Refugee Density and Dependence: Practical Implications of Camp Size

Different refugee camps may have widely differing morbidity and mortality rates. Some of these differences are ascribed to environmental factors. This paper reviews the key issues relating to one environmental factor: the size of the refugee camp, and provides a tentative theoretical framework for examining the effect of camp size on refugees. This effect may not be considered because aid workers chronically underestimate the value of the refugees' contribution to their own survival. Large camps settle great numbers of refugees to the hinterland of the camp and limit their access to resources available there. This may increase refugee dependency and vulnerability. There is some slight evidence from the analysis of data provided by Mercer (1992) that child mortality rates (aged 0–4 years) are positively correlated with camp size (as inferred from child populations). If other factors allow, it might be wise for camp planners to try to limit camps to a size which allows refugees reasonable access to local resources.     

A general assessment of the environmental impact of refugees in Somalia with attention to the refugee agricultural programme

This paper attempts to examine the broad features of Somalia's harsh physical environment into which several hundreds of thousands of refugees, with mainly a nomadic or semi-nomadic life style and culture, dramatically descended six years ago. The thirty-six rural camps in which at least half of them live are described as is the refugee agricultural programme which is training several thousand families so that they may be "self-supporting." The four regions where the camps are located are each briefly summarized in terms of their soils, their climates, their natural vegetation, and the type of agriculture which the refugee farmers practice. A more detailed analysis is then given on the following critical environmental concerns: Vegetation and erosion on refugee farms, the growing problem of refugee livestock, the destruction of trees, and irrigation practices and salinity on refugee farms. The paper concludes with an argument to preserve Somalia's environment from careless and destructive exploitation, which is leading towards desertification, and calls for an in-depth study of the situation.     

Mortality and morbidity in refugee camps in eastern Sudan: 1985-90

Civil war has disrupted life in Ethiopia since the 1960s and many people have sought refuge in Eastern Sudan, particularly during the famine emergency of 1984–85. UNHCR has provided the main financial support for the refugee programme, but began scaling down operations in 1990. Nearly 300,000 refugees still live in camps and benefit from food and health programmes. Health services are co-ordinated by the Sudanese Refugee Health Unit which operates a centralised health and nutrition surveillance system with the co-operation of the NGOs responsible for health care in the camps. A revision of the monthly reporting system and the establishment of a computer database in 1990 provided an opportunity to review the situation in the camps over the five years since the emergency. Child death rates for example, appear to have been reduced to levels below those expected in rural Africa. Patterns of mortality, morbidity, and nutritional status are outlined here and point to the general effectiveness of the health care programme. The surveillance system can, however, be used to identify those camps which have persistent problems, while monthly comparisons with the situation in previous years can provide early warning of deteriorating conditions.     

Surveillance of the Health and Nutritional Status of Rohingya Refugees in Bangladesh

Early in 1992, Bangladesh experienced an influx of Burmese refugees, reaching a total of 263,000 by May. As the health and nutritional status of the refugee population was reportedly poor, a need was felt to collect dependable data through epidemiological surveillance, on which interventions could be based. The nutritional and health status of children was dramatically poor in all camps surveyed and a deterioration was expected in the coming monsoon. Several problem areas could be identified. Based on these findings it was possible to undertake appropriate action and to avert threatening calamities. Epidemiological surveillance is an important monitoring tool to provide reliable data on the health and nutritional status of refugee populations and to help the organizations involved to prioritize and evaluate their actions.     

Reproductive health services for refugees by refugees: an example from Guinea

The need to involve refugees in their own reproductive health (RH) services has long been recognised, but there is a lack of published examples describing how this can be achieved collaboratively between refugee initiatives, UNHCR, bilateral development organisations and international relief agencies. This paper outlines the work, outputs and lessons learnt of the Reproductive Health Group (RHG), an organisation of Liberian and Sierra Leonean refugee midwives and laywomen providing RH services to fellow refugees in Guinea's Forest Region between 1996 and 2000. Working as part of the Guinean health system, RHG midwives and community facilitators helped make the RH services in their region the most effective in Guinea at the time. Looking at RHG's achievements, the challenges it faced and partly overcame, it is argued that refugee organisations can plan and implement RH services for refugees where UNHCR and its international partners ensure that they receive funding and technical assistance.     

Training refugees as primary health care workers: Past imperfect, future conditional

Many problems have been encountered in the planning and implementation of health care in refugee camps, and more specifically in the training of refugees as primary health care workers. A review of the published literature and a "survey" of the opinions and experiences of refugee, national and international health personnel regarding training has therefore been undertaken to provide an overview of what has been done and to make recommendations for future work.
The review highlights the need to reallocate resources away from high visibility emergency aid to development activities, such as training, that will create an infrastructure for primary health care and promote self-reliance.     

Rural refugees in Africa: Past experience, future pointers

Rapid change In rural Africa raises new policy problems In dealing with mass influxes of rural refugees. Self-settlement in agriculture has become less feasible and is less acceptable now that Its disadvantages are better understood. Organized smallholder settlement can be a better solution where it is economically viable, refugees have freedom of movement, and staff are suitable. But growing land shortage means that Increasing proportions of refugees are being placed in camps. To offset this trend, more attention is suggested to programmes for groups of refugees, categorized by time of arrival, by ability to self-settle or to farm, and by skills and experience. Practically-oriented social science research can contribute to these and other approaches which will require imagination and ingenuity. Solutions to future rural refugee problems should be linked with programmes of social and economic development which will make easier the achievement of humanitarian objectives.     

Quality design: a planning methodology for the integration of refugee and local health services,West Nile,Uganda

In an emergency, the international community responds to the immediate health needs of refugees through the establishment of action-oriented, life-saving services. Healthcare delivery is often managed with limited, if any, coordination with local health management structures. In situations where refugees remain in the host country for many years, sustainability issues inevitably arise. Refugee-hosting governments may ultimately be called upon to assume the management and funding of refugee services. Planning for service integration, while protecting against declines in service quality, is a challenge in the typically resource-poor host environments. This paper discusses these issues by presenting the experience of the West Nile districts in northern Uganda, and describes quality design as a relevant planning methodology. Quality design is a systematic planning approach that documents and directly incorporates the service users' self-defined expectations and needs.     

An outbreak of scurvy in Somali refugee camps*

Between June and October 1982, an outbreak of scurvy occurred in the refugee camps of Somalia. An epidemiologic investigation eventually detected more than 2,000 cases. The outbreak came at a time when the relief programme had been well established and the general health status of the refugees had otherwise stabilized. We report on 72 of the cases. Joint pain of the lower extremities and gingivitis were prominent features in the majority. Hemorrhagic phenomena were not observed and no deaths occurred. The outbreak primarily affected the poorer refugees who were unable to purchase locally available Vitamin C-containing foods. This outbreak demonstrates the vulnerability of a large population of displaced persons who are dependent on imported relief supplies for survival.     

Vulnerable groups*

As a rule, refugees arrive in their host country with a bare minimum of possessions; in this respect every refugee can be classified as vulnerable. However, a certain category is especially at risk, namely those persons who would be considered vulnerable in a "normal society." These people are doubly in need of assistance, firstly, inasmuch as they are refugees and secondly, insofar as they are vulnerable. If these refugees can be helped to overcome (or at least reduce) their handicaps, they can begin to become self-reliant and form an active, productive parts of their community, rather than remaining an extra burden to an already vulnerable part of the society in their country of asylum. Whilst their able-bodied companions work in the fields or the towns, part of this category can be trained and usefully employed in sectors of work that do not require great mobility or physical fitness (such as handicrafts, trade, teaching and services)..     

Uncovering local perspectives on humanitarian assistance and its outcomes

This paper draws on a study of Angolan refugees in Zambia to suggest ways that the perspectives and interests of the local population can be included in the assessment of relief interventions. Taking an actor-oriented approach, the paper suggests stepping back from the categorisation of the situation as an emergency and particular groups of people as the beneficiaries. Such categories are imposed from outside and may not reflect local people's outlook on the situation. In the case of Angolans in Zambia, the category of refugees had dissolved in the border villages to the extent that it was practically impossible to distinguish between refugees and hosts. This was in contrast to the official settlements where people were marked out as refugees and the label was maintained and reproduced over many years. Investigating outcomes in the border villagers in terms of refugees and the refugee problem would have been futile. The paper calls for evaluations of humanitarian assistance in complex emergencies to look beyond the 'beneficiaries' and to investigate the wider context of 'normality'. Neglecting the life and world of local people will make it impossible to understand the process by which external interventions are mediated at the local level to give particular outcomes, and valuable lessons which could help alleviate suffering will be lost.     

Cholera in Sudan: An account of an epidemic in a refugee camp in eastern Sudan, May-June 1985

In 1985 cholera has been a serious problem in the horn of Africa, particularly affecting the many famine victims and refugees in that region. In this paper the history of cholera in Africa is briefly summarized, as is the background to the current refugee situation in eastern Sudan. A cholera epidemic involving 1,175 cases in two adjacent refugee camps in eastern Sudan is described. In this epidemic there were thirteen inpatient deaths and thirty-eight known home deaths from cholera. The management of the epidemic is described in detail. Overall an average of 8 1. of intravenous fluid was used per case, a higher figure than was anticipated, probably because of the unexpected degree of vomiting and the shortage of trained nursing staff.
The relationship between cholera and malnutrition is explored and hypochlorhydria is suggested as the main reason for the increased susceptibility to cholera among malnourished populations. It was observed that severely malnourished adults and children appeared to nave less severe diarrhoea with their cholera, presumably because of reduced mucosal surface area and poor enterocyte function. Finally possible means of aborting cholera epidemics are discussed.     

The Role of the Zairian Health Services in the Rwandan Refugee Crisis

In July 1994, a stream of Rwandan refugees entered the southern part of North Kivu Region, Zaire. The public health consequences of this crisis for the host population and health services have not been analysed up to now. The lack of human and financial resources did not prevent Zairian health structures and personnel from taking care of the many refugees settled outside the camps, following their arrival. The public health consequences of the crisis for the local population should be considered an integral part of the disaster.     

Post-Emergency Epidemiological Surveillance in Iraqi-Kurdish Refugee Camps in Iran

In 1991 a computerized, comprehensive epidemiological surveillance system was developed to monitor health trends in approximately 25,000 acutely displaced Kurds in Nowsood and Saryas refugee camps, Bakhtaran region, Northwestern Iran. In addition, community-based surveys offered information unobtainable from health facilities. Weekly population movements, attack rates, point-prevalence estimates, and case fatality ratios were calculated, and the data were analysed and compared. The overall crude mortality rate (CMR) in the camps under study was still 9 times higher than the reported CMR for Iraq. Health problems with very low rates (less than 1.0/ 1,000 population/week) included the triad of measles, meningitis and tetanus. However, morbidity for the most common conditions (acute respiratory infections, diarrhoea, skin infections, eye diseases and, finally, typhoid fever) was shown to increase at the end of the intervention, highlighting that the pressure of repatriation on refugees made them progressively worse. This article concludes that epidemiological surveillance systems should be implemented during mass-migrations in developing countries also in post-emergency settings. Furthermore, surveillance appears to be indispensable in order for the international agencies to keep abreast of events and to safeguard human rights when international attention subsides.     

Practical experience with the management of a cholera outbreak in a refugee cAMP in eastern Sudan, 1985

From May to November 1985 most refugee camps in Eastern Sudan were affected by cholera. This article summarizes the experience from the refugee camp Wad Sherife with the emphasis on the practical aspects of management of cholera in a refugee context. Paramedical personnel from the refugee community were used to a great extent both in curative and preventive measures. The home visitors played an important role in the early detection of the cases and in trying to prevent the spread of cholera in the camp. A total of 1793 cases were admitted during a three month period. The results show a case fatality rate of 1.8%. A significantly higher number of women were affected in the age group 15–44. As seen in other refugee camps in Eastern Sudan, there was a relatively high intravenous fluid consumption with an average of about 6 litres in adults.     

Representing Refugees: The Role of Elites in Burundi Refugee Society

Among Burundi refugees in Tanzania, men who have a university education and know English or French are most likely to represent their concerns to officials, particularly those from UNHCR. Officials consequently learn about the perspectives of refugees from these men. Based upon findings from two years of field, research in Tanzania, the history of relations between ethnic Hutu elites and the peasantry in Burundi is outlined and it is explained why education has assumed such pronounced significance in Burundi refugee society. The use of ethnicity as a political tool for elite refugees is also described. It is concluded that elite refugees may not, as is often claimed, represent the refugee majority.     

The impact of refugees on the health status and health services of host communities: Compounding bad with worse?

Although there have been a number of recent developments in our understanding of refugee health problems that have influenced policies and action, the effects of refugees on the health status and services of host communities remain relatively neglected. This article sets out to explain why this is an important issue with implications for policy, planning surveillance and evaluation, training and research.
The first sections outline some of the problems facing host governments and communities in Africa and discuss the changing rhetoric between the first and second International Conferences for Assistance to Refugees in Africa. A number of possible ways in which refugees could affect the individual, agent and environmental causes of disease are considered, as are the characteristics of the refugees, the host communities and the response which may all modify this impact.
Policy implications of the impact of the refugees, both negative and positive, are discussed, and detailed consideration is given to the pros and cons of integrated and parallel approaches to health care provision. The need to monitor carefully the health status and services of host communities is emphasized and recommendations are made for this and other essential developments relating to training and research.     

Rapid Assessment of Population Size by Area Sampling in Disaster Situations

In the initial phase of a complex emergency, an immediate population size assessment method, based on area sampling, is vital to provide relief workers with a rapid population estimate in refugee camps. In the past decade, the method has been progressively improved; six examples are presented in this paper and questions raised about its statistical validity as well as important issues for further research. There are two stages. The first is to map the camp by registering all of its co-ordinates. In the second stage, the total camp population is estimated by counting the population living in a limited number of square blocks of known surface area, and by extrapolating average population calculated per block to the total camp surface. In six camps selected in Asia and Africa, between 1992 and 1994, population figures were estimated within one to two days. After measuring all external limits, surfaces were calculated and ranged between 121,300 and 2,770,000 square metres. In five camps, the mean average population per square was obtained using blocks 25 by 25 meters (625 m2), and for another camp with blocks 100 by 100 m2. In three camps, different population density zones were defined. Total camp populations obtained were 16,800 to 113,600. Although this method is a valuable public health tool in emergency situations, it has several limitations. Issues related to population density and number and size of blocks to be selected require further research for the method to be better validated.     

A test of stress theory: relief workers in refugee camps

The purpose of this paper is to apply a stress model drawn from the literature to the relief and social service workers who have been active in refugee camps for a prolonged period of time. Working in difficult environments, social service workers deliver essential services to refugee populations around the world. A model of four work-stress determinants--tasks, management, appreciation and collaboration--was tested on 274 social workers in five regions of the Middle East (Jordan, Lebanon and Syria, as well as the occupied Palestinian territories of the Gaza Strip and the West Bank). Statistical fit indices were adequate but two relationships were statistically insignificant. The collaboration variable was dropped to create a modified model with tasks indirectly and management and appreciation directly affecting work-related stress. The five direct relationships and two indirect relationships of this modified model are consistent with stress theory, and all relationships--direct and indirect--are statistically significant.     

An Ethiopian refugee village in Sudan: the question of employment

Abstract— There are some 460,000 Eritrean and Tigrean political refugees in Sudan. The numbers have increased dramatically since the mid-1970s, and as yet there are no convincing signs of peace which would allow the prospect of a speedy return home. Sudan is thus faced with one of the Third World's largest populations of long term refugees, and the capacity of the economy to absorb such numbers into its labour force is an acute and potentially violent issue. Discussion and planning has been hindered by a lack of specific information on the proportion of refugees who are of urban or rural origin and the proportion of those who might undertake skilled or unskilled employment. The following report of a census and survey of a refugee village in eastern Sudan offers some insight into the problem and suggests steps towards its solution.