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.     

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.     

Nutritional risk factors for older refugees

This study describes risk factors for poor nutrition among older Rwandan refugees. The most important areas of nutritional risk for older refugees are: physical ability and mobility; income and access to land; access to appropriate food rations; meeting basic needs such as water, fuel, shelter; equal access to essential services (food distribution, health services, mills, feeding programmes); and psycho-social trauma. Women and older elderly (> 70 years) are significantly more often in disadvantaged positions, such as having poor socio-economic status, poor health, poor mobility, lower food intake, diminished social status, respect and social network. Older refugees are at higher risk than younger refugees and at higher risk than older people in stable situations. They should remain in good nutritional and general health for their own well-being and that of their dependants. In addition to an adequate diet, a support network seems to be an important preventive aspect.     

Refugee health care: Similar but different?

The present review sets out to identify differences between refugees and other more stable communities living in less developed countries: demographic, mortality, morbidity, nutritional and selected epidemiological data are discussed. Although generalizations are difficult because of the variability of refugees and their differing circumstances, the health problems and diseases do not appear to differ qualitatively, although they may be quantitatively more severe.
The areas of particular concern lie not so much with the problems but with approaches to their solutions: the need to respond rapidly and appropriately to emergencies, the importance of attending to the priorities of nutrition, shelter, sanitation and water; and the necessity of providing services which are sufficiently flexible and sensitive to the changing needs of the refugees as they move from the acute emergency to the long-term settlements.
The review highlights certain areas where insufficient information is currently available, notably mental illness and the long-term issues of health and development, and outlines the implications of the conclusions for policy makers, with particular reference to training and research.     

Refugee perceptions of the quality of healthcare: findings from a participatory assessment in Ngara, Tanzania

This article describes the findings of a participatory assessment of Burundian and Rwandan refugees' perceptions of the quality of health services in camps in Ngara, Tanzania. Taking a beneficiary-centred approach, it examines a collaborative effort by several agencies to develop a generic field guide to analyse refugees' views of healthcare services. The objective was to gather information that would contribute to significant improvements in the care offered in the camps. Although the primary focus was on healthcare, several broader questions considered other general apprehensions that might influence the way refugees perceive their healthcare. Findings indicated that while refugees in Ngara were generally satisfied with the quality of healthcare provided and healthcare promotion activities, recognition of some key refugee concerns would assist healthcare providers in enhancing services. With increasing need for refugee community participation in evaluating humanitarian assistance, this assessment has relevance both in the context of Ngara and beyond.     

Training Community Health Workers in refugee camps: A case study from Pakistan

In October 1983 a training programme for refugee community health workers was begun as the major part of a primary health care programme for Afghan refugees in Pakistan. The programme began with a pilot period in Badaber camp, situated near to Peshawar. The general issues involved in training auxiliary health personnel were answered by the use of a "knowledge, attitudes and practices survey" and involvement of the refugees from the beginning of the programme. The development of the training programme is discussed with reference to these issues and the constraints arising from the special circumstances of the refugees, in addition to those common to most national training programmes, are reviewed.     

Planning basic health services in Nigeria

This article does not deal directly with disasters, but as it is recognised that natural disasters most commonly occur and are most damaging in third world countries which are often still in the process of developing their health services; and since clearly a well-functioning health service is a valuable resource in pre-disaster planning and post-disaster relief and recovery, it is thought relevant to publish this study of one local health network which appears to answer effectively the basic needs of a rural population, within the means of the community.     

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.     

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)..     

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.     

A comparison of health provision and status in ban napho refugee cAMP and nakhon phanom province, northeastern Thailand

Health care provision and health status in Ban Napho Refugee Camp is compared with that of the surrounding Nakhon Phanom Province for the year 1988. Records for the period 1984–88 were also examined to compare trends in health status. Personal experience of health services in the Camp and visits made to local schools and health facilities were also used in the comparison. Although direct comparison was difficult (because of the mobile nature of the camp population and problems to do with the interpretation of statistics), it was found that health care for refugees was more comprehensive, at a primary level, than for the Thai population of the surrounding Province. Access to primary health care facilities in the Camp was, moreover, easier and free of charge. This may explain the higher use of health facilities in the Camp but, despite this, health and nutritional status appeared to be worse in the Camp than in the Province. Possible reasons for the difference in reported health status and the use of facilities are discussed.     

THE DEVELOPMENT AND PRACTICE OF EMERGENCY AND DISASTER MEDICINE IN THE UNITED STATES

Accidents and sudden illness constitutes a major public health problem in many countries. Emergency medicine had developed as a vigorous new specialty in the U.S. and has fully integrated itself within the American medical and hospital system to provide improved emergency medical care. Emergency medicine plays a central role in disaster medical services, planning, and management and is the only specialty in American civilian medicine that includes disaster medicine as a primary field within its domain. Now that the basic framework of emergency medicine has been established, the American College of Emergency Physicians is implementing a nationwide training program on disaster planning and management for emergency physicians.     

From Relief to Development: The Long-term Effects of 'Temporary' Accommodation on Refugees and Displaced Persons in the Republic of Croatia

The increasing scale of international intervention in conflict is generating new pressures on the humanitarian community. Increased expenditure on emergency relief, static levels of overseas development aid and subsequent lack of funds for development are dictating that agencies design relief projects that positively effect developmental reconstruction.
This paper examines the provision of shelter for refugees and displaced persons in the Republic of Croatia and identifies ways in which it has encouraged and discouraged sustainable reconstruction. It argues that to promote lasting reconstruction, programmes must focus on saving livelihoods as well as lives, thus minimising the long-term psychological and physical impacts of aid on refugees, displaced persons and host communities.     

Planning environmental sanitation programmes in emergencies

Environmental sanitation programmes are vital for tackling environmental-related disease and ensuring human dignity in emergency situations. If they are to have maximum impact they must be planned in a rapid but systematic manner. An appropriate planning process comprises five key stages: rapid assessment and priority setting; outline programme design; immediate action; detailed programme design; and implementation. The assessment should be based on carefully selected data, which are analysed via comparison with suitable minimum objectives. How the intervention should be prioritised is determined through objective ranking of different environmental sanitation sector needs. Next, a programme design outline is produced to identify immediate and longer-term intervention activities and to guarantee that apposite resources are made available. Immediate action is taken to meet acute emergency needs while the detailed programme design takes shape. This entails in-depth consultation with the affected community and comprehensive planning of activities and resource requirements. Implementation can then begin, which should involve pertinent management and monitoring strategies.     

Perspectives on policy framework for trans-boundary water quality management in China

In river basins that cross jurisdictional boundaries, water quality degradation has become a crucial problem and results in intensive competition among water users, especially in developing countries. Under this situation, implementing water quality management and control across jurisdictional boundaries can strengthen watershed pollution controls, and prevent pollution from being passed on and promote active pollution control within the related jurisdictional regions. This study examined the limitations of the current trans-boundary water quality management system in China and reviewed the planning and implementation of two pilot integrated trans-boundary water management systems established in the Jiangsu and Zhejiang provinces. Based on our findings, we proposed a new policy framework for trans-boundary water quality management. As a first step toward integrated watershed management in China, this policy framework can help assess the actual water pollution status of various regions and serve as a basis for an integrated watershed management system. The framework can be easily applied in other countries with trans-boundary water pollution issues, particularly in the context of developing countries.     

Health response to a large and rapid influx of Albanian refugees in southern Italy, 1991

Over a two-day period in March 1991, more than 23,000 Albanian refugees arrived without warning in the southern Italian port of Brindisi. A simple surveillance system was established within days of their arrival to monitor health problems that were expected to have a high frequency, were of concern to the Italian health care system because of potential spread to the local population, and were susceptible to therapeutic or preventive measures. The most commonly encountered health problems were pediculosis and scabies. Despite poor sanitary conditions, only one outbreak of gastrointestinal disease was reported. Obstetric events were common, and many resulted in adverse outcomes. Hospitalization rates were high, although in the early weeks of the emergency, many were unwarranted. This experience demonstrates the value of a simple, rapid surveillance system in prioritizing health problems and preventing rumors. In future, greater emphasis should be placed on outpatient management of simple medical problems.     

Measuring the impact of rehabilitation services on the quality of life of disabled people in Cambodia

The present study aimed to measure the quality of life (QOL) of disabled people in Cambodia and the impact of rehabilitation services. The categories of services were: physical rehabilitation (prosthetics/orthotics with physiotherapy); community-based rehabilitation; and (3) labour market assistance. The 164 respondents were from a range of urban and rural settings. The results suggest that QOL was substantially lower among disabled Cambodians who had received no rehabilitation services compared to those who had received one of the three categories of rehabilitation services. QOL scores tended to be highest, however, among those who had received a combination of all three services. The results also highlighted the vulnerability of certain sub-groups who may need specific provision in planning, policy-making and service delivery. The present study suggests that an integrated approach may be the best way to maximise the impact of individual rehabilitation services in Cambodia.     

Improving flood warnings in Europe: a research and policy agenda

Abstract

Warnings and emergency planning for flooding are based on the reality that no matter how thorough our investigations and flood prevention efforts through engineered structural works or land use management, some risk will always remain. This paper examines recent experience with flood warnings in the UK and continental Europe. It combines this experience with an overview of the relevant literature to identify lessons for incorporation into policy, and problem areas which would most obviously benefit from additional research. Throughout, the emphasis is on the non-engineering aspects of warning systems. Results indicate that much is being achieved in terms of the detail of warning design, but the broader issues seem to be largely ignored by both the research literature and practice. First among these broader issues is the failure, by those charged with warning system development and operation, to conceptualise the warning task as one based explicitly on the needs of those at risk. Making this happen will require the development of processes to build the necessary culture of cooperation and learning among the many organisations involved.