Internally displaced persons
The number of IDPs has risen sharply in recent years, and the health status of the estimated 20–25 million IDPs is one of the key public health issues presently facing the humanitarian community. The situation is made particularly complex for two main reasons. Firstly, IDPs remain within the borders of their own country, and therefore under the jurisdiction of the same government that may have been responsible for their displacement or at least was unable to protect them in the first place. Secondly, IDPs cannot invoke the same legal protections as refugees. As a result, access by IDPs to health care is often very limited, particularly as often no specific international humanitarian agency is responsible for providing them with protection and humanitarian assistance. Although a representative of the UN Secretary-General on Internally Displaced People was appointed in 1992 and Guiding Principles on Internal Displacement were introduced in 1998, these are not legally binding.
Whilst particular difficulties lie in assessing the mortality and morbidity associated with IDPs, evidence suggests that IDPs exhibit some of the highest CMRs in humanitarian emergencies. In the early 1990s, CMRs in parts of Sudan and Somalia surpassed the emergency threshold of one death per 10,000 people per day, and reached a daily rate of about eight per 10,000 and seventeen per 10,000 respectively. IDPs in Kosovo also exhibited higher CMRs than those in refugee camps in Macedonia and Albania ( Salama, Buzard, and Spiegel 2001 ). In Colombia, the situation is made more difficult by the fact that much displacement occurs ‘silently’ as people merge in with the host population, with only 22 per cent of the IDPs reporting access to medical care.
- Pan American Health Organization (PAHO) http://www.paho.org/
Mortality and morbidity are often higher among women and girl refugees and IDPs. They are particularly vulnerable in situations of forced migration due to the combination of non-conflict related factors such as access to education, resources, health services, food, and ease of movement; and conflict-exacerbated factors such as social breakdown, vulnerability, sexual violence, lack of personal security, shelter, and food distribution. This is particularly so for female-headed households.
Healthcare professionals increasingly recognize the need to target the specific needs of women and girls to ensure health services are provided in a more equitable, efficient, and humane way. This includes a gendered approach to health and illness that examines differences in disease manifestations between men and women; and their perception of, and meanings given to, these events and needs. A number of agencies have expressed this approach in operational guidelines that highlight the importance of involving refugee women in planning, protection, and assistance activities. They also address issues such as physical protection; legal rights; access to health care and child health care, food, water, and fuel; the physical layout of the refugee camp setting; education and skills training; and economic opportunities.
However, many challenges remain in implementing these guidelines effectively. They include the assumption that women’s health is primarily considered from the point of view of her reproductive or maternal functions, and not in their own right. Understanding the sources of ill health for women relates to understanding how social, cultural, and economic factors interact to affect the status of women. The WHO 1995 World Health Report argues that ‘a woman’s health is her total well-being, not determined solely by biological factors and reproduction, but also by the effects of workloads, nutrition, stress, war and migration, amongst others’. Despite the clear risks faced by women and girls in times of forced migration, simplification of the situation and over-reliance on ‘vulnerability’ runs the risk of women being portrayed as passive victims, resulting in projects being imposed upon women without their participation and leadership in their design, implementation, monitoring, and evaluation ( Lindsey 2001 ; Turner 2001 ).
- WHO 1995 World Health Report http://www.who.int/whr2001/2001/archives/1995/index.htm
Children and the elderly
The experiences and circumstances of children in conflict situations and in forced migration are diverse and cannot be easily generalized. In many situations the health of children may be endangered through malnutrition, poor housing, hygiene and sanitation, and lack of access to basic health care. Adolescents in the age range 10–24 are also at most risk of HIV infection. According to UNICEF, at least 50 per cent of all new infections occur amongst this age group. The impact of conflict upon HIV/AIDS prevention programmes and access to health care, combined with increased sexual exploitation — particularly of young people — increases such risk. The high number of displaced people in areas of high HIV/AIDS prevalence further exacerbates the situation.
The notion of vulnerability also needs to be questioned for children as it potentially neglects the resilience and coping mechanisms of children, and again fosters notions of passiveness which could hinder children’s inclusion and active participation in healthcare interventions intended for them. Ensuring that children’s needs are appropriately addressed can perhaps be achieved through the combined application of the two dominant approaches to understanding the situation of children affected by armed conflict. The first is the child development approach, which aims to minimize risk and prevent further harm while reinforcing protecting factors that facilitate children’s physical and mental well-being. The second is the rights-based approach, which focuses on the fact that children not only have needs, but also the right to have these needs met.
The Convention on the Rights of the Child, which was launched by the United Nations in 1989 and widely ratified, set international norms for the recognition and observance of children’s rights. The three key principles are: (1) the best interests of the child must be observed; (2) non-discrimination must be observed to assure that all children have the right to be treated equally; and (3) children must have the right to participation ( http://www.unhchr.ch/html/menu3/b/k2crc.htm).
Despite the considerable health risk faced by the elderly during times of forced migration, their needs are frequently marginalized. This was highlighted in the Balkans crisis of 1999. Whilst the CMRs among refugees displaced from Kosovo to Macedonia and Albania were relatively low, a large proportion of deaths occurred among elderly people as a result of war-related traumatic injury and chronic diseases, with elderly people more at risk for under-nutrition than young children. Yet, they were rarely considered a vulnerable group ( Salama, Buzard, and Spiegel 2001 ).
The vulnerability of any group (women, men, children, or the elderly) differs according to its exposure to a given problem and its capacity to tackle it. The type of action necessary to respond to their needs depends on the specific circumstances and local context, and correctly identifying the specific demographic characteristics and epidemiological profiles of each displaced population. Above all is the need to involve the ‘beneficiaries’ in the planning, implementation, monitoring, and evaluation of healthcare interventions.
- The Convention on the Rights of the Child http://www.unhchr.ch/html/menu3/b/k2crc.htm
- Convention on the Rights of the Child http://www.unicef.org/crc/crc.htm
- Norwegian Refugee Council: Global IDP Project http://www.idpproject.org/
- International Committee of the Red Cross (ICRC): Women and war http://www.icrc.org/web/eng/siteeng0.nsf/iwpList2/Focus:Women_and_war
- Reproductive Health Response in Conflict Consortium (RHRC) http://www.rhrc.org/
- Saving Women’s Lives http://www.savingwomenslives.org/
- World Health Organization (WHO) http://www.who.int/disasters
- UN: Women Watch http://www.un.org/womenwatch/
- UNHCR http://www.unhcr.org
- UNICEF http://www.unicef.org/aids/index_resources.html
- Women’s Commission for Refugee Women and Children http://www.womenscommission.org/
- World Health Report (focusing on mental health) http://www.who.int/whr2001/2001/