A Tribute to Chris, Clare, Tommy and Louise Rolf and Sally Rockett

Member agencies of the British Refugee Council have been shocked by the murder of their colleagues and two of their children in Khartoum in May. But all have stressed the need to continue with the work which is so desperately needed to assist refugees not only in Sudan, but in the Horn of Africa and the rest of the continent.     

Repatriation of 150,000 sudanese refugees from ethiopia: the manipulation of civilians in a situation of civil conflict

This paper outlines the dramatic return to Sudan of 150,000 men, women and children from Itang Refugee Camp in Ethiopia in June 1991. These people were pawns in Sudan's civil war, manipulated by governments, military forces and the media – a state of affairs that the international community failed to deal with effectively. At the time of the return to Sudan, ICRC and the United Nations were working to assist the returnees in two different areas and each had a different access agreement and thus a different impact on the survival of the returnees. The paper focuses on the role of political awareness and negotiation in the protection of refugees and in the organisation of relief in the context of a civil war.     

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.     

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.     

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.     

Knowledge and Power: A Critique of an International Relief Operation

Exploring an alternative way to approach famine relief interventions, this paper draws on the work of French philosopher Michel Foucault and David Keen's recent work on south-west Sudan. It suggests that different discourses on 'famine' can lead to the dominance of certain kinds of institutional practices, and the prioritisation of special kinds of knowledge, at the expense of other modes of understanding and action. Using the case of the relief operation to Tigrayan refugees in eastern Sudan in 1984/5, the paper examines the specific ways in which 'power' was elaborated in the midst of the operation, and the manner in which institutional practices — designed to save as many lives as possible — influenced the reaction of international agencies to the spontaneous repatriation of the Tigrayans back to Ethiopia.     

From food aid to livelihoods support: rethinking the role of WFP in eastern Sudan

Despite more than 20 years of distribution of free emergency food in eastern Sudan (38 years in the case of refugees) Global Acute Malnutrition rates are currently the highest in the country. There has been no real improvement in the chronic livelihoods vulnerability that affects people in the region—particularly pastoralists. Food security must be seen from an informed livelihoods perspective. While food aid may still be required as part of transition, WFP must rethink its assistance strategy and advocate for complementarity in the efforts by development actors working across a range of sectors. Alternative models and interventions focused on the rehabilitation of markets and the development of' cargo nets' for the destitute, including cash transfers, must be developed and tested. Land tenure issues should be given particular attention. Food aid will probably remain an important element in the overall response, but its significance relative to other less developed forms of interventions should be reassessed.     

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)..     

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.     

The Mortality Experience of Kurdish Refugees Remaining in Turkey

A survey of one of the camps still holding refugees from Iraq who crossed into Turkey in the spring of 1991 showed that the majority of the population was under 15 years of age and that increased mortality occurred during the first 30 days after the refugees left their homes in Iraq. Infants, young children, and the elderly suffered the highest mortality, with infant mortality rates (IMRs) over the first month of the crisis approximately 18–29 times the MR in Iraq in the late 1980s. Still unexplained is a greater than two-fold excess mortality among males compared with females. Other demographic and health findings are also reported.     

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.     

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 Prevention and Mitigation of Famine: Policy Lessons from Botswana and Sudan

Botswana and Sudan experienced consecutive years of drought in the 1980s. Sudan faced a large decline in food entitlement and nutritional deterioration, which translated into famine in 1984/85. Botswana, on the other hand, nearly compensated income losses and averted nutritional deterioration and famine-related deaths. There are important lessons to learn from the famine prevention experience of Botswana. Its strategy for dealing with drought and famine combines policies of steady economic growth with supplementary poverty alleviation and drought relief programs. To provide continuity and stabilization of market operations in times of distress, the country channels sufficient food through market chains, provides price support to preempt market collapse and augments the income of consumers through public income transfer programs to prevent demand failure. In addition, it maintains a responsive and accountable political system and a decentralized participatory administrative structure. While Sudan should develop policies that are compatible with its own environment, it is crucial that it recognizes the critical role of public action in promoting growth, alleviating poverty, and providing timely relief responses in times of anticipated growth failure.     

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.     

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.     

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.     

The dual imperative in refugee research: some methodological and ethical considerations in social science research on forced migration

Social scientists doing fieldwork in humanitarian situations often face a dual imperative: research should be both academically sound and policy relevant. We argue that much of the current research on forced migration is based on unsound methodology, and that the data and subsequent policy conclusions are often flawed or ethically suspect. This paper identifies some key methodological and ethical problems confronting social scientists studying forced migrants or their hosts. These problems include non-representativeness and bias, issues arising from working in unfamiliar contexts including translation and the use of local researchers, and ethical dilemmas including security and confidentiality issues and whether researchers are doing enough to 'do no harm'. The second part of the paper reviews the authors' own efforts to conduct research on urban refugees in Johannesburg. It concludes that while there is no single 'best practice' for refugee research, refugee studies would advance its academic and policy relevance by more seriously considering methodological and ethical concerns.     

The resilience of households to famine in el fasher, Sudan, 1982-89

This paper examines issues related to famine resilience and describes the results of a survey of households who migrated from famine affected rural communities in Northern Darfur to the provincial capital, El Fasher, in western Sudan. It reveals that asset wealth did not enhance household resilience to famine; rather, the data indicate that households who reportedly practiced more numerous survival strategies before migrating to El Fasher were on the whole able to stay longer in their villages before migrating. The data also suggest that some households might have been better able to endure the deteriorating rural conditions by participating in intra-communal practices of sharing resources. An additional issue influencing the timing of migration to El Fasher is previous familiarity with the economic opportunities in the provincial capital.