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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