Impact of forced migration upon health

Forced migration frequently occurs at times of massive disruption to food supply, sanitation, health services, and shelter. The inability of health services to cope with an influx of displaced people can rapidly lead to increased mortality and morbidity (disease) in settlement areas. An estimated 7–9 per cent of Rwandan refugees died whilst in the refugee camps of the North Kivu region of eastern Zaire in July 1994 ( Goma Epidemiology Group 1995 ). In nearly all cases, displaced people experience a significantly higher crude mortality rate (Number of deaths over a given period per thousand persons at risk) than non-displaced populations during complex emergencies. They are particularly vulnerable due to loss of social networks and assets; lack of language, knowledge, and information on the new environment; reduced access to healthcare services; decreased food security; and often, inadequate shelter, sanitation, and access to safe water.

Among those fleeing violence, mortality rates tend to be very high when the exodus is precipitous and a large number of persons are on the move. Under these conditions, CMRs during the first days of displacement have been reported to be sixty times higher in some locations than in the country of origin. However, the varying characteristics of political violence, epidemiological conditions, settlements, levels of economic wealth, and availability and quality of health services in the war-afflicted and host countries mean that it is virtually impossible to provide a standardized picture of morbidity and mortality.

Whilst health is measured in an increasing number of ways, the most common measures amongst displaced persons at present are mortality and morbidity rates. The more complex and time-consuming nature of other studies, such as Quality Adjusted Life Years (QALY), generally precludes their use in shorter-term emergency settings. However, their broader interpretation of health would serve to highlight the effects that poverty, dependence, and lack of cohesive social support have upon the quality of physical and mental health of displaced people. Studies of refugees in the United Kingdom have found that one in six refugees has a physical health problem severe enough to affect their life and two-thirds have experienced anxiety or depression ( Burnet et al. 2001 ). In a study of Iraqi asylum-seekers in London, depression was more closely linked with poor social support than with a history of torture ( Gorst-Unsworth et al. 1998 ).

Website:

Refugee Council http://www.refugeecouncil.org.uk

Murray C. et al, Armed Conflict as a Public Health Problem, The Global Burden of Disease Working Papers (01.22), 2002: http://www.hsph.harvard.edu/burdenofdisease/publications/papers/Armed%20Conflict%20as%20a%20Public%20Health%20Problem.pdf

Communicable diseases

There is frequently a severe increase in the risk of communicable diseases and epidemics during and after complex emergencies involving armed conflict and mass population displacement, when safeguards of immunization, clean water and sanitation, and shelter are interrupted. Typhoid, tuberculosis, measles, cholera, bacillary and amoebic dysentery, acute respiratory infection, hepatitis, polio, schistosomiasis, various helminth infestations, common gastroenteritis, and other harmful effects related to exposure to cold weather, heat, or rain, have been common in settings of displaced persons, where crowding and poor sanitation is a common feature. Whilst meningitis is also a potential risk, mass immunization has proved to be an effective epidemic-control measure, and meningococcal morbidity and mortality rates have been relatively low.

Diarrhoeal diseases have emerged as possibly the most lethal public health threat to refugees and IDPs. More than 70 per cent of the deaths among Kurdish refugees in 1991 were associated with diarrhoea ( Sharp et al, 1993 ). Cholera spread by water contaminated with Vibrio cholerae is estimated to have killed more than 50,000 Rwandan refugees in camps just inside Zaire during the first weeks of July 1994 ( Goma Epidemiology Group 1995 ).

Appropriate interventions to address communicable diseases include primary, secondary, and tertiary prevention, and treatment. These include immunizations, sanitation improvements, provision of clean water, nutritional interventions including appropriate use of oral re-hydration therapy (ORT), vector control, health education, and treatment measures through laboratory services, medication, and case management. Of essential importance is the quick establishment of effective surveillance to address the susceptibility of the population; the control of pathogenic agents; effective use of treatment and resources; and monitoring and evaluation of the health intervention including vaccination coverage and effectiveness. Please also see Assessment and surveillance below for further details on surveillance techniques and methodologies.

Mass migration may lead to epidemics of communicable diseases when populations residing in areas of low disease endemicity pass through or into areas of high endemicity during the course of their migration. Alternatively, the migration of people can potentially spread the risk of communicable diseases into new areas. The association of such risk between infectious disease and migration is a historically powerful one, and drives to the heart of many wider concerns about the impact of migration on society and economy ( Markel 1995 ).

In the United Kingdom (UK), intense public and political debate about the scale and nature of asylum and migration has led to calls for pre-entry health screening to be introduced for all long-term migrants to the UK. This has also led to calls from the press and political parties for asylum-seekers to be subject to compulsory screening on arrival and, if necessary, detained in quarantine ( Conservative Party 2003 ). Health services have also been accused of stigmatising refugees, with a tendency to focus more on protecting the native population than benefiting the health of new arrivals ( Fassil 2000 ). Refugee health in many areas of Britain has become the responsibility of communicable diseases departments, giving the misleading impression that refugees are vectors of infection, with the inevitable effects of increased stigmatization.

Studies in the UK and elsewhere indicate the ineffectiveness of screening and quarantine for communicable diseases such as tuberculosis, largely due to it causing individuals to evade immigration controls and medical services rather than present themselves for fear of being refused entry or deported ( Coker 2003 ; Farmer 2003 ). In the case of HIV/AIDS, there exist strong ethical and human rights concerns over the legality of refusing entry or treatment to an individual who is HIV-positive. In addition, there is no evidence to support that such a policy would effectively protect public health

(UK All-Party Parliamentary Group on AIDS, July 2003: http://www.appg-aids.org.uk/publications.htm) .

Websites:

Medact http://www.medact.org/tbx/pages/section.cfm?index_id=3

World Health Organization: Information and Guidelines - http://www.who.int/disasters/tg.cfm?doctypeID=25

Department of Health http://www.dh.gov.uk/

HIV/AIDS

Whilst data on HIV prevalence in refugee situations is scarce, it is believed that refugees and other displaced populations are at increased risk of contracting the virus during and after displacement due to factors of poverty, disruption of family/social structures and health services, higher prevalence rates of HIV compared to their area of origin, increase in sexual violence, and increase in socio-economic vulnerability (particularly of women and children).

The association between HIV/AIDS and forced migration is particularly strong in sub-Saharan Africa, where according to UNAIDS, 70 per cent of the more than 40 million persons living with HIV/AIDS in 2002 lived, and which is a region severely affected by conflict, with a large and diverse population of displaced persons. The disruption and displacement of the Rwandan population raised awareness of the importance of HIV-prevention efforts during humanitarian emergencies. Data from post-war Rwanda showed that in 1997, HIV prevalence was 11 per cent in both rural and urban areas. This contrasts with low pre-war levels in rural areas estimated at 1 per cent, where approximately 95 per cent of the population resided, and levels of 10 per cent in urban areas. Seroprevalence among those who had lived in refugee camps in Tanzania or Zaire was 9 per cent, representing a six- to eight-fold increase over the rates in the rural areas from whence they came. Among Rwandan refugees in a camp in Tanzania, researchers were able to conclude that adolescent sexual activity might have increased since displacement, that commercial sex-work had grown in the area surrounding the camps (although not within the camp itself) and that knowledge of HIV prevention was high but condom accessibility and usage were low. Whilst Rwanda’s contraceptive prevalence rate had been among the highest in sub-Saharan Africa, women and men reported that they lacked access to family planning in the camp and that they had a strong interest in continuing to use it ( Schreck 2000 ).

Although refugees can be at increased risk and may exhibit higher prevalence rates than prior to displacement, this does not inevitably mean that they have higher prevalence rates than their surrounding host population. Indeed, HIV prevalence rates are frequently lower in refugee camps than in the surrounding populations. UNHCR and its partners measured HIV prevalence among pregnant women in more than twenty camps housing around 800,000 refugees in Kenya, Rwanda, Sudan, and Tanzania, and found that the refugee populations in three of the four countries had significantly lower HIV prevalence rates than the surrounding host communities. In the fourth, the refugees and host community had comparable rates. Possible reasons for lower prevalence include the use of agencies’ HIV/AIDS programmes; that refugees often live in camps situated in remote areas with limited freedom of movement; and that refugees often come from countries with lower HIV prevalence than the countries of asylum. Despite this, there remains a misconception that refugees spread HIV/AIDS. As a result, UNHCR felt compelled to refute this and declared that ‘refugees should neither be blamed for the HIV/AIDS pandemic nor should be ignored’

(Lubbers 2003 http://www.unhcr.org).

There has been a positive use of human rights law in the field of HIV/AIDS, particularly to increase access to drugs and to tackle discrimination and restriction to freedom of movement. UNHCR developed a strategy which closely follows the UNAIDS human rights-based approach, with objectives of respecting the right of refugees and asylum-seekers to live in dignity and free from discrimination, reducing HIV transmission, and improving HIV/AIDS treatment and care.

Challenges in this strategy include the limited technical and financial resources of most host countries, which struggle to meet the needs of their own populations, let alone contribute to refugee programmes. Despite recent advances in reducing prices of medication, the introduction of Prevention of Mother to Child Transmission (PMTCT) and Anti-retroviral (ARV) treatment programmes pose significant challenges due to high costs and limited resources available in the budget of health governments and refugee agencies. The situation is exacerbated by the failure of donor institutions and national HIV/AIDS programmes to specifically address the needs of refugees when developing programmes to combat the pandemic ( Spiegel, 2003 http://www.unhcr.org ).

A number of normative guidelines and monitoring tools on HIV/AIDS and refugees have been developed. These include:

Guidelines for HIV Interventions in Emergency Settings, WHO/UNAIDS/UNHCR, 1996 http://www.who.int/disasters/tg.cfm?doctypeID=63

Reproductive Health Manual, Inter-agency Working Group, 1999 http://www.unfpa.org/emergencies/manual/

Protecting the Future. HIV prevention, care and support among displaced and war-affected populations, IRC 2003 http://intranet.theirc.org/docs/Protecting_the_future.pdf

Refugee and AIDS Technical Update, UNAIDS, 1997 http://www.unaids.org/Unaids/EN/In+focus/HIV_AIDS_security+and+humanitarian+response/HIV_AIDS+and+conflict.asp

Second Generation Surveillance for HIV, WHO and UNAIDS 2000 http://www.who.int/disasters/tg.cfm?doctypeID=63

HIV/AIDS and Refugees: UNHCR’s Strategic Plan 2002–2004, UNHCR http://www.unhcr.org/

International Federation of Red Cross and Red Crescent Societies http://www.ifrc.org/what/health/hivaids/code/

Websites:

UNAIDS http://www.unaids.org/Unaids/EN/In+focus/HIV_AIDS_security+and+humanitarian+response/HIV_AIDS+and+conflict.asp

Refugees and AIDS: UNAIDS point of view, Geneva, 1997 (UNAIDS Best Practice Collection) http://www.unaids.org/en/default.asp

UNAIDS: HIV/AIDS and Children Affected by Armed bConflict, 2002 http://www.unaids.org/publications/documents/sectors/military/militarypve.pdf

Women’s Commission for Refugee Women and Children: Refugees and AIDS: What Should the Humanitarian Community Do? http://www.womenscommission.org/

World Health Organization: Information and Guidelines http://www.who.int/disasters/tg.cfm?doctypeID=25

Nutrition

Malnutrition and restricted production and access to food are among the most significant problems in situations of forced migration. The symbiotic relationship between malnutrition and morbidity and mortality from communicable disease further compounds poor health status, with diseases such as measles and diarrhoea inducing malnutrition, especially in young children, and malnutrition associated with high mortality rates from communicable diseases. However, it is also important to be aware of exceptions to the causal relationship between malnutrition and disease, with malaria appearing to reach higher levels after feeding programmes have been initiated ( Cahill 1999 ).

In response to acute nutritional needs in humanitarian emergencies, the provision of free relief food and other nutrition-related programmes often takes the largest share of the international resources for humanitarian response. However, it is increasingly recognized that rather than perceiving nutrition needs in emergencies as a narrow range of interventions focused around food and physiological vulnerability, nutritional activities should include a more wide-ranging consideration of the social, political, and economic risks that affect displaced populations. This includes the capacity of individuals and households to manage such risks, particularly vulnerable groups such as women, children, the elderly, and female heads of households. The effect of not recognizing such risks was highlighted by studies amongst Kurdish refugees from Iraq in 1991, in which families headed by women were significantly more malnourished ( Cahill 1999 ). In Rwandan refugee camps in eastern Zaire, one month after the influx of July 1994, the prevalence of acute malnutrition was 18–23 per cent. Children, particularly orphans or those in families headed by single women, were particularly vulnerable and had a significantly higher risk of malnutrition than other refugee children ( Goma Epidemiology Group 1995 ).

Websites:

United Nations World Food Programme (WFP): Guidelines http://www.wfp.org/index.asp?section=6

World Health Organization (WHO): Information and Guidelines http://www.who.int/disasters/tg.cfm?doctypeID=25

Mental health

Over the last two decades, humanitarian agencies have paid increasing attention to the psychological and social impact of violent conflict and displacement. Approaches to care for mental health vary widely, depending on the local context, need, and agencies’ interpretation of mental health and psychosocial support. A common approach has been to integrate mental health care into primary health care (see below for more details on primary health care), with specialized training for health staff such as nurses and community health workers. The justification for such an approach is that mental and physical well-being are closely connected, and that access to and delivery of these services is most effective when they are part of the basic primary health care and not restricted to specialized psychiatric institutions that require trained doctors and expensive drugs. An alternative approach is the training of local people as counsellors, who then provide individual and group counselling to those identified as being in need of support. The training approaches and counselling techniques vary greatly, but most are based on the belief that verbalizing memories and emotions is of benefit. There exists a great diversity in the range of services offered, with some focusing more on psychological services such as counselling for individuals or groups, whilst others prefer a combination of psychological and social services through integrated ‘psychosocial’ programmes with the aim of preventing mental problems and social difficulties ( Strange and Ager 2001 ).

Considerable debate exists over the notion of stress itself. Whilst most attention has focused upon post-traumatic stress disorder (PTSD) with regard to such distressing events as displacements, witnessing or participating in armed conflict, bombings, torture, rape, or attacks, some believe that PTSD is just one of many mental health problems that can arise as a consequence of trauma ( Newman et al. 1996 ). Similarly, it is argued that rather than focusing on individuals, attention should also be paid to whole communities. The conceptual framework and discourse of trauma itself has also been criticized ( Summerfield 1996 ). Firstly, it has been said that trauma is a Western concept that is not necessarily applicable to non-Western populations where people may have different understandings of distressing events and how to survive them ( Richters 1998; Wessells 1999 ). Generalizing people as traumatized implies they have a mental disorder and are passive, vulnerable victims to events, whereas in fact, most people are able to function and survive, developing coping mechanisms appropriate to their situations ( Bracken 1995 ; Summerfield 1999 ).

Aid agencies and their donors have also been criticized for perpetuating this image of passive victims in need of psychosocial care, and fostering asymmetrical power relations between the local population and outside ‘experts’ ( Ager 1997 ). The result may be that the material conditions and physical health support are neglected, and the needs of the displaced population ignored. In Bosnia, agencies established psychosocial programmes specifically targeting women who had been subjected to sexual violence. However, these initiatives were not always welcomed by the women themselves, some of whom felt that their own needs and requests had been largely ignored ( Richters 1998 ).

Websites:

Strang, A. B. and Ager, A., ‘Building a Conceptual Framework for Psychosocial Intervention in Complex Emergencies: Reporting on the work of the Psychosocial Working Group’, 2001 www.ishhr.org/conference/articles/strang.pdf

Forced Migration Online (FMO): Thematic Guide on Psychosocial Issues http://www.forcedmigration.org/guides/fmo004

International Trauma Research Net Conference 2002 http://www.traumaresearch.net/con_xx.htm

Save the Children Alliance: Promoting Psychosocial Well-being among Children Affected by Armed Conflict and Displacement: Principles and Approaches, 1996 http://www.savethechildren.org.uk/

International Society for Traumatic Stress Studies http://www.istss.org

World Health Organization (WHO) http://www.who.int/disasters/tg.cfm?doctypeID=21

World Health Report (focusing on mental health) http://www.who.int/whr2001/2001/

Reproductive health

Women and children make up four-fifths of the world's refugees and IDPs; and the characteristics of war and forced migration, such as the loss of security, income, home, families, social support, rape, and deliberate, forced pregnancy, increase the need for reproductive health services. This includes access to family planning, safe abortion care, prevention and treatment of sexually transmitted infections including HIV/AIDS, safe-motherhood initiatives, and tackling sexual and gender-based violence and harmful traditional practices such as female genital mutilation and early marriage.

The right to reproductive health is most clearly expressed through ICESCR’s Articles 10 and 12, and further elaborated in General Comment 14 of Article 12. Further references can be found in regional human rights mechanisms, and particularly the 1979 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in Articles 10, 12, 14, and 16.The CEDAW Committee, which is a treaty body, issued a General Recommendation in 1999 on Article 12 of the Women’s Convention, which states outright that access to health care includes reproductive health care for all women and girls, ‘even if they are not legally resident in the country’. The Committee noted that special attention should be given to the health needs and rights of refugee and internally displaced women.

Despite its articulation in international law, it is really only over the last decade that sufficient attention has been focused on the particular reproductive health needs and circumstances of refugees and IDPs. This increased recognition was assisted by the Beijing Platform of Action and the 1995 Fourth World Conference on Women. Of most significance was the International Conference on Population and Development (ICPD) of 1994. With its codified Programme of Action, the ICPD developed a broader, more expansive human rights-based definition of reproductive health, and recognized that ‘reproductive health care should be available in all situations and be based on the needs and expressed demands of refugees, particularly women, with full respect for the various religious and ethical values and cultural backgrounds of the refugees while also confirming with universally recognized international human rights’. The ICPD also set forth the action governments should take to promote and protect these rights. While such international consensus documents do not create binding obligations, they are agreed to by governments and thus reflect political will. They are also widely used by non-governmental organizations (NGOs) as advocacy tools and by treaty-monitoring bodies as standards for evaluating how states are meeting their treaty obligations.

Operational guidelines to facilitate the provision of reproductive health services include the 1995 Inter-agency Field Manual, which was developed by The Inter-agency Working Group for Refugee Reproductive Health (a collaboration of UN agencies and NGOs). This now serves as the most comprehensive and widely used manual for refugee reproductive health programmes. Further operational guidelines have been developed by UNHCR, WHO, the Reproductive Health Response in Conflict Consortium (RHRC), and the Women’s Commission. NGO involvement has been most effectively expressed through the RHRC (previously the Reproductive Health for Refugee Consortium), which comprises a number of NGOs promoting comprehensive, quality reproductive health services for refugees. Activities include advocacy, training, research, publication of thematic guides, and monitoring and evaluation tools.

Despite the advances over the past decade, coverage remains uneven. According to a 2002 survey of eighty-one NGOs working with refugees and IDPs, only eight had specific policies or guidelines on providing reproductive health services, while only thirty-eight supplied some of those services. Research also remains limited on the impact of forced migration upon the reproductive health of women and men, with data particularly poor on IDPs ( Goodyear et al. 2001 ).

The extent and type of reproductive health interventions for refugees may also depend on prevailing religious and cultural beliefs. Interventions such as emergency contraception, condom distribution to adolescents, and access to safe abortion services (which are integral to reducing maternal mortality along with other interventions such as access to antenatal and safe obstetric care) are all particularly sensitive issues. The current US President Bush administration’s opposition to reproductive rights places added pressure on the provision of such services.

Websites:

Division for the Advancement of Women (DAW): 1995 Fourth World Conference on Women http://www.un.org/womenwatch/daw/

Girard, F. and Waldman, W., ‘Ensuring the Reproductive Rights of Refugees and Internally Displaced Persons: Legal and Policy Issues’, International Family Planning Perspectives26 (4), 2000 http://www.agi-usa.org/pubs/journals/2616700.html

Global

Gag Rule (Bush administration) http://www.globalgagrule.com

Inter-agency Working Group for Refugee Reproductive Health: 1995 Inter-agency Field Manual http://www.unfpa.org/emergencies/manual/

International Centre for Migration and Health: Reproductive Health in the Context of Forced Migration http://www.icmh.ch/WebPDF/2001%20-%20UNFPA%20-%20Reproductive%20Health%20-%20Report.pdf

Reproductive Health Response in Conflict Consortium: Global Decade Report, 2003 http://www.rhrc.org/

Adolescent Refugee Reproductive Health http://www.rhrc.org/media/rhr_basics/adol/index.html

Saving Women’s Lives http://www.savingwomenslives.org/

Sphere Project http://www.sphereproject.org/handbook

UNHCR: Sexual and Gender-Based Violence against Refugees, Returnees and Internally Displaced Persons: Guidelines for Prevention and Response, 2003 http://www.rhrc.org/pdf/gl_sgbv03.pdf

United Nations Population Fund (UNFPA) http://www.unfpa.org

State of World Population 2000 http://www.unfpa.org/swp/2000/english

International Conference on Population and Development (ICPD) http://www.unfpa.org/icpd/

Ward, J., ‘If Not Now, When? Addressing Gender-Based Violence in Refugee, Internally Displaced and Post-Conflict Settings – A global overview’, RHRC, 2002 http://www.rhrc.org/resources/gbv/ifnotnow.html

WHO: Information and Guidelines http://www.who.int/disasters/tg.cfm?doctypeID=25

Reproductive Health During Conflict and Displacement: A Guide for Programme Managers, 2000 http://www.who.int/reproductive-health/publications