t a i n , Laws, Statutes, e t c . , The B r i t i s h N a t i o n a l i t y Act 1948, 11 and 12 Geo. 6.C.56, Halsbury's Statutes of England, (3rd e d . ) , 1, 861-94 (pt. 1, sec. 1).  163.  Great B r i t a i n , Laws, S t a t u t e s , e t c . , The Immigration Act 1971. 1971 c. 77. Hals'bury's Statutes of England (3rd e d . ) , 41, 12-82 (pt. 1, ss. 1-11).  164.  Great B r i t a i n , Laws, Statutes, e t c . The Race Relations Act. 1976 1976 c.74, Halsbury's Statutes of England,  Germany, 156.  Benelux Countries, 112.  Migration and Race R e l a t i o n s , p.263.  I37d e d . ) , 46, 389-468, (pt. 1,2 & 3 ) . '  180 165.  Great B r i t a i n , Parliament, House o f Commons. Command Papers. Cmnd 7750, Proposals f o r Revision o f the Immigration Rules. November 1979.  166.  Great B r i t a i n , Laws, Statutes, e t c . The Local Government Act 1966, 1966 c.42, Halsbury's Statutes o f England (3rd ed.) 19, 896-922 (pt. 1, sec. 11).  167.  Great B r i t a i n , Laws, Statutes, e t c . , The Local Government Grants (Social Need) Act 1969, 1969 c . 2 , Halsbury's Statutes o T T n g l a n d , (3rd ed.) 19, 926-27.  168.  Rees  169.  I b i d , p. 9 0 .  170.  Great B r i t a i n , Laws, Statutes, e t c . The Commonwealth Immigrants Act 1962, 10 and 11 E l i z . 2 c . 2 1 . Halsbury's Statutes o f " England, (3rd e d . ) , IV, 24-62 (pt. 1, sec. 2 ) .  171.  Jones  172.  Ibid,  173.  Bagley. The Dutch P l u r a l S o c i e t y , 247.  174.  Great B r i t a i n , Laws, Statutes, e t c . , The B r i t i s h North America Act 1867, 30 and 31 V i c t , c . 3 , Halsbury's Statutes o f England, (3rd ed), IV, 183-221 ( p t . 6 , sec. 95).  175.  Canada, Laws,s., Statutes e t c . The Immigration Act 1869. 32-33 V i c t . c.10. Statutes of Canada. 1867-68, 1869. 32-45. preamble.  176  Canada, Laws, S t a t u t e s , e t c . The Immigration Aid S o c i e t i e s Act 1872. 35 V i c t , c.29 Statutes o f Canada. 1872. 120-4.  177.  Canada. Department o f Manpower and Immigration. The Immigration Program. A report of the Canadian Immigration and Population Study. (Ottawa: Information Canada 1974), p.6.  178.  Canada, Laws, Statutes, e t c . An Act to amend the Immigration Act. 1902. 2 Edw, V I I , c.14, Statutes of Canada 1902, Page 85, ( p t . l , sec. 24A).  179.  Canada, Laws, Statutes, e t c . , The Immigration Act 1910. 9-10 Edw. V I I . c.27. Statutes of Canada 1910, 205-39. (sec. 24).  The United Kingdom 8 8 .  Immigration and Social P o l i c y , 202. p.210.  181 180.  Canada, Parliament, Debates of the House of Commons, Session 1947, V o l . 3. ( A p r i l 14- May 12, 1947), pp.2644-46.  181.  Canada, Laws, Statutes, e t c . The Immigration Act 1952. I E l i z . 11. c.42, Statutes of Canada 1952, 1. 235-66. (pt. V I I , sec. 61).  1.82.  Canada, Laws, Statutes, e t c . The Immigration Act 1947. II Geo. VI. c.19 Statutes of Canada 1947, 1, 1 0 7 - 9 ~ T s e c . 4 ) .  183.  Canada, Laws, Statutes, e t c . Immigration Regulations, Part 1. SOR/62-36. The Canada Gazette Part 11, 96, 127-39, (sec. 31).  184.  Canada, Laws, Statutes, e t c . Immigration Regulations, Part 1, amended. SOR-67-434. The Canada Gazette Part 11, 101, 1350-62 (sec. 33).  185.  Freda Hawkins "Canadian Immigration P o l i c y and Management." Internation Migration Review. 8 (1974): 144.  186.  Canada, O f f i c e of the M i n i s t e r of Manpower and Immigration. White Paper on Immigration 1966. (Ottawa: Queen's P r i n t e r 1966), pp.38-40.  187.  The Immigration Program. (Ottawa: Information Canada 1974), p.123.  188.  Hawkins Canadian Immigration P o l i c y , 152.  189.  Anthony H. Richmond. Aspects of the Absorption and Adaptation of Immigrants. Canadian Immigration and PopulationStudy. (Ottawa: Information Canada 1974),p.5.  190.  Hawkins Canada and Immigration,  191.  Gerald E. Dirks. Canada's Refugee P o l i c y . Indifference or Opportunism? (Montreal: McGill Queen's U n i v e r s i t y Press 1977), p.50.  192.  Ibid., p.53  193.  The Immigration Program, 104.  194.  Kubat. The P o l i t i c s of Migration P o l i c i e s , 24.  195.  The Immigration Program, 114.  182 196.  Rhoda Howard."Contemporary Canadian Refugee P o l i c y : A C r i t i c a l Assessment." Canadian Public P o l i c y VI (Spring 1980): 362.  197.  Anthony H. Richmond. Aspects of the Absorption and Adaptation of Immigrants^ (Ottawa: Information Canada 1974) p. 7.  198.  Dirks Canada's Refugee P o l i c y , 258.  199.  Howard Contemporary Canadian Refuge P o l i c y , 370.  200.  M i n i s t e r of Employment and Immigration, Press Release. 'Notes f o r an Address by Bud Cull en," M i n i s t e r of Employment and Immigration Canada, to the South Ottawa Kiwanis Club; Ottawa, Ontario, Tuesday, January 16, 1979, p. 6.  201.  Canada, Laws, Statutes, e t c . The Immigration Act 1976 25-26 E l i z . l l Ch.52. Statutes of Canada. 1976-77, 11, 1199-1266 (pt. 1, sec. 6 ) .  202.  Howard: Contemporary Canadian Refugee P o l i c y , 369.  203.  Nguyen Quy Bong. "The Vietnamese i n Canada: Some Settlement Problems" in V i s i b l e M i n o r i t i e s and M u l t i c u l t u r a l i s m : Asians i n Canada, ed. K. V i c t o r Ujimoto and Gordon Hirabayashi. (Toronto: Butterworths 1980), p.250.  204.  Kennedy G. Tregonning. Southeast A s i a . A C r i t i c a l Biography. (Tucson, Arizona: The U n i v e r s i t y of Arizona Press 1969),p.38.  205.  Frances F i t z g e r a l d . F i r e i n the Lake. (New York: Vintage Books 1972), p.573.  206.  Nguyen Khac Kham. An Introduction to Vietnamese Culture. (Tokyo: The Centre f o r East Asian Cultural Studies 1967)p.79.  207.  Gerald Cannon Hickey. V i l l a g e in Vietnam. (New Haven: .. Yale U n i v e r s i t y Press 1964), p.76.  208.  I b i d . p. 118.  209.  Shri Jaswant Lai Mehta. A P o l i t i c a l and Cultural History of Vietnam up to 1964. (New D e h l i : Venus. Publishing House 1970), p8.  210.  Bruce Grant. The Boat People. An 'Age' I n v e s t i g a t i o n . (Harmondsworth, England: Penguin Books L t d . 1979), p.83.  183 211.  The Committee of Concerned Asian Scholars. The Indo-China Story. A F u l l y Documented Account. (New York: Pantheon Books 1970), p.117.  212.  K e l l y From Vietnam to America, 62.  213.  Committee. Indo-China Story, 112.  214.  Jean Mayer. "Starvation as a Weapon" i n Ecocide i n Indochina. The Ecology of War, ed. Barry Weisberg. (San Francisco: Canfield Press 1970),, p.79.  215.  Richard West. Sketches from Vietnam. (London: Jonathon Cape 1968) p.65.  216.  Maslow  217.  Nguyen Van Huong. "Twenty-five years of Health A c t i v i t i e s i n the DRVN." i n 25 years of Health Work, Vietnamese Studies No.25-1970. ' - ed: Nguyen Khac Vien. (Printed i n the DRUN. 1970.p.10.  218.  E l l e n J . Hammer. Vietnam, Yesterday and Today. (New York: H o l t , Rinehart and Winston Inc. 1966), p.232.  Motivation, 43.  219.. Bodenheimer & Roth, Health and Death i n Vietnam, 164. 220.  David Rees. Vietnam S i n c e ' L i b e r a t i o n ' . Hanoi's Revolutionary Strategy. C o n f l i c t Studies, Special Report No.89. (London: I n s t i t u t e f o r the Study of C o n f l i c t . 1977) pp.6^7.  221.  Grant Boat People, 82.  222.  I b i d , , p.55.  223.  Ibid,  224.  I b i d , p.65,  225.  I b i d , p.77.  226.  Personal communication: The D i r e c t o r of Nursing, The Canadian Red Cross Society. (B.C. and Yukon Division) who spent three months as a volunteer i n refugee camps i n Thailand 1979-80.  227.  Grant.  p.84.  The Boat People p.74.  184  228.  Morris S i e g e l . "Indices of Community Health" in Preventative Medicine, ed: Duncan W. Clark and Brian MacMahon. (Boston: L i t t l e , Brown and Company 1967), p.76.  229.  Manual of the International S t a t i s t i c a l C l a s s i f i c a t i o n of Diseases, I n j u r i e s and Causes of Death. (1975 Revision) Geneva: World Health Organization, 1977.  230.  World Health S t a t i s t i c s Annual. Organization.  231.  Weekly Epidemiological Record. Organization.  232.  Anthony M.M. Payne "The Basis of Preventative Measures" in Preventative Medicine ed: Duncan W. Clark and Brian MacMahon. (Boston: L i t t l e , Brown and Company 1967) p.25.  233.  I b i d , p.25  234.  Sidney Gaines and Nguyen Thi Nhu-Tuan. "Types and D i s t r i bution of B a c t e r i a l Enteropathogens Associated with Diarrhea in Vietnam" Mi l i t . . Med, 133 (February 1968): 127.  235.  Timothy SulTran and Nguyen Thi Nhu-Tuan. " B a c t e r i a l Enteropathogens in the Republic of South Vietnam." Mil i t Med 136 (January 1971): 4.  236.  Goldsmith et a l . "Orphan Airlift,"t)AMA 235 (May 10 1976): 2114.  237.  T. B u t l e r , N.N. L i n h , K. Arnold, M. P o l l a c k . "Chloramphenicolr e s i s t a n t typhoid fever i n Vietnam associated with R f a c t o r " Lancet 2 (November 3 1973): 983.  238.  "Health Status of Indochinese Refugees" MMWR 28 (August 24, 1979): 395.  239.  Canada, Department of Employment and Immigration, Public A f f a i r s D i v i s i o n Newsletter - Indochinese Refugees. l ( J u l y 24 1979):4.  240.  Joanna K. Tan, and Kenneth K. Tan. "Health Problems of the Vietnamese Refugees". Can Fam Physician 26(March 1980): 406.  241.  M. Chan-Yeung, J . D . G a l b r a i t h , N.Schulson, A. Brown, S.Grzybowski. "Reactivation of Inactive Tuberculosis i n Northern Canada" Am Rev Respir Pis 104 (December 1971):861.  Geneva: World Health Geneva: World Health  185 242.  Canada Tuberculosis S t a t i s t i c s . Morbidity and M o r t a l i t y . 1977. (Ottawa: S t a t i s t i c s Canada 1979), 16,17.  243.  "Tuberculosis among Indochinese Refugees - United States, 1979" MMWR 29 (August 15, 1980):383.  244.  Canada, Tuberculosis S t a t i s t i c s . 1976, 51.  245.  Kurt W. Deuschle. "Tuberculosis" i n Preventative Medicine, ed: Duncan W. Clark and Brian MacMahoru (Boston: L i t t l e , Brown and Company 1967), p.514.  246.  A. Vennema "Tuberculosis i n Rural Vietnam" Tubercle. 52 (1971):52.  247.  Joan K. McMichael. ed. Health i n the Third World. Studies from Vietnam. (Nottingham, England: The Bartrand Russel Peace Foundation. 1976), p.231.  248.  G.W. Comstock, L.B. Edwards, V.T. Livesay "Tuberculosis Morbidity and the US Navy" Am Rev Respir Dis 110 (1974): 578.  249.  Elizabeth B a r r e t t - Connor. "Latent and Chronic Infections Imported from Southeast A s i a . " JAMA 239 (May 5, 1978):1902.  250.  Tan and Tan Health Problems of Vietnamese Refugees, 405.  251.  Ray G. Cowley and Robert R. Briney. "Primary Drug-Resistant Tuberculosis i n Vietnam Veterans." Amer Rev. Respir,Dis 101 ( A p r i l 1970): 706.  252.  "Hepatitis screening of Indochinese Refugees" Can Dis Weekly Rep 6(January 26 1980):: 19.  253.  T. Hersh, J . Melnick, R.K. Goyal, F.B. H o l l i n g e r . "Non-parenteral transmission of v i r a l h e p a t i t i s type B." N Eng J Med 285 (December 9, 1971): 1364.  254.  W. Szmuness, and A. Prince. "The Epidemiology of serum h e p a t i t i s i n f e c t i o n s " Am J Epidemiol 94 (1971):585  255.  T.M. Vernon, R.A. Wright, P.F. Kohler, D.A. M e r r i l l . "Hepatitus A and B in the Family Unit" JAMA 235 (June 28 1976): 2829.  186  256.  " H e p a t i t i s Screening in Indochinese Refugees." Can Dis Weekly Rep 5 (January 26, 1980): 19.  257.  " N o t i f i a b l e Diseases Summary." 5 (November 8, 1980): 224.  258.  "Refugees w i l l be screened f o r H e p a t i t i s B. V i r u s . " J , Can, Dent Assoc. 12 (December 1979): 638.  259.  Robert Goldsmith e t a l . (May 10 1976): 2115.  260.  Isaac Goodrich. "Prevalence of I n t e s t i n a l Nematodes in a C i v i l i a n , Adult, South VietnamesePopulation" A m e s J . Trop„ Med Hyg 16 (November 1967): 748.  261.  E.B. Adams A Companion to C l i n i c a l Medicine i n the Tropics and Subtropics. (Oxford: Oxford University Press 1979), p.130.  262.  R.D.P. Eaton, F. S c o t t , and E. Meerovitch. "Amebiasis: A Ten Year Review of C l i n i c a l and Epidemiological Progress in the Saskatchewan Endemic Area." Can J P u b l i c Health 64 (October 1973): 47.  263.  L. Sekla, M. Fast, M. Drulak and B. Nowicki. "A P i l o t Survey of Endemic and Imported Parasite Infections in Manitoba" Can J Public Health". 69 (November - December 1978):275.  264.  "Hansen's Disease i n Vietnamese Refugees" MMWR 24 (January 3 1976): 455.  265.  Leprosy S u r v e i l l a n c e . World Health Organization Weekly Epidemiological Record. 54 (May 25, 1979): 161.  266.  Leprosy. World Health Organization Weekly Epidemiological Record 54 (January 19, 1979): 20.  267.  Population of Canada 1976 - 22,992,604. Canada Year Book. 1978-79 (Ottawa: S t a t i s t i c s Canada 1979), p.154.  268.  Hansen's Disease i n Vietnamese Refugees, 455.  269.  Abram S. Benenson e d . , Control of Communicable Diseases i n Man. 12th ed. (Washington D . C : The American Public Health Association 1975), p.200.  Can Dis Weekly Rep.  "Orphan A i r l i f t " JAMA 235  187  270.  C. Nigg. "Serologic studies on s u b c l i n i c a l J Immunol 91 (1963): 25.  melioidosis"  271.  Brian Maegraith. Adams and Maegraith: C l i n i c a l Tropical Diseases. 6th ed. (Oxford: Blackwell S c i e n t i f i c Publications 1976), p.553.  272.  S.N. Salem and S.C. Truelove "Hookworm Infection i n Great B r i t a i n : experimental observations" B Med:J.-2(0ctober 30 1965): 1039.  273.  Myron G. Schultz "Imported M a l a r i a " .  274.  M. S i n g a l , P.K. Shaw, R.C. Lindsay, R.R. Roberts. "An outbreak of introduced malaria i n C a l i f o r n i a possibly i n v o l v i n g secondary transmission" Amer J Trop Med Hyg 26 (January 1977]1:1.  275.  "Malaria S u r v e i l l a n c e and Control - Sutter and Yuba Countries, C a l i f o r n i a . " MMWR 29 (February 8, 1980): 51.  276.  David N. G i l b e r t , Wm L. Moore J r . , Chas L Hedberg, Lay P. Sanford " P o t e n t i a l Medical Problems i n Personnal Returning from Vietnam". Ann Int Med. 68 (March 1968):666.  277.  Jerome H. Greenburg " P u b l i c Health Problems r e l a t i n g to the Vietnam Returnee." JAMA 207 (January 27, 1969): 697.  278.  Richard H. Foote and David R. Cook. Mosquitoes of Medical Importance. A g r i c u l t u r a l Handbook No. 152. (Washington, D . C : U.S. Department of A g r i c u l t u r e 1959). p.8.  279  Louis H. M i l l e r . "Transfusion Malaria and Immigrant blood donors" J Infect Pis 133 (June 1976): 727.  280.  Joel P. Brown and Nguyen Qhoc Khoa. "Fatal Falciparum Malaria Among Narcotic Injectors"Amer J Trop Med Hyg 24 (September 1975): 729.  281.  "Fatal Malaria - Arkansas, C a l i f o r n i a . " ( A p r i l 30, 1976): 125.  282.  "Update on Vietnamese Refugees Health Status". MMWR 24 (August 2, 1975): 267.  283.  "Cholera i n a Laotian Refugee - C a l i f o r n i a . " ( A p r i l 25, 1980): 191.  Bull WHO 50 (1974):332.  MMWR 25  MMWR 29  188  284.  "Human Plague in 1979" Can Dis Weekly Rep 6 (October 25, 1980) 216.  285.  Canada, Department of Employment and Immigration. Newsletter. Indochinese Refugees. 1 (July 24, 1979): Appendix A.  286.  Edward J . C o l w e l l , Duane R. Armstrong, Joel D. Brown, Ralph E. Duxburg, E l v i o H. Sadun, and Dewellyn J . Legters. "Epidemiologic and Serologic Investigations of F i l a r i a s i s in Indigenous Populations and American S o l d i e r s in South Vietnam." Amer J . Trop Med Hyg 19 (1970): 227.  287.  Tan and Tan Health Problems of Vietnamese Refugees. 407.  288.  "Follow-up on Diphtheria in Indochinese Refugees from Thailand." MMWR 28 (November 23, 1979): 546.  289.  Health Screening of Resettled Indochinese Refugees - Washington D.C., Utah. MMWR 29 (January 11, 1980): 4.  290.  Elizabeth M. Hodson and Barry J . Springthorpe. "Medical Problems in Refugee Children evacuated from South Vietnam." Med J Aust 2 (November 13 1976): 748.  291.  Tan and Tan Health Problems of Vietnamese Refugees, 404.  292.  Vennema Tuberculosis in Rural Vietnam,,54,  293.  Hodson and Springthorpe C h i l d r e n , 747.  294.  Goldsmith et a l .  295.  " N u t r i t i o n a l Status of Southeast Asia Refugee C h i l d r e n " , MMWR 29 (October 3, 1980): 477.  296.  Nong The Anh, Tran Kiem Thuc and Jack D. Welsh. "Lactose Malabromption in adult Vietnamese." Amer J , C l i n Nutr 30 ( A p r i l 1977): 468.  297.  Hodson and Springthorpe 748.  298.  L i e - I n j o Luan Eng. " D i s t r i b u t i o n of Genetic Red Cell Defects i n South-East A s i a . " Trans R Soc Trop Med Hyg 63 (1969): 667.  299.  "Health Status of Indochinese Refugees." MMWR 28 (August 24 1979): 395.  Medical Problems in Refugee  Orphan A i r l i f t , 2115.  Medical Problem in Refugee C h i l d r e n ,  189  300.  "Health Status of Indochinese Refugees: Malaria and Hepatitus B." MMWR 28 (October 5, 1979): 463.  301.  G i l b e r t et a l .  302.  S . J . Baker and V . I . Mathon. "Sprue" in Management and Treatment of Tropical Diseases, ed. B.G. Maegraith and H.M. G i l l e s . (Oxford and Edinburgh: Blackwell S c i e n t i f i c P u b l i c a t i o n s 1971), p. 477.  303.  Adams  304.  Barrett-Connor. Latent and Chronic I n f e c t i o n s . 1906.  305.  Thomas Whiteside. The Pendulum and the Toxic Cloud. The course of d i o x i n contamination. (New Haven: Yale U n i v e r s i t y Press, 1979), pp.1,2.  306.  Barnett-Connor  307.  Gentry W. Yeatman, Constance Shaw, Matthew J . Barlow, and Glen B a r t l e t t . "Pseudo-battering in Vietnamese C h i l d r e n " . P e d i a t r i c s 58 (October 1976): 616.  308.  S.K.K. Seah. "Tropical Medicine i n Canada - Problems and Prospects." 65 (July/August 1974): 269. Can J Public Health  309.  I b i d , p. 269.  310.  Nguyen Quy Bong  311.  K e l l y From Vietnam to America, 91.  312.  R.H. Rahe, J . G . Looney, H.W. Ward, T.M. Tung, W.T. L i u . " P s y c h i a t r i c Consultation in a Vietnamese refugee camp" Am J Psychiat., 135 (February 1978): 185.  313.  R.A. Mattson and D.D. Ky "Vietnamese refugee care. P s y c h i a t r i c Observations." Minn Med 61 (January 1978): 35.  314.  Richard K. Harding and John G. Looney. "Problems of Southeast Asian c h i l d r e n in a refugee camp." Am J Psychiat 134 ( A p r i l 1977): 409.  315.  K.M. L i n , L. Tazuma and M. Masuda. "Adaptational problems of Vietnamese refugees. 1. Health and mental health s t a t u s . " Arch Gen Psychiat 36 (August 1979): 958.  A  Potential Medical Problems, 662.  Companion  to C l i n i c a l Medicine i n the Tropics, 87.  Latent and Chronic I n f e c t i o n s , 1906.  The Vietnamese in Canada, 250.  190 316. Minoru Masuda, Keh-Ming L i n , and Laurie Tazuma "Adaptation Problems of Vietnamese Refugees. 11. L i f e Changes and Perception of L i f e Events." Arch Gen Psychiat 37 ( A p r i l 1980):449. 317. Nguyen Quy Bong The Vietnamese in Canada, 251. 318. William T. Liu and Maryanne L. A. Murata. T r a n s i t i o n to Nowhere Vietnamese Refugees in America. (Nashville: Charles House Publishers Inc. 1979) P.170. 319. Nguyen Quy Bong  The Vietnamese in Canada, 253.  191 BIBLIOGRAPHY MIGRATION Bagley, C.  The Dutch Plural Society: A Comparative Study in Race Relations. London: Oxford Press, 1973.  B i r r e l l , Robert, and Hay,Colin. eds. The Immigration Issue i n A u s t r a l i a : Bundoora, V i c t o r i a : La Trobe U n i v e r s i t y , 1978. Bouscaren,  Anthony T. International Migrations since 1945. New York: Frederick A. Praeger, 1963.  Bouscaren, Anthony T. European Economic Community Migrations. The Hague: Martinus N i j h o f f , 1969. B r a i n , Peter J . , Smith, Rhonda L.; Schuyers, Gerard P. Population, Immigration and the A u s t r a l i a n Economy. London: Groom Helm, 1979. Deakin, Nicholas, ed. Immigrants Society, 1972.  in Europe.  London: Fabian  Dirks, Gerald E. Canada's Refugee Policy. Indifference or Opportunism? Montreal: McGill-Queen's University Press, 1977. Do!lot, Louis. Race and Human Migration. Translated by S y l v i a and George Leeson. New York: Walker and Company, 1964. Erickson, Charlotte. Emmigration from Europe 1815-1914. London: Adam and Charles Black, 1976. Handlin, Oscar. The Newcomers. Cambridge, Mass.: Harvard U n i v e r s i t y Press, 1959. Hawkins, Freda. Canada and Immigration. Public P o l i c y and P u b l i c Concern. Montreal: McGill-Queen's University Press, 1972. Hawkins, Freda. Immigration P o l i c y and Management i n Selected Countries. Ottawa: Information Canada, 1974.  192 Holborn, Louise W. Refugees: A Problem of Our Time. N.J.: The Scarecrow Press I n c . , 1975. —  Metuchen,  ,The Immigration Program. A Report of the Canadian Immigration and Population Study. Ottawa: Information Canada, 1974.  Jackson, J.A. ed. 1969.  Migration. Cambridge: The U n i v e r s i t y Press,  Jones, Catherine. Immigration and S o c i a l . P o l i c y i n B r i t a i n . London: Tavistock P u b l i c a t i o n , 1977. Krausz, Ernest. Ethnic M i n o r i t i e s in B r i t a i n . London: MacGibbon and Kee, 1971. Kubat, Daniel ed. The P o l i t i c s of Migration P o l i c i e s . New York: Center for Migration Studies, 1979. M i l l e r , J . D . B . , and J i n k s , B r i a n . A u s t r a l i a n Government and P o l i t i c s . 4th ed. London: Gerald Duckworth and Co. L t d . , 1971. Palmer, Howard, ed. Immigration and the Rise of M u l t i c u l t u r a l ism. Toronto: Copp Clark P u b l i s h i n g , 1975. P a r a i , Louis. The Economic Impact of Immigration. Canadian Immigration and Population Study. Ottawa: Information Canada, 1974. P r i c e , Charles. The Great White Walls Are B u i l t . Canberra: A u s t r a l i a n I n s t i t u t e of Internal A f f a i r s , 1974.  The  Richmond, Anthony M. Migration and Race Relation in an English C i t y . A Study i n B r i s t o l . London: Oxford U n i v e r s i t y Press, 1973. R i v e t t , Kenneth, ed. A u s t r a l i a and the Non-White Migrants. Melbourne: Melbourne University Press, 1975. Schechtman, Joseph B. The Refugee in the World. Displacement and Integration. New York: A.S. Barnes & Co., 1963. Scott, Franklin D. ed. World Migration in Modern Times. C l i f f s , N . J . : P r e n t i c e - H a l l I n c . , 1968.  Englewood  193 Stephen, David. Immigration and Race Relations. London: Fabian Society, 1970. Thomas, B r i n l e y . Migration and Economic Growth. 2nd ed. Cambridge: The U n i v e r s i t y Press, 1973. Ujimoto, K. V i c t o r , and Hirabayashi, Gordon, eds. Visible M i n o r i t i e s and M u l t i c u l t u r a l ism: Asians in Canada. Toronto: Butterworths, 1980. Hawkins, Freda. "Canadian Immigration P o l i c y and Management." International Migration Review. 8 (1974): 141-53. Hohl, Donald G. "The IndoChinese Refugee: The Evolution of United States P o l i c y " International Migration Review 12 (Spring 1978): 128-32. Howard, Rhoda. "Contemporary Canadian Refugee P o l i c y : A C r i t i c a l Assessment" Canadian Public P o l i c y VI (Spring 1980): 361-73. Kreuzaler, Ernst. "The Federal Republic of Germany as Host Country to Foreign Guestworkers and t h e i r Dependents." International Migration XV (1977): 138-42. Lohrmann,  Reinhard. "European Migration: Recent Developments and Future Prospects" International Migration XIV (1976) : 229-40.  M a s e l l i , G. "World Population Movements" International Migration. 9 (1971): 117-125. Murphy, H.B.M. "Mental Health Guidelines f o r Immigration P o l i c y . " International Migration XII (1974): 333-350. P r i c e , Charles. "Australian Immigration" International Migration Review IX (1975): 304-18. Skulley, Micheal T. " A u s t r a l i a ' s Immigration Program: an evaluation of i t s e f f e c t i v e n e s s . " International Migration XV (1977) : 21-34.  IMMIGRANTS : ADAPTATION AND INTEGRATION B o r r i e , W.D. ed. The C u l t u r a l Integration of Immigrants. P a r i s : UNESCO. 1959. Brody, Eugene, B. ed. Behaviour i n New Environments. Adaptation of Migrant Populations. Bevelly H i l l s , C a l . : Sage P u b l i c a t i o n , 1969. Eisenstadt, S.E. The Absorption of Immigrants. Routledge and Kegan Paul L t d . , 1954.  London:  J e f f e r y , P a t r i c i a . Migrants and Refugees. Muslim and C h r i s t i a n Pakistani Families i n Bristol.Cambridge: Cambridge University Press, 1976. Kushner, G i l b e r t . Immigrants from India i n I s r a e l . Tucson Arizona: The U n i v e r s i t y of Arizona Press, 1973. Lowenstein, Wendy and Loh, Morag. The Immigrants. Melbourne: Hyland House Publishing Pty. Ltd., 1977. Morrish, Ivor. The Background o f Immigrant C h i l d r e n . London: George A l l e n & Unwin Ltd, 1971. Richmond, Anthony M. Aspects of the Absorption and Adaptation of Immigrants. Canadian Immigration and Population Study. Ottawa: Information Canada, 1974. Rose,. A.  Migrants i n Europe. Problems of Acceptance and Adjustment. Minneapolis: U n i v e r s i t y of Minnesota Press, 1959.  Tabori, Paul.  The Anatomy of E x i l e .  London: Harrop, 1972.  Weinburg, Abraham A. Migration and Belonging. A Study of Mental Health and Personal Adjustment i n I s r a e l . The Hague: Martinus N i j h o f f , 1961. Zwingmann, Charles, Pfister-Ammende Maria, eds. Uprooting and After . . . New York: Springer-Vetrlag, 1973.  195  Abramson, J . H . "Emotional disorder, Status inconsistency, and M i g r a t i o n , a health questionnaire survey in Jerusalem." The Mil bank Memorial Fund Quarterly 44 (January 1966): 23-48. Adler, Seymour. "Marlow's Need Hierarchy and the Adjustment of Immigrants." International Migration Review 11 (1977): 444-451. Bernard, William S. "Immigrants and Refugees: Their S i m i l a r i t i e s Differences and Needs." International Migration. XIV (1976): 267-81. Burnley, I.M. "Immigrant Absorption in the Australian C i t y . " International Migration Review IX (1975): 319-33. Hastings, Jan. "Adaptation Problems of Asian Migrants." A u s t r a l i a and New Zealand Journal of Psychiatry 11 (December 1977): 219-21. Koranyi, E.K., Kerenyi, A., and Sarwer - Foner, G.L. On Adaptive D i f f i c u l t i e s of some Hungarian Immigrants. A socio - p s y c h i a t r i c study." Medical ServicesJournal 14 (1958): 383-403. Taft, Ronald "A Comparative Study of the I n i t i a l Adjustment of Immigrant School Children in A u s t r a l i a . " International Migration Review 13 (1979): 71-80. IMMIGRANTS : HEALTH, AND SERVICES Dodge, J . S . , ed. The F i e l d Worker in Immigrant Health. Staples Press, 1969.  London:  Facts Paper on the United Kingdom. 1970-71. London: The I n s t i t u t e of Race Relations, 1970. Skone, J . F . Public Health Aspects of Immigration. 2nd ed. London: Community Relations Commission, 1970. Wolsenholme, G.E.W. and O'Connor, M. eds. Immigration. Medical and Social Aspects. London: J . A . C h u r c h i l l Ltd., 1966.  196  Archer, D.M., Bamford, F.N., and Lees, E. "Helminth Infestations in Immigrant C h i l d r e n . " B r i t i s h Medical Journal 2 (December 25, 1965): 1517-19. Aujaleu, E.J.Y. "Protecting and Promoting the Health of Migrant Workers." Migration News (May-June 1974): 3-7. Aykroyd, W.R. Hossain, M.A. "Diet and State of N u t r i t i o n of Pakistani Families in Bradford, Yorkshire." B r i t i s h Medical Journal 1 (1967): 42-45. Bernard, William S. "Orientation and Counselling. Their nature and role i n the adaptation and i n t e g r a t i o n of permanent immigrants." International Migration X l l (1974): 182-200. Bernard, William S. "How to Influence the Public f o r a Better Understanding of the Problems of Immigrant Families and Social Welfare Measures Needed i n Order to F a c i l i t a t e a Better Integration of the Newcomers." International Migration,XIV (1976): 84^90. Dolton, W.D. "The Health and Welfare of the Immigrant" Royal Society of Health Journal 86 (1966): 22-27. Dumon, W.A. "The A c t i v i t y of Voluntary Agencies and National Associations on Helping Immigrants to Overcome I n i t i a l Problems." International Migration. XV (1977): 113-26. Freedman, Robert L. " N u t r i t i o n Problems and Adaptation of Migrants i n a New Cultural Environment." International Migration XI (1973): 15-31. Gelinek, I . "The Role of Social Work and the Contribution of Voluntary Social Agencies" International Migration XV (1977): 127-37. Markopoulou, C h r i s t i n e . "A Project of Social Work with Cypriot Immigrants i n London" International Migration XII (1974): 3-13. M i l l e r , Louis M. "Transfusion Malaria and Immigrant Blood Donors." Journal of Infectious Diseases 133 (June 1976): 727. Muhlin, Gregory L. "Neighbourhood T r a n s i t i o n and Mental H o s p i t a l i z a t i o n Patterns." International Migration Review 13 (Winter 1979): 693-705.  197  Salem, S . N . , and Truelove, S.C. "Hookworm i n f e c t i o n in Great B r i t a i n : Experimental Observations." British Medical Journal 2 (October 30, 1965): 1038-9. Weinburg, A.A. "Mental Health Aspects of Voluntary Migration. Mental Hygeine 39 (1955): 450-464.  1  HEALTH AND SICKNESS : AN ANTHROPOLOGICAL VIEW Foster, George. T r a d i t i o n a l S o c i e t i e s and Technological Change. New York: Harper and Row, 1973. G r o l l i g , Francis X., Maley, Harold,B. eds Medical The Hague: Mouton P u b l i s h e r s , 1976. Jaco, E.G. ed. P a t i e n t s , Physicians and I l l n e s s . The Free Press, 1958.  Anthropology. Glencoe, 111.:  Knutson, Andie, L. The I n d i v i d u a l , Society and Health Behaviour. New York: Russell Sage Foundation, 1965. Leininger, Madeline, and Buck, Gary. eds. Health Care Issues. P h i l a d e l p h i a : F.A. Davis Co. 1974. Logan, Micheal H. and Hunt, Edward E. eds. Health and the Human Condition^ Perspectives on Medical Anthropology. North S c i t u a t e , Mass.: Duxbury Press, 1978. Lynch, L.R., ed. The Cross Cultural Approach to Health Behaviour. Rutherford: F a i r l e i g h Dickinson U n i v e r s i t y Press, 1969. Paul, Benjamin D. ed. Health, Culture, and Community. New York: Russell Sage Foundation, 1955. Read, Margaret, Culture, Health and Disease. London: Tavistock P u b l i c a t i o n s , 1966. Schwartz, Barton, M. and Ewald, Robert M. Culture and Society. An Introduction to Cultural Anthropology. New York: The Ronald Press Company, 1968. Wood, Corinne. Shear. Human Sickness and Health. A BioculturaT View. Palo A l t o , C a l . : Mayfield Publishing Co. 1979.  198  Al land, Alexander. "War and Disease: An Anthropological Perspective." Natural H i s t o r y 76 (1967): 58-61. C u r r i e r , Richard, L. "The Hot-Cold Syndrome and Symbolic Balance in Mexican and Spanish - American Folk Medicine" Ethnology 5 (1966): 251Fabrega, M. "The study of disease i n r e l a t i o n to c u l t u r e . " Behavioural Science.17 (1972): 183-203. Gonzalez, Nancie, S o l i e n . "Health Behaviour in Cross-Cultural Perspective: A Guatemalan Example." Human Organization. 25 (1966): 122-125. Harrison, G.G. "Primary Adult Lactose Deficiency: A Problem i n Anthropological Genetics." American Anthropologist 77 (1975): 812-35. McCracken, Robert D. "Lactose Deficiency" An example of dietary e v o l u t i o n . " Current Anthropology. 12 (1977): 479-517. Waxier, Nancy E. "Social Change and P s y c h i a t r i c I l l n e s s i n Ceylon: T r a d i t i o n a l and Modern Concepts of Disease and Treatment." In Culture-bound Syndromes, Ethnopsychiatry and A l t e r n a t i v e Therapies, pp.222-40. Edited by William P. Lebra. Honolulu: U n i v e r s i t y of Hawaii Press, 1976. GENERAL AND TROPICAL MEDICINE Adams, E.B., A Comparison to C l i n i c a l Medicine i n the Tropics and Subtropics. Oxford: Oxford University Press. 1979. Benenson, Abram, ed. Control of Communicable Diseases i n Man. 12Hed. Washington, D . C : The American P u b l i c Health A s s o c i a t i o n , 1975. Clark, Duncan, W. and MacMahon, B r i a n , eds. Preventative Medicine. Boston: L i t t l e , Brown and Company, 1967. Foote, Richard H., Cook, David R. Mosquitoes of Medical Importance A g r i c u l t u r e Handbook No. 152. Washington D . C : U.S. Department of A g r i c u l t u r e 1959.  199 J e l l i f f e , D.B., and S t a n f i e l d , J . P . eds. Diseases of Children in the Subtropics and Tropics. 3rd ed. London: Edward Arnold (Publ i s h e r s ) L t d . , 1978. Lowell, Anthony, M. Tuberculosis in the World. Washington, U.S. Government P r i n t i n g O f f i c e , 1976. Maegraith, B r i a n . Exotic Diseases in P r a c t i c e . Heinemann Medical Books, Ltd., 1965.  D.C:  London: Wm  Maegraith, Brian. Adams and Maegraith: C l i n i c a l Tropical Medicine. 6th ed. Oxford: Blackwell S c i e n t i f i c Publications 1976. Maegraith, B.G. and G i l l e s , H.M. eds. Management and Treatment of Tropical Diseases. Oxford and Edinburgh: Blackwell S c i e n t i f i c P u b l i c a t i o n s . 1971. Manual of the International S t a t i s t i c a l C l a s s i f i c a t i o n of Diseases, I n j u r i e s , and Causes of Death.(1975 Revision) Geneva: World Health Organization, 1977. Tannery. J.M. ed. Stress and P s y c h i a t r i c Disorder. Blackwell S c i e n t i f i c P u b l i c a t i o n s , 1958. World Health S t a t i s t i c s Annual  Oxford:  Geneva: World Health Organization.  Aach, R.D."Viral Hepatitis - A to E" Medical C l i n i c s of North America 62 (January 1978): 59-70 Bowmer, E.  "Parasites Galore: I n t e s t i n a l Parasites i n B r i t i s h Columbia 1956-1972." Canadian Journal of Public Health, 64 (October 1973): Supplement.  Bowmer, E. "Laboratory I n d e n t i f i c a t i o n s of I n t e s t i n a l Helminths and Protozoa. P r o v i n c i a l Laboratories, B r i t i s h Columbia, 1956 - 1978 (23 years)" Canadian Disease Weekly Report 5 (June 9 1979): 94-5. Burgess, Ann Wolbert, and Holmstrom, Lynda L y t l e "Rape Trauma Syndrome" American Journal of Psychiatry 131 (September 1974): 981-6. Cathcart, L.M., Berger, P. and Knazan, P. "Medical examination of torture victims applying for refugee s t a t u s . " Canadian Medical Journal 121 (July 21 . 1979): 179-84.  200  Chan-Yeung, M.; G a l b r a i t h , J . D . ; Schulson, N.; Brown, A.; Grzybowski, S. " R e - a c t i v a t i o n of Inactive Tuberculosis i n Northern Canada." American Review of Respiratory Diseases 104 (December 1971): 861-65. Comstock, G.W.; Edwards, L.B.; Livesay, V.T. "Tuberculosis morbidity and the U.S. Navy" American Review of Respiratory Diseases 110 (1974): 572-80. The Development of a National Data Bank f o r P a r a s i t i c Diseases" Canadian Disease Meekly Report 2 (August 7 1976): 126. Eaton, R.D.P.; Scott, F.; Meerovitch, E. "Amebiasis: A Ten-Year Review of C l i n i c a l and Epidemiological Progress i n the Saskatchewan Endemic Area." Canadian Journal of Public Health.64 (October 1973): 47-51. "Emergency Care in National D i s a s t e r s . " 96-100.  WHO Chronicle 34 (1980);  Hersh, T.; Melnick, J . ; Goyal, R.K.; and H o l l i n g e r , F.B. "Non parenteral transmission of v i r a l h e p a t i t i s type B." New England Journal of Medicine. 285 (December 9 1971): 1363-4. "Human Plague in 1979". Canadian Disease Weekly Report 6 (October 25, 1980): 216. Leprosy. WHO. Weekly Epidemiological Record 54 (January 19  1979): 20.  Leprosy Surveillance. WHO Weekly Epidemiological Record 54 (May 25. 1979): 161. "Malaria Surveillance and Control - Sutter and Yuba Countries. C a l i f o r n i a . " Morbidity and M o r t a l i t y Weekly Reports 29 (February 8 1980):51. Nayyar, K.C.; S t o l z , E.; and Michel, M.F. " R i s i n g Incidence of Chancroid i n Rotterdam" B r i t i s h Journal of Venereal Diseases 55 (1979): 439-441. Nigg, C. " S e r o l o g i c i s t u d i e s on S u b - c l i n i c a l M e l i o i d o s i s . " Journal of Immunology 91 (1963): 18-28. Peters, W., "Drug Resistance in Malaria - A Perspective." Transactions of the Royal Society f o r Tropical Medicine and Hygeine 63 (1969): 28. ~ -  201 "Protein Requirements."  WHO Chronicle 19 (1965): 286-90.  S c h u l t z , Myron G. "Imported Malaria" WHO B u l l e t i n . 50 (1974): 329-36. Seah, S.K.K. "Tropical Medicine in Canada - Problems and Prospects." Canadian Journal of Public Health 65 (July/August 1974): 269-72. Sekla, L.,  Fast, M., Drulak, M. and Nowicki, B. "A P i l o t Survey of Endemic and Imported P a r a s i t i c Infections i n Manitoba" Canadian Journal of P u b l i c Health 69 (November - December 1978): 475-80.  S i n g a l , M., Shaw, P.K., Lindsay R . C , Roberts R.R. "An outbreak of introduced malaria in C a l i f o r n i a possibly i n v o l v i n g secondary transmission." American Journal of Tropical Medicine and Hygeine. 26 (January 1977): 1-9. Suskind, Robert, M., Olson, Lloyd, C , and Olson, Robert, E. "Protein - Calori M a l n u t r i t i o n and Infection with H e p a t i t i s - Associated Antigen". P e d i a t r i c s 51 (March 1973): 525-30. Szmuness W., Prince, A. "The Epidemiology of serum h e p a t i t i s i n f e c t i o n s . " American Journal of Epidemiology 94 (1971): 585-95. Vernon, T.M., Wright, R.A., Kohler, P.F., M e r r i l l , D.A. " H e p a t i t i s A and B i n the Family U n i t . " American Medical Association Journal 235 (June 28, 1976): 2829-31. The Vietnamese: Cultural and Health Background. The Committee of Concerned Asian Scholars. The Indo-China Story. A F u l l y Documented Account. New York: Pantheon Books, 1970. Embree, John F., and Dotson, L i l l i a n 0. Bibliography of the Peoples and Cultures of Mainland Southeast A s i a . New York: Russell & R u s s e l l . 1972.  • i  YJ2  F i t z g e r a l d , Frances. 1972.  F i r e i n the Lake. New York: Vintage Books,  Gough, Kathleen. Ten Times more B e a u t i f u l . New Star Books, 1978.  Vancouver:  Grant,Bruce. The Boat People. An 'Age' I n v e s t i g a t i o n . England: Penguin Books Ltd. 1979.  Harmondsworth,  Hammer, E l l e n J . Vietnam. Yesterday and Today. New York: H o l t , Rinehart and Winston Inc., 1966. Hickey, Gerald Gannon. V i l l a g e i n Vietnam.New Haven: Yale U n i v e r s i t y Press, 1964. Mehta, Shri Jaswant L a i . A P o l i t i c a l and Cultural History of Vietnam up to 1964. New .Dehli : Venus Publishing House, 1970. McMichael, Joan, ed. Health i n the Third World.Studies from Vietnam. Nottingham, England: The Bertrand Russell Peace Foundation, 1976. Nguyen, Khac Kham. An Introduction to Vietnamese Culture. Tokyo: The Center f o r East Asian Cultural Studies, 1967. Nguyen, Khac Vien. ed. 25 years of Health Work. Vietnamese Studies no. 25 - 1970. Printed i n the D.R.V.N. 1970. Osborne, M i l t o n . Southeast A s i a . An Introductory H i s t o r y . George A l l e n and Unwin, 1979.  London:  Rees, David. Vietnam since ' L i b e r a t i o n ' . .Hanoi's Revolutionary Strategy. C o n f l i c t Studies. Special Report. No.89. London: I n s t i t u t e f o r the Study of C o n f l i c t . 1977. Smith, Harvey H.; Bernier, Donald; Bunge, Frederica M.; R i n t z , Frances C.; Shinn, Rinn-Sup; T e l e k i , Suzanne. Area Handbook f o r South Vietnam. Washington, D . C : U.S. Government P r i n t i n g O f f i c e , A p r i l 1967. Thuy, Vuong G.; Getting to know the Vietnamese and Their Culture. New York: Frederick Ungen Publishing Co., 1976. Tregonning, Kennedy G. Southeast A s i a . A C r i t i c a l Biography. Tucson, Arizona: The University of ArizonaPress. 1969.  203  Weisberg, Barry, ed. Ecocide i n Indochina. The Ecology of War. San Francisco: Canfield Press, 1 9 7 0 . West, Richard,  Sketches from Vietnam.  London: Jonathon Cape. 1 9 6 8 .  West, Richard. Victory i n Vietnam. London: Private Eye Productions. 1 9 7 4 . Whiteside, Thomas. The Pendulum and the Toxic Cloud. The course of Dioxin contamination. New Haven: Yale University Press, 1 9 7 9 . Barrett - Connor, E l i z a b e t h . "Latent and Chronic Infections Imported from Southeast A s i a . " American Medical Association Journal. 239 (May 5 , 1 9 7 8 ) : 1 9 0 1 - 6 . Brown, J o e l , and Nguyen Qhoc Khoa. "Fatal Falciparum Malaria Among Narcotic I n j e c t o r s . " American Journal of Tropical Medicine and Hygeine 24 (September 1 9 7 5 ) :  729-33.  B u t l e r , T . ; L i n h , N.N.; Arnold, K.; and Polla; , M. "Chloramphenicol - r e s i s t a n t typhoid fever i n Vietnam associated with R f a c t o r . " Lancet 2 (November 3 1973)i:. 9 8 3 - 5 .  C o l w e l l , Edward J . ; Armstrong, Duane R.; Brown, Joel D.; Duxburg, Ralph E.; Sadun, E l v i o , M.; and Legters, Llewellyn J . "Epidemiologic and Serologic Investigations o f F i l a r i a s i s i n Indigenous Populations and American Soldiers i n South Vietnam." American Journal of Tropical Medicine and Hygeine 19 (1970):  227-31.  Cowley, Ray G., and Briney, Robert R. "Primary Drug - Resistant Tuberculosis in Vietnam Veterans." American Review of Respiratory Diseases 101 ( A p r i l 1 9 7 0 ) : 7 0 3 - 5 . Eng, L i e - I n j o Luan. " D i s t r i b u t i o n of Genetic Red Cell Defects i n South East A s i a . " Transactions of the Royal Society f o r Tropical Medicine and Hygeine 6 3 (1969):  664-74.  Gaines, Sidney, and Nguyen, Thi Nhu-Tuan. "Types and D i s t r i b u t i o n o f B a c t e r i a l Enteropathogens Associated with Diarrhea i n Vietnam." M i l i t a r y Medicine 133 (February 1 9 6 8 ) :  114-27.  G i l b e r t , David N.; Moore, Wm L. J r . ; Hedberg Chas L.; Sanford, Jay P. " P o t e n t i a l Medical Problems i n Personnel Returning from Vietnam." Annals of Internal Medicine 68 (March 1968): 662-78. Goodrich, Isaac. "Prevalence of I n t e s t i n a l Nematodes i n a C i v i l i a n , Adult, South Vietnamese Population." American Journal of Tropical Medicine and Hygeine 16 (November 1967): 746-9. Greenburg, Jerome H. " P u b l i c Health Problems r e l a t i n g to the Vietnam Returnee." American Medical Association Journal. 207 (January 27 1969): 697-702. Modell, Walter. "Malaria and Victory i n Vietnam." (1968): 1346-52.  Science 162  Nong The Anh, Tran Kiem Thuc and Welsh, Jack D. "Lactose Malabsorption in adult Vietnamese." American Journal of C l i n i c a l N u t r i t i o n 30 ( A p r i l 1977): 468-9. Poffenbarger, P h i l l i p . "Tuberculosis i n South Vietnam." American Journal of Tropical Medicine and Hygeine (1972): 226-33.  21  Smith, Ralph. "Viet-Nam: History" i n The Far East and A u s t r a l a s i a . 1979-80. A Survey and Directory of Asia and the P a c i f i c . 11th ed. pp.1121-1130..London: Europe P u b l i c a t i o n s Ltd., 1979. S u l l i v a n , Timothy, and nguyen Thi Nhu-Tuan. " B a c t e r i a l Enteropathoges i n the Republic of South Vietnam." M i l i t a r y Medicine. 136 (January 1971): 1-6. Vennema, A. "Tuberculosis i n Rural Vietnam" Tubercle. 52 (1971): 51-9. THE VIETNAMESE REFUGEES 1975-76: HEALTH PROBLEMS K e 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 , William, T . , and Murata, Maryanne L.A. T r a n s i t i o n to Nowhere. Vietnamese Refugees in America. N a s h v i l l e : Charter House Publishers Inc., 1.970.  205^  Goldsmith. Robert; S t a r l e , Fred; Smith, Creed; Healy, George; Donegan, E l i s a b e t h ; Juchau, Vern; Stalcup, Alex. "Orphan A i r l i f t . " American Medical Association Journal 235 (May 10. 1976): 2114-6. •".Hansen's Disease in Vietnamese Refugees." Mobidity and M o r t a l i t y 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 ( A p r i l 1977): 407-11. Hodson, Elisabeth M., and Springthorpe, Barry J . "Medical Problems i n Refugee Children evacuated from South Vietnam." Medical Journal of A u s t r a l i a 2(November 13 1976): 747-9. Lin,  K.M.; Tazuma, L; and Masuda, M. "Adaptational problems of Vietnamese refugees. 1. Health and mental health s t a t u s . " Archives of General Psychiatry. 26 (August 1979): 955-61.  "Natural loss of i n t e s t i n a l parasites of Vietnamese immigrants following entry to Canada." Canada Diseases Weekly Report 2 ( A p r i l 24 1976): 65. Masuda, Minoru; L i n , Ken-Ming; and Tazuma, Laurie. "Adaptation Problems of Vietnamese Refugees. 11. L i f e Changes and Perception of L i f e Events." Archives of General Psychiatry 37 ( A p r i l 1980): 447-50. Mattson, R.A., and Ky, D.D. "Vietnamese refugee care. P s y c h i a t r i c observations." Minnesota Medicine 61 (January 1978): 33-6. Rahe, R.H.; Looney, J . G . ; Ward, H.W.; Tung, T.M.; L i u , W.T. " P s y c h i a t r i c consultation i n a Vietnamese refugee camp." American Journal of Psychiatry. 135 (February 1978): 185-90. "Update on Vietnamese Refugees Health S t a t u s . " Morbidity and M o r t a l i t y Weekly Report 24 (August 2 1975): 267. Yeatman, Gentry W.; Shaw, Constance; Barlow Matthew J . ; and B a r t l e t t , Glen. Pseudobattery i n Vietnamese C h i l d r e n . " P e d i a t r i c s 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 i n a Laotian Refugee - C a l i f o r n i a . " Morbidity and M o r t a l i t y Weekly Report 29 ( A p r i l 25 1980): 191. Dahlberg, K e i t h . "Medical Care of Cambodian Refugees." American Medical Association Journal 243 (March 14 1062-5.  1980):  "Follow-up on Diphtheria in Indochinese Refugees from Thailand." Morbidity and M o r t a l i t y Weekly Report 28 (November 23 1959): 546., "Health Screening of Resettled Indochinese Refugees - Washington D.C., Utah." Morbidity and M o r t a l i t y Weekly Report 29 (January 11 1980): 4. "Health Status of Indochinese Refugees: Malaria and Hepatitis B." Morbidity and M o r t a l i t y Weekly Report 28 (October 5 1979): 463. "Health Status of Indochinese Refugees." Morbidity and M o r t a l i t y Weekly Report 28 (August 24. 1979): 395. "Hepatitis Screening of Indochinese Refugees" Canada Diseases Weekly Report 6 (January 26 1980): 14-5, 18-9. " N o t i f i a b l e Diseases Summary." Canada Diseases Weekly Report 5 (November 8 1980): 224. " N u t r i t i o n a l Status of Southeast Asian Refugee C h i l d r e n . " Morbidity and M o r t a l i t y 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 f o r H e p a t i t i s B. v i r u s . " Journal of the Canadian Dental Association 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 M o r t a l i t y Weekly Report. 29 (August 15 1980): 383.  GOVERNMENT DOCUMENTS AND PUBLICATIONS CANADA Canada, Laws, Statutes, e t c . The Immigration Act 1869 32-33 V i c t . c.10. Statutes of Canada 1867-68, 1869. Canada, Laws, Statutes e t c . The Immigration Aid S o c i e t i e s Act 1872. 35 V i c t . c. 29. Statutes of Canada 1872. Canada, Laws, Statutes, e t c . An Act to amend the Immigration Act 1902, 2 Edw. V I I , c.14. Statutes of Canada 1902. Canada, Laws, Statutes, e t c . The Immigration Act 1910, 9-10 Edw. V I I , c.27. Statutes of Canada 1910. Canada, Parliament, Debates of the House of Commons, Session 1947, Vol. 3, ( A p r i l 14 - May 12, 1947). Canada, Laws, Statutes, e t c . The Immigration Act 1947. VI. c.19. Statutes of Canada 1947. Vol.1  11 Geo,  Canada, Laws, Statutes, e t c . . The Immigration Act 1952. 1 E l i z . 11. c.42. Statutes of Canada 1952, V o l . 1 Canada, Laws, Statutes, e t c . Immigration Regulations Part 1. SOR/62-36, The Canada Gazette Part 11, V o l . 96. Canada, O f f i c e of the Minister of Manpower and Immigration. White Paper on Immigration 1966.Ottawa: Queen's P r i n t e 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 i n g u a l i s m and B i c u l t u r a l i s m . Report. Ottawa: Queen's P r i n t e r , 1969. Canada, Laws, Statutes, e t c . The Immigration Act 1976, 25-26 E l i z 11, ch.52. Statutes of Canada 1976-77, V o l . 11. Canada, Department of Employment and Immigration, Press Release. "Notes f o r an Address by Bud C u l l e n , M i n i s t e r 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 i n Southeast A s i a : humanitarian and p o l i t i c a l aspects c a n ' 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, P u b l i c A f f a i r s D i v i s i o n , Newsletters. Indochinese Refugees. 1979-80. Canada, Tuberculosis S t a t i s t i c s . Morbidity and M o r t a l i t y 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, e t c . Refugee Settlement Act 1979, 28 E l i z . 2, ch 360, Revised Statutes of B r i t i s h Columbia 1979, V o l . 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 e d . ) , Vol. IV Great B r i t a i n , Aliens Act 1905 5 Edw. 7, c.13. Vol. XLIII.  The Law Reports.  Great B r i t a i n , The B r i t i s h N a t i o n a l i t y Act 1948 11 and 12 Geo. 6, c.56. Halsbury's Statutes of England (3rd e d . ) , 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 e d . ) , V o l . IV. Great B r i t a i n , The Local Government Act 1966 1966 c.42, Halsbury's Statutes of England (3rd e d . ) , V o l . 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 e d . ) , V o l . 19. Great B r i t a i n , The Immigration Act 1971, 1971 c.77. Statutes of England (3rd e d . ) , Vol. 41.  Halsbury's  Great B r i t a i n , The Race Relations Act 1976 1976 c.74. Halsbury's Statutes of England, (3rd ed.) V o l . 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 N a t i o n a l i t y Act (McCarran Walter Act) Statutes at Large, Vol. 66 (1952). U.S. Congress, Immigration and N a t i o n a l i t y Act, amendments. Statutes at Large, V o l . 79 (1965). U.S., Department of J u s t i c e , Immigrants and N a t u r a l i s a t i o n Services. Reports of Immigrants and N a t u r a l i s a t i o n Services. S t a t i s t i c a l B u l l e t i n . September 1968.  210  U.S. Congress, Immigration and N a t i o n a l i t y Act Amendments of 1976 Statutes at Large, Vol.90, (1976). —  MISCELLANEOUS Maslow, Abraham H. Motivation and P e r s o n a l i t y . Harper * 1970.  2nd ed. New York:  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0095108/manifest

Comment

Related Items