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The Health of Refugees
The Health
of Refugees
Public Health
Perspectives from Crisis
to Settlement
SECOND EDITION
Edited by
Pascale Allotey and Daniel D. Reidpath
1
1
Great Clarendon Street, Oxford, OX2 6DP,
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First Edition published in 2003
Second Edition published in 2019
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contained in any third party website referenced in this work.
For our parents, Ate, Betty, Gillian, and Kevin
whose love and support was a constant in our lives.
Foreword
The rapid movement of large populations is intrinsic to humanity, usually as a

result of climate change, famine, earthquake, political or ideological conflict, re-
ligious persecution, and war. Societies receiving such populations—now called
asylum seekers—may be profoundly affected, sometimes positively through
moral, demographic, genetic, economic, and cultural enrichment. Places that
lose such populations tend to be diminished. Only some of these groups of
people are refugees under international law.
Although in official parlance, at least in Europe, a refugee is an asylum seeker
who has been granted leave to stay, the word is highly descriptive of the en-
tire group of people who seek asylum. It captures the sense of pursuit, fleeing,
and the perils of the journey much better than the idea of seeking peace and
calm portrayed by the phrase ‘asylum seeker’. Setting aside the nuances of these
phrases, the challenges to migrants and to the societies they come to join are
immense. Recipient populations and their services have a complex tasks of
caring for them and ensuring a favourable outcome for all. These tasks are to be
accomplished in the context of the myriad of international, regional, national,
and even sub-national laws, policies, strategic documents, and service delivery
plans. Health and health care are amongst the top priorities in terms of the
immediate required actions. Public health is central in ensuring the required
actions are taken.
Historically, societies muddled through, with the indomitable human spirit
of the migrants and the recipient populations usually overcoming adversity,
through a partnership of community organizations (including faith groups),
non-governmental organizations, legally required services, and the business/
employment sector. Muddling through doesn’t, however, always work out in
the face of social prejudices, language problems, poverty, isolation, detention,
unemployment, poor health, and barriers to services.
Over the last 30–40 years there has been a growing realization that laws and
even goodwill are not enough. This realization has accelerated in our era of
globalization and conflicts with mass movement of people—for example in the
Middle East, Myanmar, and the Balkans, to name but a few. We must do better
on many fronts. This book shows us how to do so in health and health care in
and for asylum seekers and refugee across their journey from exodus, arrival,
and settlement.
viii Foreword
Sadly, this is a book of and for our times. In awaiting, and dreaming about, a
better world, we need to be armed with ethics, legal stances, principles, exem-
plars, knowledge of best practice, case studies, and resolve. Thank you to the
authors and especially the editors for providing us with all this, and much more.
Raj Bhopal CBE, DSE (hon)
Bruce and John Usher Professor of Public Health
Honorary Consultant in Public Health
Edinburgh Migration, Ethnicity and Health Research Group
Centre for Population Health Sciences
Usher Institute of Population Health Sciences and Informatics
The University of Edinburgh
4 April 2018
Contents
Abbreviations xi
Contributors xiii
Part 1 Concepts and contexts

1 Forced migration, globalization, and global public health 3
2 Humanitarianism, refugees, human rights, and health 19
Susan Kneebone
3 Social exclusion, othering, and refugee health policy 39
Daniel D. Reidpath and Pascale Allotey
4 Health in humanitarian crises 54
Mike Toole
Part 2 Health concerns

5 Populations in transition and post-settlement: an infectious
diseases and travel medicine perspective 87
Kudzai Kanhutu, Karin Leder, and Beverley Ann Biggs
6 Mental health of refugees 106
Peter Ventevogel, Xavier Pereira, Sharuna Verghis, and Derrick Silove
Part 3 Impacts of displacement

7 Urban refugees: the hidden population 131
Sharuna Verghis and Susheela Balasundram
8 Addressing the rights of women in conflict and humanitarian
settings 153
Rajat Khosla, Sandra Krause, and Mihoko Tanabe
9 The health challenges facing children on the move 169
Susan Bissell and Jacqueline Bhabha
10 The health impacts of displacement due to conflict on
adolescents 181
Anushka Ataullahjan, Michelle F. Gaffey, Paul B. Spiegel, and
Zulfiqar A. Bhutta
x Contents
Part 4 Case studies in research and ethics

11 Methodological and ethical challenges in research with
forcibly displaced populations 209
Veena Pillai, Alison Mosier-Mills, and Kaveh Khoshnood
12 Conducting health research with resettled refugees in
Australia: field sites, ethics, and methods 230
Celia McMichael and Caitlin Nunn
13 The politics of immigrant and refugee health in the United
States 245
Michael Grodin, Sondra Crosby, and George Annas
14 Dual loyalty, medical ethics, and health care in offshore
asylum-seeker detention 260
Deborah Zion
Part 5 Conclusion
15 Controlling compassion: the media, refugees, and asylum
seekers 275
Pascale Allotey, Peter Mares, and Daniel D. Reidpath
Index 295
Abbreviations
ACLU American Civil Liberties Union ICE Immigration and Customs

BCRHHR Boston Center for Refugee Enforcement
Health and Human Rights ICESCR International Covenant
BMC Boston Medical Center on Economic, Social and
Cultural Rights
BUSPH Boston University School of
Public Health ICMC International Catholic
Migration Commission
CAR Central African Republic
IDP internally displaced person
CBT cognitive behavioural therapies
IHMS International Health and
CESCR Committee on Economic,
Medical Services
Social and Cultural Rights
IRB institutional review board
CFR case fatality rates
IRHP Immigrant and Refugee Health
CMR crude mortality rates
Program
COMPASS creating opportunities
ISP Independent Study Project
through mentorship, parental
involvement, and safe spaces MDD major depressive disorder
CRC Convention on the Rights of MDG Millennium
the Child Development Goals
DACA Deferred Action for Childhood MDR TB multi-drug-resistant
Arrivals tuberculosis
DRC Democratic Republic of MHPSS mental health and psychosocial
the Congo support
ECDC European Centre for Disease MISP minimum initial service
Prevention and Control package
ECOSOC Economic and Social Council MMR measles, mumps, and rubella
(vaccination)
EU European Union
NCD non-communicable disease
FMEG Forensic Medical
Evaluation Group NGO non-governmental
organization
GBV gender-based violence
NHI National Health Insurance
GLP Global Lawyers and Physicians
NHS National Health Service
GNB Gram-negative bacteria
ODA official development assistance
HIA Health Induction Assessment
OECD Organisation for Economic Co-
HINAP Health Information Network
operation and Development
for Advanced Planning
PCTF Polio Control Task Force
HRW Human Rights Watch
PoC person of concern
IASC Inter-agency Standing
Committee POV polio oral vaccine
IAWG Inter-agency Working Group PSSA psychosocial structured
activities
ICCPR International Covenant on
Civil and Political Rights PTSD post-traumatic stress disorder
xii Abbreviations
RAN Royal Australian Navy UDHR Universal Declaration of

RPC Regional Processing Centre Human Rights
RSD refugee status determination UHC universal health coverage
RUTF ready-to-use therapeutic foods UNHCR United Nations High
Commission for Refugees
SDG Sustainable Development Goals
UNRWA United Nations Relief and
SGBV sexual and gender-based
Works Agency
violence
VFR visiting family and relatives
SRH sexual and reproductive health
WASH water, sanitation, and hygiene
STI sexually transmissible infection
WCH women’s and children’s health
TB tuberculosis
WHO World Health Organization
TST tuberculin skin test
Contributors
Pascale Allotey Susan Bissell

Director, International Institute for Former Director, Global Partnership
Global Health (UNU-IIGH), United to End Violence Against Children,
Nations University, Kuala Lumpur, New York, USA
Malaysia Sondra Crosby
George Annas Associate Professor, Center for
William Fairfield Warren Health Law, Ethics & Human Rights,
Distinguished Professor; Director of Boston University School of Public
the Center for Health Law, Ethics & Health, Boston, MA, USA
Human Rights, Boston University Michelle F. Gaffey
School of Public Health, Boston, Senior Research Manager, Centre for
MA, USA Global Child Health, The Hospital for
Anushka Ataullahjan Sick Kids, Toronto, Canada
Research Analyst, Centre for Global Michael Grodin
Child Health, The Hospital for Sick Professor, Center for Health Law,
Kids, Toronto, Canada Ethics & Human Rights, Boston
Susheela Balasundram University School of Public Health,
Doctor, United Nations High Boston, MA, USA
Commissioner for Refugees, Kuala Kudzai Kanhutu
Lumpur, Malaysia Refugee Health Fellow, Doherty
Jacqueline Bhabha Institute, The Royal Melbourne
FXB Director of Research, Professor Hospital, Melbourne, Australia
of the Practice of Health and Human Kaveh Khoshnood
Rights at the Harvard School of Associate Professor of Epidemiology
Public Health, Cambridge, MA, USA (Microbial Diseases); Program
Zulfiqar A. Bhutta Director BA-BS/MPH Program in
Co-Director, Director of Research, Public Health, Yale University, New
Centre for Global Child Health, Haven, CT, USA
The Hospital for Sick Kids, Rajat Khosla
Toronto, Canada Human Rights Adviser, Department
Beverley Ann Biggs of Reproductive Health, World
Professor, Royal Melbourne Hospital, Health Organisation, Geneva,
Melbourne, Australia Switzerland
xiv Contributors
Susan Kneebone Daniel D. Reidpath

Professorial Fellow and Associate, Professor of Population Health
Asian Law Centre, Melbourne Law and Director, South East Asia
School, Melbourne, Australia Community Observatory, Jeffrey
Cheah School of Medicine and
Sandra Krause
Health Sciences, Monash University,
Sexual and Reproductive Health
Malaysia
Program, Women's Refugee
Commission, New York, USA Derrick Silove
Professor, School of Psychiatry, Brain
Karin Leder
Sciences, University of New South
Professor, Head of Infectious
Wales, Sydney, Australia
Disease Epidemiology Unit, Monash
University, Clayton, Australia Paul B. Spiegel
Director, Center for Humanitarian
Peter Mares
Health, Johns Hopkins University
Adjunct Fellow, Swinburne
University, Melbourne, Australia Mihoko Tanabe
Sexual and Reproductive Health
Celia McMichael
Program, Women's Refugee
Lecturer, School of Geography,
Commission, New York, USA
University of Melbourne, Melbourne,
Australia Mike Toole
Alison Mosier-Mills Professor, School of Public Health
‎Fulbright Student Researcher in and Preventive Medicine, Monash
Public Health, Yale University, New University, Victoria, Australia
Haven, CT, USA Peter Ventevogel
Caitlin Nunn Senior Mental Health Officer, United
Assistant Professor (Research), Nations High Commissioner for
Department of Sociology; and Refugees, Geneva, Switzerland
Fellow of the Wolfson Research Sharuna Verghis
Institute for Health and Wellbeing, Senior Lecturer, Jeffrey Cheah School
Durham University, of Medicine and Health Sciences,
Durham, UK Monash University, Malaysia;
Xavier Pereira Director, Health Equity Initiatives,
Associate Professor of Psychiatry, Kuala Lumpur, Malaysia
Taylor School of Medicine, Deborah Zion
Malaysia Associate Professor and Chair of the
Veena Pillai Human Research Ethics Committee,
Doctor, Dhi Consulting & Training, Victoria University, Melbourne,
Kuala Lumpur, Malaysia Australia
Part 1
Concepts and contexts

Chapter 1
Forced migration, globalization,

and global public health
People move. They move within countries and between countries. They move to
improve their opportunities for a better life, and they move to escape intolerable
hardship or the threat of intolerable hardship (Triandafyllidou, 2017, p. 3). In
understanding the impetus to move, the notions of ‘structure’ and ‘agency’ have
often been highlighted. Structure is broadly used to describe the macro-level,
sociopolitical, and environmental features that encourage or discourage move-
ment, and agency is used to describe the individual motivations and personal
resources that promote or suppress movement.
In social and political theory the interplay between structure and agency has
remained fertile territory for academic contest: see for example Squire (2017)
and Hay (1995). Our purpose here is not to contribute to that debate but to give
a sense of that complexity.
[Structure] and agency logically entail one another—a social and political structure
only exists by virtue of the constraints on, or opportunities for, agency that it effects.
Thus it makes no sense to conceive of structure without at least hypothetically positing
some notion of agency which might be affected (constrained or enabled). (Hay, 1995,
p. 189)
For those potentially in search of refuge, the interplay between structure and
agency affects who moves and the circumstances under which they move,
and how they are received and the opportunities they have to establish or re-
establish their lives.
Furthermore, the circumstances of the individual and their country of origin,
the circumstances of their movement, the time it takes, the route, and their des-
tination all have individual and population health effects. The trends in forced,
global migration since the publication of the first edition in 2003 give some
insight into this. It also grounds the remaining chapters of this book in the
reality of the early twenty-first century. It is crucial, however, that we have a
shared understanding of the population that is the focus of this book, or at
4 Forced migration and public health
least a shared understanding of the potential disagreements in defining that

population.
1.1 Who is a refugee?
In epidemiology and health measurement there is an assumption that the rules
for case definition represent natural, intrinsic classes: with disease—without
disease. We might therefore expect inclusion or exclusion criteria or a case def-
inition for defining concepts and populations; for separating the refugee from
the non-refugee. However, these ‘natural definitions’ are frequently muddied by
blurred edges, hubris, and political and disciplinary bias (Reidpath et al., 2003;
Reidpath, 2007). The term ‘refugee’ falls into this imprecise category. It is rele-
vant primarily as a sociolegal definition, but in the context of public health and
clinical medicine it is important for providing background about exposures,
social determinants of health, access to services, and protections by the state
and the international community.
In outlining the ‘counting rules’ for refugees, we make it clear that there are ar-
bitrary social dimensions involved, with underlying political agendas (Lomell,
2010). Different authors will use different counting rules, and these rules may
not always be explicit. It is incumbent on the reader, therefore, to understand
this and understand that any analysis is necessarily embedded in a particular
understanding of ‘refugee’. One person’s ‘economic migrant’ is another person’s
‘climate change refugee’, and one person’s ‘refugee’ is another person’s ‘internally
displaced person’ (IDP). Even within this volume, authors do not necessarily
adopt the same definition of a refugee.
An eminent international lawyer who was once asked what defined a
refugee responded: ‘a person who satisfies the criteria laid down in Article
1 of the Refugee Convention’ (Grahl-Madsen, 1966, p. 278). This, of course,
is not the definition of a refugee, it is a description of a refugee under inter-
national law. In common usage the word refugee is used much more broadly.
The English word has its origins in the flight from persecution of the French
Calvinists (Huguenots) in Catholic-dominated seventeenth-century France,
and their search for refuge in other European countries (and later the North
American colonies of European countries), as the Oxford dictionary defin-
ition indicates:
Refugee (/rɛfjʊˈdʒiː/) Noun: A person who has been forced to leave their country in
order to escape war, persecution, or natural disaster. Origin: Late 17th century: from
French réfugié ‘gone in search of refuge’, past participle of réfugier.
That idea of fleeing persecution in one place and seeking protection in an-
other, at least in the European tradition, had been known since medieval times
Who is a refugee? 5
and even earlier. It became more prominent with the Reformation, the growth
of Protestantism, and the need for classes of people to flee religious persecution.
The modern European tradition of asylum dates from the year 1685. In that year Louis
XIV repealed the Edict of Nantes, while in the same year Friedrich Wilhelm, the Great
Elector of Brandenburg, issued his Edict of Potsdam, whereby the French Huguenots
were authorised to establish themselves in his territories. (Grahl-Madsen, 1966, p. 278)
In Judeo-Christian tradition one of the best-known refugees was Moses who,

according to the second book of the Pentateuch, fled from Egypt to Midian,
fearing persecution by the Pharaoh, where he settled, married and had chil-
dren as ‘a stranger in a strange land’ (Exodus, 2:15–22). Subsequently, Moses
returned to Egypt and led the exodus of the Hebrews out of slavery to a place
of refuge and final settlement in Canaan—the first recorded mass movement
of refugees.
There is an interesting juxtaposition between the refugee status of the
Huguenots or the Hebrews and the dictionary definition. The dictionary def-
inition includes natural disaster as a cause to seek refuge—which it certainly is.
If there is not enough food and water to sustain life where you currently live,
move! In contrast, the Huguenots and the Hebrews sought relief from politico-
religious persecution:
owing to well-founded fear of being persecuted for reasons of race, religion, nationality,
membership of a particular social group or political opinion, is outside the country
of his nationality and is unable or, owing to such fear, is unwilling to avail himself of
the protection of that country; or who, not having a nationality and being outside the
country of his former habitual residence as a result of such events, is unable or, owing
to such fear, is unwilling to return to it. (Article 1)
As Hathaway put it, the difference between a common-sense refugee who pulls
at our heartstrings and a Convention Refugee is the concept of a rights-bearer
under international law (Hathaway, 2014).
The legal instruments have been applied to individuals who seek asylum out-
side their country of nationality for a range of political reasons. Recent examples
include Julian Assange who sought protection in the Embassy of Ecuador in
London against potential future extradition to the United States where he faces
prosecution for publication of leaked documents. Similar asylum regulations
have been used by politicians who are in opposition to the prevailing political
power in their countries. However, unless they are recognized as refugees under
international law, the protection granted is restricted to the countries that grant
asylum. From a public health perspective, there is greater concern when the
drivers for mobility affect a significant population group.
In its totality, this book considers the common-sense notion of refugees, al-
though some authors may focus more narrowly on ‘Refugees’—under the legal
definition. For that reason, for the most part, we therefore use the umbrella
term ‘forced migration’ to emphasize the health implications for a population
group. Formal definitions of the different populations affected by forced migra-
tion are discussed in detail by Kneebone in Chapter 2.
1.2 Forced migration
The push factors for forced migration can conceptually be divided into
precipitating events, and a process of social or environmental change, resulting
in a catastrophic failure: a sociopolitical failure, an economic failure, or an en-
vironmental failure (Figure 1.1).
Against a backdrop of political, economic, or environmental conditions,
changes occur.
◆ Government policy is implemented that blames and targets a minority group.
◆ There is an economic depression.
◆ An economic policy encourages unsustainable farming practice.
◆ The rate of population increase (from birth and migration) is beyond the
capacity of the country.
◆ There is an earthquake or other large-scale natural disaster.
The sociopolitical failure to protect (sub-)populations, the economic failure re-
moving food from the table, or some sudden or gradual environmental failure
becomes the impetus or force to move. The concept map is not intended to
identify all contingencies, nor reflect the full complexity of feedback loops,
nor address the confluence of inseparable causes. When there is a drought, do
people move because of an environmental failure or an economic failure? In
times of conflict, is it persecution or a loss of livelihood that creates the duress
precipitating movement? What Figure 1.1 does illustrate is that those who move
have gone in search of refuge (réfugié). They have gone away from their homes
looking for greater safety and security.
The concept map focuses on the structural and is intentionally quieter on
agency, although it is implicit. We are not interested in a tally-column of suf-
fering. Who has suffered enough to be a refugee? Who was truly forced? We do
not support the argument that one is not allowed to seek refuge until one’s life
has been utterly destroyed. It is also clear, however, that the health sequelae will
be different for different people. Some of that difference will relate to the extent
to which a person can preserve their agency and act within the world rather
than have the world act upon them.
Events Process Outcome Exemplar Class
Refugees
Conflict
Political Socio-Political
War
Failure
Persecution
Social
Change Internally
Displaced
Economic Economic Loss of

Failure Livelihood
Environmental Asylum
Change Seekers
Floods
Environmental
Natural Droughts
Failure
Earthquakes
Economic
Migrants
Figure 1.1 Conceptual map of the events, processes, and outcomes leading to forced migration.
Reproduced courtesy of the authors.
1.3 Definitions
The need to categorize and label the types of forced migration is politically ex-
pedient to direct public opinion, influence policy, and determine states’ obli-
gation. If health is a public good, the rules for who can access health services
and the cost of these services are determined by states. Legal status and citi-
zenship therefore often becomes the primary consideration (regardless of push
factors for forced migration) and has fuelled recent debates in the movements
of people across borders.
A Refugee is a person who meets the eligibility criteria under the applic-
able refugee definition, as provided for in international or regional refugee in-
struments, under the mandate of the United Nations High Commissioner for
Refugees (UNHCR), and in national legislation.
An asylum seeker is an individual who is seeking international protection. In
countries with individualized procedures, an asylum seeker is someone whose
claim has not yet been finally decided by the country in which he or she has
submitted it. Not every asylum seeker will ultimately be recognized as a refugee,
but every refugee is initially an asylum seeker.
Internally displaced persons (IDPs) are those forced or obliged to flee from
their homes, ‘. . . in particular as a result of or in order to avoid the effects of
armed conflicts, situations of generalized violence, violations of human rights
or natural or human-made disasters, and who have not crossed an internation-
ally recognized State border’ (UNHCR, 1998, p. 5).
Mandate Refugees are persons who are recognized as refugees by UNHCR
acting under the authority of its Statute and relevant UN General Assembly
resolutions. Mandate status is especially significant in states that are not parties
to the 1951 Convention on Refugees or its 1967 Protocol.
Under national laws, Stateless Persons do not have the legal bond of nation-
ality with any State. Article 1 of the 1954 Convention relating to the Status of
Stateless Persons indicates that a person not considered a national (or citizen)
automatically under the laws of any State, is stateless. These persons may differ
from undocumented migrants, who lack legal documentation and therefore
need to make a case for citizenship and migration status.
Persons of Concern to UNHCR is a generic term used to describe all persons
whose protection and assistance needs are of interest to UNHCR. These include
refugees under the 1951 Convention, persons who have been forced to leave
their countries as a result of conflict or events seriously disturbing public order,
asylum seekers, returnees, stateless persons, and, in some situations, IDPs.
UNHCR’s authority to act on behalf of persons of concern other than refugees is
Trends in global forced migration 9
based on United Nations General Assembly and Economic and Social Council
(ECOSOC) resolutions.
1.4 Trends in global forced migration

In the first edition of Health of Refugees, Zwi and Alvarez-Castillo (2003)
identified the major forced migration events since World War II. Rather than
look back again, we carry that timeline forward to cover the years since that
publication.
We have the advantage of better data systems and better tracking.
Unfortunately, there are no perfect mechanisms for tracking all formal and in-
formal movements of people. A quick look at the data from the Population
Division of the United Nations Department of Economic and Social Affairs
(UNDESA, n.d.) reveals the paucity of aggregated migration data. Data chal-
lenges notwithstanding, UNHCR tracks their ‘persons of concern’ (PoC) to a
greater degree. Within UNHCR, PoC are categorized under ‘Refugee’, ‘Asylum
Seeker’, ‘IDPs, ‘Stateless’, and ‘Other’. Each category has a specific legal defin-
ition, and while the UNHCR counting rules may not encompass everyone that
one might regard as a (small ‘r’) refugee, or might cover additional people one
might not regard as a refugee, it does give a snapshot of the broad trends in
forced migration.
We reviewed the UNHCR Global Reports from 2004, the year after the first
edition was published, to the latest report published in 2016.1 We focused prin-
cipally on the High Commissioner’s foreword and summary data (Table 1.1).
For the majority of those years (2005–2014), the current Secretary General
of the United Nations, António Guterres, was the High Commissioner for
Refugees. As a lead into those years, it is worth noting that the foreword to the
2003 Global Report opened with the sentence, ‘2003 was a good year for refugee
returns’. Since then, and with the exception of 2004, good news openings have
been increasingly rare.
The succession of Global Reports characterizes an increasingly fragile global
situation. The arc of countries through West Asia, the Middle East, the Horn
of Africa, Central Africa, and the Lakes Region have dominated the refugee
numbers. Some countries that were host countries for refugees have themselves
become destabilized (e.g. Syria and Yemen). Other regions, however, have not
been immune, including South and Central America, South East Asia, and
Central Asia.
Figure 1.2 uses UNHCR data to illustrate the shift in refugee numbers since
1990 through to 2016.
Table 1.1 Information from UNHCR Global Reports, 2004–16
Year Highlights
2004 The number of Persons of Concern to UNHCR continued to
Acting High decline. A three-year downward trend with fewer asylum seekers
Commissioner arriving in industrialized countries during 2004 than in any year
Wendy since 1988.
Chamberlin Crisis in Darfur region, Sudan: 200,000 refugees shelter in arid
eastern Chad.
2005 600,000 people in Indonesia and Sri Lanka were displaced by a

High Commissioner tsunami. In late 2005 the South Asia earthquake levelled hundreds
António Guterres of villages throughout Pakistan-administered Kashmir. Darfur
worsened, affecting over 2 million people. Conflicts in Burundi and
South Sudan continued, raising prospects for two of Africa’s largest
refugee populations.
2006 For the first time since the turn of the century, the number of
High Commissioner refugees increased in 2006 by 12% to almost 10 million. This was
António Guterres largely a result of the crisis in Iraq. The overall number of persons
of concern to UNHCR rose from 21 million in 2005 to 34.4 million
in 2006.
50,000 people a month crossed Iraq’s western border, seeking
refuge in Syria and Jordan. By the end of 2006, the cumulative
total of displaced Iraqis inside and outside the country had
reached 3.8 million. Half-way through 2006 there was a 34-day
war in Lebanon. Around 1 million Lebanese were displaced. Many
sought refuge inside their own country; others fled into Syria.
2007 There were 2 million IDPs in Iraq and 2.2 million Iraqi refugees in
High Commissioner neighbouring countries. Insecurity in the Central African Republic
António Guterres (CAR), Chad, and Darfur region brought the overall number of
refugees and IDPs in these three places to almost 3 million. In
Chad, cross-border raids destroyed several villages and uprooted
thousands of people. More than 20,000 Chadians fled into Darfur
in 2007. Violence in the eastern areas of the Democratic Republic
of the Congo (DRC) displaced an additional 435,000 people
internally. In south and central Somalia fighting brought the total
number of IDPs to 1 million. It also added some 30,000 Somali
refugees to some 325,000 refugees already in neighbouring
countries.
2008 By the end of 2008, the total number of refugees under UNHCR’s
High Commissioner mandate exceeded 10 million. The number of conflict-induced
António Guterres IDPs reached 26 million worldwide. Conflicts in an arc from South
and South West Asia, through the Middle East to Sudan and
the Horn of Africa generated two-thirds of the total number of
refugees worldwide.
In Darfur more than 2 million people remain internally displaced,
while nearly a quarter of a million Darfurians remained in exile in
Chad. 300,000 people became internally displaced in Pakistan.
Trends in global forced migration 11
Table 1.1 Continued

Year Highlights
2009 There are 36 million persons of concern to UNHCR including
High Commissioner 10 million refugees—the highest number on record. Two-thirds of
António Guterres the world’s refugees are in developing countries, many in the arc of
conflict from South West Asia, the Middle East, Horn of Africa, and
the Great Lakes and Central region. Three-quarters of IDPs are also
to be found in this arc.
2010 An estimated 20 million Pakistanis were displaced by floods.
High Commissioner Afghan refugees in 19 camps were among those affected, as were
António Guterres people previously displaced internally. The emergency in Kyrgyzstan
broke out in the southern city of Osh. Clashes between ethnic
Uzbeks and Kyrgyz left hundreds dead and as many as 400,000
displaced. Approximately 75,000 refugees, mostly women and
children, fled to the Andijon area of neighbouring Uzbekistan.
2011 Hundreds of thousands of people were forced to abandon their
High Commissioner homes as violence erupted in Côte d’Ivoire and Libya. The Somali
António Guterres conflict, already 20 years old, degenerated further and, combined
with the worst drought in decades, drove close to 300,000
refugees into neighbouring Kenya, Ethiopia, Djibouti, and Yemen—
bringing the total number of Somali refugees in the region to some
950,000 by the end of 2011. An upsurge in fighting in Sudan
resulted in an influx of nearly 100,000 new refugees into South
Sudan and Ethiopia. Old crises in Afghanistan, DRC, and Iraq have
not been resolved. As a result, durable solutions have remained
elusive for a large number of refugees under UNHCR’s mandate.
Over 7.2 million people are now living in protracted situations of
exile.
2012 More than 1 million people fled their countries of origin due to
High Commissioner conflict and persecution, mainly from Syria, Mali, Sudan, and
António Guterres the eastern DRC. That is the highest number of newly displaced
refugees during any 12-month period since the beginning of the
21st century.
2013 Nearly 2 million people fled the brutal conflict in Syria and hundreds
High Commissioner of thousands escaped war, violence and persecution in the CAR,
António Guterres the eastern DRC, Myanmar, South Sudan, and Sudan. By the end
of 2013, almost 43 million people—the highest number ever—
relied on UNHCR for protection.
In just 5 years, from being the second largest refugee-hosting
country in the world, Syria has become the second largest
refugee-producing country, after Afghanistan. More than
9 million people were in flight inside and outside the country in
2013, and hundreds of thousands were trapped and under siege.
Syria’s neighbours shouldered the brunt of the burden, as did
other countries in the vicinity of conflict areas.
(continued )
Table 1.1 Continued

Year Highlights
2014 Conflict and persecution forced some 13 million people from their
High Commissioner homes in 2014, and thousands died trying to get to safety.
António Guterres
2015 The world witnessed record levels of forced displacement in 2015.
High Commissioner More than 65 million people were uprooted by war, conflict,
Filippo Grand persecution, or human rights abuses by year end, including over
10 million displaced during the year.
The war in Syria was the single largest driver of displacement. At
the end of the year, more than 4 million Syrians were living in exile
in neighbouring countries and 6.5 million people were internally
displaced. Escalating violence in Afghanistan in the second half
of 2015 brought the number of internally displaced people to
a new high of 1 million. In South East Asia, large numbers of
migrants and refugees, including many Rohingya, put their lives
in the hands of smugglers in search for safety and a future. In
Central America, shocking levels of gang violence in El Salvador,
Guatemala, and Honduras displaced tens of thousands of people
and forced many of them along traditional migrant routes, mostly
travelling north, in search of safety and protection.
This was also the year that the global refugee crisis reached
Europe. More than 1 million refugees and migrants arrived on
the southern European shores. Tragically, nearly 4,000 died in the
attempt.
2016 At the end of the year the global number of people of concern
High Commissioner to UNHCR exceeded 67 million. It encompasses those who fled
Filippo Grand conflict and violence in Burundi, Myanmar, the Lake Chad region,
the Northern Triangle of Central America, and Yemen. It includes
millions of refugees, internally displaced people and returnees
affected by the unresolved situations in Afghanistan and Somalia.
Violent conflict and persecution, compounded by rising food
insecurity, environmental degradation, poor governance, and
countless other factors, drove more than three million people to
leave their countries as refugees or to seek asylum.
Figure 1.2a shows that the number of refugees, approximately 18 million in

1990, declined to approximately 10 million by 2004, before rising again to ap-
proximately 17 million in 2016. A dramatic rise in IDPs can be seen from 2003
when the figure hovered around 5 million, rising sharply in 2005, and then
again in 2012 to approximately 37 million people in 2016. The total magnitude
of the problem, however, is best illustrated by Figure 1.2b, which shows the ac-
cumulated numbers of Refugees, Asylum Seekers, IDPs, and ‘Others’ from 1990
to 2016. Until 2003, there was a relatively steady number of people who moved
The distributive burden 13
IDP
60
30
People (Millions)
People (Millions)
40
20
Refugee
10 Other 20
Asylum-seeker
0 0
90
95
00
05
10
15
90
95
00
05
10
15
19
19
20
20
20
20
19
19
20
20
20
20
Year Year
Refugee Other
IDP Asylum-seeker
Figure 1.2 The numbers of refugees, asylum seekers, internally displaced persons, and
‘others’ recorded by UNHCR in each year from 1990 to 2016.
Reproduced courtesy of the authors.
under duress—a total of around 20 million. Because of the rise in Refugees,

IDPs, and ‘Others’ over the subsequent years, by 2016 the total number of
people exceeded 60 million.
These dramatic increases have been driven by exactly the kinds of processes
described in Figure 1.1—sociopolitical failures, economic failures, and envir-
onmental failures, often feeding into each other.
The world is facing unprecedented levels of environmental and sociopolitical
failure. Climate change, particularly variations in temperature, has been shown
systematically to drive migration (Berlemann and Steinhardt, 2017). Similarly,
large-scale environmental events, such as hurricanes, have also been shown
to force migration; and it is middle-income countries that ‘experience signifi-
cant push and pull effects on migration from natural hazards’ (Gröschl and
Steinwachs, 2017, p. 445). Issues of governance, climate change, water access,
food production, and economic security have been highlighted by UNHCR
Global Reports during the last decade as structural factors leading to forced
migration.
1.5 The distributive burden of forced migration

In 2003 we looked at the inequitable distribution of refugees globally. We ar-
gued that a country’s capacity to support refugees needed to be taken into
account in deciding on equitable distribution, where capacity combined con-

siderations of national wealth and population size (Allotey and Reidpath, 2003).
Our analysis showed clearly that the countries with the least capacity bore the
highest burden, and the burden was essentially log-linearly distributed across
the wealth/population domains. Currently, it is the proximate states that bear
the heaviest responsibility for supporting refugees (Reeves, 2017). That is, the
countries that share a border with a country in crisis absorb the largest share of
the refugees. Because, globally, regions in crisis tend to be poorer than regions
without crisis, poorer countries carry the greater burden. The challenges, how-
ever, are compounded, particularly when refugees are generated by conflict.
Poorer countries have less capacity to provide appropriate support for the re-
settlement of refugees. Countries proximate to war are more likely to become
destabilized by that war (Phillips, 2015). And the combination of managing
a refugee population and maintaining national security creates a synergistic
burden.
This problem is understood. Reeves (2017, p. 642) in a recent argument on
the moral redistribution of refugees noted that European Union (EU) ministers
suggested relocating refugees to member states along the lines for which we had
argued earlier: by the national wealth, population size, and adding unemploy-
ment rate and current refugee numbers. Increasing xenophobia, nationalism,
and the rise of the #MeFirst movement has unfortunately not worked in favour
of refugees. In Europe for example, EU member states showed they preferred to
‘sacrifice European integration because they are not ready to accept their duties
towards refugees’ (Bauböck, 2017, p. 1).
The problem is not, however, as the French prime minister, Manual Valls,
claimed in 2016, that refugees destabilize the state (Chrisafis, Elliott, and
Treanor, 2016). Instead, it is that,
[R]‌efugee protection and state stability are strongly connected; undermining one factor
weakens the other. Policies to protect refugees, both physically and legally, reduce po-
tential threats from the crisis and bolster state security. Overwhelmed and often im-
poverished, host states cannot provide this protection without significant international
assistance. (Lischer, 2017, p. 95)
1.6 Health and forced migration

Publication of this second edition has been driven by the rapid escalation
in forced migration over the last 10 years and the ‘global migration crisis’.
The numbers of refugees have more than doubled since the first edition
was published. There have been significant shifts in the global landscape;
in the factors that forcibly drive people from their homes creating asylum
seekers, refugees, IDPs, and various categories of economic migrants. The
Health and forced migration 15
scale and types of conflicts have changed, the effects of extreme weather
events, natural and human-made disasters, economic catastrophes, and
pandemics is significantly different. Furthermore, there has been a shift in
the national and international mechanisms for responding to mass move-
ments of people and other humanitarian responses, coupled with major
epidemiological transitions in health and diseases and the ability of health
systems to respond.
The response of the international community to forced migration is tem-
pered by the complexity of political interests, immigration policies, and border
sovereignty. In spite of broader equity-related discussions on the Sustainable
Development Goals (Global Goals; UN, 2015) to ensure leaving no one behind,
many governments still argue against an obligation to protect people who no
longer enjoy the protection of their own governments. Often lost in these com-
plexities are the specific health needs of this group whose vulnerabilities are ex-
acerbated by the intersectionality of multiple layers of disadvantage that results
from the instability of being on the move.
These complexities are the focus of the discussion by Reidpath and Allotey
in Chapter 3. Specific health needs are created by the outcomes of conflict, dis-
placement, poverty, natural disasters, violence, and other rights violations, and
these are addressed by Toole in Chapter 4 and Leder et al. in Chapter 5. Mental
health consequences are addressed by Ventevogel et al. in Chapter 6.
Also lost in addressing the needs of forced migrants and refugees is the het-
erogeneity of the populations; diversity with regard to gender, culture, and
socioeconomic status all influence the experience of health and disease in the
course of the journey and resettlement. Also, mobility offers no protection from
other epidemiological trends, such as non-communicable and communicable
diseases or environmental exposure. The lack of stable and robust health sys-
tems and problems with access to health services present major challenges
to ensuring prevention, clinical management, and appropriate follow-up for
chronic illness.
Refugee health, while clearly under the rubric of public health, has a spe-
cific meaning depending on the context in which it is used. In humanitarian
settings and other mass movements resulting from natural disasters, there is a
focus on the acute management of health issues created by conditions of poor
hygiene, overcrowding, and lack of health infrastructure. In the process of re-
settlement to third countries, refugee health involves rigorous health screening
and assessment to identify exotic communicable diseases that might threaten
the public health of host nations. Following resettlement, it refers to the man-
agement of health and health services to control the potential for the marginal-
ization of minority resettled populations, ranging from the provision of cultural
competencies for health services staff, to addressing the specific physical and
mental health needs of torture and trauma survivors.
Human rights discourse and rights-based approaches in health have ex-
panded the role of public health researchers and practitioners to include a more
central role in advocacy. The Global Goals and universal health coverage re-
quire a more equitable distribution of the resources that enable health and ac-
cess to health care, particularly for the marginalized and vulnerable. There is
a greater imperative for involvement in the political, economic, and social de-
terminants that shape a rapidly globalizing world with increasing disparities in
health and wealth, simmering tensions, and potential for conflict and the events
that result in the drivers of forced migration.
1.7 Outline of the book

Like the first edition, the aim of this volume is to provide a multidisciplinary
perspective on refugee health, tracing the health repercussions on individuals
and populations from the drivers of forced mass movements of populations
from situations of conflict and other disasters through to the process of re-
settlement in countries other than their countries of origin. The contributors
are drawn from public health, infectious diseases medicine, human rights law,
paediatrics, psychiatry, social work, and international relations. They include
researchers, policy-makers, and practitioners. They bring experience and ex-
pertise from academia, various United Nations organizations including the
United Nations University International Institute for Global Health, the World
Health Organization, the UNHCR, and UNICEF as well as community-based
and civil society organizations. In updating the first edition, the intention is
to highlight the complexity of factors that influence the health of refugees and
asylum seekers, the global and national policy environments, ethical dilemmas,
and compromises made by health-care providers and the lived experiences of
individuals, families, and communities displaced from their homes.
The book is divided into three broad sections. Part 1 provides background
information, establishing the international context and concepts. Kneebone ex-
plains the human rights and humanitarian framework on which international
protection of refugees is based. Reidpath and Allotey place the refugee health in
the framework of the social and ecological determinants of health with a focus
on intersectionality. Toole, Leder Kanhutu et al. outline the public health and
clinical guidelines, drawing on several years of experience with Medicins sans
Frontières, the Centers for Disease Control and Prevention, and travel medi-
cine. Ventevogel et al. outline the mental health considerations in working with
forcibly displaced populations.
References 17
Part 2 addresses specific refugee populations, highlighting again the

intersectionality of factors that exacerbate vulnerabilities. Verghis et al. de-
scribe the challenges for refugees in urban settings, noting the paradox of the
safety and invisibility of urban environments, particularly for those who are
undocumented on the one hand, and the increased vulnerability due to poor
access to services and protections offered by the state on the other. Khosla et al.
note the specific vulnerabilities and rights violations for women in humani-
tarian settings, drawing out the gendered nature of conflict and displacement.
Bissell and Bhabar, and Bhutta and team focus specifically on the issues for chil-
dren and adolescents respectively.
Part 3 presents a series of case studies in undertaking research with refugees,
drawing out the ethical issues and lived experiences of individuals and families
displaced for a range of reasons. The case studies situate and draw together
the impact on displaced persons of the changing global and national policy
environments. While the cases are drawn from diverse settings, ranging from
the Middle East (Khoshnood et al.), the United States (Annas et al.), Australia
(McMichael et al.) and its offshore detention centres (Zion), they provide a
powerful illustration of the importance of resilient and robust health systems
to support vulnerable populations. They also highlight the use (and abuse) of
the policy environment and health systems to enable or hinder the prevailing
populist political and economic ideologies.
We conclude with a chapter by Reidpath and Allotey which updates the in-
sightful chapter led in the first edition by the renowned journalist Peter Mares.
Using discourse analysis, the chapter addresses the role of the media in shaping
popular opinion and influencing policy on humanitarianism and the health
and well-being of refugees.
Note
1. We do not reference the individual UNHCR Global Reports. They can all be found online
at http://www.unhcr.org/en-my/the-global-report.html.
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Chapter 2
Humanitarianism, refugees,
human rights, and health
Susan Kneebone
2.1 Introduction
Over the past two decades, the number of persons displaced globally has
doubled. This increase has brought with it increased focus by states on con-
trolling entry to national territory. The perception is that: ‘We are witnessing
in today’s world an unprecedented level of human mobility’ (UN, 2016, para.
3). This perception has a natural flow-on effect for access to health services.
Not only has demand for such services increased, but states are internalizing
the concept of ‘border’ by using access to health services to deter the mobility
of asylum seekers. Control of access is achieved by creating hierarchies of en-
titlements to health services based on immigration status rather than medical
need or status in international law. In this context, doctors and health workers
are often at the ‘front line’ of border control, positioned between the state and
the individual.
The United Nations High Commissioner for Refugees (UNHCR) as at 31 May
2017 estimated that there were 22.5 million refugees (UNHCR, 2017). In 2007,
by contrast, the number of refugees worldwide was 9.9 million (Kneebone,
2009, p. 4, n10). Furthermore, the nature of displacement has changed over the
past decade, pointing to particular health consequences and issues for access to
health services. The United Nations 2016 New York Declaration for Refugees
and Migrants states that ‘armed conflict, persecution, and violence, including
terrorism, are among the factors which give rise to large refugee movements’
(UN, 2016, para. 64). The main reasons for flight today are civil wars and vio-
lence, as well as denial of social and economic rights (Kneebone, 2010, p. 216).
Moreover, a large percentage (84%) of refugees and asylum seekers are in
developing rather than industrialized countries (UNHCR, 2017). A new cat-
egory of ‘urban refugee’ has emerged; in 2012 UNHCR estimated that poten-
tially more than half of the world’s refugees are living in large cities, rather than
20 Refugees, human rights, and health
in camps. In the New York Declaration, this figure was stated to be 60% (UN,
2016, para. 73).
Several reports also recognize that there are
particular vulnerabilities of women and children during the journey from the country
of origin to country of arrival . . . [including] potential exposure to discrimination
and exploitation, as well as to sexual, physical and psychological abuse, [and] vio-
lence . . . (UN, 2016, para. 29).
The UNHCR has documented an increase in the number of reported inci-

dents of sexual and gender-based violence among refugees and asylum seekers,
from 18,245 in 2014 to 26,632 in 2015 (Türk, 2016).
These causes of displacement and methods of shelter bring with them new
challenges for the provision of health services, especially in developing coun-
tries. In developed countries which practise deterrent measures against entry,
access to health care is also a contested issue. In this context, it is important
to understand the human rights of individual refugees and asylum seekers,
including their right to health at all stages of displacement. While lack of access
or discrimination in access to health may be a source of persecution at the place
of origin, at the destination, refugees and asylum seekers are often discrimin-
ated in access to health on the basis of their migration status. In such situations,
doctors and health workers may be faced by ethical conflicts of interest. In gov-
ernment policy, the right to health becomes conflated with access to public
services, under a libertarian, ‘consumer–provider’ model of service provision
(Taylor, 2013, p. 297). The tension between the individual rights of refugees and
asylum seekers and their status as non-citizens plays into the hands of policy-
makers intent on deterring movement.
In this chapter, I explain the legal concepts of refugees and asylum seekers, the
term humanitarianism, and the applicable human rights principles. I then focus
on issues which reflect this context, in particular the conflicted roles of doctors
and other health workers in receiving countries, including when working with
urban refugees. An analysis of the human right to health is presented to high-
light gaps in the human rights frameworks which states can exploit to limit
refugee protection.
2.2 Refugees, asylum seekers, and protection

seekers: some definitions
In everyday parlance, a refugee is a person in flight, a person seeking refuge.
However, in international law, a Refugee is a person who falls within the def-
inition of the 1951 Convention relating to the Status of Refugees (Refugee
Convention, Art. 1A (2)). As the European Union (EU) Qualification Directive
Some definitions 21
2011 says, the act of ‘recognition of a refugee is a declaratory act’ (preambular

clause 21) which confirms the status of an asylum seeker in international law
(UNHCR Handbook, 1992, para. 28). Although international treaties and con-
ventions are not generally self-executing but require good faith transposition
and implementation into national legal systems, the status of the refugee in
international law is distinct due to this declaratory theory. This status distin-
guishes the refugee from other international migrants, including the humani-
tarian entrants considered below. Importantly, the New York Declaration for
Refugees and Migrants (UN, 2016) recognizes these separate categories with
specific needs.
An asylum seeker is a person seeking asylum from persecution who has yet
to be formally recognized as a refugee as defined in Art. 1A(2) of the Refugee
Convention. It needs to be recognized that many refugees and asylum seekers
are undocumented or irregular migrants under national laws, as few if any
countries provide a legal means to enter a country to apply for asylum. Further,
many refugees are present in host countries as migrant workers and may not
necessarily self-identify as asylum seekers (Pittaway, 2017). Although the two
categories—refugees and migrant workers—are separate and distinct in law, in
reality they are often blurred.
The Refugee Convention is an instrument of human rights protection which
was intended to implement the basic right to flee persecution and to seek and
enjoy asylum (Universal Declaration of Human Rights (UDHR) Art. 14), and
to enshrine the basic right against refoulement (Art. 33(2))—the negative right
to not be returned ‘in any manner whatsoever to the frontiers of territories
where . . . life or freedom would be threatened’ (emphasis added). Although
the Convention does not state a specific right to seek asylum, the right is con-
sistent with the right to freedom of movement (International Covenant on Civil
and Political Rights (ICCPR), Art. 12), which includes the right to leave one’s
country, as well as the fundamental right to life (UDHR Art. 3; ICCPR Art. 6.1).
Humanitarianism is a term which in this context has mixed connotations.
In everyday use, it means ‘having regard to the interests of humanity or man-
kind at large’ and thus has ethical and moral connotations (Kneebone, 2010).
In the context of refugee protection, it is used to stress complementary protec-
tion. That is, for those who may not satisfy the Refugee Convention definition,
it means substitute (and sometimes inferior) protection granted on ‘a discre-
tionary basis on compassionate or humanitarian grounds’ (EU Qualification
Directive, 2011, preambular clause 15). Within the EU, the Qualification
Directive has created a status of ‘subsidiary protection’ for those who do not
qualify as refugees but who are identified as in need of international protec-
tion, defined in Art. 15 of the Directive, as being under ‘a real risk of suffering
serious harm’. This test recognizes the prohibitions against torture and cruel,
inhumane or degrading treatment, or punishment in the ICCPR, Art. 7 and
the UN Convention Against Torture and Other Cruel Inhuman or Degrading
Treatment or Punishment (CAT), Art. 3.
Whereas both refugees and asylum seekers are entitled to protection in
international law because of their status, humanitarian entrants or ‘protection
seekers’ rely on states to protect their human rights, in particular the right not
to be returned to a place where they would suffer torture or inhumane and
degrading treatment, standards which mirror the non-refoulement obligation
in the Refugee Convention (Kneebone, 2009, pp. 11–14).
2.3 Human rights: access to health for refugees

and protection seekers
In this section, I first summarize the human rights which are relevant to access
to health and then explain their application to refugees, and to asylum seekers
and protection seekers at different stages of displacement.
Several human rights instruments, which States Parties are bound to imple-
ment in good faith, are relevant to access to health and apply to refugees and
asylum seekers, irrespective of their status as refugees (referred to here as gen-
eric instruments). This is important because the Refugee Convention does not
specifically mention the right to health (see below). Some other instruments
apply to refugees, asylum seekers, and protection seekers because they have an-
other specific vulnerability status, such as being a migrant worker, a child, or a
woman. In the following sections I describe the human rights which apply to all
refugees, and to asylum seekers and protection seekers under the generic and
the specific instruments, and consider their application. As we will see, migra-
tion status and nationality may be relevant in determining access to health care.
2.3.1 What is the right to health?

The 1966 International Covenant on Economic, Social and Cultural Rights
(ICESCR), to which 146 states are parties, contains the most recognizable
universal statement of a right to health. In Art. 12.1 of the Covenant, States
Parties recognize ‘the right of everyone to the enjoyment of the highest attain-
able standard of physical and mental health’. General Comment No. 14 of the
Committee on Economic, Social and Cultural Rights (CESCR) which oversees
the implementation of the Covenant, begins:
Health is a fundamental human right indispensable for the exercise of other human
rights. Every human being is entitled to the enjoyment of the highest attainable
standard of health conducive to living a life in dignity.
Human rights and access to health 23
Clearly, the reference in Art. 12.1 of the Covenant to ‘the highest attainable
standard of physical and mental health’ is not confined to the right to health
care. As the CESCR points out, the drafting history and the express wording of
Art. 12.2 of the Covenant (which sets out steps to be taken by State Parties to
achieve the rights specified) acknowledge that the right to health embraces a
wide range of socioeconomic factors that promote conditions in which people
can lead a healthy life. It extends to the underlying determinants of health, such
as food and nutrition, housing, access to safe and potable water and adequate
sanitation, safe and healthy working conditions, and a healthy environment.
Some of these rights are recognized for example in ICESCR, Art. 11, in ‘the
right of everyone to an adequate standard of living for himself and his family,
including adequate food, clothing, and housing’.
The ICESCR builds on the earlier statement of a right to access to health in
the 1948 UDHR, Art. 25, which pairs it with ‘the right to a standard of living
and livelihood’. It includes medical care and necessary social services and so-
cial security in the list of basic rights which support a right of access to health.
The link between the right to social security and the right to health care is
discussed below.
The clearest statement of a right to access to health is in the Convention on
the Rights of the Child 1989 (CRC), Art. 24.1 whereby ‘States Parties recognize
the right of the child to the enjoyment of the highest attainable standard of
health and to facilities for the treatment of illness and rehabilitation of health.’
It continues: ‘States Parties shall strive to ensure that no child is deprived of his
or her right of access to such health care services.’ Other provisions of the CRC
recognize the right of every child ‘to benefit from social security, including so-
cial insurance’ (Art. 26), and to ‘a standard of living adequate for the child’s
physical, mental, spiritual, moral and social development’ (Art. 27).
The Convention on the Elimination of All Forms of Discrimination Against
Women (CEDAW, 1979) also contains the right of ‘access to health care services,
including those related to family planning’ (Art. 12.1), and ‘appropriate services
in connection with pregnancy, confinement and the post-natal period, granting
free services where necessary, as well as adequate nutrition during pregnancy
and lactation’ (Art. 12.2). CEDAW requires States Parties to take ‘all appropriate
measures to eliminate discrimination against women in rural areas’ in relation
to access to ‘adequate health care facilities, social security and adequate living
conditions’ (Art. 14.2).
The pattern which emerges from these instruments is that at the most basic
level, access to health is an aspect of the individual ‘right to life, liberty and se-
curity of the person’ (UDHR Art. 3; see also ICCPR Art. 6.1). It is dependent on
recognition of other socioeconomic rights and the specific circumstances of the
individual (such as child or woman). Such socioeconomic rights are included in

the (non-binding) Sustainable Development Goals (SDGs), such as SDG 3 (en-
sure healthy lives and promote well-being for all at all ages), and SDG 6 (ensure
access to water and sanitation for all). The human rights instruments some-
times include both access to health care and the right to social security (see
CRC Arts. 24.1, 26). In recent years the World Health Organization (WHO)
has promoted universal access to public health-care schemes and affordable
health care for all (Lougarre, 2016), but the human rights instruments are not
consistent on this issue. CRC Arts. 24.1, 26 for example, includes both access to
health-care services and social security (see also CEDAW Art. 14.2) but other
instruments suggest the migration status of the refugee, asylum seeker, or pro-
tection seeker is relevant.
2.3.2 Limitations based on migration status and nationality

ICESCR and other human rights instruments (including the Refugee
Convention Art. 3) contain prohibitions against discrimination of any kind, re-
lating for instance to race, nationality, or status (ICESCR Art. 2.2). This suggests
that non-discrimination is a universal principle or rule of customary inter-
national law or jus cogens. There are, however, countervailing indications that
discrimination is permitted against some non-nationals for certain economic
rights, specifically the right to social security. Although ICESCR Art. 2.3 gives
developing countries a discretion to determine the extent to which economic
rights apply to non-nationals having regard to their ‘national economy’, the
breadth of the qualifications in other instruments suggest that migrant status is
a basis for discrimination.
ICESCR Art. 9 says unequivocally:
The States Parties . . . recognize the right of everyone to social security, including social
insurance [emphasis added].
By contrast, UDHR Art. 22 appears to limit the right to social security to na-
tionals and residents when it states:
Everyone, as a member of society, has the right to social security and is entitled to real-
ization, through national effort and international co-operation and in accordance with
the organization and resources of each State, of the economic, social and cultural rights
indispensable for his dignity and the free development of his personality [emphasis
added].
The CESCR in General Comment No. 19 (2008) on ICESCR Art. 9 recognizes

the link between access to ‘affordable health care’ and social security (para 2). It
lists health care for all as the first of nine normative principles of the right to so-
cial security (CESCR No 19, 2008, para. 13). It refers to the non-discrimination
principle in ICESCR Art. 2.2 (CESCR No. 19, 2008, para. 29), and urges States
Parties to particularly consider vulnerable groups such as women, children,
refugees, and asylum seekers in that context (CESCR No. 19, 2008, para. 31).
But General Comment No. 19 also distinguishes contributory and non-
contributory social security schemes, echoing distinctions made in both the
1951 Refugee Convention and the 1990 International Convention on the
Protection of the Rights of All Migrant Workers (ICRMW). Each of these in-
struments endorses the notion that rights to access to social security, and thus
health, can discriminate based on migration status.
The Refugee Convention does not mention the right to health as such, but
it does grant to ‘refugees lawfully staying in their territory the same treatment
with respect to public relief . . . as is accorded to their nationals’ (Art. 23).
Article 24, which also applies to those ‘lawfully staying,’ grants the ‘same
treatment as is accorded to nationals’ in relation to labour protection and so-
cial security—which includes ‘sickness . . . and any other contingency’, subject
to the limitation that where such benefits are contingent on contributions
to public funds, ‘special arrangements’ may apply (Art. 24.1(b)(ii)) (Lester,
2011). The Convention generally recognizes that refugees are entitled to so-
cial and economic rights as the status of the refugee becomes more settled
(Kneebone, 2009, pp. 6–8). It distinguishes, for example, those who presence
is merely ‘lawful’ (such as those who are in the process of applying for refugee
status) and those who are ‘lawfully staying in their territory’ (who may have
some residency status). In other words, the Refugee Convention grants the
right to social security only to those who have some settled status, rather than
‘mere’ asylum seekers.
The idea that international migrants can be discriminated based on status is
reinforced by the provisions of the International Convention on the Protection
of the Rights of All Migrant Workers and Members of Their Families (ICRMW).
ICRMW contains a non-discrimination clause with a comprehensive list of
prohibitions; however, it does not include migrant status. Indeed, the whole
scheme of ICRMW reinforces discrimination based on status as it distinguishes
the rights of regular (documented) and undocumented (irregular) migrant
workers. Under Part IV of ICRMW additional rights apply to documented mi-
grant workers and members of their families. This includes, for example, greater
rights to social and health services—regular migrants enjoy equality of treat-
ment with nationals of the State with respect to employment ‘provided that the
requirements for participation in the respective schemes are met’ (Arts. 43.1(e)
and 45.1(c)). By contrast, Art. 27 in Part III (which applies to both irregular
and regular migrant workers) makes such rights dependent on ‘the applicable
bilateral and multilateral treaties’. Such treaties are likely to be in place only for
regular migrant workers (see CESCR No. 19, 2008, para. 56 for recognition of
that fact).
As mentioned, many refugees, asylum seekers, and protection seekers present
in host countries as (irregular) migrant workers to whom Part III of ICRMW
applies. Article 28 grants equality of treatment with nationals to access emer-
gency medical care ‘required for the preservation of their life or the avoidance
of irreparable harm to their health’. ICRMW thus endorses discrimination
against non-nationals in relation to social and health services based on migra-
tion status.
General Comment No. 19 para. 37 referring to refugees and asylum seekers
states:
Non-nationals should be able to access non-contributory schemes for income support,
affordable access to health care and family support. Any restrictions, including a quali-
fication period, must be proportionate and reasonable. All persons, irrespective of their
nationality, residency or immigration status, are entitled to primary and emergency
medical care [emphases added].
This is consistent with Part III of ICRMW. General Comment No. 19 continues:
Refugees, stateless persons and asylum seekers, and other disadvantaged and mar-
ginalized individuals and groups, should enjoy equal treatment in access to non-
contributory social security schemes, including reasonable access to health care and
family support, consistent with international standards (para. 38).
As we will see, states discriminate against non-nationals in access to health,

for deterrence purposes, and in so doing apply standards that are arguably not
proportionate and reasonable. This suggests that the ‘right to health’ is conflated
with access to public services, that the ‘economic’ aspect of the right overrides
the basic human ‘right to life’.
2.3.3 Protection from persecution and health rights

The root causes of flight can be interconnected with access to health. The
Refugee Convention (Art. 1A(2)) defines a ‘refugee’ as a person who:
. . . . owing to [a]‌well-founded fear of being persecuted for reasons of race, religion,
nationality, membership of a particular social group or political opinion, is outside
the country of his nationality and is unable or, owing to such fear, is unwilling to avail
himself of the protection of that country; or who, not having a nationality and being
outside the country of his former habitual residence as a result of such events, is unable
or, owing to such fear, is unwilling to return to it.
The meaning of ‘persecution’ is not defined in the Convention, but generally

requires targeted acts which are discriminatory against an individual. Some
accepted definitions include ‘severe pain or suffering, physical or mental, in-
tentionally inflicted’ (Goodwin-Gill and McAdam, 2007, p. 90) and ‘sustained
or systemic violation of basic human rights’ (Hathaway, 1991, pp. 104–105). It

is well established that breach of the right to an ‘adequate standard of living’
and threats to health may amount to ‘persecution’ (Hathaway and Foster, 2014,
pp. 228–238; Foster, 2007, pp. 226–235). Decision-makers have relied upon
ICESCR Art. 12.1 and the statement in the CESCR General Comment No. 14:
States are under the obligation to respect the right to health by, inter alia, refraining
from denying or limiting equal access for all persons, including prisoners or detainees,
minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative
health services; abstaining from enforcing discriminatory practices as a State policy;
and abstaining from imposing discriminatory practices relating to women’s health
status and needs (para. 34).
Thus, asylum claims from members of minority religions in Iran denied access
to medical care on religious grounds have been recognized, as have the claims
by persons with HIV denied equal access to medical services. It has also been
recognized that severe pollution and/or environmental degradation may ser-
iously affect health and be linked to a Convention ground (such as religion or
nationality). In the decision of the High Court of Australia in 2000, Chen Shi
Hai (HCA, 2000) it was decided that denial of access to food, shelter, and med-
ical treatment to a child born outside China’s one-child policy amounted to
persecution.
2.3.4 Rights at destination
It follows from the fact of persecution and flight that newly arrived refugees
and protection seekers often suffer from serious health issues, including mental
health problems (Simich, 2006), connected to their reasons for or experiences
during flight. As one writer expresses: refugees and asylum seekers suffer ‘a dis-
proportionate burden of illness’ (Taylor 2013, p. 293). A study of refugees ar-
riving in Australia found that many refugees arrive with complex health needs.
It estimated that one in six refugees has a physical health problem with a severe
impact on quality of life and that two-thirds experience mental health prob-
lems, signifying the important role of rehabilitation (Khan and Amatya, 2017).
Further, refugees often face continued disadvantage, poverty, and dependence,
which are determinants of both poor physical and mental health, due to lack
of support in the receiving country. This is compounded by language barriers,
impoverishment, and lack of familiarity with the local environment and health-
care systems (Khan and Amatya, 2017). In Canada, it was found that many
refugees suffer from lack of understanding of the health-care system, language
and cultural barriers, or discrimination in access to services (Rahman, 2017).
The process of making and proving a claim for refugee status, the seeking of
asylum, is a challenge for every claimant. Refugee status determination (RSD)
has been described as ‘one of the most complex adjudication functions in in-
dustrialized societies’ (Rousseau et al., 2002); it imposes a substantial burden of
proof on the claimant, and the need to overcome a tangible ‘credibility deficit’
(Coffey, 2003; Taylor, 2013, p. 290). Moreover, the risk of re-traumatization on
retelling a story of persecution is well recognized (Herlihy and Turner, 2009).
To negotiate the RSD process a refugee needs to be in good health, but, as Khan
and Amatya recognize, many newly arrived refugees need first to recover their
health. To enable refugees and protection seekers to have a proper opportunity
to present their case for asylum or protection, they need to be physically and
mentally well. The denial of the right to properly present the case for asylum or
protection is tantamount to refoulement.
The EU Reception Directive 2013 recognizes the link between material well-
being (which includes health) and the right to seek asylum. Article 17.1 states:
Member States shall ensure that material reception conditions are available to appli-
cants when they make their application for international protection.
The Reception Directive 2013 Art. 17.2 states:

Member States shall ensure that material reception conditions provide an adequate
standard of living for applicants, which guarantees their subsistence and protects their
physical and mental health.
In Fedasil v. Saciri (ECR, 2014) the EU Court of Justice stressed that the purpose
of the Directive is linked to ensuring the right to seek asylum. The court’s pos-
ition was that the reception measures must guarantee asylum seekers dignified
living, subsistence, and physical and mental health, and be sufficiently stable
to adequately satisfy health and other material needs of those undergoing an
(often lengthy) asylum procedure.
However, the reality is that the current ‘refugee crisis’ in Europe since 2015 has
led to a focus on deterrent measures such as detention, and that many asylum
seekers are housed in substandard accommodation (Mousourakis, 2016).
There is growing discrimination and lack of consistency in standards between
Member States. In light of the current situation, the European Commission is
considering a further recast of the (already recast) Reception Directive 2013.
2.3.5 Deterrent measures and the role of doctors

In contrast to the objectives of the EU Reception Directive, many developed
states around the globe when acting as destination countries have developed
deterrent policies which fundamentally undermine the rights of asylum seekers
to seek asylum, including measures which discriminate against asylum seekers
and ‘undocumented migrants’ in access to health care. These states exploit the
ambiguities around the human right to ‘access to health’ explained above, and
in so doing undermine the fundamental right to seek asylum. For example, a

study of Denmark, Sweden, and the Netherlands revealed that entitlements at
national levels for undocumented migrants are inconsistent and often at odds
with the international human rights summarized above (Biswas et al., 2012).
Further, states often position doctors in situations of conflict. For example, in
the United States, doctors have a direct role in the assessment of claims in the
RSD process, which puts them in a potential position of conflict between their
medical and ‘judicial’ roles (Asgary and Smith, 2013).
One of the leaders in this trend to deny health rights as a deterrent measure
is the United Kingdom, beginning with the 1999 Immigration and Asylum
Act (Cohen et al., 2002) and subsequently the Nationality, Immigration and
Asylum Act 2002 and Asylum and Immigration (Treatment of Claimants) Act
2004 (Ghanea, 2007, pp. 125–127). The Nationality, Immigration, and Asylum
Act 2002 s. 55 required asylum seekers to make their claims ‘as soon as reason-
ably practicable’ upon arrival in the United Kingdom. Failure to do so could
lead to the withdrawal of social welfare benefits. This measure led to hundreds
of applications for injunctions (Ghanea, 2007, p. 125). In several cases, suc-
cessful judicial challenges were brought to decisions to remove benefits, e.g. R
(on the application of Q) v Secretary of State for the Home Department (EWHC,
2003) and R (on the application of Limbuela) v Secretary of State for the Home
Department (EWCA, 2004), which led to some modification of the legislation.
However, the Committee on Economic, Social and Cultural Rights in their
Concluding Observations on the Sixth Periodic Report of the United Kingdom of
Great Britain and Northern Ireland (CESCR, 2016) expressed concern that refu-
gees and asylum seekers, as well as Roma, Gypsies, and Travellers, continue to
face discrimination in accessing health-care services (para. 55). The Committee
noted that the UK Immigration Act 2014 has further restricted access to health
services by temporary migrants and undocumented migrants.
Moreover, in the United Kingdom, the design of the National Health Service
(NHS) positions doctors in a position of conflict. Taylor (2013) explains that
under the NHS a doctor has the discretion to register a patient (for primary
care only). He says:
[The] fundamental issue here is the extent to which an individual doctor practising
within the NHS is governed by a moral versus a political obligation. At present, there
is an uneasy tension between the NHS as the monopoly provider of health care on the
one hand, and on the other, the duty of the medical practitioner as an advocate for the
care of the sick irrespective of citizenship (Taylor, 2013, p. 294).
In Canada in April 2012 the former Harper government announced ‘a

drastic rollback of health coverage for refugees and refugee claimants’ (Raza,
2012) which was available only for conditions deemed to be of an ‘urgent or
essential nature’ or those to ‘prevent or treat a disease that is a risk to public

health or a condition of public safety concern’. The measures were even harder
on refugees who arrive from so-called safe countries, and were clearly intended
to deter refugees. These cuts were restored in 2016 (following a successful chal-
lenge under the equality rights guaranteed in the Canadian Charter of Rights).
2.3.6 Offshore and onshore detention

under Australian policy
Australia’s offshore immigration detention centres, the Regional Processing
Centres (RPCs), provide one of the most challenging environments for the
provision of health care to refugees and asylum seekers, and is also challen-
ging for the health workers. This policy is part of a suite of deterrent measures
practised by the Australian government against asylum seekers following the
implementation of the ‘no advantage’ principle in 2012 and the reintroduction
of offshore processing. It is well recognized that offshore processing of asylum
seekers can have serious consequences for both physical and mental health
(de Boer, 2013, p. 1). The delivery of health-care services for asylum seekers
on Nauru and Manus Island is governed by Heads of Agreement between the
Commonwealth of Australia (represented by the Department of Immigration
and Border Protection) and International Health and Medical Services (IHMS).
IHMS is required to provide ‘primary level health care’ to asylum seekers and
to establish a network of health providers on Nauru and Manus Island (de Boer,
2013, p. 3). IHMS works with local health-care providers for emergency and
acute care. This is a challenging environment for health workers both physically
and professionally (de Boer, 2013, p. 22; Sanggaan, Ferguson, and Haire, 2014).
Riots, violence, abuse, self-harm, and some deaths have been reported in off-
shore centres (Essex, 2016).
A number of reports have raised serious concerns about the quality of care
provided and whether health professionals have been able to fulfil their profes-
sional and ethical obligations to patients in RPC facilities (Sanggaan, Ferguson,
and Haire, 2014; and see Chapter 14 of this volume). The death of Hamid
Kehazaei from an untreated skin infection in 2015 illustrated the risk that med-
ical recommendations for treatment may be ignored (Essex, 2016, p. 1042).
In the detention environment, dual loyalty issues confront health and welfare
professionals both in Australia and offshore (Briskman and Zion, 2014). This is
particularly acute when mental health issues are present as carers ‘risk making
themselves complicit in the system that by its nature causes mental harm’
(Fazel and Silove, 2006). Others have commented that all public health profes-
sionals (psychiatry, nursing, and social work) have a responsibility to protect
and promote the right to health among populations, especially vulnerable and
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secrets which are treasured in his breast, I come to proclaim myself
his slave, his apostle, his martyr.”
The divinity did not respond, but after a long silence, the same
voice asked:—“What does the partner of thy long wanderings
intend?”
“To obey and to serve,” answered Lorenza.
Simultaneously with her words, profound darkness succeeded the
glare of light, uproar followed on tranquillity, terror on trust, and a
sharp and menacing voice cried loudly:—“Woe to those who cannot
stand the tests!”
Husband and wife were immediately separated to undergo their
respective trials, which they endured with exemplary fortitude, and
which are detailed in the text of the memoirs. When the romantic
mummery was over, the two postulants were led back into the
temple, with the promise of admission to the divine mysteries. There
a man mysteriously draped in a long mantle cried out to them:
—“Know ye that the arcanum of our great art is the government of
mankind, and that the one means to rule them is never to tell them
the truth. Do not foolishly regulate your actions according to the rules
of common sense; rather outrage reason and courageously maintain
every unbelievable absurdity. Remember that reproduction is the
palmary active power in nature, politics, and society alike; that it is a
mania with mortals to be immortal, to know the future without
understanding the present, and to be spiritual while all that
surrounds them is material.”
After this harangue the orator genuflected devoutly before the
divinity of the temple and retired. At the same moment a man of
gigantic stature led the countess to the feet of the immortal Count de
Saint-German, who thus spoke:—
“Elected from my tenderest youth to the things of greatness, I
employed myself in ascertaining the nature of veritable glory. Politics
appeared to me nothing but the science of deception, tactics the art
of assassination, philosophy the ambitious imbecility of complete
irrationality; physics fine fancies about Nature and the continual
mistakes of persons suddenly transplanted into a country which is
utterly unknown to them; theology the science of the misery which
results from human pride; history the melancholy spectacle of
perpetual perfidy and blundering. Thence I concluded that the
statesman was a skilful liar, the hero an illustrious idiot, the
philosopher an eccentric creature, the physician a pitiable and blind
man, the theologian a fanatical pedagogue, and the historian a word-
monger. Then did I hear of the divinity of this temple. I cast my cares
upon him, with my incertitudes and aspirations. When he took
possession of my soul he caused me to perceive all objects in a new
light; I began to read futurity. This universe so limited, so narrow, so
desert, was now enlarged. I abode not only with those who are, but
with those who were. He united me to the loveliest women of
antiquity. I found it eminently delectable to know all without studying
anything, to dispose of the treasures of the earth without the
solicitation of monarchs, to rule the elements rather than men.
Heaven made me liberal; I have sufficient to satisfy my taste; all that
surrounds me is rich, loving, predestinated.”
When the service was finished the costume of ordinary life was
resumed. A superb repast terminated the ceremony. During the
course of the banquet the two guests were informed that the Elixir of
Immortality was merely Tokay coloured green or red according to the
necessities of the case. Several essential precepts were enjoined
upon them, among others that they must detest, avoid, and
calumniate men of understanding, but flatter, foster, and blind fools,
that they must spread abroad with much mystery the intelligence that
the Count de Saint-Germain was five hundred years old, that they
must make gold, but dupes before all.
The truth of this singular episode is not attested by any sober
biographer. If it occurred as narrated, it doubtless served to confirm
Cagliostro in his ambitious projects. The change which had taken
place in the adventurer since his second visit to England is well
described by Figuier. “His language, his mien, his manners, all are
transformed. His conversation turns only on his travels in Egypt, to
Mecca, and in other remote places, on the sciences into which he
was initiated at the foot of the Pyramids, on the arcana of Nature
which his ingenuity has discovered. At the same time, he talks little,
more often enveloping himself in mysterious silence. When
interrogated with reiterated entreaties, he deigns at the most to draw
his symbol—a serpent with an apple in its mouth and pierced by a
dart, meaning that human wisdom should be silent on the mysteries
which it has unravelled.... Lorenza was transfigured at the same time
with her husband. Her ambitions and deportment became worthy of
the new projects of Cagliostro. She aimed, like himself, at the glory
of colossal successes.”
The initiates of the Count de Saint-Germain passed into Courland,
where they established Masonic lodges, according to the sublime rite
of Egyptian Freemasonry. The countess was an excellent preacher
to captivate hearts and enchant imaginations, her beauty fascinated
a large number of Courlandaise nobility. At Mittau, Cagliostro
attracted the attention of persons of high rank, who were led by his
reputation to regard him as an extraordinary person. By means of his
Freemasonry he began to obtain an ascendency over the minds of
the nobles, some of whom, discontented with the reigning duke, are
actually said to have offered him the sovereignty of the country, as to
a divine man and messenger from above. The Italian biography
represents him plotting with this end in view. “He pretends,” say the
documents of the Holy Inquisition, “that he had virtue enough to
resist the temptation, and that he refused the proffered boon from
the respect due to sovereigns. His wife has assured us that his
refusal was produced by the reflection that his impostures would
soon be discovered.” He collected, however, a prodigious number of
presents in gold, silver, and money, and repaired to St Petersburg,
provided with regular passports. But the prophet soon found that a
sufficiently brilliant reputation had not preceded him, and he,
therefore, simply announced himself as a physician and chemist, by
his retired life and air of mystery soon attracting attention.
His assumption of the rôle of physician leads to a brief
consideration of the miraculous cures which have been attributed to
him. They are generally referred to a broad application of the
principles and methods of Mesmer, his contemporary. They were
performed without passes, iron rods, or any of the cumbrous
paraphernalia of his rival in the healing art; he trusted simply to the
laying on of hands. Moreover, he did not despoil his patients, but
rather dispensed his wealth, which now appeared unlimited, among
the poor, who flocked to him in great numbers as his reputation
increased. The source of this wealth is not accurately known, but it is
supposed to have been derived from the Masonic initiates, whose
apostle and propagandist he was.
Many of the miraculous cures which Cagliostro performed in
Germany spread widely, and in Russia he was soon surrounded by
the curious. Lorenza played her own part admirably; she answered
discreetly and naturally, making the most outrageous statements
with apparently complete unconsciousness. The physician-chemist,
besides his healing powers, had his reputation as an alchemist and
adept of the arcane sciences. The supposed restoration in a
miraculous manner of the infant child of an illustrious nobleman to
health exalted him to the pinnacle of celebrity, and his extravagant
pretensions, assisted, as they powerfully were, by the naïve beauty
of his wife, were beginning to be taken seriously, but the combined
result of an amour between Lorenza and Prince Poternki, Prime
Minister and favourite of the Czarina, Catherine, and the discovery
that the nobleman’s child had been apparently changed, caused
them to depart hastily with immense spoils towards the German
frontier.
They tarried at Warsaw for a time, and there the Italian biographer
tells us that Cagliostro made use of all his artifices to deceive a
prince to whom he was introduced, and who was exceedingly
anxious to obtain, with the help of the pretended magician, the
permanent command of a devil. Cagliostro puffed him up for a long
time with the expectation of gratifying this preposterous ambition,
and actually procured presents from him to the amount of several
thousand crowns. The prince at length perceiving that there was no
hope of retaining one of the infernal spirits in his service, wished to
make himself master of the earthly affections of the countess, but in
this too he was disappointed, the lady positively refusing to comply
with his desires. Finding himself thus balked in both his attempts, he
abandoned every sentiment but revenge, and intimidated our
adventurer and his wife so much by his menaces that they were
obliged to restore his presents.
The veracity of this account is not, however, beyond suspicion,
and other of his biographers represent Cagliostro proceeding directly
to Francfurt and thence to Strasbourg, into which, more wealthy and
successful than ever, he made a triumphal entry. The distinguished
visitor, the Rosicrucian, the alchemist, the physician, the sublime
count, had been expected since early morning by the bourgeois of
the old town, and the following extraordinary account in the
Dictionnaire des Sciences Occultes has been given by an
anonymous biographer.
“On the 19th of September 1780, in a public-house just outside
Strasburg, surrounded by a group of humble tipplers, who stared
from the little window at the vast crowd collected below them, there
might have been remarked the countenance of a bald and wrinkled
man, some eighty years of age, and evidently of southern origin; this
was the goldsmith Marano. Successive failures, and debts which he
did not see fit to liquidate, had forced him to leave Palermo, and he
had established himself in his former trade at Strasbourg. Like the
rest of the townsfolk he had come out to behold the phenomenal
personage whose arrival was expected, and who made a greater
sensation than many a powerful monarch. He had come by way of
Germany from Varsovia, where he had amassed immense riches,
said popular rumour, by the transmutation of base metals into gold,
for he was possessed of the secret of the philosophic stone, and had
all the incalculable talents of an alchemist.”
“By my faith,” said a hatter, “I am indeed happy since I am
destined to behold this illustrious mortal, if indeed he be a mortal.”
“’Tis asserted,” added a druggist, “that he is a son of the Princess
of Trebizond, and that he has withal the fine eyes of his mother.”
“Also that he is a lineal descendant of Charles Martel,” said a town
clerk.
“He dates still further back,” put in a rope-maker, “for he took part
in the marriage feast of Cana.”
“Beyond doubt then, he is the wandering Jew!” exclaimed Marano.
“Still better, some credible persons assert that he was born before
the deluge.”
“What hardihood! Yet suppose he is the devil.”
These notions here reproduced with fidelity, and which were
adorned by the most extravagant commentaries, were actually at
that period in general circulation among the crowd. Some regarded
the mysterious Count Cagliostro as an inspired saint, a performer of
miracles, a phenomenal personage outside the order of Nature. The
cures attributed to him were equally innumerable and unexplainable.
Others regarded him merely as an adroit charlatan. Cagliostro
himself boldly asserted that all his prodigies were performed under
the special favour and help of heaven. He added that the Supreme
Being had deigned to accord him the beatific vision, that it was his
mission to convert unbelievers and reinstate catholicism, but in spite
of this exalted vocation he told fortunes, taught the art of winning at
lotteries, interpreted dreams, and held séances of transcendental
phantasmagoria.
“But,” contended the rope-maker with much animation, “a man
who converses with angels is never the devil.”
“Is he in communication with angels?” cried Marano, struck by the
circumstances. “In that case I must see him at all costs. How old is
he?”
“Bah!” said the druggist, “as if such a being could have an age! He
looks about thirty-six.”
“Oh!” muttered the goldsmith. “What if he were my rascal? My
rascal should now be thirty-seven.”
As the hoary Sicilian ruminated over his lamentable past, he was
roused by a tumult of voices. The supernal being had arrived, and he
passed presently in the road, surrounded by a numerous cortege of
couriers, lacqueys, valets, &c., all in magnificent liveries. By his side,
in the open carriage, sat Lorenza or Seraphina Feliciani, his wife,
who seconded with all her ability the intrigues of her husband, whom
reasonable people regarded as a wandering member and emissary
of the masonic templars, his opulence insured by contributions from
the different lodges of the order.
A great shout rose up when Count Cagliostro passed before the
inn. Marano had recognised his man, and flying out had contrived to
stop the carriage, shouting as he did so—“Joseph Balsamo! It is
Joseph! Coquin, where are my sixty ounces of gold?”
Cagliostro scarcely deigned to glance at the furious goldsmith; but
in the middle of the profound silence which the incident occasioned
among the crowd, a voice, apparently in the clouds, uttered with
great distinctness the following words: “Remove this lunatic, who is
possessed by infernal spirits!”
Some of the spectators fell on their knees, others seized the
unfortunate goldsmith, and the brilliant cortege passed on.
Entering Strasburg in triumph, Cagliostro paused in front of a large
hall, where the equerries who had preceded him had already
collected a considerable concourse of the sick. The famous empiric
entered and cured them all, some simply by touch, others apparently
by words or by a gratuity in money, the rest by his universal
panacea; but the historian who records these things asserts that the
sick persons thus variously treated had been carefully selected, the
physician preferring to treat the more serious cases at the homes of
the patients.
Cagliostro issued from the hall amidst universal acclamations, and
was accompanied by the immense crowd to the doors of the
magificent lodging which had been prepared against his arrival. The
élite of Strasburg society was invited to a sumptuous repast, which
was followed by a séance of transcendental magnetism, when he
produced some extraordinary manifestations by the mediation of
clairvoyant children of either sex, and whom he denominated his
doves or pupils. The unspotted virginity and innocence of these
children were an indispensable condition of success. They were
chosen by himself, and received a mystical consecration at his
hands. Then he pronounced over a crystal vessel, filled with water,
the magical formulæ for the evocation of angelic intelligences as
they are written in the celestial rituals. Supernal spirits became
visible in the depths of the water, and responded to questions
occasionally in an intelligible voice, but more often in characters
which appeared on the surface of the water, and were visible to the
pupils alone, who interpreted them to the public.
Contemporary testimony establishes that these manifestations, as
a whole, were genuine, and there is little doubt of the mesmeric
abilities of Cagliostro, who had probably become acquainted in the
East with the phenomena of virginal lucidity, especially in boys, and
had supplemented the oriental methods by the discoveries of
Puséygur, which were at that time sufficiently notorious.
For three years Cagliostro remained at Strasburg and was fêted
continually. Here he obtained a complete ascendency over the mind
of the famous cardinal-archbishop, the Prince de Rohan. His first
care, on taking up his abode in the town, was to prove his respect for
the clergy by his generosity and zeal. He visited the sick in the
hospitals, deferentially participated in the duties of the regular
doctors, proposed his new remedies with prudence, did not condemn
the old methods, but sought to unite new science with the science
which was based on experience. He obtained the reputation of a
bold experimenter in chemistry, of a sagacious physician, and a
really enlightened innovator. The inhabitants of the crowded quarters
regarded him as a man sent from God, operating miraculous cures,
and dispensing riches from an inexhaustible source with which he
was alone acquainted. Unheard-of cures were cited, and alchemical
operations which surpassed even the supposed possibilities of the
transmutatory art.
Anything which savoured of the marvellous was an attraction for
the cardinal-archbishop, and he longed to see Cagliostro. An
anonymous writer states that he sought an interview with him again
and again unsuccessfully; for the cardinal-prince of trickery divined
even at a distance the character of the prince-cardinal, and
enveloped himself in a reserve which, to the imagination of his dupe,
was like the loadstone to the magnet. Others represent him,
however, courting the favour of the great ecclesiastic’s secretary, and
so obtaining an introduction. At the first interview he showed some
reserve, but permitted certain dazzling ideas to be glimpsed through
the more ordinary tenour of his discourse. After a judicious period he
admitted that he possessed a receipt for the manufacture of gold and
diamonds. A supposed transmutation completed his conquest of the
cardinal, and the Italian historian confesses that he accordingly
lavished immense sums upon the virtuous pair, and to complete his
folly, agreed to erect a small edifice, in which he was to experience a
physical regeneration by means of the supernal and auriferous elixir
of Cagliostro. The sum of twenty thousand francs was actually paid
the adept to accomplish this operation.
Doubtless during his sojourn at Strasburg he propagated with zeal
the mysteries of his Egyptian Freemasonry, and at length, laden with
spoils, he repaired to Bordeaux, where he continued his healing in
public, and then proceeded to Lyons, where for the space of three
months he occupied himself with the foundation of a mother-lodge,
and, according to the Italian biographer, here as elsewhere, in less
creditable pursuits. At length he arrived at Paris, where, says the
same authority, he soon became the object of general conversation,
regard, and esteem. His curative powers were now but little
exercised, for Paris abounded with mesmerists and healers, and the
prodigies of simple magnetism were stale and unprofitable in
consequence. He assumed now the rôle of a practical magician, and
astonished the city by the evocation of phantoms, which he caused
to appear, at the wish of the inquirer, either in a mirror or in a vase of
clear water. These phantoms equally represented dead and living
beings, and as occasionally collusion appears to have been well-
nigh impossible, and as the theory of coincidence is preposterous,
there is reason to suppose that he produced results which must
sometimes have astonished himself. All Paris at any rate was set
wondering at his enchantments and prodigies, and it is seriously
stated that Louis XVI. was so infatuated with le divin Cagliostro, that
he declared anyone who injured him should be considered guilty of
treason. At Versailles, and in the presence of several distinguished
nobles, he is said to have caused the apparition in mirrors, vases,
&c., not merely of the spectra of absent or deceased persons, but
animated and moving beings of a phantasmal description, including
many dead men and women selected by the astonished spectators.
The mystery which surrounded him abroad was deepened even
when he received visitors at home. He had lived in the Rue Saint
Claude, an isolated house surrounded by gardens and sheltered
from the inconvenient curiosity of neighbours. There he established
his laboratory, which no one might enter. He received in a vast and
sumptuous apartment on the first floor. Lorenza lived a retired life,
only being visible at certain hours before a select company, and in a
diaphanous and glamourous costume. The report of her beauty
spread through the city; she passed for a paragon of perfection, and
duels took place on her account. Cagliostro was now no longer
young, and Lorenza was in the flower of her charms. He is said for
the first time to have experienced the pangs of jealousy on account
of a certain Chevalier d’Oisemont, with whom she had several
assignations. Private vexations did not, however, interfere with
professional thaumaturgy, and the evocation of the illustrious dead
was a common occurrence at certain magical suppers which
became celebrated through all Paris. These were undoubtedly
exaggerated by report, but as they all occurred within the doubtful
precincts of his own house of mystery, they were in all probability
fraudulent, for it must be distinctly remembered that in his normal
character he was an unparalleled trickster, that the genuine
phenomena which he occasionally produced were simply
supplements to charlatanry, and not that his deceptions were aids to
normally genuine phenomena.
On one occasion, according to the Mémoires authentiques pour
servir à l’histoire du Comte de Cagliostro, the distinguished
thaumaturgist announced that at a private supper, given to six
guests, he would evoke the spirits of any dead persons whom they
named to him, and that the phantoms, apparently substantial, should
seat themselves at the banquet. The repast took place with the
knowledge and, it may be supposed, with the connivance of
Lorenza. At midnight the guests were assembled; a round table, laid
for twelve, was spread, with unheard-of luxury, in a dining-room,
where all was in harmony with the approaching Kabbalistic
operation. The six guests, with Cagliostro, took their seats, and thus
the ominous number thirteen were designed to be present at table.
The supper was served, the servants were dismissed with threats
of immediate death if they dared to open the doors before they were
summoned. Each guest demanded the deceased person whom he
desired to see. Cagliostro took the names, placed them in the pocket
of his gold-embroidered vest, and announced that with no further
preparation than a simple invocation on his part the evoked spirits
would appear in flesh and blood, for, according to the Egyptian
dogma, there were in reality no dead. These guests of the other
world, asked for and expected with trembling anxiety, were the Duc
de Choiseul, Voltaire, d’Alembert, Diderot, the Abbé de Voisenon,
and Montesquieu. Their names were pronounced slowly in a loud
voice, and with all the concentrated determination of the adept’s will;
and after a moment of intolerable doubt, the evoked guests
appeared very unobtrusively, and took their seats with the quiet
courtesy which had characterised them in life.
The first question put to them when the awe of their presence had
somewhat worn off was as to their situation in the world beyond.
“There is no world beyond,” replied d’Alembert. “Death is simply
the cessation of the evils which have tortured us. No pleasure is
experienced, but, on the other hand, there is no suffering. I have not
met with Mademoiselle Lespinasse, but I have not seen Lorignet.
There is marked sincerity, moreover. Some deceased persons who
have recently joined us inform me that I am almost forgotten. I am,
however, consoled. Men are unworthy of the trouble we take about
them. I never loved them, now I despise them.”
“What has become of your learning?” said M. de —— to Diderot.
“I was not learned, as people commonly supposed. My ready wit
adapted all that I read, and in writing I borrowed on every side.
Thence comes the desultory character of my books, which will be
unheard of in half a century. The Encyclopædia, with the merit of
which I am honoured, does not belong to me. The duty of an editor is
simply to set in order the choice of subjects. The man who showed
most talent in the whole of the work was the compiler of its index, yet
no one has dreamed of recognising his merits.”
“I praised the enterprise,” said Voltaire, “for it seemed well fitted to
further my philosophical opinions. Talking of philosophy, I am none
too certain that I was in the right. I have learned strange things since
my death, and have conversed with half a dozen Popes. Clement
XIV. and Benedict, above all, are men of infinite intelligence and
good sense.”
“What most vexes me,” said the Duc de Choiseul, “is the absence
of sex where we dwell. Whatever may be said of this fleshly
envelope, ’twas by no means so bad an invention.”
“What is truly a pleasure to me,” said the Abbé Voisenon, “is that
amongst us one is perfectly cured of the folly of intelligence. You
cannot conceive how I have been bantered about my ridiculous little
romances. I had almost confessed that I appreciated these puerilities
at their true value, but whether the modesty of an academician is
disbelieved in, or whether such frivolity is out of character with my
age and profession, I expiate almost daily the mistakes of my mortal
existence.”
Amid these marvels, Cagliostro proceeded with the dearest of all

his projects, namely, the spread of his Egypto-masonic rite,[AN] into
which ladies were subsequently admitted, a course of magic being
opened for the purpose by Madame Cagliostro. The postulants
admitted to this course were thirty-six in number, and all males were
excluded. Thus Lorenza figured as the Grand Mistress of Egyptian
Masonry, as her husband was himself the grand and sublime Copt.
The fair neophytes were required to contribute each of them the sum
of one hundred louis to abstain from all carnal connection with
mankind, and to submit to everything which might be imposed on
them. A vast mansion was hired in the Rue Verte, Faubourg Saint
Honoré, at that period a lonely part of the city. The building was
surrounded with gardens and magnificent trees. The séance for
initiation took place shortly before midnight on the 7th of August
1785.
On entering the first apartment, says Figuier, the ladies were
obliged to disrobe and assume a white garment, with a girdle of
various colours. They were divided into six groups, distinguished by
the tint of their cinctures. A large veil was also provided, and they
were caused to enter a temple lighted from the roof, and furnished
with thirty-six arm-chairs covered with black satin. Lorenza, clothed
in white, was seated on a species of throne, supported by two tall
figures, so habited that their sex could not be determined. The light
was lowered by degrees till surrounding objects could scarcely be
distinguished, when the Grand Mistress commanded the ladies to
uncover their left legs as far as the thigh, and raising the right arm to
rest it on a neighbouring pillar. Two young women then entered
sword in hand, and with silk ropes bound all the ladies together by
the arms and legs. Then after a period of impressive silence,
Lorenza pronounced an oration, which is given at length, but on
doubtful authority, by several biographers, and which preached
fervidly the emancipation of womankind from the shameful bonds
imposed on them by the lords of creation.
These bonds were symbolised by the silken ropes from which the
fair initiates were released at the end of the harangue, when they
were conducted into separate apartments, each opening on the
Garden, where they made the most unheard-of experiences. Some
were pursued by men who unmercifully persecuted them with
barbarous solicitations; others encountered less dreadful admirers,
who sighed in the most languishing postures at their feet. More than
one discovered the counterpart of her own lover, but the oath they
had all taken necessitated the most inexorable inhumanity, and all
faithfully fulfilled what was required of them. The new spirit infused
into regenerated woman triumphed along the whole line of the six
and thirty initiates, who with intact and immaculate symbols re-
entered triumphant and palpitating the twilight of the vaulted temple
to receive the congratulations of the sovereign priestess.
When they had breathed a little after their trials, the vaulted roof
opened suddenly, and, on a vast sphere of gold, there descended a
man, naked as the unfallen Adam, holding a serpent in his hand, and
having a burning star upon his head.
The Grand Mistress announced that this was the genius of Truth,
the immortal, the divine Cagliostro, issued without procreation from
the bosom of our father Abraham, and the depositary of all that hath
been, is, or shall be known on the universal earth. He was there to
initiate them into the secrets of which they had been fraudulently
deprived. The Grand Copt thereupon commanded them to dispense
with the profanity of clothing, for if they would receive truth they must
be as naked as itself. The sovereign priestess setting the example
unbound her girdle and permitted her drapery to fall to the ground,
and the fair initiates following her example exposed themselves in all
the nudity of their charms to the magnetic glances of the celestial
genius, who then commenced his revelations.
He informed his daughters that the much abused magical art was
the secret of doing good to humanity. It was initiation into the
mysteries of Nature, and the power to make use of her occult forces.
The visions which they had beheld in the Garden where so many
had seen and recognised those who were dearest to their hearts,
proved the reality of hermetic operations. They had shewn
themselves worthy to know the truth; he undertook to instruct them
by gradations therein. It was enough at the outset to inform them that
the sublime end of that Egyptian Freemasonry which he had brought
from the very heart of the Orient was the happiness of mankind. This
happiness was illimitable in its nature, including material enjoyments
as much as spiritual peace, and the pleasures of the understanding.
The Marquis de Luchet, to whom we are indebted for this account,
concludes the nebulous harangue of Cagliostro by the adept bidding
his hearers abjure a deceiving sex, and to let the kiss of friendship
symbolise what was passing in their hearts. The sovereign priestess
instructed them in the nature of this friendly embrace.
Thereupon the Genius of Truth seated himself again upon the
sphere of gold, and was borne away through the roof. At the same
time the floor opened, the light blazed up, and a table splendidly
adorned and luxuriously spread rose up from the ground. The ladies
were joined by their lovers in propria persona; the supper was
followed by dancing and various diversions till three o’clock in the
morning.
About this time the Count Cagliostro was unwillingly compelled to
concede to the continual solicitations of the poor and to resume his
medical rôle. In a short time he was raised to the height of celebrity
by a miraculous cure of the Prince de Soubise, the brother of the
Cardinal de Rohan, who was suffering from a virulent attack of
scarlet fever. From this moment the portrait of the adept was to be
seen everywhere in Paris.
In the meantime, the cloud in his domestic felicity, to which a brief
reference has been made already, began to spread. A certain
adventuress, by name Madame de la Motte, surprised Lorenza one
day in a tête-à-tête with the Chevalier d’Oisemont. The count at the
time was far away from Paris, and the adventuress promised to keep
the secret on condition that Lorenza should in turn do all in her
power to establish her as an intimate friend in the house, having free
entrance therein, and should persuade Cagliostro to place his
knowledge and skill at her disposal, if ever she required it. The result
of this arrangement was the complicity of Cagliostro in the
extraordinary and scandalous affair of the Diamond Necklace. When
the plot was exposed, Cagliostro was arrested with the other alleged
conspirators, including the principal victim, the Cardinal de Rohan.
He was exonerated, not indeed without honour, from the charge of
which he was undoubtedly guilty, but his wife had fled to Rome at his
arrest, and had rejoined her family. He himself began to tremble at
his own notoriety, and grew anxious to leave France. He postponed
till a more favourable period his grand project concerning the
metropolitan lodge of the Egyptian rite.[AO] A personage, calling
himself Thomas Ximenes, and claiming descent from the cardinal of
that name, sought to reanimate his former masonic enthusiasm; but
the vision of the Bastile seemed to be ever before his eyes, and
neither this person, nor the great dignitaries of the Parisian lodges,
could prevail with him. In spite of his acquittal he nourished
vengeance against the Court of France, and more than once he
confided to his private friends that he should make his voice heard
when he had passed the frontier. He prepared to depart, and one
day his disconsolate adepts learned that he was on the road to
England.
Once in London he recovered his energy. He was received with
great honour; many of his disciples from Lyons and Paris followed
him. The English masons invited him to the metropolitan lodge, and
gave him the first place, that of grand orient. He was entreated to
convene a masonic lodge of the Egyptian rite, and consented with
some sadness, for the memory of the brilliant Paris lodge which he
had been on the point of founding was incessantly before him. He
could not console himself for the fall of that beautiful and long-
cherished plan, which had cost him so much study, pains, and
preaching.
It was from this discreet distance that Cagliostro addressed his
famous Letter to the People of France, which was translated into a
number of languages, and circulated widely through Europe. It
predicted the French Revolution, the demolishment of the Bastile,
and the rise of a great prince who would abolish the infamous lettres
de cachet, convoke the States-General, and re-establish the true
religion.
The publication was intemperate in its language and revolutionary
in its sentiments, and close upon its heels followed his well-known
quarrel with the Courrier de l’Europe, which resulted in the exposure
of the real life of Cagliostro from beginning to end.
Dreading the rage of his innumerable dupes, and extreme
measures on the part of his creditors, he hastened to quit London,
disembarked in Holland, crossed Germany, took refuge in Basle,
where the patriarchal hospitality of the Swiss cantons to some extent
reassured the unmasked adept. From the moment, however, of this
exposure, the descent of Cagliostro was simply headlong in its
rapidity. Nevertheless, he was followed by some of his initiates, who
pressed him to return to France, assuring him of the powerful
protection of exalted masonic dignitaries. In his hesitation he wrote
to the Baron de Breteuil, the king’s minister of the house, but, as it
chanced, a personal enemy of the Cardinal de Rohan. Considering
Cagliostro as a protégé of the prince, he replied that if he had
sufficient effrontery to set foot within the limits of the kingdom, he
should be arrested and transferred to a prison in Paris, there to await
prosecution as a common swindler, who should answer to the royal
justice for his criminal life.
From this moment Cagliostro saw that he was a perpetual exile
from France, and feeling in no sense assured of his safety even in
Switzerland, he left Basle for Aix, in Savoy. He was ordered to quit
that town in eight and forty hours. At Roveredo, a dependency of
Austria, the same treatment awaited him. He migrated to Trent, and
announced himself as a practitioner of lawful medicine, but the
prince-bishop who was sovereign of the country discerned the
cloven hoof of the sorcerer beneath the doctor’s sober dress, and
showed him in no long space of time his hostility to magical
practices. The wandering hierophant of Egyptian masonry,
somewhat sorely pressed, took post to Rome, and reached the
Eternal City after many vicissitudes. Here, according to Saint-Félix
and Figuier, he was rejoined by his wife; according to the Italian
biographer, Lorenza had accompanied him in his wanderings, and
persuaded him to seek refuge in Rome, being sick unto death of her
miserable course of life. The former statement is, on the whole, the
most probable, as it is difficult to suppose that she left Italy to rejoin
Cagliostro at Passy, and she appears to have returned to him with
marked repugnance. She endeavoured to lead him back to religion,
which had never been eradicated from her heart. He lived for some
time with extraordinary circumspection, and consented at last to see
a Benedictine monk, to whom he made his confession. The Holy
Inquisition, which doubtless had scrutinised all his movements, is
said to have been deceived for a time, and he was favourably
received by several cardinals. He lived for a year in perfect liberty,
occupied with the private study of medicine. During this time he
endeavoured to obtain loans from the initiates of his Egyptian rite
who were scattered over France and Germany, but they did not
arrive, and the sublime Copt, the illuminated proprietor of the stone
philosophical and the medicine yclept metallic, came once more, to
the eternal disgrace of Osiris, Isis, and Anubis, on the very verge of
want.
His extremity prompted him to renew his relations with the
masonic societies within the area of the Papal States. A penalty of
death hung over the initiates of the superior grades, and their lodges
were in consequence surrounded with great mystery, and were
convened in subterranean places. He was persuaded to found a
lodge of Egyptian Freemasonry in Rome itself, from which moment
Lorenza reasonably regarded him as lost. One of his own adepts
betrayed him; he was arrested on the 27th of September 1789, by
order of the Holy Office, and imprisoned in the Castle of St Angelo.
An inventory of his papers was taken, and all his effects were sealed
up. The process against him was drawn up with the nicest
inquisitorial care during the long period of eighteen months. When
the trial came on he was defended by the Count Gætano Bernardini,
advocate of the accused before the sacred and august tribunal, and
to this pleader in ordinary the impartial and benign office, of its free
grace and pleasure, did add generously, as counsel, one Monsignor
Louis Constantini, “whose knowledge and probity,” saith an unbought
and unbuyable witness (inquisitorially inspired), “were generally
recognised.” They did not conceal from him the gravity of his
position, advised him to refrain from basing his defence on a series
of denials, promising to save him from the capital forfeit, and so he
was persuaded to confess everything, was again reconciled to the
church; and being almost odoriferous with genuine sanctity, on the
21st of March 1791 he was carried before the general assembly of
the purgers of souls by fire, before the Pope on the 7th of the
following April, when the advocates pleaded with so much eloquence
that they retired in the agonies of incipient strangulation, Cagliostro
repeated his avowal, and as a natural consequence of the unbought
eloquence and the purchased confession, the penalty of death was
pronounced.
When, however, the shattered energies of the advocates were a
little recruited, a recommendation of mercy was addressed to the
Pope, the sentence was commuted to perpetual imprisonment, and
the condemned man was consigned to the Castle of St Angelo. After
an imprisonment of two years, he died, God knows how, still in the
prime of life, at the age of fifty.
Lorenza, whose admissions had contributed largely towards the
condemnation of her husband, was doomed to perpetual seclusion in
a penitentiary. The papers of Cagliostro were burned by the Holy
Office, and the phantom of that institution keeps to the present day
the secret of the exact date of its victim’s death. It carefully circulated
the report that on one occasion he attempted to strangle a priest
whom he had sent for on the pretence of confessing, hoping to
escape in his clothes; and then it made public the statement that he
had subsequently strangled himself. When the battalions of the
French Revolution entered Rome, the commanding officers,
hammering at the doors of Saint-Angelo, determined to release the
entombed adept, but they were informed that Cagliostro was dead,
“at which intelligence,” says Figuier, “they perceived plainly that the
former Parlement de France was not to be compared with the
Roman Inquisition, and without regretting the demolished Bastile,
they could not but acknowledge that it disgorged its prey more easily
than the Castle of Saint Angelo.”
The personal attractions of Cagliostro appear to have been

exaggerated by some of his biographers. “His splendid stature and
high bearing, increased by a dress of the most bizarre magnificence,
the extensive suite which invariably accompanied him in his
wanderings, turned all eyes upon him, and disposed the minds of the
vulgar towards an almost idolatrous admiration.”
With this opinion of Figuier may be compared the counter-
statement of the Italian biographer:—“He was of a brown
complexion, a bloated countenance, and a severe aspect; he was
destitute of any of those graces so common in the world of gallantry,
without knowledge and without abilities.” But the Italian biographer
was a false witness, for Cagliostro was beyond all question and
controversy a man of consummate ability, tact, and talent. The truth
would appear to lie between these opposite extremes. “The Count
de Cagliostro,” says the English life, published in 1787, “is below the
middle stature, inclined to corpulency; his face is a round oval, his
complexion and eyes dark, the latter uncommonly penetrating. In his
address we are not sensible of that indescribable grace which
engages the affections before we consult the understanding. On the
contrary, there is in his manner a self-importance which at first sight
rather disgusts than allures, and obliges us to withhold our regards,
till, on a more intimate acquaintance, we yield it the tribute to our
reason. Though naturally studious and contemplative, his
conversation is sprightly, abounding with judicious remarks and
pleasant anecdotes, yet with an understanding in the highest degree
perspicuous and enlarged, he is ever rendered the dupe of the
sycophant and the flatterer.”
The persuasive and occasionally overpowering eloquence of
Cagliostro is also dwelt upon by the majority of his biographers, but,
according to the testimony of his wife, as extracted under the terror
of the Inquisition and adduced in the Italian life:—“His discourse,
instead of being eloquent, was composed in a style of the most
wearisome perplexity, and abounded with the most incoherent ideas.
Previous to his ascending the rostrum he was always careful to
prepare himself for his labours by means of some bottles of wine,
and he was so ignorant as to the subject on which he was about to
hold forth, that he generally applied to his wife for the text on which
he was to preach to his disciples. If to these circumstances are
added a Sicilian dialect, mingled with a jargon of French and Italian,
we cannot hesitate a single moment as to the degree of credibility
which we are to give to the assertions that have been made
concerning the wonder-working effects of his eloquence.”
But the Inquisition was in possession of documents which bore
irrefutable testimony to the extraordinary hold which Cagliostro
exercised over the minds of his numerous followers, and it is
preposterous to suppose it could have been possessed by a man
who was ignorant, unpresentable, and ill-spoken. Moreover, the
testimony of Lorenza, given under circumstances of, at any rate, the
strongest moral intimidation is completely worthless on all points
whatsoever, and the biassed views of our inquisitorial apologists are
of no appreciable value.
I have given an almost disproportionate space to the history of
Joseph Balsamo, because it is thoroughly representative of the
charlatanic side of alchemy, which during two centuries of curiosity

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The Health of Refugees: Public Health

Perspectives from Crisis to Settlement

The Public Health Crisis Survival Guide 2nd Edition

Essentials of Health Behavior (Essential Public Health)

Essentials of Health Economics (Essential Public

Environmental Health: From Global to Local (Public

Health Behavior Theory for Public Health 2nd Edition,

Introduction to Public Health

Essentials of Public Health (Essential Public Health)

Health Promotion Programs: From Theory to Practice

The rapid movement of large populations is intrinsic to humanity, usually as a

Part 1 Concepts and contexts

Part 2 Health concerns

Part 3 Impacts of displacement

Part 4 Case studies in research and ethics

ACLU American Civil Liberties Union ICE Immigration and Customs

RAN Royal Australian Navy UDHR Universal Declaration of

Pascale Allotey Susan Bissell

Susan Kneebone Daniel D. Reidpath

Concepts and contexts

Forced migration, globalization,

least a shared understanding of the potential disagreements in defining that

In Judeo-​Christian tradition one of the best-​known refugees was Moses who,

Economic Economic Loss of

1.4 Trends in global forced migration

Table 1.1 Information from UNHCR Global Reports, 2004–​16

2005 600,000 people in Indonesia and Sri Lanka were displaced by a

Table 1.1 Continued

Table 1.1 Continued

Figure 1.2a shows that the number of refugees, approximately 18 million in

under duress—​a total of around 20 million. Because of the rise in Refugees,

1.5 The distributive burden of forced migration

account in deciding on equitable distribution, where capacity combined con-

1.6 Health and forced migration

1.7 Outline of the book

Part 2 addresses specific refugee populations, highlighting again the

The UNHCR has documented an increase in the number of reported inci-

2.2 Refugees, asylum seekers, and protection

2011 says, the act of ‘recognition of a refugee is a declaratory act’ (preambular

2.3 Human rights: access to health for refugees

2.3.1 What is the right to health?

individual (such as child or woman). Such socioeconomic rights are included in

2.3.2 Limitations based on migration status and nationality

The CESCR in General Comment No. 19 (2008) on ICESCR Art. 9 recognizes

As we will see, states discriminate against non-​nationals in access to health,

2.3.3 Protection from persecution and health rights

The meaning of ‘persecution’ is not defined in the Convention, but generally

or systemic violation of basic human rights’ (Hathaway, 1991, pp. 104–​105). It

The Reception Directive 2013 Art. 17.2 states:

2.3.5 Deterrent measures and the role of doctors

in so doing undermine the fundamental right to seek asylum. For example, a

In Canada in April 2012 the former Harper government announced ‘a

essential nature’ or those to ‘prevent or treat a disease that is a risk to public

2.3.6 Offshore and onshore detention

Amid these marvels, Cagliostro proceeded with the dearest of all

The personal attractions of Cagliostro appear to have been

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In Judeo-Christian tradition one of the best-known refugees was Moses who,

1.4 Trends in global forced migration

Table 1.1 Information from UNHCR Global Reports, 2004–16

under duress—a total of around 20 million. Because of the rise in Refugees,

1.5 The distributive burden of forced migration

1.6 Health and forced migration

1.7 Outline of the book

2.2 Refugees, asylum seekers, and protection

2.3 Human rights: access to health for refugees

2.3.1 What is the right to health?

2.3.2 Limitations based on migration status and nationality

As we will see, states discriminate against non-nationals in access to health,

2.3.3 Protection from persecution and health rights

or systemic violation of basic human rights’ (Hathaway, 1991, pp. 104–105). It

2.3.5 Deterrent measures and the role of doctors

2.3.6 Offshore and onshore detention