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The number of refugees in the world is rising fast. Twenty years ago
there were about 2.5 million; by 1980 the figure had reached 8.2 million
and this year, there are 17.5 million. If you count not just those who have
fled across a border, but also those displaced within their own country
by civil war, the number doubles again to at least 35 million. What are
the implications of this mass movement for people’s health?

Most uprooted groups are already poor, and the countries to which they
flee are no richer. As a result, groups already vulnerable to disease through
poverty are exposed to acute risks that worsen their condition. It is not
only the displaced people themselves, but also those who receive them, that
may be affected. Of today’s 17.5 million cross-border refugees, about 13
million are in Africa, southwest Asia and the Middle East. Most have little
hope of genuine resettlement, but face instead a future in the makeshift,
restricted life of a camp, long after the television cameras have departed.
For example, Cambodians who fled Pol Pot in 1979 are still living in camps
on the Thai border, surviving in a lifestyle they have had to establish
for themselves.

Epidemiologists have built up a detailed knowledge of the health problems
that affect refugees in the emergency phase of their flight, including physical
injury, infectious diseases and malnutrition. Now they are looking also
at the long-term consequences. Malnutrition remains a severe problem: the
international agencies now admit that the food aid provided in refugee camps
is frequently inadequate both in quantity and quality. And increasingly,
researchers are beginning to recognise that persecuted and displaced people
may be mentally disturbed by their experiences.

This year, with unprecedented numbers of new refugees swelling the ranks
of the long-term displaced, the international agencies are beginning to
ask themselves difficult questions. Their experience of refugees’ health
needs has grown dramatically, yet malnutrition and high death rates continue.
Are they doing as well as they could? How could they work more efficiently?
Does the fault lie with the agencies or with their paymasters, the governments
of rich countries?

To tackle these questions, it is essential to understand the basic link
between poverty and ill health. Most displaced people are already poor;
their displacement simply intensifies the problem. ‘Refugees don’t suddenly
start suffering from weird and exotic diseases,’ says Bruce Dick, head of
the health department at the League of Red Cross and Red Crescent Societies
in Geneva. ‘They suffer from just the same problems as other vulnerable
groups, except that they are worse. It is these vulnerable groups who are
most affected and least able to cope with disasters.’

In the short term, refugees are likely to suffer the consequences of
inadequate food, dirty water and lack of shelter: malnutrition, diarrhoeal
diseases and respiratory infections. They are also likely to be vulnerable
to diseases of overcrowding, particularly measles and meningitis in children.
Sometimes a population that lacks immunity to a particular disease moves
into an area where the disease is endemic. For example, refugees who came
down from the Tigray highlands to eastern Sudan in 1985 suffered severe
malaria when they were exposed to the parasites for the first time.

There is no doubt that refugees fare worse than the general population.
Michael Toole of the Centers for Disease Control (CDC) in Atlanta estimates
that during the emergency phase of refugees’ displacement, death rates are
between 30 and 60 times greater than the expected rate for that population.
The worst death rates documented among refugees have been among those in
northern Ethiopia during 1985 and in southern Sudan in 1988. Measles and
dehydration caused by diarrhoea are the main killers. ‘It is not the type
of illness but rather the incidence and high mortality rates that make these
populations remarkable,’ explains Toole.

Worldwide, diarrhoea kills 3.2 million children under the age of five
every year, so it should come as no shock to learn that it kills many thousands
of refugee children. Nevertheless, there is widespread ignorance in the
industrialised world about this. For example, cholera and typhoid are not
usually the main causes of diarrhoeal disease in refugee camps, according
to epidemiologists. Toole at the CDC says there were only a few small clusters
of cholera cases among Kurdish refugees on the Turkish border – far fewer
than Western journalists predicted. Even when cholera affects large numbers,
the death rate is usually relatively low compared with the diarrhoeal diseases
caused by other common bacteria, such as shigella and salmonella. Giardia
and amoeba are also common, debilitating infections.

Shigella and salmonella were probably responsible for most of the deaths
among Kurdish children, says Toole. He and his colleagues estimate that
at least 6700 of the 400 000 Kurdish refugees on the Turkey-Iraq border
died. If the death rate for the population had remained at its normal level,
only 500 might have been expected to die during the same period. More than
70 per cent of the deaths were associated with diarrhoea, dehydration and
acute malnutrition.

For most of us in the West, images of refugee camps consist of high-tech
medicine or special feeds being dispensed by expatriates to sick and passive
victims. These are the images that appear on television and bring public
pressure on governments to make donations. But epidemiologists in relief
agencies say the real picture is different. First, high-tech medicine is
not what the majority of people need; they simply require clean water, proper
latrines, shelter and adequate food (and, in the longer term, the opportunity
to provide for themselves). Only a minority of the children arriving in
a camp will need intravenous infusions of fluid, for example; most will
be saved simply by oral rehydration therapy.

In countries with experience of providing for refugees, the local people
may sometimes be more effective than the competing, but photogenic, rescue
squads that eventually arrive. In Iran after the Gulf War, for example,
the Iranian Red Crescent’s officials erected camps and latrines rapidly
and effectively, says John Seaman, senior medical officer for Save the Children
Fund in London. SCF provided material support but the Iranians held overall
responsibility for the relief operation, he says. And last year when thousands
of refugees fled Liberia during civil war and went to neighbouring Guinea,
local people fed them for six months before any international supplies of
food arrived, according to Toole.

This is not to say that outside relief is not urgently needed, he adds.
But the reality of good relief care is less glamorous than TV images might
suggest. For example, the physical layout of a camp can make crucial differences
to the refugees’ health, says Seaman. If latrines are put all together,
no one is responsible for them and they may rapidly become filthy and unusable:
the result is that people defecate in inappropriate places and water supplies
are contaminated. If, however, latrines are built in small blocks, each
for a known number of families, individuals are more likely to keep them
clean and continue to use them.

No one doubts that refugees need good medical care, but providing that
care raises difficult questions, say researchers. Are we prepared to sustain
the same standard of care after the initial interest of the rich world wanes?
And, says Nancy Godfrey at the London School of Hygiene and Tropical Medicine,
can we continue to provide for refugees’ needs without also considering
the needs of the people who host them? In many of the African countries
that host large refugee populations, the standard of medical care is low.

Despite these controversies, there are certain emergency services that
are relatively simple and cheap to provide, and which have been shown to
save many lives. The biggest single one is measles vaccination. Measles
is one of the main killers in refugee camps. This virus is much more likely
to affect children who are malnourished or otherwise weakened, and many
vulnerable children crowded together will hasten its spread. According to
Toole, the death rate from measles in a refugee camp in Sudan during 1985
rose as high as one in every three cases diagnosed, with a total of 2000
deaths between February and May. This is exceptionally high even for a refugee
camp; in Thailand in 1980, the death rate from measles in one camp was 2.3
per cent of diagnosed cases. The high rate in Sudan probably occurred because
relief workers failed to immunise children in time, say epidemiologists.

With measles as with all infectious diseases for which there is a vaccine,
a minimum proportion of children in any population must be immunised to
prevent epidemics. That proportion depends on the population, but 85 per
cent is a good rule of thumb for normal conditions. Even then, there will
be cyclical outbreaks whenever the number of unvaccinated children has accumulated
to create a sizeable group at risk.

The French agency Medecins sans Frontieres believes that in order to
avoid outbreaks in crowded camps, between 90 and 95 per cent of refugee
children must be vaccinated against measles. Marc Gastellu-Etchegorry from
Epicentre, MSF’s epidemiology unit in Paris, recalls a five-month outbreak
in Malawi during 1988. Although about 60 per cent of children had been immunised,
there were 300 cases of measles a month and more than 200 deaths in all.
Even with coverage as high as 95 per cent, epidemics will occur but they
will be smaller, says Alain Moren at Epicentre. Prompt action is essential:
for example, when tens of thousands of people left Burundi for Rwanda during
civil disturbances in 1988, MSF immunised 20 000 children in four days.
‘There was no outbreak, so it paid off,’ says Moren. Virtually all epidemiologists
agree that the case for vaccinating against measles is so strong that it
should always be done.

Practices such as this are now so well established that health workers
do not wait to assess the situation before taking action. But monitoring
the trends of illness and deaths in a refugee camp is essential to enable
health workers to avert problems at an early stage. Seaman at SCF says that
even the simplest data can provide crucial information. To establish how
many people are dying, for example, members of the community may need to
take paid shifts watching the area assigned as a graveyard and asking families
who come to bury their relatives basic details about the age and the symptoms
of the deceased person. For monitoring illness, it is not sufficient to
note only those who come to the clinic for care; many more cases of a disease
may go untreated and the clinic visitors will then provide a distorted picture.

Death rates and estimates of the incidence of diseases should be estimated
initially every week, not only for the whole population but also for the
under-fives and infants. Without this information, aid agencies will not
know whether the system is working or whether important changes need to
be made. After the initial phase when life has stabilised, data should still
be collected at least twice a year, says Seaman.

In most developing countries, the average death rate for overall populations
is around 0.5 per 10 000 people daily. In an emergency relief programme,
the situation is ‘under control’ as long as the death rate for the population
stays below 1 per 10 000 daily, according to Mohamed Dualeh, public health
officer to the United Nations High Commissioner for Refugees (UNHCR) in
Geneva. By the time the death rate reaches 2 per 10 000, the situation is
out of control and with 5 deaths per 10 000 daily, the refugees face catastrophe.
Dualeh, who has just returned from Kenya, says Somali refugees there are
dying at a rate of 4 per 10 000 per day. The vast majority of the dying
are children. This crisis extends, he says, to many of the refugees in the
Horn of Africa.

If mortality rates prove impossible to measure, a reliable alternative
is to record the prevalence of protein-energy malnutrition (PEM) in the
population, says Toole. A person is defined as having PEM if their ratio
of weight to height is less than 80 per cent of the World Health Organization’s
accepted standard figure. Measurements of weight and height can be taken
by anyone with basic training. Toole says the average prevalence of PEM
in general populations unaffected by famine in sub-Saharan Africa is less
than 5 per cent. Where the prevalence rises to between 5 and 9.9 per cent,
the mortality rate also rises more than two-fold. Where PEM rises to between
10 and 19.9 per cent, the risk of death more than quadruples.

In Ethiopia in March 1989, more than a quarter of the refugees in the
Hartisheik A camp had PEM, and the overall mortality rate rose accordingly.
In Kenya now, says Dualeh, the prevalence of this malnutrition among Somali
refugees is 29 per cent. Other researchers warn, however, that the picture
of death rates provided by PEM prevalence may sometimes be skewed. If the
death rate is extremely high, those children with the worst weight-for-height
ratio will not be alive to be counted.

Clearly, says Godfrey, relief workers need to get their hands on data
quickly. But, she says: ‘Decision makers are faced with the very difficult
challenge of balancing the need for information with the urgency of the
situation. We know enough from previous experience to start certain relief
activities at once.’

Malnutrition is probably the most serious health problem for refugees
– partly because their flight from home is usually in conditions of near-starvation
and may follow a period of prolonged food shortages. The common types of
malnutrition they suffer include: simple protein-energy deficiency; vitamin
A deficiency, which causes immune suppression and eventually blindness;
and vitamin C deficiency, which causes scurvy. The WHO says that a basic
diet should provide 1900 kilocalories daily and a full range of nutrients,
but other researchers say refugees need more than this to help them to recover
from earlier shortages. In fact, many refugees get just 1000 kilocalories,
and the bulk of it is maize, cereal or rice with oil and beans. Obviously,
any failure to deliver the food to camps reduces people’s intake even further.

The World Food Programme, a UN agency, is responsible for providing
food aid. The food that it distributes is surplus on the world market, so
it is basically whatever is available at the time. As a result, it is not
always appropriate for the needs of refugees. For example, says Jean-Pierre
Revel of the League of Red Cross/Red Crescent Societies in Geneva, wheat
grain has been supplied to refugees in Ethiopia. This is an alien food for
these people, says Revel, and perhaps more importantly, they have no means
to mill it. In a better-publicised situation, the Kurdish refugees on the
Turkish border were provided with flour, but they had no means of cooking.
Another problem with surplus rations is that they may not offer the food
in the most nutritious form. For example, says Andrew Tomkins at the Institute
of Child Health in London, finely milled cereals may lack important minerals
such as potassium and magnesium.

Toole says the standard refugee diet is artificial; for example, it
may contain little or no vitamin C. This is unacceptable, he says: every
population whose diet is natural is able to find some source of this vitamin.
Privately at least, health officials in the UN agencies accept that the
international community must take the blame for continuing to provide refugees
with a diet which is known to be substandard. In many long-term camps, people
have set up their own trading arrangements with the locals to obtain tomatoes,
fruit and other foods to improve their diet.

‘It’s fairly outrageous that we still have outbreaks of disease (caused
by malnutrition),’ says Bruce Dick at the Red Cross. Only last year in Malawi,
for example, 18 000 refugees developed pellagra – a disease caused by niacin
(vitamin B) deficiency which begins with skin rashes and diarrhoea and which
can progress to dementia if untreated.

The reason for the niacin deficiency was that the refugees’ supply of
groundnuts had run out and their diet relied on maize. The UN agencies were
apparently unable to find any more groundnuts on the world market, say researchers
from the private aid organisations. A group of these aid agencies identified
and bought a supply in South Africa. ‘The international community was very
slow to respond to this problem. This was surely the biggest outbreak of
pellagra ever documented,’ says Moren at Epicentre. Toole is more critical
still: ‘Basically it happened because the world did not see it as a high
enough priority.’ Officials at the UNHCR say pellagra is also affecting
refugees in other parts of southern Africa, for example Zimbabwe.

Agencies recommend that all under-fives are given supplements of vitamin
A to help to boost their immune response to infection. Some agencies also
recommend giving vitamin C tablets. However, vitamin supplements are ‘an
admission that the system is a failure’, says Tomkins. Such supplements
should be seen as a temporary measure, he says, with more attention paid
to improving the basic diet.

This diet is particularly important in the long term. Toole has documented
one survey of scurvy outbreaks in certain African refugee camps. The longer
the refugees were in camps, the more prevalent scurvy became. In an article
in the Journal of the American Medical Association last year, Toole wrote:
‘Such preventable problems result from the failure of major relief agencies
to make the quality of refugee rations a priority, and the lack of consensus
among agencies regarding practical solutions to the problem.’

Malnutrition, however, is not the only long-term problem. Until recently,
researchers had concentrated on the physical needs of refugees, believing
that all their problems would be solved if these were met. But people living
for a decade in a camp face not only physical hardship but also intense
boredom and the frustration of being incarcerated. Many refugees will have
fled torture, harassment or violence, or will have had to witness violence
to their relatives. The emotional impact may be severe, according to Giovanni
de Girolamo of the Division of Mental Health at the World Health Organization.

‘The camp refugee can be seen as someone facing a past world of loss,
an uncertain future, and a present sense of being controlled,’ he says.
Almost nobody has studied the mental health of refugees, or acknowledged
until recently that such people might have problems, says de Girolamo. However,
the WHO has now commissioned studies in Thailand, Afghanistan and Namibia.
Margaret McCallin of the International Catholic Child Bureau in Geneva has
done one of the very few studies so far. She interviewed Mozambican women
who have recently fled to Zambia. Of 110 women interviewed, 87 had witnessed
traumatic events, such as murder or torture. Between them, these 87 women
had experienced 698 traumatic events. Many of the women found that memories
of the events intruded in their thoughts repeatedly, and many were unable
to cope with everyday events, says McCallin.

It is not, of course, unhealthy to react with shock, unhappiness or
dismay to traumatic events. Psychologists are keen to stress the difference
between healthy unhappiness and psychological problems. Someone who was
not unhappy after witnessing war, torture, intimidation and death would
be an unusual individual, and well-meaning aid workers who try to help by
‘cheering up’ the refugee have clearly misunderstood what is meant by mental
health, says Jean-Pierre Hiegel of OHFOM, a French aid agency in Thailand.
It is normal to suffer the so-called post-traumatic stress disorder – for
example, irritability, sleeplessness and indigestion – after loss and fear.
Nevertheless, health workers can be trained to listen and offer support
to disturbed people which may enable them to work through their grief more
easily.

Provided their situation stabilises, the vast majority of people will
adjust mentally, with only a minority suffering abnormal mental disturbance.
Such people may need specialised psychiatric help. For example, one aid
worker described a terrified Cambodian refugee who has shut herself away
in a cupboard for four years, refusing to emerge even briefly. De Girolamo
says members of the refugees’ own community may be best able to listen and
support each other, since they share the same culture.

Boredom is a serious difficulty for refugees, particularly for children.
There are rarely any jobs or cultivable land available to them. Sometimes
this is due to overcrowding: in Malawi, for example, there are a million
refugees in a small country with a population of 8 million people who are
already short of land.

In many camps, refugees have taken their own steps to organise their
time. Children have devised ingenious toys out of whatever is available
to them. Adults have organised education classes or light industries, such
as making soap. Increasingly, members of the refugee community are training
as primary health workers, often with responsibility for a part of a camp
or a group of families.

Life in a camp is not only boring, but also disrupted socially. With
families separated and, sometimes, an imbalance of males and females, do
refugees face an unusually high risk of sexually transmitted diseases such
as HIV? There is no evidence of this, says the WHO. The international agencies
are most anxious to avoid the idea that refugees are more likely to be HIV-positive
than anyone else, because host countries might regard them as importers
of the virus and restrict their movements still further. According to Dualeh,
the rate of infection among refugees in some African countries is actually
lower than that of the local population.

But if refugees’ risk of infection appears to be no higher than anyone
else’s, neither is it usually any lower. HIV tends to spread most rapidly
in conditions of poverty where prostitution may be one of the few employment
opportunities for women. Refugees are not exempt from such conditions, and
indeed their opportunities for paid work may be even more restricted than
others’. Thus no matter how low the level of infection may be when refugees
arrive, they may be at risk of infection by having sex with the locals.
And at least until recently, few refugees received the AIDS education that
health ministries offered to their own populations.

Dualeh at the UNHCR says the agency is now trying to work with governments
to ensure refugees receive as much health information as local populations.
Such efforts might help if condoms were available, but traditionally few
aid agencies have thought to provide them. Another problem is that some
refugee groups have been suspicious of others’ efforts to offer them family
planning, seeing it as an attempt to control their already beleaguered populations.

Given the rising numbers of refugees and the depressed state of most
African economies in particular, the outlook appears bleak. It seems that
reliance on the UN agencies can only increase, yet the agencies’ funds are
grossly inadequate and their support for those who need them is diminishing.
The UNHCR’s income, for example, has scarcely changed in a decade that has
seen a doubling of refugee numbers.

Part of the problem, say researchers, is that the donors are not interested
in funding development but only in making dramatic responses to disasters.
Godfrey at the London School of Hygiene and Tropical Medicine says that
ideally, international organisations could help governments in countries
that receive refugees to prepare for their influx and at the same time,
improve health services to their own people. For example, the agencies could
fund improvements to the health infrastructure in rural areas and border
zones. They could also invest in agricultural schemes and appropriate technology.
Not only would this improve life for people in the host country; it would
also ensure that refugees could become self-sufficient as soon as possible.

But Godfrey doubts whether the agencies would actually do this. In a
study of the policy on refugees in Somalia before 1988, she and Husein Mursal,
formerly director of the Somali government’s Refugee Health Unit, concluded
that there was ‘a marked reluctance of many international agencies to relinquish
their autonomy and control over resources’. The agencies lacked trust in
the government’s own refugee health unit, the researchers found. ‘Neither
the government nor the refugees were given the authority and means to participate
on equal terms with international agencies.’

In Seaman’s view, the current system is tending to fail because no one
is in charge and everyone can blame everyone else. ‘We have a system but
we don’t always care to make it work,’ he says. In international law the
only body with authority over refugees is the host government, the sovereign
power. But many sovereign powers are in fact powerless because they are
bankrupt. ‘Unless you want to change international law you are stuck with
this situation so, realistically, you accept it and work within it. But
at the moment, we are accepting the law but not observing it.’

Thus, he says, the donor governments can blame the international agencies,
the agencies can plead a shortage of funds from the donors, and poor host
governments can blame the donors and the agencies. Refugees have no voice
at all. No one is accountable. The answer, Seaman believes, lies in making
agencies and governments accountable so that donors can at least learn how
well or how badly the health needs of refugees are being met and how effectively
their long-term problems are being resolved. This could be done, he says,
by feeding back regular data, for example on measures of health such as
PEM prevalence and mortality rates, to ‘those who could potentially do something
about it’. This means, for example, UN executive committees. Other data
that could be sent back include regular assessments of the type and quantity
of food delivered.

The main fault at present is that we know what goes into the system
but have no way to monitor what comes out, says Seaman. ‘Materially it works
out like a pipeline. What goes in at the top is chiefly what’s available
to throw into it at the time. Whether it’s what people need or if there
is enough of it is only found out in a purely accidental manner,’ he says.
‘All that is required is a route for that information to go back into the
system. Then we could at least close the circle so that the donors were
aware what was happening. At the moment they are working in complete ignorance.
If they were to have the information and turn their back on it, then it
would at least be very clear what they were doing.’

For refugees already making their own way in an uncertain future, such
improvements might seem remote and academic. But for aid workers, governments
and the refugees of tomorrow, the need could hardly be more urgent.