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.     

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.     

Evaluation of Two Kurdish Refugee Camps in Iran, May 1991: The Value of Cluster Sampling in Producing Priorities and Policy

Following the end of the Gulf war in March 1991, Kurdish refugees from Iraq crossed the border into Western Iran. To plan public health interventions and to assist in priority setting for scarce resources, a rapid epidemiological assessment of two camps, Hafez and Kaliche, was conducted in May 1991. A 30 cluster sampling method was used to determine the demographics of the camp population, the morbidity and mortality from certain diseases, and the nutritional status of the children <5 years of age. The estimated population of the camps at the time of the survey was 28,500 and 22,500 for Hafez and Kaliche respectively; children < 5 years of age accounted for approximately 25 per cent of both camp populations. The mortality rate was highest in Hafez and estimated to be 2.5/10,000 per day (95%CI:0.3–5) for adults (> 14 years of age) and 4.9/10,000 per day (95%CI:2.4–7.4) for children. Diarrhoeal and respiratory diseases accounted for major morbidity in both camps with diarrhoea the commonest stated cause of death. Little malnutrition was found but it was greater in Hafez where 6 per cent (19/327) of the children between 1 and 5 years of age had a mid upper arm circumference (MUAC) <12 cm and eleven (5.2 per cent) of the 211 children measured for height and weight were below 80 per cent of the median (95%CI:2.6%;7.8%). The survey identified that morbidity and mortality were less severe than in the Kurdish camps on the Turkish border and provided information for camp authorities to plan appropriate relief interventions.     

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.     

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.     

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.     

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.     

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.     

Refugee income generating projects and occupational health

The shift from purely emergency relief for refugees in developing countries to aid within the context of development strategies is slowly gathering momentum (UN, 1983; UNHCR, 1984; Simmonds, 1984). Such a move implies that if self-reliance is to be a realistic goal then employment for refugees is essential; a number of income-generating schemes are therefore being both proposed and developed (ILO, 1983 and 1984).
Many of these schemes have implications for the health of the refugees, so this paper summarises some occupational health hazards and offers suggestions for future action.     

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.     

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.     

MEDICAL MISSION TO A REFUGEE CAMP IN THAILAND

Abstract— During the latter part of 1979, hundreds of thousands of Kampuchean refugees fled from all parts of their war-and hunger-ridden country to the Thai–Cambodian border, thousands perishing from hunger, disease and by stepping onto mine fields on their way. The majority of those who survived settled in several large villages straddling the border in relative security from the advancing Vietnamese army, receiving food and medical supplies from many international welfare organizations.
Widespread public interest in the plight of these refugees arose in Israel after a television program late in October 1979, and a public campaign was initiated by Mr. Abie Nathan, an Israeli citizen. The ensuing large-scale fund raising efforts resulted in the substantial sum of 1.2 million dollars, most of which originated from private donations. These contributions enabled the Israeli government to equip 5 medical teams and send them to Thailand, covering the last 2 months of 1979 and the first 4 months of 1980.
The first medical team, consisting of 5 physicians and 4 medics started i t s work in the camp of SaKaeo in Thailand on 4th November 1979.
This paper summarizes our experiences in this refugee camp.     

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)..     

Medical supplies management in the cholera epidemic in Somalia 1985

In March/April 1985 a cholera epidemic of explosive speed affected a population of 45,000 newly arrived refugees in the town of Hargeysa in the North-West region of Somalia. Seven hundred and sixty one people were killed by the disease within ten days. Great efforts were made on regional, national and international levels in order to reduce mortality and to control the spread of the disease, and large amounts of relief supplies were immediately flown into the country from various aid organizations and governments. This paper describes the supplies management during the operation, with an emphasis on the mobilization of supplies from abroad and from the capital into the emergency area. Recommendations are offered for the organization of medical supplies during cholera outbreaks. The author worked during the epidemic as co-ordinating secretary for relief supplies in Mogadishu.     

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.     

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.     

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.     

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.     

Anatomy of an ambush: security risks facing international humanitarian assistance

The 2003 war with Iraq has generated security concerns that present unique challenges to the practice of providing international humanitarian assistance during war and conflict. Objective research studies on security management are lacking. However, case studies have proven to be an important education and training tool to advance situational awareness of security risks. These challenges are illustrated by an analysis of the events surrounding the first ambush of, and assassination attempt on, a senior US aid official in Baghdad. Before deployment to conflict areas, especially those characterised by insurgent activity, humanitarian providers must realistically assess the threats to life and to the mission. They must obtain pre-deployment situational awareness education, security training and optimal protective equipment and vehicles.     

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.