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11.9 Refugees and other displaced populations

11.9 Refugees and other displaced populations
Oxford Textbook of Public Health

11.9
Refugees and other displaced populations

Mohamed Dualeh and Paul Shears

Introduction
Implications for public health
Public health priorities
Health needs assessment
Communicable disease, nutrition, and public health

Diarrhoeal diseases

Measles

Acute respiratory infections

Malnutrition

Malaria

Other health problems

Micronutrient deficiencies

Vaccine-preventable diseases (excluding measles)

Reproductive health

Mental health and psychosocial needs
Land mines and public health
Essential drugs management

The new emergency health kit

Donation guidelines
Monitoring and surveillance: the health information system
Co-ordination of health services

Co-ordination mechanisms in emergencies
Conclusion
Chapter References

Introduction
Large-scale movements of refugees and other forced migrants have become a defining feature of the contemporary world. At few times in recent history have such large numbers of people in so many parts of the globe been obliged to leave their own countries and communities to seek safety elsewhere. The global refugee problem confronts the world with a range of practical and ethical dilemmas. Refugees and other displaced persons will continue to find refuge in remote regions (with limited infrastructures) where the provision of basic health care requires innovative approaches to the implementation of appropriate public health interventions.
The thrust of this chapter is to address the public health issues encountered by this population and how the international community can respond more effectively and expeditiously to large and sudden movements of displaced people. It provides a general framework of the priority health problems encountered by displaced people, and advocates the development of mutual awareness and shared understanding for a common approach.
Refugees are defined as people who have crossed international borders fleeing war or persecution for reason of race, religion, nationality, or membership of particular social and political groups. They are protected by several international conventions and protocols (UNHCR 1967). In contrast, persons who flee their homes for the same reason as refugees but who remain inside their own countries enjoy no such legal status. These ‘internally displaced’ persons are in a particularly precarious situation because they are often beyond the reach of international agencies, which rely on the co-operation of national governments to deliver relief aid. They are victims of civil strife or natural disaster within their own country (Fig. 1).

Fig. 1 Estimated numbers of convention refugees, 1989–1998.

Other important categories of displaced populations include economic migrants, seasonal workers, illegal aliens, and migrants from rural areas to urban centres. These groups are displaced populations who have left their own area because of disaster, environmental deterioration, or economic hardship; all of which reasons fall outside the judicial definition of convention refugees. However, there are broad commonalties of the public health needs of all migrant populations, as they encounter similar conditions of displacement in their new environment.
Apart from the primary reasons which initiate migration (political, economic, social, etc.), other factors also influence population movement and mobility, and so further the risk of increased transmission of diseases. It is important to consider the influence of time in this process. Rapid migration will have less health impact than a journey of long duration. Internal migration is a common phenomenon in all continents, and particularly in developing countries. It is most marked in South and East Asia—China, India, Vietnam, and Myanmar. This is also true for Africa and Latin America. China now has internal migration on a large scale, with between 80 and 100 million persons travelling within the country (IOM 1998). Many of these so-called ‘floating populations’, or surplus rural labour, travel in search of work. Many live in shanty towns where there is no basic public health infrastructure—water, sanitation, garbage disposal, etc. The public health implications in these surroundings are enormous, as overcrowding, poor living conditions, and the lack of basic health services for these populations are common characteristics for migrant populations.
Displaced people are victims of the political and social crises which affect our time; governments that refuse to respect human rights of their citizens; narrow-minded armed factions which use political goals as an impetus for personal or communal ambition, and social and religious groups which cannot tolerate alternative opinions and lifestyles. In addition, deep-rooted trends such as the growing inequality within and between nations; the rapid increase of the global population; and the depletion of the world’s natural resources have a major impact on the movement of populations. Since the beginning of the 1990s, the world has witnessed a succession of internal armed conflicts that have led to major humanitarian emergencies and massive refugee movements; Iraq, Liberia, Rwanda, Somalia, Sri Lanka, and the former Yugoslavia are some of the most prominent examples. During the first quarter of 1998, the number of people of concern to UNHCR worldwide was 21.2 million. Most of these people were living in Africa, Asia, and Europe. Slightly more than half of them were refugees; the remainder were internally displaced persons, returnees, asylum seekers, and stateless persons. In addition, the international community has witnessed, during the twentieth century, an unprecedented development of mega-cities and big towns as a result of internal migration from rural areas to urban centres.
Analysis of trends in the global refugee population during the period 1989 to 1998 indicate that the estimated refugee population in 1998 was the lowest for the past 10 years. At the same time there has been a marked increase of the internally displaced in war-affected countries and population movements from least developing countries in the south to the more prosperous and highly industrialized countries in the north (Table 1).

Table 1 Refugees and others of concern to UNHCR, 31 December 1998

Implications for public health
Displaced people are often suffering the devastating effects of exhaustion, bereavement, separation from loved ones, ill health or injury, separation from family and community, poor shelter, inadequate nutrition and food availability, poor water supplies, and impoverishment (Toole and Waldman 1993; Toole et al. 1993).
Over the past three decades the most common emergencies affecting the health of large populations in developing countries have been associated with famine and forced migration (CDC 1992). Public health, depending as it does on so many non-medical factors, is too large a subject to be left only to medical workers (UNHCR 1999). In an emergency, many refugees will be exposed to insecurity, poor shelter, overcrowding, and lack of sufficient safe water, inadequate or inappropriate food supplies and a possible lack of immunity to the diseases of the new environment. Furthermore, on arrival, displaced persons may be in a debilitated state from disease, malnutrition, hunger, fatigue, harassment, physical violence, and grief. Poverty, powerlessness, and social instability, conditions that often prevail for refugees and other displace populations, can also contribute to increased sexual violence and spread of sexually transmitted diseases (STDs) including HIV.
In many conflict areas, the residual effect of land mines after the cessation of hostilities has resulted in a new and potentially devastating public health problem. As well as the physical components of public health, there is now an increasing awareness of the impact of displacement, insecurity, and refugee status on the mental health of affected communities. These various components of the wider concept of public health among refugee and displaced communities are described in this chapter.
Public health priorities
Displacement is a situation where needs are great, human and material resources are scarce, and action must be immediate. Health staff cannot deal with everything at once; they must assign priorities to problems. The emotional and physical stress of working in an emergency may cause intense anxiety and one of the survival mechanisms sometimes adopted unconsciously by inexperienced relief workers is to focus all of their energies upon conditions or activities with which they feel comfortable. Unfortunately, these often tend to be low-priority areas such as reconstructive surgery, tuberculosis control, or unreasonably detailed epidemiological studies often conducted by academics for research purposes only. Such misplaced emphasis is a gross error. The challenge is how to alleviate the suffering and prevent unnecessary loss of life with limited resources.
Health services for refugees and other displaced populations are based upon the well-known principles of primary health care, which normally underpin the pre-existing health structures of the national ministries of health. Another principle that must be woven through the fabric of the entire health programme is that of outreach. This principle means services must, as far as possible, be taken to the refugees and other migrant populations. Outreach is particularly important in non-camp situations where refugees or other displaced populations are scattered among local villages or in shanty towns located at the peripheries of major cities in the developing world. Cultural practices may preclude some portion of the population such as refugee women from attending clinics. This type of cultural obstacle is often exacerbated rather than relaxed in the context of a refugee or other displaced setting in which traditions are reinforced to counter rapid changes.
Whenever people are uprooted, for whatever reason, they are placed at an increased risk of disease and death. This holds true for persons suddenly fleeing their homes, but also, to a lesser extent, for refugees involved in voluntary repatriation. The sudden migration of people is associated with high mortality (Toole and Waldman 1997). The movement per se determines the risk. The public health consequences of mass population displacement have been extensively documented. The most severe consequences of population displacement have occurred during the acute emergency phase, when relief efforts are in the early stage. In some cases, deaths during this phase were 60 times the crude mortality rate among non-refugee populations in the country of origin (Toole and Waldman 1990). In the first few weeks, mortality rates were high in all Kurdish refugee camps with a rate 45 times higher than expected in the Iraqi citizen population (CDC 1991). The death rates in Zaire (34.1–54.5 deaths per 10 000 per day) were among the highest to be documented during recent population displacements (CDC 1994). Existing epidemiological data have effectively demonstrated those health problems that consistently cause deaths and severe morbidity. Even in normal migrations, recent studies showed also an increasing mortality among migrants to China: the crude death rate rose from 28.9 per 1000 in 1995, to 45.6 per 1000 in 1996, and to 56.0 per 1000 in 1997 (Robinson et al. 1999).
Health needs assessment
The initial assessment determines as accurately as possible the health and nutritional effects of a displacement, identifies the health needs, and establishes priority interventions for health programming. The refugees and other displaced populations, relief agencies, donors, and local authorities need to know that interventions are appropriate and effective. Analysis of the effects of the displacement and of the impact of the proposed health activities is therefore critical. If problems are not correctly identified and understood then it will be difficult, if not impossible, to implement the right response. Assessment of health needs of refugees and other displaced populations aim at:

assessing the magnitude of the displacement

determining major health and nutrition needs of the affected population

initiating a health and nutrition surveillance system

assessing the immediate needs and the local capacity

identifying strengths and weaknesses of the existing co-ordination mechanisms

ensuring the inclusion of local expertise (technical capacities) in the planning process

defining existing constraints to expand and accelerate the response.
Assessments for emergency health projects aim to determine what the reality of the emergency situation is, which improvements are required, and the action needed to implement them. The initial assessment and subsequent health information analyses should demonstrate an awareness of underlying structural, political, economic, and environmental issues operating in the area. The current and pre-emergency living conditions of displaced and non-displaced people in the area and local resources must be considered. At every step the inclusion of local expertise and knowledge in data collection and analysis of resources, capabilities, vulnerabilities, and needs is important. The needs of groups that are at risk such as women, children, elderly people, and mentally disturbed persons must be considered (WHO 1996; IFRC 1998).
Communicable disease, nutrition, and public health
In emergencies that are characterized by large numbers of civilian casualties, including earthquakes, cyclones, and war, trauma-related injuries and deaths are the major causes of morbidity and mortality in the immediate aftermath of the disaster. However, in most situations of mass refugee exodus and population displacement, and in the weeks and months following acute disasters where infrastructure and health services are not immediately restored, communicable diseases and malnutrition represent the greatest risks to the affected communities. From the evidence of past refugee and displaced population crises, it is possible to categorize these risks into priorities for public health action.
The major contributing and causal factors of ill health are:

overcrowded living conditions which facilitate increased transmission of infectious diseases

poor nutritional status (and consequent lowered immunity) due to lack of adequate food before, during, and after displacement

inadequate quantity and quality of water to sustain health and allow personal hygiene, and poor sanitation facilities.
It is self-evident that the trauma prior to and during their exodus is all-important in determining the health status of refugees on arrival in the country of asylum. Nevertheless, observers sometimes forget these rigours of flight. The possibly moribund condition of refugees and other displaced populations who may have just trekked for several weeks through war-torn and famished countryside can be falsely attributed to inadequate care on arrival. During flight, refugees and other migrant populations may have little or no food and no clean water; they may not be able to stop anywhere to cook or allow children or pregnant women to rest, and they may be exposed to rain or extremes of cold or heat for long periods. Harassment, physical violence, and grief will, in many cases, have added to the trauma of flight. All these elements combine to reduce the physical and emotional reserves of the affected population, and the natural resistance to disease is thus compromised.
Diarrhoeal diseases, measles, acute respiratory infections, malnutrition, and malaria constitute the top five recorded causes of morbidity and mortality (CDC 1992).
Diarrhoeal diseases
The crowded and insanitary conditions of refugees and displaced groups create an environment in which faecal–oral infections are rapidly transmitted. Studies in Somalia, Ethiopia, Mozambique, and Malawi have all demonstrated the high morbidity and mortality caused by diarrhoeal diseases in these communities (Shears 1991).
Epidemiology
In the early weeks of a refugee exodus, both water supplies and sanitation are likely to be inadequate. Natural water sources, such as rivers, wells, and ponds, rapidly become polluted as an increasing population uses them in an uncontrolled way. Excreta is invariably disposed of indiscriminately, with potential contamination of water supplies and the household environment, leading to contamination of both food and stored water.
The spread of enteric infections in such conditions has occurred in different refugee situations, ranging from mass exodus in tropical Africa to displacement in the former Soviet Union. The spectrum of diarrhoeal diseases ranges from increases in rates of infantile gastroenteritis to specific outbreaks of cholera, typhoid, and bacillary dysentery.
Gastroenteritis has been responsible for 30 to 40 per cent of all reported childhood illnesses in most refugee situations where surveillance data has been collected. Among malnourished children, mortality rates due to gastroenteritis have been as high as 30 per cent.
The massive outbreaks of cholera and dysentery that occurred among Rwandan refugees in 1994 in the former Zaire represent one of the greatest public health disasters reported among refugee communities. Over a period of 4 weeks, an estimated 80 000 cases, and 15 000 to 20 000 deaths, occurred from the use of polluted untreated water. The use of polluted untreated water, extreme difficulty of latrine construction in the rocky soil, and difficulties in organizing treatment centres all contributed to the high transmission and mortality rates (Goma Epidemiology Group 1995).
Control of diarrhoeal disease outbreaks among refugee and displaced populations requires both urgent public health interventions, and appropriate and timely case management. The public health priorities are the prevention of faecal contamination of water supplies, the provision of adequate quantities of water from protected natural sources, and the organization of simple but effective latrines (Medècins sans Frontières 1994).
In the majority of cases treatment of diarrhoea is based on early detection of cases and effective oral rehydration, preferably organized through community-level health workers, using standardized protocols according to the degree of dehydration.
Outbreaks of cholera may involve large numbers of patients initially requiring intravenous rehydration. Table 2 summarizes the rehydration strategies for diarrhoea and cholera cases. If appropriate intravenous therapy is implemented early in the course of cholera, mortality rates should be less than 3 per cent. However, where numbers overwhelm the medical staff and supplies are limited, as occurred in the early stages of the Goma epidemic, mortality rates in excess of 20 per cent may occur. Detailed analysis of the cholera management in Goma highlighted a number of reasons for the high mortality rates including delayed diagnosis, slow rates of rehydration, and inadequate experience of health work (Siddique et al. 1995).

Table 2 Rehydration regimens for patients (more than 1 year old) with diarrhoea and cholera

Outbreaks of Shigella dysenteriae type 1 have been less extensive than cholera in refugee communities, but may be associated with significant morbidity and mortality. In Central Africa, outbreaks of S. dysenteriae type 1 among displaced communities have occurred in Burundi, Zaire, and Tanzania (Engels et al. 1995).
Shigella dysentery is highly contagious as only 10 to 100 organisms are required for transmission of disease. In crowded refugee camps with inadequate hygiene, attack rates may exceed 30 per cent.
In the absence of laboratory facilities, an appropriate clinical case definition should be agreed upon so that early detection of an increasing number of cases is possible. Where possible, stool specimens from representative cases should be collected to confirm the causative organism and determine antimicrobial resistance patterns. Multiple antimicrobial resistance in S. dysentriae is rapidly increasing globally. In outbreaks of shigellosis among refugees in Zaire and Burundi, strains resistant to all locally available antimicrobials, including nalidixic acid were responsible, requiring the use of fluoroquinolones such as ciprofloxacin.
Management of outbreaks of shigellosis requires early detection and treatment of cases, and improvements in hygiene both generally in the camp but particularly within refugee living areas as most transmission is within households rather than from a communal water or food source. Case management may involve using special treatment centres, with antimicrobial therapy for the most severe cases, and the young, elderly, and malnourished, and supportive therapy of hydration and nutrition for all cases. The use of antimicrobials must be decided according to the local conditions, depending on the severity of illness, knowledge of antimicrobial sensitivity patterns of local strains, availability of antimicrobials, and likelihood of compliance with antimicrobial treatment. The World Health Organization (WHO) guidelines are to use a 5-day course of nalidixic acid as the mainstay of therapy. However, studies in recent epidemics have shown increasing resistance to nalidixic acid, requiring the use of ciprofloxacin. Control measures must involve improved hygiene within refugee living areas, particularly safe handling of food and water, the provision of soap, and attempts to improve safe disposal of faeces.
Epidemics of bloody diarrhoea caused by Escherichia coli 0157, initially thought to be shigellosis, have occurred in refugee communities in southern Africa. Laboratory investigations are necessary to distinguish the causative agent.
Measles
Measles has been consistently reported as one of the major causes of morbidity and mortality among children in refugee camps, particularly in Africa but also in other areas (Toole et al. 1989). Where there is a high prevalence of malnutrition, measles case-fatality rates may reach 30 per cent. Morbidity and mortality in measles are complicated by vitamin A deficiency, diarrhoeal disease, and lower respiratory tract infections (Shears et al. 1987).
Mass immunization against measles is an absolute priority in most refugee situations. In areas where displacement has occurred following several years of civil unrest, it is likely that recent immunization coverage rates will be low. Even where coverage rates are 60 to 80 per cent, there will be large numbers of non-immune children, with risk factors of malnutrition and crowding, resulting in high rates of measles transmission and morbidity.
Children with measles are at a high risk of worsening malnutrition, vitamin A deficiency, diarrhoea, and secondary respiratory infections, with each of these factors contributing to the high mortality rates that have occurred. The management of individual cases will require attention to the above medical complications, and demands a high degree of clinical staff input. It is for these reasons that effective measles immunization must be organized at a very early stage in the relief process.
There are now agreed strategies for implementing mass measles immunization ampaigns among refugee and displaced communities (Toole et al. 1989) and ‘immunization’ kits, enabling the necessary cold chain to be maintained, and vaccine, needles, and syringes to be available in the most remote locations (Fig. 2).

Fig. 2 Components of a mass measles immunization programme in refugee and displaced communities.

Effective mass measles immunization in refugee communities should have as its target over 90 per cent coverage of all children aged between 6 months and 12 to 15 years. These recommendations differ from the standard Expanded Programme for Immunization recommendations, but are based on the epidemiological evidence of measles outbreaks in these communities, and the increased risk factors they face. Where numbers are overwhelming and resources are limited, an initial programme to achieve high coverage of children aged 6 months to 5 years may be justified, but it is essential that it is rapidly followed by a programme to cover the older age group.
As high coverage is essential for the measles immunization strategy to be effective, the immunization campaign must be based on an accurate census of the target population, full participation of the community, and accurate registration of the vaccines. There is no justification for an initial measles programme based on random clinic attendance, or unplanned house-to-house visiting.
It is recommended that vitamin A supplementation is linked to the measles immunization campaign, with a dose of 200 000 IU being administered orally to each child at the time of immunization. Where the camps are receiving new arrivals, the immunization campaign must be extended to provide immunization on arrival.
The initial mass campaign must evolve into an ongoing campaign for the following groups:

children missed by the initial campaign

new arrivals

children vaccinated in the age group 6 to 9 months who should receive a second dose after age 9 months

new groups of children reaching the age of 6 months.
Follow-up of the immunization programme is essential to ensure that adequate coverage was achieved, and to locate children who may not have been included.
Acute respiratory infections
Acute respiratory infections are an important cause of morbidity and mortality among children in refugee camps in both tropical and temperate areas. Risk factors for increased morbidity include crowding, poor shelter, vitamin A deficiency, and malnutrition (Toole and Waldman 1990). Studies among displaced communities ranging from regions of Nepal and Iran to Africa and Central America have all shown acute respiratory infection to be responsible for 30 to 40 per cent of morbidity (Desenclos et al. 1990; Babille et al. 1994).
Strategies to reduce the morbidity of acute respiratory tract infections include both minimizing risk factors and providing appropriate accessible management.
In camps where crowding, malnutrition, measles, and pertussis are not controlled, acute respiratory infections will be responsible for excessive morbidity and mortality, even where treatment programmes are functioning, and emphasis must be given to preventing or minimizing these risk factors. Case management must be based on early recognition using an appropriate case definition, for example fever, cough, and respiratory rate greater than 50 breaths/min. While it will be difficult to differentiate virus and bacterial causes, standardized case management should include antimicrobial therapy, aimed at treating Streptococcus pneumoniae or Haemophilus influenzae infections.
For moderately ill children, the antimicrobial of choice is cotrimoxazole for ambulatory or home treatment. Supervision by community health workers to ensure antimicrobial compliance and adequate nutrition are essential. Severely ill children, particularly if malnourished, may initially require intravenous therapy, although the feasibility of this will depend on the staff and resources available.
Malnutrition
High rates of malnutrition among refugee and displaced communities are a major cause of increased morbidity and mortality. Malnutrition rates are likely to be highest among groups that have been displaced for extended periods in areas affected by crop failures resulting from drought or disease, and among war affected communities where agriculture and food distribution have been interrupted. Probably the single most important factor in predisposing refugees and other migrant populations to high mortality during the emergency phase is an inadequate food ration. Malnutrition has often been a major contributing factor to high death rates among refugees and internally displaced population. Conversely, as malnutrition takes weeks or months to develop, it does not occur in the early days following acute disasters such as earthquakes, floods, etc.
Malnutrition encompasses both protein-energy malnutrition, ranging from moderate malnutrition to severe cases of marasmus and kwashiorkor, and specific vitamin and mineral deficiencies.
Assessing nutrition status by cluster sample surveys is required to determine the prevalence of malnutrition and follow up nutrition monitoring of all children is required to plan feeding programmes.
Nutrition status may be assessed by a range of anthropometric techniques, the most practical of which are mid upper-arm circumference and weight/height. Standardized cut-offs are used, which may occasionally need to be modified for different ethnic groups. Table 3 shows cut-off values which are generally accepted for assessing nutrition status in refugee and displaced communities.

Table 3 Cut-off values for assessment of protein-energy malnutrition for children aged 1 to 6 years

Malnutrition rates in excess of 30 per cent have been reported from refugees in the Horn of Africa and in earlier studies among Myanmar refugees in Bangladesh (Aall 1979). Several studies have demonstrated the increased mortality associated with malnutrition (Nieburg et al. 1992; Yip and Sharp 1993).
The management and prevention of malnutrition are based on the following strategies.

An adequate general ration for the whole community.

Targeted (selective) feeding:

supplementary feeding for moderately malnourished children

therapeutic feeding to severely malnourished children

mass (blanket) supplementary feeding to all children if excessive malnutrition rates

inclusion of other groups (e.g. pregnant and lactating women) where appropriate

older persons and medically sick cases.
Random untargeted food distribution, often initiated by well-meaning groups with little effective refugee experience, should be avoided.
The general ration should aim to provide a minimum of 2100 kcal (UNHCR/WFP 1997), with vitamin and mineral fortification where necessary. Distribution should be based on a highly organized system, involving family registration and assuming availability of utensils, fuel, and dry storage facilities. These aspects are not the direct responsibility of the health workers, but should be monitored as part of the health surveillance programme.
Supplementary feeding to moderately malnourished children should aim to provide an additional 500 to 1000 kcal/day assuming that the children are also receiving appropriate general rations. Moderately malnourished children must be registered, and progress monitored by weekly or monthly weighing. They should continue to receive supplementary foods until they have achieved 85 to 90 per cent weight/height. Supplementary feeding may be provided in specific feeding centres providing on-site meals or, with adequate community participation, by home distribution of supplementary foods.
Therapeutic feeding of severely malnourished children is demanding in terms of staff, time, and clinical input. Many of the severely malnourished children will have associated infections, particularly acute respiratory infections or diarrhoeal diseases, and mortality rates may be high despite nutrition and medical interventions. Therapeutic feeding will require four to five feeds per day, often by nasogastric tubes. In both supplementary and intensive feeding programmes, the primary object must be a food mix containing sufficient calories. Most correctly balanced relief foods will contain appropriate amounts of protein and mineral nutrients. It is particularly important that this is understood for children with kwashiorkor. Specifically high-protein foods, which are often donated in relief supplies are not appropriate. The aetiology of kwashiorkor is more complex than simple protein deficiency, and provision of high-protein diets has been shown to worsen the metabolic derangement associated with kwashiorkor.
The problems associated with infant formulas, milk products, and feeding bottles are exacerbated in an emergency. Clean safe water is essential but rarely available in most situations, and careful dilution of the feeds is of critical importance but difficult to control. Infant formulas, if unavoidable, should be distributed in health facilities under strictly controlled conditions and proper supervision. It is mandatory not to distribute feeding bottles in emergency situations as the associated risk is very significant.
Malaria
High rates of malaria transmission have occurred in many refugee camps in endemic malaria areas. Malaria has been reported as a major cause of morbidity and mortality in Southeast Asia, central and southern Africa, Central America, and parts of Afghanistan and Central Asia (Suleman 1988; Toole and Waldman 1990).
Malaria morbidity and mortality may be particularly high where non-immune communities have been displaced into hyperendemic areas, as has occurred in migration from highland to lowland Ethiopia (Kloos 1990), and where crowding, poor environmental control, and the peak malaria transmission season coincide.
Surveillance is particularly important in providing a basis for the appropriate management and control of malaria. In the absence of laboratory diagnosis, case definitions for malaria are often non-specific and it is likely that other causes of fever will be included. Wherever possible, a basic laboratory for examination of blood films should be established at refugee camps where malaria is thought to be a major problem. In hyperendemic areas, a clinical case definition should be combined with laboratory findings.
Strategies for the prevention and control of malaria, which may include vector control and the use of impregnated bednets, must be planned effectively, with input from personnel experienced in malaria control.
Early detection and appropriate management of cases is essential. With the increasing prevalence of resistance to antimalarial drugs in many areas, local expertise should be utilized in planning treatment schedules, and attention given to WHO guidelines (WHO 1991).
Other health problems
While the above are the priority public health problems in many refugee and displaced communities, a wide range of other communicable disease and nutrition problems may occur and be responsible for significant morbidity and mortality. Some of these conditions only become apparent after camps have been in existence for some months, for example tuberculosis, micronutrient deficiencies, or vaccine-preventable diseases apart from measles. Other diseases may have specific geographical locations, including typhus/relapsing fever, viral haemorrhagic fevers, and leishmaniasis. The impact of these conditions on refugee and displaced communities, and strategies for prevention and control, are described in below.
Tuberculosis
The control and management of tuberculosis presents difficult problems in displaced and refugee communities who may remain in camps for only limited periods of time. Decisions on when to initiate a tuberculosis programme, case definitions for treatment, which treatment regimens to use, and the relevance of contact tracing and BCG prophylaxis are all more complex than in settled communities. While small numbers of cases may be present during the emergency phase of a refugee programme, it is often in the postemergency phase that tuberculosis may become a major public health problem, when crowding and high transmission rates produce clinical and infectious cases. Several studies have shown the importance of tuberculosis in refugee camps in the postemergency phase, and the difficulties in treatment and control.
In a study among refugees in Somalia in 1982, over 50 per cent of patients started on treatment were lost to follow-up and of the 50 per cent remaining over 25 per cent were intermittent defaulters. In camps with less mobile populations and greater health resources, improved follow-up and compliance are possible, but where such conditions are not met, poor compliance and treatment failures will continue.
The difficulties of effectively controlling and treating tuberculosis in such situations have led to the development of standardized guidelines for refugee and displaced communities (WHO 1997). The principal components of these guidelines are as follows.

The emergency phase is over, and water, sanitation, nutrition, measles immunization, and essential clinical services are all adequately met.

The stability of the camp is envisaged for at least 6 months, preferably longer, and the implementing organization, particularly if a foreign relief agency, is committed to maintaining the programme.

The programme is based on passive case-finding and diagnosis by smear microscopy.

Treatment by directly observed therapy (DOT) using short-course chemotherapy.

Monitoring of tuberculosis patients by a standardized recording and reporting system.
It is important, where possible, that the decision to implement a tuberculosis control programme among refugee and displaced groups involves the national tuberculosis programme co-ordinators of the host country.
The recommended (adult) treatment regimen is that proposed within the WHO DOT guidelines:

intensive phase (2 months): rifampicin, isoniazid, pyrazinamide, and ethambutol, under direct supervision, given daily or three times weekly

maintenance phase (4 months) rifampicin and isoniazid given three times per week under direct supervision.
The priority in a tuberculosis control programme in refugee and displaced communities is to interrupt transmission by effectively treating sputum smear positive patients. Decisions to treat pulmonary smear negative and extrapulmonary cases must be made according to the local circumstances, but they should form only a small part of the tuberculosis programme.
Treatment of children with suspected tuberculosis, requires a careful assessment of each child, and often a trial period of supervised improved nutrition and management of other possible infections. The WHO guidelines provide a useful scoring system to assist the diagnosis and management of tuberculosis in children.
Meningococcal meningitis
Although limited to specific geographical areas, outbreaks of meningococcal meningitis (primarily Neisseria meningitidis serogroup A) have occurred among refugees in many locations ranging from the ‘meningitis belt’ of sub-Saharan Africa to camps in northern Thailand. The pattern of crowding, poor hygiene, and (often) delayed recognition of cases can result in extensive epidemics with significant mortality.
The greatest potential risk is among refugee and displaced communities in the African meningitis belt, particularly if the displacement is in a year and season when meningococcal transmission is likely to be high.
Prevention and control of meningococcal meningitis outbreaks is based on surveillance, case management, and, where appropriate, mass immunization.
Effective surveillance is essential if the first few cases, which may indicate the beginning of an epidemic, are to be detected. Case definitions must be appropriate to the resources that exist, but wherever possible should include laboratory confirmation by latex agglutination, Gram stain, or culture of the first reported cases (WHO 1995).
Several epidemiological studies have attempted to define epidemic ‘threshold’, based on the number of new cases per 100 000 in defined time periods, to predict the potential for an epidemic and the need to initiate mass immunization. In an extensive study in Burkina Faso, it was found a rate of 15 or more new cases per 100 000 per week, averaged over 2 consecutive weeks, had a high positive predictive value for detecting epidemic levels of disease. These data were determined from a large population base, not living in the crowded conditions of refugee camps, and modifications are required in displaced communities. In refugee camps with populations below 30 000 and where the occurrence of cases is not part of a wider epidemic, simple guidelines such as weekly doubling of cases over a 3-week period have been suggested (Moore et al. 1990).
Once a locally appropriate epidemic threshold has been reached, a mass immunization campaign must be implemented within 10 to 14 days if it is to have an impact on controlling the outbreak. Immunization should attempt to cover the age range from 6 months to 30 years. The decision to initiate a meningococcal immunization campaign must be weighed against other priorities within the camp health programme, particularly in the acute phase of an emergency, when measles, malnutrition, and inadequate water and sanitation may be much greater risk factors for morbidity and mortality.
Early detection and treatment of cases is essential to reduce morbidity and mortality. Cases may not be brought to health centres, and case-finding by community health workers will be necessary. Several studies have shown that a single intramuscular dose of long-acting chloramphericol is an effective treatment in the majority of cases, certainly in Africa meningococcal septicaemia and severe complications seem relatively uncommon.
Chemoprophylaxis of case contacts in refugee settings is not considered to be appropriate, as it is difficult in a crowded refugee camp to define ‘close contacts’, recolonization may occur rapidly in the crowded conditions, and with increasing prevalence of sulphonamide-resistant strains, widespread use of rifampicin would be required, which would be both expensive and undesirable in the context of restricting the availability of antimicrobials.
Relapsing fever and typhus
Relapsing fever (Borrelia recurrentis and Borrelia duttoni) and typhus fever (Rickettsia spp.) have limited geographical foci, but have occasionally caused outbreaks in refugee communities.
Both epidemic (louse-borne) relapsing fever and louse-borne typhus (Rickettsia prowazeki) are endemic in the highlands of Ethiopia, and have caused major epidemics among displaced communities in that area (Brown et al. 1988). In 1999, an epidemic of louse-borne relapsing fever was reported among displaced groups in war-affected areas of southern Sudan. Epidemic typhus has recently caused outbreaks among displaced communities in Burundi and Rwanda.
The prevention of both louse-borne relapsing fever and epidemic typhus is based on delousing the affected community and preventing further lice infestation by reducing crowding and improving hygiene. Delousing campaigns require major logistical input, and continued further surveillance to determine effectiveness (Thomson 1995).
Surveillance for possible cases is essential in detecting outbreaks, and ensuring appropriate case management. Because of the non-specific clinical picture, where possible initial relapsing fever cases should be confirmed by detection of Borrelia in blood films. Recommended antimicrobial treatment is a single oral dose of tetracycline or doxycycline. Because of the risk of a Herxheimer reaction, patients should be monitored during treatment. For epidemic typhus, treatment is a single dose of doxycycline or chloramphemicol.
Outbreaks of murine (flea-borne) and scrub (mite-borne) typhus have occurred in refugee camps on the Thai–Kampuchea border. Again, treatment is by a single dose of doxycycline, but where cases are sporadic and laboratory confirmation is not possible, rickettsial infections may be confused with other febrile infections.
Viral haemorrhagic fevers
Outbreaks of viral haemorrhagic fevers, including yellow fever, Rift Valley fever, and dengue, have been reported from several refugee and displaced communities. Because of the ecological and geographical occurrence of viral haemorrhagic fevers they are a potential risk only to refugee groups in selected areas. However, these risks may be increased where displaced groups move into new ecological zones, where environmental change leads to modified vector breeding habits, and where crowded conditions increase the rates of transmission.
Yellow fever outbreaks occurred on a large scale during population movements from Ethiopia into Sudan, and also during internal displacement of communities to new ecological zones in Ethiopia (Kloos 1990).
An extensive outbreak of Rift Valley fever occurred among Somali refugees in northern Kenya in 1995. The remoteness of the area, and uncertainties of diagnosis, resulted in an epidemic involving over 400 reported deaths (CDC 1998a). The epidemic had been preceded by increasing livestock mortality, and was associated with atypical heavy and prolonged rainfall, which may have increased vector-breeding sites. Dengue fever has affected refugee communities in endemic areas in Southeast Asia and has been reported, on the basis of serological evidence, among refugees in Somalia. Less common haemorrhagic fevers, including Congo–Crimean haemorrhagic fever in Iraq and haemorrhagic fever with renal syndrome in Kosovo have been reported among displaced communities.
Although outbreaks of Ebola haemorrhagic fever have not been reported from refugee or displaced communities, the presence of the infection in areas of central Africa, where population displacements are occurring, requires constant surveillance and contingency control planning.
For yellow fever outbreaks, mass immunization of the at-risk population, as has successfully been implemented in non-refugee populations in Africa, is the major control strategy to be implemented. If transmission is occurring in a camp setting, vector control, particularly in relation to breeding sites in water storage containers, should be implemented. Where refugees are displaced in small groups in forested areas, little can be done to control vector populations.
Dengue control should be primarily aimed at vector control within the refugee or displaced camps.
Hepatitis
Hepatitis in refugee communities presents two different issues. Enterically transmitted hepatitis (A and E) is a potential risk wherever water, sanitation, and hygiene are inadequate. In many tropical areas, a large proportion of the population will be immune at least to hepatitis A and few clinically apparent infections will occur. However, several outbreaks of hepatitis E virus have been reported, and more may be apparent as the epidemiology of this virus is understood in different areas.
Two extensive outbreaks of hepatitis E virus have occurred among Somali displaced groups: in north-western Somalia in 1985, and in northern Kenya in 1991. Transmission occurred both within households and from common water sources, reinforcing the importance of the need for adequate water and sanitation and improved hygiene in living areas.
The risks for hepatitis B and C are similar for refugee populations as for non-refugee communities in Africa and Asia, where 5 to 10 per cent of the population may be hepatitis B virus carriers. Risks of transmission may increase in the early days of refugee programmes through lack of clean medical equipment and transmission through injections. There is a definite risk to health care workers, particularly in disasters involving major trauma, and health care workers from non-endemic areas should be immunized.
Typhoid fever
Typhoid fever is endemic in most tropical areas, and in cooler areas where water and sanitation facilities are inadequate. Sporadic cases of typhoid fever may occur in any refugee setting. Relatively few outbreaks have been reported but in the absence of laboratory facilities, cases may be under-reported.
Outbreaks have been reported among Kurdish refugees in southern Iran and displaced persons in Bosnia-Herzegovina (Bradaric et al. 1996). In addition to these specific outbreaks, large increases in endemic cases have occurred in parts of the former Soviet Union. During 1996 and 1997, an epidemic of typhoid fever involving in excess of 20 000 cases were reported from Tajikistan, with over 8000 cases in the capital Dushanbe. The epidemic was characterized by multiple point sources of infection, overflow of sewage, contaminated water supplies, and person to person spread (CDC 1988b). The management of cases of typhoid fever is complicated by the increasing prevalence of multiple antimicrobial resistance in S. typhi. In Tajikistan, over 90 per cent of isolates of S. typhi were multidrug resistant (chloramphamicol, cotrimoxazole, ampicillin, and nalidixic acid) and, as the epidemic progressed, ciprofloxacin-resistant strains were isolated.
In refugee camps without access to laboratory investigations, management of individual cases should be in accordance with known treatment strategies in that locality. However, every effort should be made to confirm the diagnosis and monitor antimicrobial sensitivity patterns.
Prevention and control of typhoid is largely dependent on the provision of adequate water and sanitation facilities. For outbreaks in refugee camps, it may be necessary to undertake additional hygiene measures to attempt to interrupt transmission. Although oral typhoid vaccines have a high efficacy in individual cases, mass immunization is not currently recommended in most refugee and displaced communities, as compliance with the multidose vaccine may be poor and it may detract efforts from improving water, sanitation, and hygiene.
Leishmaniasis and trypanosomiasis
Among vector-bone parasitic diseases, in addition to malaria, major epidemics of visceral leishmaniasis and trypanosomiasis have been reported in displaced communities in southern Sudan and Uganda.
The leishmamiasis epidemic in the Western Upper Nile region of Sudan in 1988 to 1989 is estimated to have resulted in over 10 000 cases with high mortality. The epidemic was related to displacements among non-immune communities, high rates of malnutrition, and changes in local vector ecology (Seaman et al. 1996). Management of such large numbers of cases in a war-affected area with limited resources presented major difficulties. Field treatment centres in the villages treated over 3000 cases with a 30-day course of sodium stibogluconate.
Visceral leishmaniasis has a non-specific clinical presentation, and other disease of refugees including tuberculosis, typhoid fever, and chronic malaria must be considered. The outbreak in southern Sudan, despite the difficulty of access, was investigated and managed with a high degree of expertise, and is a model for how similar outbreaks should be managed.
Human African trypanosomiasis (sleeping sickness), although localized geographically, has been a major recent public health problem among displaced groups in the Democratic Republic of Congo and northern Uganda. The most documented outbreak, providing important information on the epidemiology of the disease in mobile and displaced communities, is an epidemic that occurred in northern Uganda between 1987 and 1992. The epidemic occurred in refugees returning to northern Uganda from a highly endemic area in southern Sudan. The return to the depopulated area, an increase in tsetse fly levels, and continuous in-migration of infected cases led to over 6000 cases being reported, with over 30 per cent of the community infected in some villages.
As with the outbreak of visceral leishmaniasis in southern Sudan, the control of trypansomiasis in displaced communities requires a high level of expertise in case-finding, management, and control.
HIV/AIDS and other sexually transmitted diseases
During the emergency phase of refugee camps, and among displaced communities, HIV/AIDS and STDs will reflect the pattern within the community prior to the refugee displacement period. In situations in which gross human rights violations have occurred, and where there may be large numbers of rape victims, HIV and/or other STDs present a major, acute, and complex medical and psychosocial problem, requiring very specific inputs (Toole and Waldman 1996).
In longer-term refugee camps, particularly where family and social structures may be disrupted, and when camps are part of a war-zone environment, STDs may become an important communicable disease problem. HIV spreads fastest in conditions of poverty, powerlessness, and social instability—conditions that are often at their most extreme during displacement (UNAIDS 1996). Mandatory testing is sometimes a reaction by authorities to the fear that a displaced population or refugee may infect a local population. However, mandatory testing in such situations does not stop the spread of infection from one population to another for the following reasons.

HIV/AIDS is already present in all populations; testing itself does not stop the spread of the disease. Testing diverts resources from programmes for prevention, education, and information, management of STDs, and condom distribution, all of which are more effective in reducing the spread.

Testing does not identify all those infected because of the false results and/or ‘window period’ during which a person may be infected and highly infectious but the antibodies to the disease have not yet developed and do not register on the test. Furthermore, a person who tests negative may become infected any time after the test.
Mandatory testing not only has no public health justification, but it also violates the rights of people, including the rights to privacy and security, as well as the ethical principles of autonomy, informed consent, and confidentiality. If HIV status is made known, HIV-positive people may be subject to discrimination, stigma, ostracism, harassment, and physical abuse (UNAIDS 1996). HIV/AIDS and STD prevention and treatment guidelines in refugee and displaced settings should follow standardized WHO recommendations. Because the risk of HIV transmission is greatly increased in the presence of other STDs, early establishment of STD-related services is a priority. STDs and their complications are a major cause of ill health and are usually grossly under-reported (UNAIDS 1996). The prevention of STDs involves the promotion of safer sex as well as early and effective case management and case-finding.
STD services should be user friendly and confidential. Appropriate and effective case management involves the following (UNAIDS 1996):

guidelines for case management—case definition and management protocol

training health care providers

consistent availability of appropriate drugs

consistent supply of condoms

referral facilities

monitoring.
All health care providers, including volunteer workers, should receive some training in prevention, be provided with information materials, and serve as channels for the distribution of condoms.
Micronutrient deficiencies
Nutrition programmes with refugee and displaced communities have generally been directed at monitoring and alleviating protein-energy malnutrition. However, deficiencies in micronutrients, particularly vitamin A deficiency, pellagra, scurvy, and beri beri, have been reported from a number of refugee and displaced communities dependent on food rations with little local supplementation (Toole 1994). Overall, vitamin A deficiency is potentially the most serious, as both insufficient vitamin A in the rations and coexisting malnutrition and measles can rapidly lead to severe vitamin A deficiency and xerophthalmia.
In any refugee and displaced communities where significant malnutrition exists, there should be a mass distribution of vitamin A to children aged 6 months to 15 years (200 000 IU), usually at the same time as measles immunization.
Outbreaks of scurvy (vitamin C deficiency) have been reported from refugee camps in Somalia and Ethiopia, generally becoming evident 3 to 4 months after the refugees arrived in the camps. In these programmes, the relief food was almost totally deficient in vitamin C and no fresh foods were available locally. Management of cases of scurvy requires vitamin C drug supplementation, but mass distribution as a preventive measure is unlikely to be successful as weekly distribution would be necessary and compliance may not be high. Food fortification is unlikely to be effective as vitamin C is destroyed by cooking. Food diversification, to introduce fresh foods into the diet, is the only effective long-term strategy.
Outbreaks of pellagra (niacin (vitamin B3) deficiency) have occurred on a large scale among Mozambican refugees in Malawi, where the rations were based largely on maize, and groundnuts, which should have been in the rations, were unavailable. Beri beri (thiamine (vitamin B1) deficiency) has occurred among Bhutanese refugees in Nepal (Upadhyay 1998) and among refugees in Thailand and West Africa, where the rations were based on polished rice with an inadequate amount of beans or groundnuts.
Prevention of pellagra and beri beri is primarily by ensuring that the distributed rations are sufficiently diversified to provide adequate amounts of B vitamins. Treatment of individual cases will require appropriate vitamin doses.
Vaccine-preventable diseases (excluding measles)
Among the vaccine-preventable diseases included in the Expanded Programme for Immunization (diphtheria, pertussis, tetanus, poliomyelitis, tuberculosis (BCG), and measles), only immunization against measles, described above, is a priority in the acute phase of health programmes with refugees and displaced communities.
Decisions on further immunizations in the Expanded Programme for Immunization in the postemergency phase are based on a number of different factors including:

information on current immunization status

short-term stability of the population

resources available (a major logistic exercise only to be attempted if adequate coverage for the whole target population)

relation to the host country national immunization programme

difficulty of organization if refugees partially integrated into local community

importance of registration and records.
While current strategies for poliomyelitis eradication are meeting with increasing success there have been small clusters of poliomyelitis cases in displaced communities in the past decade and in current war-affected communities, there may continue to be inadequately immunized cohorts of children. If there are a significant number of unimmunized children, crowding and poor sanitation will greatly increase the risk of transmission and subsequent cases. Any suspected cases must be assessed according to WHO guidelines as part of the global eradication programme. If cases occur, control involves oral poliomyelitis vaccine and improvements in water and sanitation.
Where there are significant numbers unimmunized children, pertussis is a risk in crowded, malnourished children. Outbreaks have not been specifically reported, but it is possible that pertussis has been underdiagnosed and under-reported. Management of individual cases is primarily supportive, through maintaining hydration and nutrition. If erythromycin if given before the paroxysmal stage, the severity of the disease may be reduced. Vaccination as an outbreak control measure will not be useful because of the time needed for immunity to develop.
Cases of neonatal tetanus may occur in displaced and refugee communities, particularly if conditions leading to the displacement had resulted in a breakdown of administration of tetanus toxoid in pregnancy. Apart from providing tetanus toxoid immunization as part of a wider immunization strategy in the postemergency phase, prevention will include assisting traditional birth attendants to ensure clean delivery techniques.
Although outbreaks of diphtheria have not recently been reported from refugee communities in tropical Africa or Asia, outbreaks that have occurred in states of the former Soviet Union are a reminder that such epidemics need to be considered, particularly in crowded communities where recent Expanded Programme for Immunization coverage has been reduced (Vitek and Wharton 1998).
BCG immunization should be included for newborns and for children below 5 years of age without an obvious BCG scar as part of the Expanded Programme for Immunization programme in the postemergency phase.
Unavoidable morbidity and mortality due to communicable diseases and malnutrition in refugee and displaced communities will only be achieved if interventions are based on the epidemiology of the particular crisis and on a systematic set of priorities. Figure 3 summarizes these as a strategic plan for public health intervention.

Fig. 3 Priorities for public health in refugee and displaced populations.

Reproductive health
Providing adequate food, clean water, shelter, sanitation, and primary health care are priority activities in an emergency. These interventions help to combat the major killers in displacement situation: malnutrition, diarrhoeal diseases, measles, acute respiratory infections, and malaria (where prevalent). However, reproductive health care is also crucial for the physical, mental, and social well being of any individual. As an integral part of primary health care, reproductive health care is important in overcoming such problems as:

complications of pregnancy and delivery, which are the leading causes of death and disease among refugee women of child-bearing age

malnutrition and epidemics which can further diminish the physiological reserves of pregnant or lactating women, thus endangering their health and that of their child

an absence of law and order, commonly seen in refugee and other displaced settings, which, together with men’s loss of power and status, leads to an increased risk of sexual violence; violence against refugee women, rape, sexual abuse, involuntary prostitution, domestic violence, and even physical assault during pregnancy have been found to be far more widespread than was previously acknowledged (UNHCR 1999).
Increasing numbers of refugees who have endured the terrible hardships of forced migration and long-term displacement desperately need reproductive health care. The needs and priorities of beneficiaries in situations of migration and displacement vary from region to region, and these must be fully studied and addressed. The majority of refugees are women, yet it is rarely women who determine what services are to be provided, and their very real public health problems often remain undetected.
Reproductive health care should be made available in all situations and be based on the needs and demands of the displaced population, particularly those of women (UNHCR 1999). The various religious beliefs, ethical values, and cultural backgrounds of the displaced population should be respected, in conformity with universally recognized international human rights. The major objectives of reproductive health care in a displacement situation are to:

prevent and manage the consequences of sexual violence

decrease HIV transmission by practising universal precautions and the availability of condoms

prevent excess neonatal and maternal morbidity and mortality by providing clean home deliveries, ensuring clean and safe deliveries at health facilities, and managing complications by establishing a referral system

plan for provision of comprehensive reproductive health services, integrated into primary health care, as soon as possible.
Men, women, and children can be victims of violence in conflict situations (including torture, rape, or solitary confinement) and suffer consequent trauma. Rape is a crime of violence, and is sometimes used as a systematic method of intimidation. Survivors of rape can be any age from the very young to the very old and can belong to any social group. It is documented that 25 per cent of women in a Burundian refugee camp in Tanzania had experienced sexual violence from the start of their flight to the time of the survey. Perpetrators of violence against women in refugee and displaced populations can be other refugees, including family members, or border guards, police, and soldiers. Types of violence include rape, and forced prostitution to obtain food and other basic amenities.
Another survey has shown that 22 per cent of women refugees between the ages of 12 and 49 years had experienced sexual violence since the start of the conflict in Burundi. UNHCR estimates that, because of the severe stigma attached to a woman who has been raped, the actual figures could be 10 times greater than the number of reported cases. There was a high rate of violence against Somali refugee women in Kenya when they left the camps to search for firewood. During a 1-month period there were 24 assaults on women ranging from 10 to 50 years old. Many of them were gang raped. They were also shot, knifed, severely beaten, and robbed. Sexual violence among refugees and other displaced populations is a major public health problem. It is of utmost importance to develop culturally appropriate public health measures to support and counsel women who have been raped. It is crucial that a safe environment is provided for women in camps.
Mental health and psychosocial needs
The shock of having to leave home and the circumstances of life as a displaced person, particularly in the early stages of displacement, create major emotional and social problems and exacerbate existing problems in the community. The trauma of flight and its aftermath may leave refugees confused, frightened, lonely, and insecure, facing an unknown future in a strange, sometimes hostile, environment. Separation from or loss of other family members as well as lack of community support are common in refugee emergencies, and causes emotional stress and problems for individuals and their community.
In every emergency, there will be refugee groups at risk with psychological or social problems that require particular attention. The most vulnerable are those with no family support who are dependent on external assistance for their daily survival. This dependence may be because of their age, physical condition, psychological condition, or socio-economic problems. The social disruption of emergencies causes these problems to be both aggravated and overlooked, while in stable non-emergency situations the community itself meets many of the needs of groups at risk. The psychological impact of war in emergency situations is a new emerging public health problem that invites further research.
Post-trauma reactions to sexual violence include feelings of shame and guilt, anger, humiliation, nightmares, withdrawal, depression, and suicidal tendencies. Family, friends, and community support groups must be alerted to these possible reactions so that they can understand and assist the survivors of violence.
Social attitudes to rape are usually very judgemental. A woman who becomes pregnant by rape may need help in being accepted by her family and the community or in placing a child for adoption.
It is useful to consider the major psychosocial systems, both within the individual and across the community as a whole, that are disrupted or threatened by the refugee experience. A simplified framework suggests that five fundamental ‘systems’ can be identified (Silove 1999).
The attachment system
Traumatic losses and separation from close attachment figures affect many refugees. Disruptions to bonds are often of the most threatening nature, for example, being witness to the murder or kidnappings of close relatives. Such losses and bereavements are often unresolved, with the family member living in a state of uncertainty for prolonged periods of time, not knowing the fate or whereabouts of key relatives. The disruption of attachments poses major threats to particular groups such as unaccompanied minors and single women with children, since they do not have the capacity to ‘repair’ or ‘substitute’ for their losses. Unresolved grief, difficulties in forming and maintaining relations, separation anxiety, and other emotional difficulties are some of the psychosocial outcomes that may supervene if collective and individual coping mechanisms break down.
The security system
It is common for refugees to have witnessed or encountered successive threats to the physical safety and security of themselves and those close to them. Exposure to war, combat, bombardment, land mines, and torture all pose direct threats to life, involving the self and others. Post-traumatic stress disorder and its variants represent core psychic reactions to exposure to such experiences, but a range of other reactions may occur, for example severe anxiety (panic), depression, phobias, and reactive psychosis.
The identity/role system
The refugee experience poses a major threat to the sense of identity of the individual and the group as a whole. Loss of land, possessions, and professions divest individuals of a sense of purpose and status in society. Many have no defined role in the new camp environment, a problem that can be exacerbated by the idleness and inactivity that prevail in the refugee camps. Certain extreme reactions such as ‘hysteria’ and dissociation may have their roots in severe identity and role conflicts. The undermining of traditional cultures and the rapidity of cultural change also pose major threats to the integrity and identity of families and communities in general. Revisions of gender roles, responsibilities, and power relationships may be necessary to meet the demands of camp life. The loss of community leaders, elders, traditional healers, and group knowledge about traditions, customs, and rituals may further undermine the sense of group identity and empowerment.
The human rights system
Almost all refugees have been confronted with major challenges to their human rights. These include arbitrary and unjust treatment, persecution, brutality, and in some instances torture. Such experiences may provoke long-lasting feelings of dehumanization, outrage, anger, and resentment, especially if there are no mechanisms available to redress feelings of grievance. Thus violated groups may have limited trust in governing structures, being quick to react against perceived injustice or discrimination.
The existential-meaning system
The refugee experience poses a major threat to the sense of coherence and meaning that stable civilian life usually provides for most communities. Historical continuities linking past, present, and future have been radically disrupted by the upheavals associated with refugee experience, often leaving those affected in a state of bewilderment and uncertainty. Traditional meaning systems such as religion may no longer provide the sense of security and predictability that they once did in the home country. Alternatively, individuals may turn more fervently to religion and other sources of traditional meaning to re-establish a sense of coherence in their lives. The fantasy of resettlement may be elevated to an unrealistic status to the extent that life in the camp is seen as a state of paralysed waiting. Erosion of systems of values may loosen usual ethical and moral constraints in some individuals, making them more prone to antisocial behaviours. By its nature, camp life risks eroding traditional value systems without offering a new sense of meaning or direction.
It is important to initiate mental health programmes during the emergency phase of a refugee crisis: local staff must be identified and trained, and time is required to understand the local cultural context and the need to become aware such help exists. Providing adequate response to the psychosocial and mental health needs of traumatized displaced population helps to restore the bond between the individual and the surrounding society. Simplified methods of assessing the mental health and psychosocial needs of refugees and other displaced people need to be refined and developed.
Land mines and public health
There is a growing concern about the problem of land mines as a leading cause of deaths and injuries in war-torn countries. Rates of 8.1 and 16.7 casualties per 1000 living people were found in Manica and Metuchuria (Mozambique) respectively. The prevalence of amputees was 3.2 per 1000 in Manica, and 2.3 in Metuchuria. The case-fatality rate was 48 per cent. Most of the victims were civilians (68 per cent) and were injured by antipersonnel mines. Sixteen per cent of victims were women, and 7 per cent were under 15 years of age (Ascherio et al. 1995). Similar situations have been documented in Cambodia, Afghanistan, Somalia, and many other countries in every continent.
Essential drugs management
Health information systems provide data which determine drugs and medical supplies needs. Procurement must be based on accurate assessment of needs.
When setting up an essential drugs programme in an emergency population it is important to integrate it into the essential drugs programme of the host country, if one exists. The provision of a different set of drugs from those in an established national programme is inappropriate. This integration minimizes disputes between health professionals from different backgrounds and facilitates the prompt implementation of health services. Among the points mentioned by Coninx (1988) as being crucial to the effective management of essential drugs, are co-ordination of expatriate input with the national system and use of a standard drug list and treatment protocols.
The new emergency health kit
The new emergency health kit, which was jointly developed by several United Nations agencies, includes written management principles based on an essential drugs list for emergency populations and treatment guidelines. Medical supplies for a population of 10 000 people for a period of 3 months are provided. The kit is made up of 10 basic kits of medical supplies and equipment and one supplementary kit of more specialized medical supplies and equipment, each for 1000 people for a period of 3 months. Use of the supplementary kit depends on the use of the basic kits within a primary health care management programme, based on the work of community health workers referring to secondary and tertiary levels of care.
This emergency health kit, which was developed and field-tested in the light of surveillance of common diseases and problems found in emergency populations, has continued to prove relevant to the major problems (Coninx 1988; Toole and Waldman et al. 1990, 1993). In the initial management phases of an emergency, the kits can be extremely useful. They are not meant to be used as a continuing source of supply. However, in the early stages, before information has been gathered, the contents of the kits can be used and drug use can be documented to form a basis for ongoing procurement of separate essential drugs.
Donation guidelines
Emergency situations requiring international help continue to occur. Problems caused by inappropriate donations are frequent. According to the Guidelines for Drug Donations (WHO 1999), existing national and WHO essential drugs lists should be respected by donors, and only donations of known good quality with a shelf-life 1 year beyond the estimated date of arrival should be offered. Generic names should be clearly included and packaging units of larger quantities are much preferred. For some donors a financial contribution may be more appropriate, as this can allow purchase of listed drugs and transport from procuring agencies closer to the scene at a fraction of the cost of the same products supplied from the donor countries.
Continuing experience with troublesome inappropriate donations in other refugee settings in Eastern Europe as well as in developing countries has led to more aggressive publication of the need for appropriate response to appeals (Forte 1994). Refugees do not need slimming aids and other inappropriate donations.
Monitoring and surveillance: the health information system
From the early stages of displacement, a health information system that is simple, reliable, and action oriented is a priority. It provides continuous information on the health status of displaced populations and comprises both on-going routine surveillance and intermittent community-based sample surveys. This health information system can be assessed periodically to determine its accuracy, completeness, simplicity, flexibility, and timeliness. Lack of reliable data impedes the efficient delivery of health care in displacement situations. To optimize care, the gathering and dissemination of epidemiological data, the development of laboratory facilities and treatment protocols, standardization of essential supplies, and the initiation of programmes for disease prevention deserve close attention and further research. The proper use of health information data by programme planners and key decision-makers is essential in order to:

quantify the health and nutritional status of the displaced population

follow trends in health status and monitor the impact and outcomes of the relief programme

detect and respond to epidemics

evaluate health programme effectiveness and service coverage

ensure that resources are targeted to the greatest needs

reorient the programme as necessary

set programme priorities.
Instituting a sustainable health surveillances system to guide health planning for refugee and other displaced populations during the emergency phase of a relief programme is important (Marfin et al. 1994). The modern concept of surveillance was defined by Langmuir (1963) as ‘the continued watchfulness over the distribution and trends of incidence (of disease) through the systematic collection, consolidation, and evaluation of morbidity and mortality reports and other data’. Even when data are incomplete, the systematic collection of information over time can detect changes in disease, assuming that methods of case ascertainment have remained constant.
Surveillance is a tool for continuous monitoring of changes in health status. The value of surveillance for rapidly assessing the health status of a large population of refugees was demonstrated in Thailand by Glass et al. (1982): the rapid collection of basic health data allowed for a co-ordinated health plan to be established, directed at eliminating preventable causes of death and severe illness. The use of a health surveillance system has also been shown to improve routine delivery of health services. On the basis of surveillance information, a highly targeted health delivery system was directed at those preventable causes of death identified by the system. The health information system should evolve as the need for information changes.
The planning and design of public health programmes need strong input from experienced technical specialists, academicians, and emergency management decisions need to be based on sound technical information (Toole and Waldman 1993). Timely public health and nutrition data need to be more widely disseminated.
Another form of input into the programming design is evaluation of lessons learnt from other emergencies. A key element of evaluation is balance and understanding of the conditions and constraints inherent to any particular emergency health programme. A high level of judgement and experience is required when evaluating on the basis of any set criteria and/or indicators. Indicators are measures of progress. They can be quantitative (numerical) or qualitative (non-numerical). Analysis of indicators can demonstrate changes in situation. They can be applied to show what performance has been achieved. When linked to desired results or objectives, they can be used to measure results.
Co-ordination of health services
Given the extraordinary human and material resources required to meet the public health needs of a mass influx or a major emergency operation, a concerted effort is required on the part of a number of agencies. A variety of agencies are involved in humanitarian aid for refugees and other displaced populations including United Nations organizations, bilateral agencies, non-governmental organizations, the military, the media, and the refugees themselves, to cite some examples. In order to respond in a cost-effective manner to the main health and nutrition needs of a refugee or displaced population, the activities of the various actors involved need to be well harmonized.
Effective co-ordination avoids gaps and unnecessary overlaps, and enables organizations from different backgrounds to adopt a complementary approach. The dual goals of emergency response are to ensure the protection of displaced populations and to reduce morbidity and mortality in the affected population. In theory, current technical knowledge is adequate to put in place effective programmes so as to reduce much of the disease burden related to complex emergencies. In reality, there are numerous constraints to the co-ordination of timely, efficient and effective relief programmes. Among the most important constraints are the following:

political and conflicting interests

lack of security and inaccessibility to the beneficiaries

complex humanitarian emergencies

lack of appropriate expertise among key players

overlapping mandates

increasing number and diversity of external agencies

the commercialization of humanitarian aid

competition for available resources

Social constraints and cross-cultural barriers.
Effective co-ordination from the outset of any emergency will mean more effective and faster response on behalf of those who need it. It will also mean that precious health personnel and resources are not misdirected into areas which are already covered or which are non-essential in the first days of an emergency. Work in war-torn societies and in crisis and conflict situations in general is demanding and requires a special type and quality of staff, but current personnel and recruitment procedures and practices are not geared to this. Outside resources are complementary and supportive to the local initiatives, and they should not be devised as parallel systems to substitute and take over. Assistance should always be provided in such a way that it enhances rather than hinders the development of local capacity and the attainment of self-sufficiency by the people concerned. The role of outside help is primarily that of training, transfer of knowledge, and ensuring the application and implementation of best practices in public health interventions. This implies the involvement of experienced health workers in public health interventions at the onset of an emergency.
In theory, current technical knowledge and experience gained from previous refugee situations could enable us adequately to address much of the disease burden related to emergencies. However, it is difficult to achieve results as quickly as required without giving enough attention to the co-ordination elements of the health programme.
Co-ordination mechanisms in emergencies
An important and essential step is the establishment of a co-ordination meeting. There will be resistance from those professionals who see the need to act in life-threatening emergencies, rather than attend ‘meetings, bloody meetings’. These meetings should include representatives of government structures, hospitals, etc., as well as key United Nations agencies and non-governmental organization personnel. If possible, health professionals from the refugee community should also participate. These meetings help to identify gaps, share information, and develop mutually agreed upon policies and priorities. They also reduce the risk of misunderstandings, agency jealousies, and overlap of work.
It is essential in an emergency to have a health co-ordinator. This co-ordinator is usually assigned to the UNHCR, which is the lead agency in refugee emergencies. Apart from involvement in the establishment and running of the meetings described above, this person has an important role in developing the policies for standardized treatment protocols and other medical response. He or she will also develop the strategy for health response and priorities. The co-ordinator will also have a responsibility to identify and attract additional international resources if needed, and act as an arbiter if there are agency disputes about modalities and assignment of tasks and geographical areas of responsibility.
There is a tendency to ignore or overlook local resources (government officials or resources within the refugee community) in an emergency when they can be perceived as having little relevant experience or capabilities. Co-ordination of these local and international inputs requires both a strong leadership and flexibility to work both for the displaced population and for the surrounding local population. The health co-ordinator will have an important role in encouraging their involvement and integration in the decision-making process. Steps taken early in the emergency will ensure a longer-term sustainability of health programmes.
It is also important to find a way to disseminate information on a regular basis. This can be achieved through co-ordination meetings, but also by other means that allow key players to keep informed about emerging problems, ongoing or new activities, etc. Co-ordination of the inputs of other sectors vital to the health and nutritional status of the populations should be ensured. These include water and sanitation, food security, shelter, and community services.
Conclusion
The effective management of refugee and other displaced population health activities rests on an understanding of the disease patterns which confront displaced populations, and focuses on the use of available health resources so that the greatest population coverage is achieved. The international community needs to address the issue of access to internally displaced and war-affected civilians in countries where the government either has ceased to function effectively or intentionally obstructs aid efforts (Toole and Waldman 1993).
Medical interventions must be based on the major causes of morbidity and mortality that have arisen from the crisis. Different disasters will cause different health and nutrition problems, and an initial assessment of needs is essential. Providing an adequate general ration, improving water and sanitation, and directing health resources to improving malnutrition and controlling communicable diseases should form the basis of the health intervention programme in the acute phase. Where refugee and displaced communities remain for extended periods of time in displaced or camp locations, a longer-term health programme based on the principles of primary health care must be planned and implemented.
There are several challenges to providing effective mental health services to refugees and other displaced persons. Some of the constraints are practical and logistical and relate to limitations in resources and skills. Others are attitudinal, for example the belief that mental health services are expensive, ineffective, and inappropriate, or require highly sophisticated skills. Yet, there is compelling evidence to support two key arguments from a public point of view: mental health problems associated with displacement may constitute some of the most important impediments to the long-term development of the community, and the advantages of providing a service far outweigh the costs—personal, familial, social, and in terms of human rights—of not doing so.
Ignoring the needs of the mentally ill, or conversely stigmatizing those with mental illness, are issues of central relevance to principles of equity and social justice. Whenever possible, efforts should be made to integrate indigenous methods of healing with ‘Western’ interventions. Traditional methods of healing appear to be used variably in different refugee settings and depend on levels of preserved knowledge and the availability of traditional healers and resources. Mental health services should be community based and be sensitive to gender and cultural issues and the needs of particular demographic groups (the young, the elderly, unaccompanied minors, widows, and single mothers) as well as high-risk groups such as the physically injured and disabled, the severely mentally disabled, and survivors of extreme trauma, torture, and sexual abuse.
Research focusing on practical issues is fundamental to establishing a knowledge base for future developments, but research endeavours should reflect a partnership model in which priorities in the refugee setting are given preferential attention. Objective methods of assessment of mental health needs in displacement situations and outcome evaluation are areas for further development.
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