The impact of workplace exclusion on the humanitarian response to the refugee crisis in Lebanon

A contemporary issue of major concern is the millions of people fleeing homelands owing to political and socioeconomic challenges and seeking assistance elsewhere throughout the world. An effective response to this crisis includes support models that meet the various needs of refugee populations. In the complex system of humanitarian action, aid workers, among a multiplicity of actors, are the most important assets. This study utilised an inclusion–exclusion theoretical lens to examine the impact of their workplace experiences on activities in the context of the refugee crisis in Lebanon. In-depth interviews were held with 36 humanitarian practitioners, representing five international organisations that are involved in refugee aid programmes in the country. The study led to a new understanding of the link between inclusion and exclusion and the effectiveness of the humanitarian response to emergencies. In addition, it yielded new insights into apprehension about the national–international divide and its consequences for humanitarian assistance.     

Tuberculosis in a Refugee Camp: A campaign to reduce transmission

In November 1985, tuberculosis was highly prevalent among the 6,250 Tigrayan refugees ofFau I camp in Eastern Sudan. It was therefore decided to launch an active case-finding campaign aimed at decreasing transmission, to be carried out by primary health care workers. The entire population of the camp was screened for symptoms of pulmonary tuberculosis and the sputum of people with productive cough was examined by direct microscopy. However, it was considered that this examination was insufficiently sensitive in the camp situation. For this reason, people with non-productive cough or sputum-negative were enrolled in a follow-up program whose length was determined by the severity of their symptoms.
The campaign was interrupted by circumstances that are typical of refugee situations. On the basis of results obtained a few conclusions can nonetheless be made on the appropriateness of introducing an active screening program in situations where a stable refugee population has good access to basic health care of good quality.     

Planning STI/HIV prevention among refugees and mobile populations: situation assessment of Sudanese refugees

This article reflects an investigation of knowledge, attitudes and behaviours and HIV/STI prevalence of Sudanese refugees and Ethiopian sex workers in 1992. It represents one of the earliest such investigations within an African refugee population. The investigation took place in the Dimma refugee settlement in south-western Ethiopia and study participants included Sudanese refugee men and women and Ethiopian female sex workers. Methods used for this investigation included focus group discussions, behavioural surveys and serologic testing. The main outcome measures of the investigation were HIV/STI knowledge, attitudes and behaviours and biological markers for HIV, syphilis and herpes simplex 2. The study findings indicate that in the early 1990s, knowledge about AIDS and condom use was low among Sudanese refugee women and not one reported having ever used a condom. Furthermore, sexual contact between refugee men and sex workers was frequent during the time of this study and the prevalence of HIV and other STIs was high. The results confirm a widely held assumption that highly mobile and transient populations in Africa are susceptible to STIs and HIV, in large part due to their knowledge, attitudes and behaviours.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Why Aid Agencies Need Better Understanding of the Communities They Assist: The Experience of Food Aid in Rwandan Refugee Camps

Refugee views on food aid reveal the ignorance of the international community regarding Rwandan culture, economy and politics. This ignorance carries a number of costs. On one level, the main cost is that a professional service is not carried out to the best of one's ability. Ignorance of Rwanda's North–South divide, for instance, has caused agencies to be insensitive to in-camp discrimination based upon regional identity and its impact on programme activities. On a deeper level, agency ignorance about Rwandan culture, economy and the dynamics of camp politics, reduces refugee confidence in humanitarian agencies and workers. Better information would not only result in the greater likelihood of appropriate responses to specific needs, but would also encourage greater credibility in the political arena where the ultimate stake is to see lasting peace and a dignified return of refugees to their homes.     

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.     

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.     

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.     

Practical evaluation of a pilot immunization campaign against typhoid Fever in a cambodian refugee cAMP

An epidemic outbreak of typhoid fever in the largest refugee camp of the besieged capital of Phom-Penh, Cambodia; the concomitant lack of personal and public hygiene and the availability of a locally manufactured Tetanus-Typhoid-Paratyphoid vaccine, prompted us to test the practicability of a mass immunization campaign by carrying out a trial in the smaller, well delineated refugee camp of Pochentong. Attendances by adults as well as children throughout the three or four inoculation rounds showed a steady decline with only 30 (20%) of the people completing the course. The general initial acceptance by the people on the other hand was good, due to a comprehensive service (information, health education and individual care of patients). It is concluded from these results that multi-injection immunization campaigns against typhoid-paratyphoid are a waste of money in a war-torn situation with an unstable population.     

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.     

Disaster mental health training programmes in New York City following September 11, 2001

The need for mental health resources to provide care to the community following large‐scale disasters is well documented. In the aftermath of the World Trade Center (WTC) disaster on September 11, 2001, many local agencies and organizations responded by providing informal mental health services, including disaster mental health training for practitioners. The quality of these programmes has not been assessed, however. The National Center for Disaster Preparedness at Columbia University's School of Public Health reviewed disaster mental health training programmes administered by community‐based organizations, professional associations, hospitals, and government agencies after September 11. Results indicate that the quality and the effectiveness of programmes are difficult to assess. A wide range of curricula and a widespread lack of recordkeeping and credentialing of trainers were noted. Most of the training programmes provided are no longer available. Recommendations for improving the quality of disaster mental health training programmes are provided.     

Women at risk: gender and AIDS in Africa

AIDS in Africa is a gender, development and rights issue involving power and differential access to resources. The risk situations for women in stressed development contexts of war, destabilisation and displacement, and the many contexts of transactional sex, are poorly understood by policy makers and the medical community. The dominant epidemiological paradigm has focused on female 'prostitutes' in a number of African cities. The limitations of this approach are discussed, as are the different contextualised meanings of sexual exchange. The importance of women's experience of sexually transmitted diseases and HIV and their perceptions of risk are stressed, as is the need for non-judgmental services linked to primary and comprehensive health care, and for sensitive, qualitative research. It is argued that all women who engage in unprotected penetrative sex are at risk. Most health promotion messages, however, construct an image of women as prostitutes ('Avoid prostitutes') or seek to mobilise women as carers and educators of families and communities.     

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.     

The need for innovative strategies to improve immunisation services in rural Zimbabwe

Gokwe South, a rural district in Midlands Province, Zimbabwe, reported the lowest rate of immunisation coverage in the country in 2005: 55 per cent of children vaccinated with three doses of diphtheria/pertussis/tetanus vaccine (DPT3) and 35 per cent dropout between the first and third dose of DPT. In January 2007, the authors assessed local barriers to immunisation and proposed strategies to improve immunisation rates in the district, in the face of nationwide economic and political challenges. A situational analysis was performed to assess barriers to immunisation using focus-group discussions with health workers, key informant interviews with health management and community leaders, and desk reviews of records. Responses were categorised and solutions proposed. Health workers and key informants reported that immunisation service delivery was hampered by insufficient availability of gas for cold-chain equipment, limited transport and fuel to conduct basic activities, and inadequate staff and supervision. Improving coverage will require prioritising gas for vaccine cold-chain equipment, identifying reliable transportation or alternative transportation solutions, and increased staff, training and supervision. Local assessment is critical to pinpointing site-specific barriers, and innovative strategies are needed to overcome existing contextual challenges.