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THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION
In this issue
Refugees: a challenge to humanity Sadako Ogata Let us join forces Mohamed W. Dualeh Bosnia and Herzegovina Manuel Carballo & Arif Smajkic The plight of the long-term refugee Joseph A. Hazbun Refugee families Carol Djeddah Preventing stress among refugees Joop T.V.M. de Jong Helping refugees to stay healthy Ann A very The Netherlands scene Loes van Willigen Migrants are vulnerable Mary Haour-Knipe Health needs of migrants Paola Bollini & Harald Siem International Centre for
3 4 6 8
10 12 15 16 18 20
Migration and Health 22 Manuel Carballo Migration and aging 23
Alexandre Kalache Nomads in the Horn of Africa 25 Mayeh Abu Omar & Maymuna Muhiddin Omar
People on the move 26 Sani Aliou Networking child health 28 Zeil Rosenberg & lrwin Redlener Supervising TB treatment 30
Courtenay Singer
World Health • 48th Year, No. 6 November-December 1995
IX ISSN 0043-8502
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HEALTH
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page 26
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World Health •. 48th Year, No. 6, November-December 1995 3
Guest Editorial
Refugees: a challenge to humanity
The Director-General of WHO invited Mrs Sadako Ogata, United Nations High
Commissioner for Refugees, to contribute this guest editorial, which reflects the common approach of WHO and UNHCR to the urgent health needs of refugees and migrants.
I
n recent years, we have witnessed a rapid succession of humanitar- ian crises following the outbreak of wars and internal conflicts which have forced millions of people to abandon their homes and liveli- hoods. Combined with the cata- strophic effects of natural and environmental disasters, refugee emergencies have marginalized whole sectors of society and pose new challenges for the provision of humanitarian relief.The United Nations High Commissioner for Refugees
(UNHCR) has been mandated by the international community to provide protection and seek solutions for the more than 27 million refugees and other people of concern to UNHCR.
Adequate health services are an integral part of any assistance strat- egy for people in need.
Providing health services to marginalized populations is itself a challenge; doing so in response to a rapidly unfolding emergency is a taxing undertaking for any system in terms of preparedness and response capacity. One of the most painful episodes which I had to witness as
High Commissioner was the death of thousands of Rwandese refugees in eastern Zaire during the summer of 1994. Although they received protection and asylum, for many the relief and health assistance arrived too late. With more than a million Rwandese refugees fleeing within a week to Goma and Uvira, the level of preparedness was clearly inade- quate to deal with a humanitarian crisis on such a scale. Some 50 000 lives were lost, primarily to cholera.
The lessons learnt must be fully incorporated into our planning and responses for the future.
During the first few days and weeks of a humanitarian emergency, preparedness and immediate deploy- ment of health staff and services are essential to save lives. Later, the major causes of death are preventable. Overcrowded and inadequate living conditions, lack of food, poor quality of water and environmental sanitation, all con- tribute to the transmission of infec- tious diseases. So besides meeting the immediate health requirements, a multisectoral approach is essential from the outset. In developing and setting standards on refugee health, WHO has the lead role.
Seeking solutions to refugee crises is UNHCR's main concern today, voluntary repatriation being the most desirable. Good health for the returnee is essential to rebuild a way oflife. Small-scale community health projects facilitate the reinte-
Mrs Sadako Ogoto, UN High Commissioner for Refugees.
gration of the retumee population.
In areas receiving large numbers of returnees, as in the case of
Cambodia and Mozambique, UNHCR has set up primary health centres and provided training which benefit returnees and the local com- munity equally. This is one of the many areas where UNHCR's work dovetails with that of WHO.
Disease and poor health are often root causes of a refugee emergency.
Improving health care and standards should be seen as part of the larger effort to avoid conflict and prevent displacement. The provision of basic health services is not only sound development policy; it is also a human right which must be respected. •
4
let us ioin forces
Mohamed W. Dualeh
In 1994, cholera and other wafer-borne diseases claimed a huge toll in human lives among refugees from Rwanda in Zaire.
lt is a grave mistake to expect medical expertise and
technology alone to ensure the adequate health of a population. The other vital assistance aspects - food, water, sanitation and shelter - are equally important in contributing to the success of all emergency health work.
I
t has been rightly said that"refugee emergencies kill".
Nowhere was this more evident than in the recent human tragedy where some two million refugees fled ethnic strife in Rwanda in 1994.
The mass exodus overwhelmed the world's capacity for response, and refugees poured into Burundi, the United Republic of Tanzania, and Zaire. In Zaire alone, to which some 850 000 Rwandese refugees fled over a period of days in mid-1994, nearly 50 000 refugee lives were lost within days, primarily due to an outbreak of cholera. At the same time, nearly a quarter of the children in these camps were found to be suffering from acute malnutrition.
The factors which most affect the health of the displaced, and the fragility of the international system
World Health • 48th Year, No. 6, November-December 1995
of response itself, are illustrated in the case of the Rwandese emergency.
Such events overwhelm the human and physical resources immediately available in such devastating circum- stances, and an examination of these factors, and of the strategies of pre- vention and response, form the core principles in public health actions relating to emergencies.
The basic aims and principles of refugee health and nutrition are simple, yet they pose a substantial challenge to all working in both emergency and long-term refugee situations. The displacement of huge numbers of people introduces many complex variables that are not en- countered in normal settings. The priorities can be summarized as follows:
• saving lives;
• using multisectoral and preven- tive approaches;
• meeting the special health needs of women and children;
• striving for sustainability and the integration of refugee health services into the national health system.
By definition, an emergency is a situation in which needs are great, human and material resources are scarce, and action must be immedi- ate. Health staff cannot deal with everything at once, and must estab- lish priorities. The emotional and physical stress of working in an emergency may cause intense anxiety, and one of the survival mechanisms sometimes adopted unconsciously by inexperienced relief workers is to focus all their energies on conditions or activities with which they feel comfortable.
Unfortunately, these often tend to be low-priority areas such as surgery, tuberculosis control or unnecessarily detailed epidemiological studies.
Such misplaced emphasis is a gross error. The public significance of any given disease or condition must be
World Health • 48th Year, No. 6, November-December 1995
Immunization campaign in an Iraqi refugee camp in Turkey. Health services for refugees should be sustainable and, if possible, integrated into general health services.
determined in terms of its incidence or prevalence, and its severity.
Causes of sickness
It has been documented for the last two decades that the common causes of fatal illness in refugee emergen- cies usually relate to a few simple contributing factors:
• overcrowded living conditions, which fosters increased transmis- sion of infectious diseases;
• inadequate quantities and quality
Living in the Gaza strip. The health of refugees crucially depends on water supplies being sufficient in quantity and of high quality.
of water to sustain health and personal hygiene, and poor sani- tation facilities;
• poor nutritional status (and conse- quent lowered immunity) due to lack of adequate food before, during and after displacement.
Saving lives in any refugee situation (emergency or long-term) means tackling these underlying factors as well as taking preventive measures such as controlling diarrhoea! dis- eases and endemic communicable diseases, running nutrition and im- munization programmes, training community health workers, and in general using the preventive ap- proach to health care. To avoid excess loss of life we must ensure that the quantity and quality of food are adequate, as well as space, shel- ter, water supply and sanitation facilities.
In refugee settings more than anywhere else, it is a grave mistake to expect medical expertise and technology alone to ensure the ade- quate health of a population. The effects of poor living conditions cannot be rectified by health services, even if these are fully equipped, staffed and operational.
Indeed, it can be said that the other vital assistance sectors - food, water, sanitation and shelter- are as impor- tant as health itself. Any evaluation of the health and nutrition status of
s
refugees must also assess the ade- quacy of these other vital sectors.
Likewise, if the health and nutrition status of a refugee population is poor, the contribution made by sectors as diverse as sanitation, education and income-generation will be reduced.
These vital sectors directly affect the health of refugees, just as health affects other sectors. It is a matter of policy that refugee health and nutrition programmes should be approached from a multisectoral standpoint.
The yardsticks for determining the success of activities both in health and in other vital sectors, especially during the emergency phase, are the mortality rate and the prevalence of malnutrition. These are the basic indicators of how well the multisectoral relief effort is going; such statistics can usually be estimated accurately by relief work- ers and should be furnished on a regular basis.
In conclusion, the essential ele- ments of a refugee relief programme that can prevent excess deaths in- clude the following: adequate food which is culturally appropriate and preferably available locally, measles immunization, clean water and sanitation, prompt prevention and treatment of dehydration with oral rehydration therapy, effective case- management of malaria and acute respiratory infections, a health infor- mation system that includes mortal- ity and nutritional surveillance, and an effective outreach programme that provides adequate access to health services. At the same time, it is essential to coordinate relief efforts and streamline health services if emergency aid is to be effective and timely. •
Or Mahomed W. Duo/eh is Senior Public Health Officer, Programme and Technical Support Section, Office of the United Notions High Commissioner for Refugees, 15 chemin Louis Dunont, 1202 Geneva, Switzerland.
6 World Health • 48th Year, No. 6, November-December 1995
Bosnia and Herzegovina
Manuel Carballo & Arif Smajkic
The war in former Yugoslavia has produced hundreds of thousands of displaced people.
Some will never regain their mental or physical health, and some children will be psychologically scarred for life.
W
ars have displaced individu- als and families throughout history. The twentieth cen- tury has been no exception. The displacement of populations often helps to save lives, but it is always painful and dangerous. It is often accompanied by aggression directed against specific individuals, families, and entire communities. Forced displacement is a political tool, directed towards debilitating people and disorganizing society. Its health implications are dramatic.Bosnia and Herzegovina's popu- lation numbered some 4.5 million people before the war-an ethnically mixed and culturally heterogeneous population that brought together Islam, Christianity and Judaism. Its capital city, Sarajevo, was home to over 600 000 Moslems, Serbs and Croats. Health care was universal and health indicators such as infant and maternal mortality and immu- nization were equivalent to those in most western European countries.
With the onset of war in 1992, the ethnic and cultural heterogeneity of Bosnia and Herzegovina (as indeed of former Yugoslavia as a whole) was dramatically disrupted. Over the next three-and-a-half years, more than 50% of the original population
villages and towns. Most fled to other parts of Bosnia and Herzegovina, but over a million sought sanctuary elsewhere in Europe. According to data provided by the National Institute of Public Health in Sarajevo, they are distrib- uted as follows:
Germany
Serbia and Montenegro Croatia
Austria Slovenia Sweden France Switzerland Italy Netherlands Norway Turkey Denmark United Kingdom
350 000 300 000 100 000 73 000 60000 50000 40000 35 000 30000 30000 25 000 25 000 20000 20000 For the displaced who remained in Bosnia and Herzegovina, towns such as Bihac, Mostar, Sarajevo, Tuzla, Travnik and Zenica became sources of relative safety, but truly safe havens rarely materialized. "UN safe zones" were besieged and subjected to repeated attacks. In Sarajevo
alone, more than 10 000 civilians were killed and another 61 000 injured. Water supplies and electric- ity were cut off for months at a time.
Fuel for heating became impossible to find, and parks and sidewalks were quickly denuded of any trees and shrubs that could be burned.
Cold winter weather made the care of the ill and wounded all the more precarious, and freezing tempera- tures were common for weeks on end in hospitals and in the city.
Thousands of Bosnian men of so-called military age (from 16 to 60 years) were conscripted. Those who survived returned with serious physical and even more profound psychological injuries. In the mean- time many families were forced to move on, often losing contact with their menfolk.
Housing became a critical issue.
Where possible, empty houses and apartments were allocated to dis- placed families, and local families were also asked to provide rooms for the homeless. But many schools, hotels, disused factories and ware- houses had to be requisitioned and hurriedly converted into temporary,
was forced to move from its homes, A patient being evacuated by aircraft from the Bosnian capital Saraievo.
World Health • 48th Year, No. 6, November-December 1995 7
A United Notions humanitarian convoy en route to Saraievo. Refugees from former Yugoslavia reach safety in Switzerland.
and often grossly unsatisfactory, shelters for thousands of the dis- placed. As in all wars, many of these temporary shelters quickly become
"permanent" and will continue to be needed pending the reconstruction of towns, villages and individual homes that were destroyed as part of the
"ethnic cleansing" campaigns that were waged.
The besieging of key towns exposed hundreds of thousands of displaced as well as local people to severe and persistent food shortages.
Although periodic WHO nutrition monitoring surveys indicated an absence of gross malnutrition, hunger was widespread and most people experienced severe weight loss. Elderly people and pregnant women were particularly vulnerable and in danger, the incidence of low- birth-weight babies tripled, and the number of nutrient deficiency-related congenital abnormalities increased even more.
To these health problems were added the effects of overcrowding, poor sanitation and badly ventilated rooms in displaced persons' centres.
In Sarajevo, where few buildings had intact windows, the plastic sheeting provided through UNHCR was an important life-saving measure but not always a sufficient source of insulation. Epidemic outbreaks of respiratory diseases were a frequent problem.
Water shortages, with even greater shortages of chlorine to purify what water there was, pro- duced widespread gastrointestinal infections and hepatitis outbreaks.
Displaced people in collective cen- tres were inevitably more affected than others. The task of providing health care to them was shared be- tween local health services and nongovernmental organizations, but many displaced people, especially those coming from small rural com- munities, were often too traumatized or unused to the health care system to make effective use of it.
Many of the elderly and the disabled (including young men with war injuries) became psychosocially and physically isolated. Unable to carry water when it was available from neighbourhood standpipes, unable to carry firewood, and unable to collect food when humanitarian aid supplies got through, they suf- fered more than others.
Sexual violence became closely associated with "ethnic cleansing". Whether used as a means of inciting departure, or as an expression of ethnic aggression and gratuitous violence, sexual abuse became a major health problem and a cause of severe post-traumatic stress.
Counselling of sexually abused people (both women and men) had to become an important part of the care of displaced people throughout Bosnia and Herzegovina.
Throughout the war health care workers everywhere provided a strong and highly visible source of leadership at every level of society.
They became involved in a wide
variety of humanitarian relief activi- ties as well as providing health care.
From the onset of the war their work was supplemented by that of UN agencies, nongovernmental organi- zations and volunteers from all over the world. Action carried out by agencies such as UNHCR, WHO, UNICEF, WFP, IOM and UNPRO- FOR combined well with that of national staff in a vast arena of emergency work.
The war in former Yugoslavia has caused the death, injury or dis- placement of hundreds of thousands of people. Some will never regain their mental or physical health, and many children may be psychologi- cally scarred for life. But important lessons have also been learnt. The most important is that, although humanitarian crises may not always be preventable, the combination of national resilience and commitment - when supported by international humanitarian efforts- can help to avert even greater man-made disas- ters. •
Or Monuel Carbo I/o was based in Soroievo os the WHO Health Development Adviser for Bosnio and Herzegovino; he is now Coordinator of the International Centre for Migration and Health, 24 Avenue de Beau·
Seiour, I 206 Geneva, Switzerland. Professor Arif Smoikic is Director of the Notional Institute of Public Health and Head of the Department of Community Medicine at the University of Soraievo.
a
World Health • 48th Yeor, No. 6, November-December 1995The plight of the long·term refugee
Joseph A. Hazbun
A
ubstantial percentage of the world's 20 million refugeesnd 24 million internally displaced persons are, for one reason or another, unable to return to their homes. Palestinians and Tibetans, or Biharis in Bangladesh, are examples of people in this situation. In the last five years, many other groups have come to swell the numbers in this category of refugees and displaced persons because of man-made disas- ters, civil war and ethnic conflicts.
The end of the Cold War resolved some major conflicts, but fierce assertions of nationalism and ethnic identity, long suppressed by Cold War rivalries, have caused intense strife in many parts of the world and with it vast numbers of refugees and internally displaced people. The Liberians, the Rwandese, the Somalis, and the inhabitants of former Yugoslavia are examples.
Birth of UNRWA
To meet the needs of displaced per- sons, various mechanisms and orga- nizations have been created by host governments, local communities, and international agencies during the last 50 years. One such organization, created by the United Nations General Assembly in 1949, is the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA). This agency began its operations in 1950 on an ad hoc basis, in the hope of finding equitable solutions to the problems of these refugees. With time it was realized that its mandate had to evolve from emergency relief for the population displaced by the 1948 Arab-Israeli war to administra- tion of the quasi-governmental ser-
Recent studies have revealed that long-term refugees face additional emotional problems caused by the stresses of living with an uncertain future where unemployment,
crowded living conditions and a host of other problems prevail.
school health, nutrition, sanitation, health education, training, disease prevention and community medi- cine.
UNRWA runs some 100 clinics or health centres staffed by over 160 medical officers, 600 nurses and a similar number of other paramedical personnel assigned to Jordan, Lebanon, Syrian Arab Republic and the Palestinian Self-Rule Areas. It also subsidizes hospital care for refugees in private or government hospitals in the area. A measure of the success of UNRWA's health
An Afghan refugee settlement in the Islamic Republic of Iron.
vices of public education, public health and social welfare.
UNRWA provides a variety of services to the refugee population in the Middle East including the newly autonomous Palestinian territories in Gaza and the West Bank. In the health sector, the agency operates primary health care services, empha- sizing maternal and child care,
inputs is that they have brought the infant mortality rate in refugee camps to below that in neighbouring communities. This success is attrib- uted to UNRWA's pioneering work in introducing the use of growth monitoring of infants born in clinics in the refugee camps. Growth charts have been in use in all these clinics since the mid-l950s.
World Health • 48th Year, No. 6, November-December 1995
Many years have passed since the days when a majority of births among the refugees were assisted by untrained birth attendants. A fact still known to very few public health experts today is that in the 1950s UNRWA pioneered an oral rehydra- tion t~erapy much like that which WHO' and UNICEF promote today.
An uncertain future
These efforts have certainly helped to provide basic health services to the refugees, but recent studies have revealed that long-term refugees face additional emotional problems caused by the stresses of living with an uncertain future where unemploy- ment, crowded living conditions, and a host of other problems prevail.
To help cope with these prob- lems, WHO has cooperated with UNRWA in introducing a mental health programme. Its objective is to help these long-term refugees to attain a more fruitful and productive life, and a state of health that ap- proximates more closely to WHO's definition, of "complete physical, mental and social well-being".
The strategy used to reduce stress-related health problems in- volves three main approaches. The first is to strengthen community structures and programmes for comprehensive stress management.
The second is to ensure the presence of a multidisciplinary and appropri- ately trained team to introduce stress
Supplementary feeding is among the services that UNRWA provides for Palestinian refugees.
management techniques within the primary health care services. The third is to establish community health forums which draw their membership from primary health care teams, local authorities and relevant voluntary organizations.
More and more health care providers are finding that these services for refugees and long-term refugees are indispensable for im- proving their quality of life. The model approach used in this case relies on receiving comprehensive and synergistic contributions from a variety of sectors: health, other services and the community itself.
Such a low-cost approach to
Long-term refugees should be given opportunities to continue their education.
9
tackling a health problem could be used elsewhere with little outlay in funds or expertise. The gist of the programme is to make maximum use of the resources available through intersectoral coordination and a clarification of responsibilities, whereby existing knowledge is applied in:
• identifying risk situations and anticipating group reactions;
• increasing awareness;
• preparing general and specific strategies;
• cooperating with sectors other than health;
• training care providers;
• promoting citizen participation.
In summary, services that are capa- ble of dealing with severe stress- related health problems should be made available to the long-term refugee community. Such services should be provided by psychiatrists and psychologists trained in the field and linked to the primary health care network. They should support people under severe stress, assess their condition and help to identify and solve their problems by develop- ing the coping abilities of all those concerned.
Finally, these services should also undertake preventive activities through more general training in coping skills. Such training should be aimed at people suffering from stress-related health problems as well as those who belong to potentially vulnerable groups. •
Mr )oseph A. Hazbun is Chief of the Eastern Mediterranean and Central Asia Unit, Division of Emergency and Humanitarian Action, World Health Organization, 121 1 Geneva 27, Switzerland.
10
Refugee families
Carol Djeddah
A refugee woman's health is central to her children's well-being
S
ince 1970, the world has wit- nessed a tenfold increase in the number of refugees seeking asylum outside their countries of origin, and an even greater number of internally displaced persons.Refugees, displaced and up- rooted people in general live in many settings besides camps, but in most cases about 80% of this popu- lation are women and children.
They face the same problems as do other poor women and children in developing countries, including lack of food and drinking-water, malnu- trition, anaemia, diarrhoea! diseases and acute respiratory infections, unregulated fertility, high birth rates and high maternal, infant and child mortality rates. Added to these problems are those associated with their uprootedness, particularly during the four main phases of migration (see box on page 11): the breakdown of family networks, the loss of income, the loss of physical and emotional security, the destruc- tion of health and other social sup- port services and the effects of violence.
Physical and psychological violence rates are high among the health risks faced by refugees and displaced people. Wide-scale rape in Bosnia and Rwanda, perceived as
a war crime, has focused world attention on reproductive health as a fundamental part of the basic human rights of women and girls. The consequences of sexual violence include special health problems posed by the risks of sexually transmitted diseases, HIV I AIDS, unwanted pregnancies, unsafe abor- tion, post-traumatic stress syndrome and social ostracism. Among vic- tims of rape, suicide is a far too common occurrence.
Children need support
During war and other emergency situations with population displace- ments, children are often separated from their families; they may be abandoned,orphaned,lostorab- ducted. They have to fit into a new or hostile environment, and the lack of protective and caring support is often a leading cause of major physi- cal and psychosocial problems.
Ensuring the survival, protection and healthy development of these popu- lations is an everyday challenge for carers.
In these situations, the family (or a family-like environment) remains an irreplaceable source of care and support for its individual members
World Health • 48th Year, No. 6, November-December 1995
and, to the extent that it can continue to function, protects them from the negative impact of the stress factors.
The mother's support will have a direct impact on the health of her children. This makes a refugee woman's health central to her chil- dren's well-being, especially if she is their sole carer.
Women too
Since one of WHO's major repro- ductive health strategies is to address the needs of underprivileged groups, it is of fundamental importance to identify the reproductive health needs of refugee populations and include adequate measures for meeting them in refugee pro- grammes. The emphasis placed on such measures in refugee situations may be quite different from that needed in normal circumstances.
Reproductive health programmes must include a minimum package of care related to the issues of family planning, maternal mortality, un- wanted pregnancy, sexually trans- mitted diseases including HIV I AIDS, and physical and sexual violence. Culturally appropriate services must be accessible to refugees to offer information, educa- tion, counselling, prevention, detec- tion and management of their repro- ductive health problems.
Given their economic vulnerabil- ity and their dependence on external support, refugee women have little control over decisions affecting their lives and those of their children.
Sexual subordination and abuse contribute to many reproductive health problems. Since gender- based inequity is usually exacer- bated during situations of extreme violence, particular attention must be paid to women's empowerment, to adolescent behaviour and to the safety and security of children.
Understanding reproductive health needs through the eyes of
World Health • 48th Yeor, No. 6, November-December 1995
it is of fundomentol importance to include reproductive health programmes in refugee settings
refugee communities represents an essential step in the progress towards providing appropriate and culturally sensitive services and information.
A participatory approach is needed in order to bring together decision-makers, health care providers, women's groups, non- governmental organizations, youth, and child-to-child groups that are working with refugees. Programmes to build awareness and sensitivity about reproductive health and health in general should be initiated from the community. Involving refugee women in the control of camp and community resources and in deci- sion-making is crucial to decreasing their dependence on external support and their vulnerability to exploita- tion and violence.
Do not forget men
Men also need a thorough under- standing of their family and commu- nity responsibilities, which include production, reproduction and the maintenance of the domestic group.
Still a new area, developing effective reproductive health pro- grammes in which refugees, espe- cially women, have a sense of ownership calls for continuous exchange of experience and infor- mation between the different providers and the users of the ser- vices. Only in this way will refugee women and their children and fami- lies regain their health, dignity and self-respect.
The task is not easy, particularly for nongovernmental organizations working in situations of extreme insecurity and continuous population displacement. In fact, reproductive
Migration phases and reproductive health issues
Phase l: Exodus
11
health must be addressed as a long- term issue throughout the four phases of exodus from the home country, establishment of emergency camps, stabilization of the camp situation, and repatriation or volun- tary return to the country of origin.
The creation of linkages between the relief phase and long-term develop- ment activities is vital to provide refugees with new skills and re- sources and to improve their lives in the camps, in the host country and when they return home. Relief for refugees and displaced people must be linked with support to the coun- tries providing asylum so as not to place unsustainable burdens on local populations who may already be living in difficult circumstances.
Such issues were raised during an Inter-agency Symposium on
Reproductive Health in Refugee Situations, organized in Geneva in June 1995 by UNHCR and UNFPA with the collaboration of WHO and UNICEF. WHO is committed to supporting policies and programmes that improve the reproductive health of refugees and displaced people, and to monitoring the progress being made in this field. But all concerned must be aware that the impact on the health of refugee women and chil- dren will become a reality only when there is a real political will to achieve durable solutions. •
Or Carol Dieddah is Responsible Officer for Women and Children in Emergencies, Division of Family Health, World Health Organization,
l 2 l l Geneva 27, Switzerland.
Refugees leave their homes to seek safety- families may lose one or more members. Women remain generally heads of households as their husbands join military forces Women are often subject to rape and other forms of violence. Younger children may die from hunger or disease while fleeing. Traditional family patterns are disrupted.
Phase 2: Emergency
Family members succumb to epidemics and malnutrition. Women are powerless and vulnerable to exploitation of all kinds. Rape and sexual violence continue to occur. Reproductive health services do not exist.
Phase 3. Stabilization
Reproductive health needs are acute during this phase. Women who have lost their children during the exodus or the emergency phase may want to rebuild their families. This constitutes a leading cause of very high birth rates in many camps. Death among women of childbearing age from pregnancy-related complications is due to poor care, lack of trained attendants and absence of referral services for complications. In most settings, sexually transmitted diseases are a major public health problem Complications of abortion are high, especially if rape is widespread Female genital mutilation often continues in the camps, posing additional health risks to young girls.
Phose 4. Return
Repatriation to the country or place of origin takes place after conditions have changed sufficiently to permit peaceful and safe reintegration Refugees or displaced persons may return to villages that have no health, social or other basic services. During their return they may be subject to physical and sexual abuse.
12 World Health • 48th Year, No. 6, November-December 1995
Preventing stress among refugees
In refugee camps, the
refugees are often obliged to protect themselves from bandits, shelling or landmines.
A simple preventive measure is to create as safe an
environment as possible, especially in camps with a majority of women and children.
P
ost-traumatic stress syndrome can theoretically be prevented by eliminating traumatic events or by reducing their impact. But the psychological consequences of disasters such as war often affect so many people that current models of clinical psychology and psychiatry are inadequate to deal with them. A public mental health approach based on community action is needed to take on stress problems on this enor- mous scale.A large international collabora- tive programme is currently being tested among refugee populations in a number of African and Asian countries, while similar initiatives are being prepared in Europe. The programme has been set up by IPSER-Amsterdam (the Institute for Psychosocial and Socio-Ecological Research) in collaboration with WHO. It is carried out mainly by local personnel, but if a country or organization requires professional expertise from abroad, the programme recruits international professionals who can support the national staff. At present the pro- gramme is being implemented through government and non govern- mental agencies in Cambodia,
Joop T. V. M. de Jong
An orphaned war refugee in Mozambique seeks help at the hospital
Ethiopia, Gaza, Mozambique and Uganda, and among the Tibetans in India and the Bhutanese in Nepal.
Psychological preventive inter- ventions designed and carried out at the level of the community focus on security and empowerment, in the
sense of decreasing dependency, stimulating rural development and strengthening social support.
After surviving a natural disaster or escaping from a war zone, sur- vivors are often further traumatized by attacks from bandits, shelling,
World Health • 48th Year, No. 6, November-December 1995 13
A knitting proiect organized in a Nepalese refugee camp provides women with a small income and helps to relieve psychological stress.
ambushes or landmines. In refugee camps, the relief workers and expa- triates often live in protected areas, while the refugees are obliged to protect themselves. A simple pre- ventive measure is to create as safe an environment as possible, espe- cially in camps with a majority of women and children.
Head trauma is common among victims of war and torture, and its consequences are often hard to differentiate from post-traumatic stress syndrome. From a medical point of view, security measures can reduce both the neuropsychiatric and the psychological consequences of head trauma.
Dependency syndrome
Refugee camps easily become "total institutions" to the point where a dependency syndrome may develop which reinforces the helplessness that quickly emerges in the wake of war or natural disaster. This can happen especially in camps that reproduce the authoritarian regimes
from which the refugees escaped.
Refugees should be seen as resilient people living in cultures that have often developed ingenious coping strategies. By empowering the refugees, the IPSER programme tries to break the vicious circle of disempowerment; for example, it tries to stimulate women and men to engage in the management and administration of the area; they are involved in the organization of tasks in the camp including such primary health care activities as filling in vaccination cards, ensuring hygiene, helping with health education, dis- tributing food and helping with education.
Another important example of stress prevention at the community level is the stimulation of rural development, especially among populations that have been displaced for long periods of time. Rural development helps to restore a sense of control and to create a perspective for the future. It also fosters self- reliance by stimulating a sustainable agricultural system and by generat- ing income for refugees. This can be
done by setting up small-scale tech- nological projects and by vocational skills training (such as palm-oil presses, leather handicraft, fishing, or pottery), improving the water supply, diversifying food and cash crops, or reforestation.
Working with children
Children and their mothers consti- tute about 50% to 70% of the world's refugee population, espe- cially in less technologically ad- vanced countries.
Preventive interventions include promoting the well-being of children who have suffered intense trauma.
Non-professionals can play an important role and are quite capable of running a variety of activities for children, including games, role- playing, drawing, writing and telling stories, music and puppet theatre.
Another aim of the programme is the selective prevention of disturbed personality development among children. Those with potentially chronic disorders such as silent
14
withdrawal and mutism, hyperactiv- ity with violent behaviour, or chronic regression to an earlier developmen- tal stage are of particular concern. The programme can help them by supporting the social network, strengthening existing coping skills, and training schoolteachers. Ideally, orphans or children from disrupted families should be accommodated within their extended families or with foster families, while at the same time efforts are made to deter- mine whether one or both parents are still alive.
Since teachers have daily contact with the children, they get additional training to identify children with serious problems and to develop skills to help them. However, the teachers, and often health workers as well, may themselves be so seriously traumatized that they have difficulty in helping their pupils, so the partici- pants in the training programme first have to learn to work through their own trauma.
Using existing resources
One simple intervention that has an important preventive effect is to improve the basic physical aspects of the camp. This includes ensuring that there is enough water, curbing overcrowding, setting aside land to grow vegetables, making diets more varied, and draining or irrigating the terrain. Similarly, teachers can begin education programmes for children and adults, primary health care workers can provide basic health care, and traditional birth attendants can assist in deliveries and birth control. The programme encourages religious leaders and healers to undertake ceremonies and rituals, and musicians, dancers and story- tellers to organize leisure activities.
It is important for relief workers to identify victims of rape. They receive training on respecting confi- dentiality, on dealing with the possi- bility that the victim has contracted a sexually transmitted disease, on ending the social isolation of the victim, and on organizing support groups.
World Health • 48th Year, No. 6, November-December 1995
In Pakistan, a refugee from Afgonistan receives training in car repair. Learning such skills reduces the risk of refugees becoming dependent on outside help.
The programme uses a train-the- trainer approach, with trainees gradu- ally becoming trainers themselves, learning how to set up a public men- tal health programme, how to design a psychosocial and rural develop- ment programme, and how to adapt activities to the local culture. Part of this training is based on the WHO/
UNHCR manual on refugee mental health.
Experience has shown that pre- vention of post-traumatic stress syndrome in refugee situations is both feasible and necessary.
However, training primary care workers, teachers or relief workers cannot alone compensate for the lack of psychosocial and mental health professionals that still exists in most post-war situations.
A final comment: mental health professionals often feel that they should avoid taking any political position when war or genocide oc- curs. Many prefer to provide therapy instead of making their views known to the national or international com- munity. Although this attitude may be professionally and politically correct, many colleagues have valu- able information to impart on human rights violations or the consequences
of wars. In combination with their insight into the psychological mech- anisms of escalating conflicts, they possess a powerful means of sensi- tizing politicians and the community at large. •
Professor joop T V.M. de)ong is at the Institute for Psychosocial and Socio·Ecological Research (IPSER), Kerkstraat 2 19, I 0 17 GK Amsterdam, and the Free University of Amsterdam, Netherlands.
World Health • 48th Year, No. 6, November-December 1995 15
Helping refugees to stay healthy
Ann Avery
S
table populations have well-tried routines for maintaining health, but migration means leaving such support systems behind.Everyday tasks such as obtaining food and water, cooking, washing and disposing of waste become a matter of improvisation and adapta- tion, while grief and trauma often depress the spirit and lower the body's natural resistance to disease.
Particuarly in refugee camps, an unaccustomed effort must be made to avoid ill-health.
At the Imishli refugee camp in Azerbaijan, there are about 30 000 refugees, many of whom have been there since it was set up for those Azeris who were displaced by Armenian occupation in 1991. In such circumstances, emergency relief is not enough; agencies and refugees must look to longer-term modes of existence. This is where health education comes in; the health educator and the team of refugees working with her spread such mes- sages as: "Wash your hands and dispose of waste safely to prevent diarrhoea", or "Wash your bodies and change into clean clothes to prevent scabies".
After the first emergency, health education activities for refugees have to cover such areas as sanitation, nutrition and immunization. Two standard ways of getting health messages across are to train refugees themselves as health educators, giving them responsibility for a designated zone of the camp, and to work through existing groups in the camp, such as women's associations, and regular meetings of camp leaders.
In 1994, nearly 500 000 persons applied for asylum in the industrial- ized countries and nearly five million have done so since 1983, but only a
In a centre for asylum-seekers in Geneva, Switzerland, women receive information and advice about many aspects of their health, including practical demonstrations.
small percentage of these are accepted officially as refugees. Many others spend years in the limbo of knowing that they may be sent away from their country of refuge at very short notice. But all of them have to find ways to keep healthy.
To meet this need, several organi- zations run programmes specifically geared to helping refugees maintain health in their new and uncertain environments. In Geneva,
Switzerland, a centre for women in exile has met with a very positive response from Eritrean, Somali and Sri Lankan women who have partici- pated in ten-month courses on health.
The women spend two hours twice a week exploring first aid, major illnesses, mothers' and children's health, and basic hygiene. They then receive a simply written and illus-
trated book called Women: partners in health, summarizing what they have learnt. L' Association
Genevoise d'Entraide pour Refugies (AGER) has published this book in English, French, Portuguese, Somali and Tigray. It was written by a tropical health nurse with experi- ence in Africa and Latin America, who is now preparing a detailed teacher's guide.
Such efforts are a worthwhile investment for refugees, especially when what they learn is conveyed in a way that enables them to pass on essential health information to others. •
Mrs Ann A very is a consultant in refugee education. Her address is 8 rue des Asters,
1202 Geneva, Switzerland.
16 World Health • 48th Yeor, No. 6, November-December 1995
The Netherlands scene
Loes van Willigen
The sooner refugees can receive proper care for their health problems that result from the traumatic experiences and stress they hove experienced, the easier it is to prevent them from suffering from major psychological problems at a later dote.
S
ince the 1970s, the Netherlands has admitted around 100 000 refugees from countries all over the world. During the last few years, the largest groups have been formed by refugees from Bosnia and other areas of former Yugoslavia, Somalia, the Islamic Republic of Iran and Iraq. Only a relatively small number arrive by invitation of the Dutch Government on recommendation from the UNHCR; most of them seek asylum in our country on their own initiative. Many refugees had suffered a series of traumatic experi- ences in their country of origin where they were persecuted, threat- ened or tortured for political, reli- gious or ethnic reasons.The abnormal ond traumatic situations that many refugees hove experienced con result in anxiety or depression disorders.
Some have been imprisoned and have been subjected to sexual vio- lence; others have lost relatives who were executed "on the spot" or have disappeared. They may have survived bombings and, not infre- quently, have experienced different forms of organized violence, de- mands for bribes, and threats.
On arrival in the Netherlands, a long and uncertain period awaits the asylum-seekers, during legal proce- dures while the Ministry of Justice decides whether to grant them asy- lum. Depending on the stage of these procedures they are housed in different refugee centres, often sharing sleeping rooms with other asylum-seekers. Few social, cultural or other activities which could increase their independence
are offered. Refugees may neither work nor study during the asylum procedure.
Once in possession of a resident's permit, refugees are spread through- out the country to be housed, and little note is taken of the place of residence of other family members or friends. Consequently they often become isolated, particularly if they have left other members of their extended family behind. Reports in the media about the violent situation in their country or telephone conver- sations with friends or family tend to add to their worries, and the possi- bilities of family reunification are extremely limited.
Over the past year, all new arrivals in our country have been offered a programme under which
they learn the Dutch language and about the structure of our society, so that they will be able to integrate more easily. But as many as 70% of refugees cannot find employment in the Netherlands and opportunities for further studies are limited.
Extreme stress
From all of this, it can be seen that refugees have not only experienced serious and extreme stress in their country of origin and during their flight, but also after their arrival in the host country as a result of prob- lems in adapting to and integrating into what is, for them, an alien society. These tensions express themselves in physical and psycho-
World Heolth • 48th Year, No. 6, November-December 1995
logical symptoms and social prob- lems. The most common are headaches, stomach and intestinal complaints, neck and shoulder pains, insomnia, nightmares, feeling de- pressed, anxious and irritable, diffi- culty in concentrating, loneliness, marriage tensions, problems with bringing up children, and homesick- ness. These symptoms and prob- lems should be considered as normal reactions to abnormal and inhuman situations.
Sometimes, however, they may indicate the presence of a psychiatric illness, such as post-traumatic stress disorder or other anxiety or depres- sion disorders.
Health problems too can interfere with the integration process, as a result of which a vicious circle of symptoms and social problems threatens. On arrival in the country, refugees are insured for medical care, so they can call on the health care service like any other resident.
Because it was recognized that regular health care did not take sufficient note of the specific prob- lems of refugees and the background to their problems, the Ministry of Health, Welfare and Sport has since the 1970s initiated various specific health care programmes for refugees.
A medical team was made re- sponsible for the primary care of
invited refugees, while preventive measures are primarily taken with respect to imported diseases and health problems resulting from injuries and violence. Since 1987, medical teams with similar objec- tives have actually been operating in the reception centres for asylum- seekers. In 1982, a pavilion called the "Phoenix" was opened at the General Psychiatric Hospital in Wolfheze, offering clinical psychi- atric care to Vietnamese refugees.
The Phoenix has recently extended its care to include refugees of all nationalities. Another centre, the
"Yonk", offers clinical psychiatric and day care to seriously trauma- tized refugees. This clinic is a de- partment of "Centre '45", which has already had many years of experi- ence in treating victims of the Second World War. Six regional organizations for sheltered housing have, since 1995, been extending accommodation to asylum-seekers.
Finally, the Pharos Foundation for Refugee Health Care offers ambu- lant psychosocial, psychological and psychiatric care to refugees.
Better access to care
The Pharos Foundation differs from other specific organizations by having a special aim entrusted to it
Two young asylum seekers from Bosnio and Herzegovino receive o medical check·up in Denmark.
Proper core of on early stage helps to ovoid ma;or psychological problems.
17
by the government, namely to ensure better access to regular health care for refugees. The Foundation's experience in direct health care is used to promote knowledge and expertise in this area among family doctors, social workers, district nurses and providers of mental health care. Pharos has a service desk which offers daily telephone advice, information and consulta- tions to individual care providers.
At the same time, Pharos organizes information meetings, study days, seminars, courses and congresses.
These are often arranged in co- operation with other specific care organizations for refugees or with institutions such as women's groups.
Locally and regionally, Pharos supports networks of regular health care providers who are involved with looking after refugees.
In the last few years it has been evident that the work done by Pharos is bearing fruit. Individual care providers as well as organizations for mental health care now recognize their joint responsibility for the adequate care of refugees. One favourable development is that they are starting projects to improve the health guidance and treatment of this target group. The sooner refugees can receive proper care for their health problems that result from the traumatic experiences and stress they experienced before, during and after their forced migration, the easier it is to prevent major psycho- logical problems at a later date.
The existence of specific care organizations for refugees in the Netherlands symbolizes the recogni- tion by the government of the special problems that refugees are facing.
But refugees would benefit even more if they could truly integrate into our society, including our regular health care system. •
Or {Mrs} Loes van Willigen is Medical Director
of the Pharos Foundation for Refugee Health Core, P.O. Box 13318, 3507 LH Utrecht, Netherlands.
18 World Health • 48th Year, No. 6, November-December 1995
Migrants are vulnerable
Mary Haour-Knipe
In search of a better life in Switzerland. New arrivals like these pose new challenges to host countries.
W
hy are migrants of particular concern for HIV I AIDS prevention? Because mi- grants move from one country to another, they are particularly affected by worldwide differences in both HIV patterns and prevention efforts. Being in a high-incidence country (such as France, Switzerland, or the United States) and having a low level of knowledge about prevention can be dangerous.Social inequalities in health per- sist, and the spread of HIV and AIDS is very much related to them. In developed countries, migrants often tend to live in economic, sanitary, and housing situations that are less ade- quate than those of the host popula- tion. They may be more subject to unemployment, to poverty, and also to racism. Migrant health often falls into gaps between programmes, especially where prevention is concerned, and some migrants may not even have access to adequate health care.
Furthermore, the situation of such migrants puts them at risk through
lack of access to information and to health care, through linguistic and cultural difficulties in comprehending prevention messages (for example, because of different attitudes towards sexuality), through separation from their families, or through social and economic hardship which could lead to high-risk behaviours
Efforts to harmonize
Reactions from the host countries are similarly varied. Although attempts are being made to harmonize official migration policies in view of the development of a common European approach, these still vary widely from country to country, as do policies concerning assimilation and citizen- ship. On a less official level, there are signs of growing integration, such as an increasing rate of mixed marriages, but also alarmingly more frequent incidents of racism and xenophobia.
People in the host countries may have subliminal fears of "disease-bringing
foreigners", while the minority com- munities may, in turn, feel unfairly singled out and threatened if they are mentioned in even remote conjunction with a stigmatized disease such as AIDS. Epidemics of communicable disease create uncertainty, and tend to be accompanied by epidemics of fear and suspicion, focusing not only on individuals affected by the disease, but also on those belonging to groups suspected of spreading it.
It is here that foreigners become vulnerable, since they are already
"different". Over a period of ten years around the turn of the century, more than two-thirds of a million Europeans crossed the Atlantic, the massive influx eventually stimulating fear that
"degenerate racial stocks" would pollute the gene pool of those already settled, or outnumber the respectable middle class. The 1891 US
Immigration Act which excluded
"persons suffering from a loathsome or dangerous contagious disease"
codified the fear surrounding venereal disease. In arguments that curiously
World Health • 48th Year, No. 6, November-December 1995
presage things said about HIV today, some experts singled out immigrant populations as particularly prone to infection; some suggested that poor urban conditions contributed to im- morality and the spread of venereal diseases. The number of immigrants actually found to be infected remained low, but those who did not want to be convinced were not; critics suggested
· that the low number of such diseases
found among immigrants revealed only that they had not been examined ade- quately. It was feared that venereal disease would spread to the local middle class via foreign-born prosti- tutes.
Today, if "the war against AIDS"
has, by definition, to be fought against an enemy, it is far easier if the enemy is someone else. Communities and governments have tended first to deny that there is a problem, then to blame homosexuals, drug users, sailors, prostitutes, various categories of foreigners- in fact anyone except
"us". In Africa, AIDS was for years often called the "European" or the
"American" disease, while in Europe and the USA popular and scientific debates attempted to place the origins of the epidemic in Africa. Thus, foreigners, migrants or ethnic minori- ties are particularly liable to stigmati- zation where HIV and AIDS are concerned. In other respects, since foreign or migrant populations are not usually a priority for country health programmes, they have tended to be ignored.
Prevention programmes
Although they began several years after those for host country residents, most western European countries now have HIV I AIDS prevention
programmes for migrants. Generally these programmes are of three types:
government-sponsored, those of non- governmental organizations, and what can best be described as informal. The latter category includes some of the most interesting and creative work being done, although often on the simple basis of immediate need, and with very little or no funding.
As for more official government-
sponsored programmes for migrants, the first had already begun in 1986- a discreet programme in Brussels, as- sessing knowledge and attitudes before starting to work with the African community. The first larger national programmes for ethnic minorities were established in 1988 in the Netherlands and the United Kingdom, followed during 1989 and 1990 by programmes developed in at least seven other western European countries, including France, Germany, Norway, Sweden, and Switzerland. Some national HIV I AIDS prevention campaigns - in the Netherlands, Sweden and the United Kingdom, for example-have approached the problems of racism and xenophobia by putting a multicultural accent on messages addressed to the general population. Posters, for exam- ple, might show people obviously of many different races and cultures.
Programmes need to be based on the idea that migrants, like anyone else, have the right to know and be
informed, in the terms of their own language and culture. Calculations of relative risk do not enter into the equation since the programme is based on the idea that everyone is potentially at risk.
Working with the community
A second basic set of principles for establishing HIV I AIDS prevention programmes for migrants, infinitely easier to state than to manage on a daily basis, involves working with the community. Such organizations as the AIDS and Mobility Project in Amsterdam ensure that interventions with their target communities are culturally appropriate, and that needs are defined and integrated into the programme from within the commu- nity itself. One highly sensitive subject specific to migrants is the delicate problem of people becoming infected during visits to their home countries of high HIV prevalence.
Substantial progress has been made in establishing HIV I AIDS prevention programmes for migrants and ethnic minority communities in European
19
there is none at all for complacency.
There is need for both rigorous pro- gramme evaluation and supportive collaboration and cooperation. Links must also be forged between workers and programmes in host countries and those in the countries of origin, since knowledge could flow in both direc- tions. Migration is hardly likely to cease, and new populations are bound to raise new issues and bring new challenges. •
Mrs Mary Haour-Knipe is at the University Institute for Social and Preventive Medicine, Lausanne, Switzerland. This article is ex- cerpted from The economic and social impact of AIDS in Europe, edited by Fitzsimans, Hardy and Tolley, and published by Casse/1, London,
1995.
countries in the past five years, but, if A German iob recruitment bureau in Turkey there is some room for satisfaction, some years ago.
