1. This paper is prepared in response to a request made during the planning meeting for the 1995 inter-sessional meetings of the Sub-Committee on Administrative and Financial Matters. It provides the Executive Committee with a summary overview of the main issues and challenges. Examples are cited and data provided only to illustrate these; detailed analyses of specific issues and operations may be found in the increasing body of technical literature on refugee health care.
2. It has been aptly said that "refugee emergencies kill". The recent human tragedies when 2 million refugees fled ethnic and political violence in Rwanda are a dreadful illustration. The mass exodus overwhelmed the world's response capacity. One million Rwandan refugees fled to Zaire over a period of days in mid-1994, where some 50,000 refugee lives were lost in a few weeks, primarily to cholera. At the same time, nearly one quarter of the children in the camps hastily established for these refugees were found to have acute malnutrition.
II. THE CHALLENGES
3. Any population displacement introduces risks, but a mass influx of refugees always creates the immediate danger of major loss of life. Mortality rates that are truly catastrophic have been documented during large refugee emergencies (Annex 1).
4. The period of greatest risk for refugees is during the first days and weeks of a new influx. There is frequently high mortality in the emergency phase as compared to the stable refugee situations and reference populations. The only way to prevent this high mortality is to ensure appropriate preparedness and response in all vital sectors.
B. Cause-specific mortality
5. The major causes of morbidity and mortality among refugees are measles, diarrhoeal diseases, acute respiratory infections, malaria and malnutrition. These diseases consistently account for between 60 per cent and 80 per cent of all reported causes of death, as illustrated in Annex 2. Malnutrition is both a primary and secondary cause of death. There is a direct causal relationship between malnutrition and mortality in refugee sites, and this is most pronounced among children under five years of age.
6. The various forms of Protein-Energy-Malnutrition (PEM) remain the most common problems, but in recent years more and more micronutrient deficiency diseases have been reported among refugee populations entirely dependent on external food aid. The most serious outbreaks have been pellagra among the Mozambicans in Malawi in 1988, scurvy in the Horn of Africa and beriberi in South-East Asia. All these are preventable by timely provision of food of adequate quality and quantity to meet the daily minimum requirements.
D. Other causes of morbidity
7. Tuberculosis, vector-borne diseases, sexually transmitted diseases (STDs) including HIV/AIDS, pregnancy and childbirth complications, and childhood vaccine-preventable disease (aside from measles) are examples of potentially serious and fatal illnesses commonly seen in displaced populations, but whose impact does not contribute significantly to mortality during the initial emergency phase. The prevention and control of these diseases should be institutionalized as soon as the health problems that have the most immediate impact on large-scale mortality are under control.
8. The emotional stress of displacement and the toll that this takes can have a great impact on physical as well as mental health. Harassment, physical violence and grief will in many cases have added to the trauma of flight. All of this combines to deplete the physical and emotional reserves of the population, and natural resistance to disease is thus lost. Mental health needs should be identified, and where necessary met with support from qualified personnel, as part of the primary health care services.
9. Recent experience has underlined the importance of meeting the reproductive health needs of refugees, and most particularly of women and adolescents. The conclusions of the inter-agency symposium on the reproductive health of refugees held at the end of June 1995 found that specific reproductive health needs have not been systematically met, and highlighted the urgent need to address the areas of safe motherhood, control of HIV/AIDS/STD, family planning services, and management of sexual and gender based violence within the overall primary health care services.
III. PRINCIPLES AND OBJECTIVES OF REFUGEE HEALTH AND NUTRITION INTERVENTIONS
10. The aims and principles of refugee health and nutrition are simple, yet pose a substantial challenge to all working in both emergency and long term refugee health care. The context of displacement is complex, and introduces many variables not encountered in "normal settings". These principles and objectives can be summarized as follows:
The main objective:
- To prevent excess mortality and morbidity.
The main strategies to achieve the objective:
- Adopt a multi-sectoral and preventive health approach;
- Involve refugees in planning and implementation
- Meet specific needs of refugee children;
- Meet specific needs of refugee women;
- Institute an appropriate health and nutrition information system;
A. Multi-sectoral and preventive approach
11. The health and nutrition policies of UNHCR have been developed and refined with other organizations in order to address the common causes of morbidity which kill in refugee emergencies. There are usually a few simple contributing and causal factors:
- 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 quantities and quality of water to sustain health and allow personal hygiene;
- Poor environmental sanitation;
- Inadequate shelter.
12. There is agreement that the priority health interventions are immunization against measles, control of diarrhoeal diseases, control and prevention of acute respiratory infection, and management and control of malaria. An effective outreach programme is essential. However, if excess mortality and morbidity are to be prevented, refugee health and nutrition programmes must be approached from a multi-sectoral standpoint. In refugee settings, perhaps more than anywhere else, it is a grave mistake to rely on medical expertise and technology alone to ensure the adequate health of a population. The effects of poor living conditions cannot be rectified by medical services, even if these are fully equipped, staffed and operational. Indeed, it may be said that the other vital assistance sectors such as food, water, sanitation and shelter are more important than curative health care.
13. UNHCR, in collaboration with its partners, has developed basic standards for the most vital sectors. The following indicative parameters and values are important among those used for planning purposes.
Water - Minimum survival 7 litres/person/day
- Target 15-20 litres/person/day
Food - Daily caloric requirements 2100 Kcals/person/day
Sanitation - Excreta disposal 1 Latrine/20 persons
Shelter - Minimum shelter area 3.5 sqm/person
- Minimum site area 30 sqm/person
B. Involvement of refugees
14. The earliest involvement of the refugee community in its own health care is essential, both for the effectiveness of that health care and in preparation for the time when the community will eventually have to support its own primary health services. Such participation should be at all levels: the deployment of refugee community health workers and traditional birth attendants; deployment in appropriate posts of health staff among the refugee population; and involvement of the refugee community leadership in coordination. This approach will ensure a health care programme that is culturally appropriate, accessible and affordable.
1. Refugee children
15. Children under five years of age usually constitute 15 per cent to 20 per cent of a refugee population and are the group at greatest risk. It is essential to collect specific under-five mortality rates. Among the Kurdish refugees on the Turkey-Iraq border in 1991, 63 per cent of all documented deaths occurred among children under 5 years of age. Refugee children are particularly at risk from malnutrition (Annex 3), diarrhoeal diseases, and infectious diseases, especially measles. Priority must be given to the provision of the following services: immunization; feeding programmes for malnourished children; basic curative care; oral rehydration therapy; Vitamin A prophylaxis; and family health services. Respect of United Nations policy on the promotion of breastfeeding and restriction of the use of milk substitutes is an essential preventive measure.
2. Refugee women
16. Women play the central role of primary care providers for the whole family. At the same time, refugee women generally bear a disproportionate share of the suffering and hardship brought upon a population in exile. Certain health problems specific to women are likely to be exacerbated by the living conditions in a refugee setting. The causes are many and include: exhaustion following flight; grief at - and the effects of - loss of family members; the emotional burden of caring for the whole family in new and very difficult conditions; increased workload; disrupted family and social ties; altered or inadequate diet; infectious diseases that sap resistance; and a disadvantaged position in terms of access to assistance. In some situations, the risk of sexual and gender-based violence is greatly increased: not only the violence but the risk alone affects women's lives in exile.
17. Refugee health care can only be delivered effectively if the specific needs of refugee women are met. These must be considered as an integral part of all aspects of planning, including the physical layout of the camp and its security, the design of health services in full consultation with refugee women, their employment as health care providers, and the training of health staff, including refugees, to identify and address problems of sexual abuse and gender-based violence. Cultural or other constraints that may limit women's access to life-sustaining assistance or services must be identified and overcome. Gender sensitive planning allows programmes to work for the persons who most need them. It should be noted that such programmes often provide a medium through which women refugees find access to assistance, social support and opportunities that go well beyond the health services themselves.
3. Health and nutrition information
18. Mortality and malnutrition rates are the most specific indicators of the health status of refugee populations, and they reflect the adequacy and quality of the overall relief effort. These are statistics that can usually be accurately collected by the health staff and this must be done regularly and systematically. Reliable collection, collation and analysis of data is a prerequisite for effective planning and monitoring. Segregation of data by gender as well as age is essential.
19. During the emergency phase of a relief operation, death rates should be expressed as deaths/10,000/day to allow detection of sudden changes. In a refugee emergency, reduction of the two key indicators to (1) a crude mortality rate of less than 1/10,000/day and (2) a malnutrition rate of less than 5 per cent below 80 per cent of weight for height would suggest that the situation has been brought under control (see Annexes 1 and 3). This mortality rate still represents approximately twice the "normal" crude mortality rate for non-displaced populations in developing nations and does not warrant any relaxation of efforts.
IV. IMPLEMENTATION AND COORDINATION
20. The host Government has the primary responsibility for refugees residing within its territory. UNHCR assists the Government in ensuring the refugees' protection and assistance. In many cases, the host Government is unlikely to be able to mobilize immediately the extraordinary human and material resources necessary to meet the needs in a mass influx. Outside help must be organized to assist the host Government but, in mobilizing this help, the goal of sustainability and eventual integration of health services has to be borne in mind.
21. Emergency interventions must therefore emphasize a primary health care (PHC) approach, focusing on preventive programmes, promoting involvement by the refugee community in the provision of health services, and ensuring effective coordination and information gathering. The PHC approach offers long term advantages, not only for the directly affected population, but also for the host country. A PHC strategy is sustainable and strengthens the national health development programme.
22. Proper coordination enhances a programme's collective capacity to respond cost-effectively to the critical health and nutrition needs of refugees. Effective coordination avoids gaps and unnecessary overlaps and builds complementarity among interventions of organizations from different backgrounds. UNHCR must ensure sustained and coordinated efforts to mobilize and optimally use resources. In this regard, UNHCR has concluded or is in the process of preparing Memoranda of Understandings with UNFPA, UNICEF, WFP, WHO and other international agencies with proven technical competence, for example the Centers for Disease Control and Prevention (CDC), in order to develop common objectives, standards and priorities and a mutually reinforcing network of professional support. This of course extends to NGOs who, as the major implementing partners in health and nutrition programmes, constitute the backbone of UNHCR assistance and provide substantial resources.
A. Sustainability and integration into the national health system
23. Achieving sustainability involves reaching broad parity and integration of refugee and national health services. Parity requires that the services provided for refugees should be at a level equivalent to that appropriate to host country nationals. The best way of achieving this parity is to support and strengthen local - and where necessary central - health services so as to extend them also to the refugee population.
24. During the emergency phase of a large influx of refugees, when extraordinary resources must be mobilized in order to prevent major loss of life, parity and integration may not be possible. Even during the emergency phase, however, the evolution of the health programme must already be planned to bring it rapidly into line with national health principles and guidelines, and to promote sustainability.
V. UNHCR RESOURCES
25. UNHCR maintains a small technical health and nutrition team at Headquarters, currently comprising two health specialists and one nutritionist, responsible for providing technical expertise in the health and nutrition programmes. This team is reinforced by technical field staff in major operations, consultants as well as staff seconded from other agencies, and by the professional and material support of specialized organizations and agencies as already described. Expressed as a percentage of the total budget, UNHCR's health sector budgets represented 5.8 per cent in 1993 and 8.6 per cent in 1994.
26. The timely provision of effective refugee health care requires a multi-sectoral and preventive approach. In the most serious challenges, national and locally available resources will be insufficient and lives will depend on rapid and effective outside support. General agreement among all concerned with refugee health care on the standards and priorities outlined above must be complemented by effective coordination of the response, priority setting, procedures and structures appropriate to each specific situation. UNHCR is responsible for ensuring this, a responsibility that can only be discharged within the framework of a collaborative effort in which the roles, responsibilities and expectations of all involved are clear, and the necessary resources are available.