*5.8. The Global Refugee Crisis: Empirical Evidence and Policy Implications for Improving Public Attitudes and Facilitating Refugee Resettlement*

As part of their broader investigation into the global refugee crisis, Esses, Hamilton, and Gaucher conducted three literature reviews. The two most relevant to this paper are: (1) the determinants of public attitudes toward refugees, and (2) factors affecting refugee mental health [33].

Esses et al. use the UNHCR definition of refugees, which is "a person who is outside his or her country of nationality or habitual residence; has a well-founded fear of being persecuted because of his or her race, religion, nationality, membership of a particular social group or political opinion; and is unable or unwilling to avail him- or herself of the protection of that country, or to return there, for fear of persecution [33] (p. 79)". While they do not specify and define racism as the public attitude of concern, they note that "citizens of Western countries (i.e., developed countries of Europe, North America, and Oceania) do not always regard refugees with compassion and focus on their safety. Instead, at times they approach refugees with intolerance, distrust, and contempt, partly because they believe there is a trade-off between the well-being of refugees and the well-being of established members of potential host countries [33] (p. 80)".

In their first literature review, the authors found that public attitudes toward refugees tend to construct refugees as threats. These constructs are: (1) threat to safety, such as the association of refugees with terrorism; (2) threats to the economy, such as bogus claimants who are only here for the money; (3) threats to culture, such as flawed beliefs about "how Muslims treat women;" and (4) threats to health, such as carriers of disease, particularly communicable disease. These perceptions of refugees as threats were found to be the strongest predictors of racism toward refugees [33] (p. 9).

Esses et al. also reviewed the literature on the factors influencing refugee mental health. This is an important area of inquiry since research demonstrates that refugees experience higher rates of mental health issues and mental illness than the population of their country of origin population, the host population, and other categories of newcomers. This may be due to the uniquely traumatic experiences refugees endure including trauma from violence, loss, and grief [33]. The factors that affect refugee mental health are divided into four areas: (i) refugee characteristics, (ii) pre-migration trauma, (iii) the resettlement process, and (iv) post-displacement factors. Many of the factors in the latter two categories, which occur in host countries, are examples of racism. These include time spent in detention, the asylum interview process, economic opportunities, host country language proficiency, and experiences of discrimination [33].

#### **6. Racism as a Social Determinant of Health and Wellness of Newcomer Populations**

To reiterate, the purpose of this paper is to demonstrate how racism affects the acculturation process for newcomers. We use John Berry's model of acculturation to demonstrate this. We begin by briefly describing the model and then demonstrating how racism disrupts newcomer acculturation.

John Berry's model of acculturation identifies four forms or paths of acculturation, that refugees often take. Among these pathways are: (1) Integration occurs when newcomers maintain their culture and values while adopting certain aspects of the host society's culture and values. This is often regarded as the most ideal form of acculturation [34]; because it allows people to maintain the core aspects their identity while adopting the values and practices of their host country that help them successfully navigate their new worlds (2) Assimilation occurs when newcomers reject their heritage and adopt most or all aspects of the host society's culture; (3) Separation occurs when newcomers maintain their heritage culture and values and reject that of the host society; and (4) Marginalization occurs when newcomers reject both their own and the host society's heritage [35].

We contend that racism affects newcomer populations at the site of acculturation, specifically on the paths they select or are obliged to pursue in response to their settlement experiences. These acculturation paths are, in part, coping strategies for refugees dealing with post-displacement stress and trauma, as shown in Paradies' (2006) five pathways between racism and health. According to Esses, Hamilton, and Gaucher (2017), "one of the major solutions to the refugee crisis must be refugee resettlement in new host countries" [33] (p. 78). This must involve more than simply allowing refugees to enter western countries. As the World Health Organization states, we must create an environment that promotes the mental health and wellness of incoming refugees. (WHO 2018) Integration is most conducive to this goal. When refugees experience racism, they are more likely to choose assimilation, separation, or marginalization as a coping strategy [35]. Evidence suggests that these coping strategies have detrimental effects on health and wellness [32].

In this section, we will compare each of the three scenarios of racism outlined previously to Dovidio, Gaertner, and Kawakami's (2010) definition of racism. We will also demonstrate how each scenario may lead to a less-than-ideal path of acculturation according to Berry's typology, as well as poor health and wellness based on Paradies' (2006) pathways. Each of these scenarios is provided as an example of possible outcomes, not as proof of the only conceivable pathways.

The establishment of Christmas as a statutory holiday is an example of cultural racism, as defined by Dovidio, Gaertner, and Kawakami (2010), whereby one racial group sets cultural standards for all. Assimilation may result from the stigmatization of cultural practices. Stigmatization often leads to shame and internalized racism, which is the adoption of racist views toward one's own race [13]. For example, consider the language of Canada's Zero Tolerance for Barbaric Cultural Practices Act of 2015. This Act was an amendment to the Immigration and Refugee Protection Act [33]. While the Act pertains to marriage practices, many Canadians have extended the notion of barbarism to other cultural practices followed by non-white newcomers. In this context of stigma, diverse cultural behaviours are frequently impossible to distinguish, rendering them all "barbaric" in the eyes of policy and mainstream discourse. This form of racism may lead a racialized minority newcomer to follow Berry's separation pathway, rejecting the cultural practices of their heritage to avoid shame. This scenario best exemplifies Paradies' second pathway, namely adverse cognitive and emotional experiences as a result of racist, stigmatizing language used in policy discourse [2].

Because it has unjust effects on racialized minorities, "carding" is an example of Dovidio, Gaertner, and Kawakami's (2010) concept of institutional racism [13]. The experience of carding can be traumatic, leading to feelings of fear and mistrust toward host societies [36–38]. Research has found that newcomers in the United States who are subjected to carding in host societies are more likely to develop feelings of hostility toward host cultures, as well as heightened identification with their heritage identity. Thus, they are more likely to adopt Berry's separation pathway of acculturation. In extreme cases, these practices, combined with a lack of supports and services for mental health, education, and employment during settlement, can lead to engagement in violence and extremist activities [33]. Outcomes associated with this scenario are most consistent with Paradies et al.'s (2006) first pathway, increased contact with police, and third pathway, injury as a result of racist violence [2].

The experiences of South Asian immigrant women in Australia illustrate Dovidio, Gaertner, and Kawakami's (2010) concept of individual racism [13]. We contend that, while race/ethnicity is the label that many organizations and literatures use, individual health is not determined by race itself. People are not at risk of poor health outcomes by virtue of their race, but rather because of unfair and unjust treatment based on their racialized identity. Patient-centered care, for example, is an empowering style of medicine that results in effective health outcomes for patients by involving patient values and preferences [39]. Racist perceptions of patient efficacy act as a barrier to patient-centered care, preventing many racialized refugees from making informed, supported decisions about their health. It

may also lead to Berry's marginalization path of acculturation, which includes a rejection of the host society's medical community as well as a rejection of (or lack of access to) one's heritage health practices. (Berry 1997) This form of acculturation is possibly the most alienating and dangerous, particularly in terms of health. This type of racism can create barriers to healthcare access and is most closely aligned with Paradies' 2006 fourth pathway to poor health, reduced participation in healthy behaviors [2], such as attending regular medical appointments.

#### **7. Conclusions**

While previous research has demonstrated that racism is a social determinant of health [1,2], little research has been conducted on how racism is a social determinant of health for newcomers during the acculturation process. The discussion in this paper has underscored that racism is a social determinant of health on a global scale. There is examples of this in Canada, the US, New Zealand, Australia, and European countries. Using Berry's typology, we illustrated (Figure 1) how racism functions as a social determinant of health by interfering with integration, the process of ideal acculturation. As a result of racism, refugees are more likely to be forced into assimilation, separation, or marginalization as a means of coping. These coping methods have a number of harmful physical and mental health consequences. According to the World Health Organization, it is the obligation of refugee-welcoming nations to promote the mental health and wellness of incoming refugees [40]. A fundamental means of supporting health and wellness is healthy acculturation (integration), which is heavily dependent on reducing the impact of cultural, institutional, and individual racism. This exploration demonstrates a need for future research in racial studies, examining the association between racism and acculturation for newcomers. Furthermore, our discussion necessitates a multi-sectoral approach that includes the entities discussed in this paper (immigration policy, healthcare service delivery, and policing), as well as other institutions and organizations that have an impact on population wellbeing. This contributes to the population public health goal of ensuring that all individuals, regardless of race, religion, or citizenship status, have access to optimal health.

**Author Contributions:** J.N., E.O.P. and T.C.T. conceptualized this manuscript. J.N. drafted the manuscript. E.O.P. and T.C.T. provided intellectual inputs throughout the manuscript development process and critically reviewed the manuscript toward completion. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Conflicts of Interest:** The authors declare no conflict of interest.
