The health trajectories of refugees and how they differ from those of other migrants

Alessandro Ferrara investigates whether refugees arriving in Germany during the 2010s follow the same health trajectories as other migrants. He finds that, like other newcomers, refugees arrive with strong physical health that gradually erodes. Their mental health is initially poorer but steadily improves, ultimately narrowing the gap with native Germans.

For years, scholars have been puzzled by a peculiar paradox: migrants often arrive in better health than the locals they join – only to see that advantage erode over time. Newly arrived immigrants tend to be healthier than the native-born, even when they are poorer or less educated. Yet the longer they stay, the more their health advantage declines.

The prevailing wisdom attributes this to “positive selection” and “unhealthy assimilation.” Only the most capable – or healthiest – are willing or able to migrate. Once settled, exposure to discrimination, stress, new diets, sedentary lifestyles, and limited access to healthcare gradually wears away their edge.

But what about refugees – those who did not choose to leave? Can people fleeing war and persecution still be described as “positively selected”? And if not, should we expect their health to follow the same arc as other immigrants?

In a recent study, I explored these questions for asylum seekers and refugees (AS&Rs) in Germany, the European country that absorbed the largest share of individuals displaced by conflicts in Syria, Iraq, and Afghanistan during the 2010s (Ferrara 2025). Using data from the German Socio-Economic Panel, a large longitudinal survey, I compared the health of refugees with other immigrants arriving around the same time and with native-born Germans. The findings challenge some comfortable assumptions in migration and health research.

A tale of two migrations

The academic worlds of “migration studies” and “refugee studies” have often operated in parallel. Most migration research focuses on economic migrants, and its conclusions are frequently generalized to other groups. Yet refugees may differ in crucial ways.

Standard explanations for immigrants’ health advantage rely heavily on selectivity: moving countries requires resources, initiative, and often physical stamina. Those who go abroad are therefore atypical of the populations they leave behind.

Refugees, by contrast, are forced to move – often abruptly and under dire circumstances. Conventional wisdom suggests they should be less positively selected than other migrants, and thus start off in worse health. Yet recent work complicates that picture. Studies find that refugees in Germany were among the most educated coming from their origin countries (Spörlein et al., 2020). Reaching Germany from a war-torn region is no easy feat. It requires navigating dangerous routes, evading legal obstacles like the EU’s Dublin Regulation, and often paying smugglers. Those who make it are, in a sense, doubly selected: first by circumstance, then by endurance.

Refugees also face additional hurdles compared with other migrants, which may cause their health to deteriorate. They are more likely to experience traumatic events before and during their journeys, women especially, and often have limited access to health care in the initial period after arrival.

Challenging the health paradox

Using survey data, I analyzed the health of AS&Rs and other immigrants arriving in Germany in the first half of the 2010s. The former mostly included individuals from Syria, Iraq, and Afghanistan, while the latter mostly included migrants from Eastern Europe. Their health trajectories were compared with those of native Germans.

Non-AS&R immigrants followed the familiar script. They started off healthier than Germans across most indicators, but their advantage faded with time.

Asylum seekers and refugees, however, did not fit neatly into the Immigrant Health Paradox. Two to three years after arrival, they reported better physical and self-rated health than both natives and other immigrants, but this advantage declined over time. Conversely, they had markedly worse mental health upon arrival, which improved significantly as they settled.

The initially strong physical health of refugees may reflect the extreme selectivity of those who reach Germany. Surviving arduous journeys across deserts and seas, and enduring long waits in refugee camps, likely discourages the less robust. Their poorer mental health is less surprising: war, flight, and uncertainty leave lasting scars, compounded by protracted asylum procedures, legal limbo, and restricted access to psychological care. Yet the modest improvement in mental health over time signals resilience. Stabilization – securing legal status, housing, and family reunification – appears to sustain mental well-being, countering the “unhealthy assimilation” narrative that dominates immigrant health studies.

Implications for research and policy

These findings underscore that the health trajectories of migrants are not uniform. Refugees’ experience challenges simple assumptions about selection and assimilation. Future research should treat refugees and economic migrants as analytically distinct groups, exploring how pre-migration adversity, migration pathways, and post-migration conditions jointly shape health outcomes.

For policy, the message is clear: timely access to healthcare, legal protection, and social integration programs can significantly influence refugee health. Mental health support, in particular, can foster resilience and mitigate the long-term consequences of trauma. Recognizing heterogeneity among migrants is not merely an academic exercise – it is central to designing effective public health and social policies in an era of unprecedented displacement.

References

Ferrara, Alessandro. 2025. “A Refugee Health Paradox? Self-Reported Health Trajectories of Refugees and Immigrants in Germany”. Population and Development Review, https://doi.org/10.1111/padr.70027.

Spörlein, Christoph, Cornelia Kristen, Regine Schmidt, and Jörg Welker. 2020. “Selectivity Profiles of Recently Arrived Refugees and Labour Migrants in Germany.” Soziale Welt 71 (1–2): 54–89. https://doi.org/10.5771/0038-6073-2020-1-2-54.