Health care for refugees: what lessons have we learned?
Once the media spotlight has dimmed...
Von Doris Schopper / Médecins Sans Frontières Schweiz
For the last three decades the majority of the people fleeing war, famine and repression have been from developing countries, seeking refuge in neighbouring countries. Since the end of the cold war, the great concentrations of refugees have been found around countries in conflict such as Cambodia, Burma, Tajikistan, Azerbaijan, Georgia, ex-Yugoslavia, Chechenya, Afghanistan, Liberia, Somalia, Sudan, Burundi, Rwanda... the list is long. In most instances Médecins Sans Frontières (MSF) has supported refugees providing emergency medical care and helping in the aftermath of the crisis. Lessons we have learned are summarised in this article.
Population movements into areas with poor resources have usually led to high mortality rates during the first weeks or months. These can be up to 60 times higher than the mortality rates in the host country. The major causes of death are common diseases which can be easily prevented or treated: measles, diarrhoeal diseases, acute respiratory infections, malnutrition and, in areas where it is endemic, malaria. Studies indicate that these diseases account for up to 95% of all reported deaths in refugee populations. A poorly planned refugee settlement is one of the most pathogenic environments possible due to the typical overcrowding, poor water supply and sanitation, and inadequate shelter which are the main risk factors for communicable diseases. In addition, the poor nutritional status of many refugee populations and their lack of acquired immunity for some diseases, combined with disruptions to the immunisation services, all contribute to increasing their vulnerability. Psycho-social factors, such as stress, family disruption and change of environment, which destroy many of the refugees’ coping mechanisms, also make them more vulnerable to illness.
For example, outbreaks of measles are common among refugee and displaced populations. Case fatality rates (CFR) ranging from 2% to 21% in stable populations can reach rates above 30%, as was the case, for example, in the Wad Kowli camp in Sudan in 1985. Over 2,000 children died of measles over a four-month period. However, these deaths could have been prevented through early mass immunisation and vitamin A distribution. Diarrhoeal diseases are another major killer in refugee and displaced populations: in refugee camps in Somalia, Malawi, Ethiopia and finally in Zaire, 30 to 85% of all deaths were attributable to diarrhoeal diseases. An inadequate water supply, both in quantity and quality, poor sanitation, overcrowding and malnutrition are the main factors responsible for the spread and severity of diarrhoeal diseases. Most of these deaths could be prevented by oral rehydration therapy. When refugee or displaced populations come from, pass through or settle in a cholera-affected area the risk of a cholera outbreak is particularly high. A major cholera outbreak hit the newly arrived refugees in Goma in 1994. The outbreak lasted only a few weeks, but this lead to an estimated 60-80,000 cases and around 1,000 cholera deaths per day among an estimated refugee population of 500,000 to 800,000. Cholera is a disease that can rapidly kill if left untreated, with case fatality rates up to 50%. Adequate preparedness, including early detection of first cases, clear treatment protocols, well staffed and equipped cholera treatment units and ensuring an adequate and safe water supply, can achieve that the CFR is kept below 2%.
Until recently HIV/AIDS was not regarded as a priority in emergencies. However, the Rwanda crisis in 1994 signalled the need for a change of attitude. Never before had there been an emergency of such magnitude in a country with such high HIV prevalence, and it soon became clear that the epidemic posed a threat that could not simply be ignored until some sort of stability was re-established. Now there is general agreement among humanitarian actors that HIV and AIDS should be considered a priority even in the first phase of an emergency. In these situations when previously existing national AIDS prevention and care programmes have broken down, at least four elements of a minimum package of prevention measures should be implemented: (1) to ensure an HIV-free blood supply; (2) to prevent HIV transmission in the health care setting through other invasive procedures; (3) to make condoms - still the only means to prevent sexual transmission of HIV - freely available to those who seek them, condoms should thus be considered an essential item in emergency relief supplies; (4) to provide some basic and relevant HIV/AIDS information on how and where to get free condoms, and where and how to get medical attention if necessary.
Mental health care is also an emergency
There is usually a tendency to focus entirely on the physical needs of refugees, neglecting their psycho-social problems. Once physical survival is ensured, many people may start to show physical or psychological symptoms that are rotted in their traumatic experiences. MSF has witnessed this most recently during the dramatic crisis in Kosovo. In response to the overwhelming trauma suffered by the refugees, mental health programmes were set up in most of the refugee camps. MSF believes it is important to initiate mental health programmes during the emergency phase of a refugee crisis: local staff must be found and trained, time is required to understand the local cultural context, and people need to become aware that such help exits. Other medical programmes become quickly overburdened during the emergency phase and mental health can help to alleviate this burden. Helping traumatised people is a matter of restoring the bond between the individual and the surrounding society. MSF programmes are implemented in co-operation with and with the active input of trained national staff. National staff is vital to overcome language and cultural barriers, and are ultimately the only way to ensure acceptance and sustainability of the programmes.
Refugee settings are usually characterised by the high number of patients using health services, especially in the early stages: this is due to the high morbidity, high population density, high demand for health care and easy access to health services. As a result, the health services of the host country, even when reinforced, are seldom able to cope with a large refugee influx; and this problem may be aggravated by tensions between refugee and resident populations, administrative obstacles and the distance to existing services. For all these reasons, new facilities have to be set up in a high proportion of refugee emergencies. If possible, the specialised services of a referral hospital are provided in an existing hospital in the vicinity of the settlement. Health centres should be able to deal with all common priority diseases, with one central facility for every 10,000 to 30,000 refugees. Peripheral health facilities (health posts or health clinics), one for every 3,000 to 5,000 refugees, will provide a basic level of care. In addition, home-visitors are necessary for conducting active case finding and to ensure the link between the fixed health facilities and the population.
Health care programmes should be co-ordinated with and involve all the partners: the local health authorities, the refugee community and all agencies involved in refugee assistance. Agreement should be reached on the common use of some standardised systems in order to improve and then maintain the coherence in the services offered by all parties involved, including clinical and therapeutic protocols, an essential drugs policy, a well organised referral system and health data collection. The presence of multiple organisations working in the same field but with conflicting objectives, unclear tasks and poor organisation will lead to overlap on the one hand, and uncovered needs on the other hand. It is thus essential that good co-ordination mechanisms be established in the early stages of an emergency.
While providing health care in refugee settings, health agencies should be careful not to impose the model of emergency care onto the host area, but at the same time ensure that health care provided also benefits local inhabitants. Conflicts may arise due to the fact that the level of health care is often better in the refugee setting than the host country and that services are usually free-of-charge in the refugee settlements, whereas payment for services is the standard in the host environment.
While the impact of medical relief programmes on reducing death and illness rates has been well documented, these efforts have focused on the most extreme instances of populations deprived of their basic needs and their access to even minimal levels of health services. The fact is that such relief programmes scarcely address the overall problem of the poor health status of hundreds of millions of the world’s inhabitants. We must acknowledge that emergency health programmes do little to contribute to the concept of "Health for All". They rather try to undo the harm caused by the world’s diplomatic and political failures. One step in the right direction would be to integrate development activities more effectively within relief programmes and to take a long term view of the needs of emergency-affected populations. Ensuring that community health workers are employed and trained during a medical relief programme may provide lasting skills. Restoration of the health structures destroyed during the conflict involves forging relationships with local partners and indigenous NGOs, a process that requires a long-term commitment to institution building. Many agencies face a difficult challenge in finding the means to maintain support beyond the crisis phase. This often comes down to finding funds, which in turn relies on educating the public and government funding bodies so that they do not abandon emergency-affected communities once the media spotlight has dimmed.
Doris Schopper is honorary president of Médecins Sans Frontières (MSF). She has been actively involved with MSF since 1982, including as president of MSF Switzerland from 1991 until 1998 and twice (1995/96 and 1997/98) as international president of MSF. Special areas of work: AIDS and evaluation of health programmes.