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Refugee Health Care
Timothy Myrick MD University of Missouri Kansas City Family Medicine
Attribution
ò This lecture contains some material from the Johns Hopkins School of Public Health series called “Refugee Health Care” by Gilbert Burnham.
ò This material used under a Creative Commons license.
Disclosure
ò I have no conflict of interest to disclose
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Learning Objectives
ò Understand the scope of the worldwide refugee situation
ò Know basic issues involved in meeting the needs of refugees
ò Explain differences between problems faced by refugees in camps, and those in cities.
ò Describe subjective experiences of refugee caregivers
Introduction
ò Refugee health care is becoming a more pressing issue each year. There are more refugees seeking asylum now than at any time since the end of WWII.
ò UNHCR estimates more than 51 million people are uprooted.
ò Among these are around 11.7 million refugees, and 23.9 million IDP
Definitions
ò Refugee:
ò Fear of persecution- race, religion, politics, social group
ò Outside their nation
ò Cannot be protected by that nation
ò Internally displaced persons (IDP)
ò Forced to flee home for above reasons
ò Remain inside their nation
ò May be more vulnerable than refugees
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Numbers
ò 2.5 million Afghans, largely in Pakistan
ò 3.9 million Syrian refugees, 1 million in Lebanon, making 25% of the total population
ò 6.5 million internally displaced people in Syria, mostly without any access to external aid
ò 350K of the 1million Somalis refugees in Dadaab, founded in 1994
ò 120K in camps on Thai border founded in 1984
ò 5 million Palestinians in camps dating from 1949
Problems
ò 86% of refugees hosted in developing countries
ò Refugees divided between camps and cities
ò Severe strain on existing systems of public health, medical care, schooling, water, sewage, waste disposal, roads, environment, and politics.
ò Refugees are needier that migrants
ò Loss of assets, and experience of trauma
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Unique Needs
ò Most refugees are fleeing violence
ò Refugees need more help for a longer time than migrants or victims of natural disasters
ò Breakdown in political system leads to war, chaos, and displacement of people.
ò Access to refugees becoming more difficult
UNHCR and Asylum
ò Asylum—protection, refuge, security
ò Right of asylum established in 1948 UN Universal Declaration of Human Rights
ò Basic premise of UNHCR foundation in 1950 with mandate to protect refugees
ò Refugee rights and responsibilities defined by 1951 Convention
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Refugee Rights
ò Not be punished for entry or expelled
ò Work, housing, education, public assistance, courts
ò Religious freedom
ò Right to move about
ò Right to ID and travel documents
Convention and protocol relating to the status of refugees UNHCR.org
Whose Responsibility?
ò State—responsible for its own citizens
ò Host country—poor, resources limited
ò UN—not an implementing agency
ò Non-governmental organizations are implementing partners of UN
ò For example Red Cross, CARE, and MSF
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Syria
ò Jan 28, 2011- Limited anti-government protests begin
ò Mar 20- Police fire on demonstrators. Gov’t bldgs burned
ò July 29- Free Syrian Army forms, based in Turkey
ò Jan 2012- large scale artillery bombardment of homes
ò June 12, 2012 UN declares Syria in a state of war
ò July 28, 2012- Zaatari camp opened
Refugee Emergencies
ò Pre-Emergency Phase
ò Emergency Phase
ò Post-Emergency/ Maintenance Phase
ò Repatriation Phase
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Pre-emergency
ò Time for intervention
ò Negotiation
ò Mitigation
ò Preparation for emergency
Emergency
ò Defined by crude death rate (deaths/1,000/yr)
ò Normal CDR for sub-Saharan Africa 0.5– 0.9 deaths per 10,000 persons per day
ò Death rates > 1/10,000/day – May approach 10/10,000/day
ò Death rates may be 5–60 times higher than the normal rates
World Crude Death Rates
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Mortality
ò A few conditions account for 60 to 80 per cent of refugee deaths
ò Measles
ò Diarrheal diseases
ò Acute respiratory infections
ò Malaria
ò Malnutrition is both a primary and secondary cause of death. This is most pronounced among children under five years of age.
Malnutrition
ò Protein-Energy-Malnutrition (PEM) most common
ò Micronutrient deficiency diseases reported among refugees entirely dependent on external food aid.
ò Pellagra among the Mozambicans in Malawi
ò Scurvy in the Horn of Africa
ò Beriberi in South-East Asia.
ò Preventable by timely provision of food of adequate quality and quantity to meet the daily minimum requirements.
Emergency priorities
ò Water- 20L/person/dy
ò Food- 2100 calories/person/day
ò Shelter-
ò 30sqm/person in settlement
ò 3sqm/person in shelter
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Emergency health needs
ò Treatment of common acute diseases
ò Prevention of epidemic diseases
ò Measles
ò Cholera
ò Shigella
ò Basic health information system
Emergency health needs
ò Prevent endemic disease
ò Typhus
ò Lice
ò Scabies
ò Prevent injuries
ò Household
ò Conflict violence
ò Sexual assault
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Maintenance Phase
ò Death rates < 1/10,000 persons/day
ò Basic services of food, water, and shelter in place plus:
ò Fuel- 1kg/pax/dy
ò Sanitation- 1toilet/20pax or per family
ò Solid and medical waste disposal
ò Health services
Maintenance
ò Security and safety situation improved
ò Improving infrastructure and community structure
ò Gardens and income generating initiatives
ò Increased use of refugee community health workers and refugee health professionals
ò Improving efficiency of systems
ò Prevent environmental degradation
Maintenance Health Systems
ò Improving health information system
ò Standard case definitions and protocols
ò Developing referral system in host country
ò Emphasis on specialized programs
ò Mental health
ò TB control
ò Reproductive health
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Special Issues
ò Security
ò Place of settlement
ò Stress
ò Mental health
ò Dependency
ò Host guest relations
Security
ò Raids from country of origin
ò Recruitment by insurgents
ò Exploitation by host country
ò Protection of vulnerable
ò Protection of relief workers
ò Prevention of forced repatriation
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Place of settlement
ò In Camps
ò UNHCR and partners
ò Provision of needs
ò Limited movement
ò Urban Refugees
ò Freedom to move and work
ò Uncertain legal status
ò Exposed to conflict with hosts/insurgents/opportunists
Host guest relations
ò Conflict over resources, especially water
ò Glut of cheap labor
ò Burden on schools and health care facilities
ò Political imbalance in host country exacerbated by guests
ò Wealthy donors and valuable resources go to guests
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Stress
ò Emotional trauma of displacement
ò Pre-existing mental illness exacerbated
ò Resettlement/repatriation stress
ò Adolescent issues
ò PTSD
Mental health services
ò Low priority in acute settings
ò Single episodes of emotional disorders
ò Mental health issues common
ò Community efforts major resource
ò Violence and delayed social development
ò Role of traditions and cultural activities
Dependency
ò Create dependency by providing essential services
ò Food
ò Health care
ò Environmental health
ò Or enabling community to meet needs
ò Community power structure
ò Allow local trade and service economy
ò Food allotment vs currency allowance
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Politics
ò Everything about refugee situations is political
ò Origins of the crisis
ò Care of the people
ò Persistence of the situation
ò Resolution
Available Solutions
ò Repatriation
ò Voluntary return to home of origin
ò Always most desirable
ò Must be preceded by political change
ò Integration
ò less common unless similar culture or language
ò Resettlement in a third country
ò Most difficult and time consuming
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Repatriation Phase
ò Return home is usually spontaneous
ò Refugees make their own decisions
ò Most refugees return unassisted
NGOs in Repatriation
ò Provide information to inform decisions
ò Restore lost IDs and papers
ò Assist refugees returning
ò Rehabilitate essential services in country of origin
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Closure
ò Relief organizations relinquish control
ò Development-oriented national NGOs
ò Community-based organizations
ò Reliance on refugees for sustainability
ò Training to promote repatriation
ò Treaties, laws, court decisions, and other political solutions
