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Health Needs of Refugees
Gilbert Burnham, MD, PhD
Johns Hopkins University
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Section A
Emergencies
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Phases of Emergencies
Emergencies divided into phases by death
rates
– Mostly among children
Needs and services differ for each phase
Continued
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Phases of Emergencies
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Phases of Emergencies
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Phases of Emergencies:Crude Death Rate
Death rates > 1/10,000/day
– May approach 1/1,000/day
Death rates may be 5–60 times higher than
the normal rates
– Normal CMR for sub-Saharan Africa
0.5–0.9 deaths per 10,000 persons per day
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Phases of Emergencies
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Pre-Emergency Phase
Events developing
Access prevents full understanding
Political interventions still possible
Preparation for mass migration
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Emergency Phase
Length of emergency phase determined by
excess mortality
– Concentration is in getting mortality rates
down as fast as possible
Strong emphasis on food, water, sanitation,
prevention of epidemics
Requires a simple information system
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Post-Emergency Phase
Death rates < 1/10,000 persons/day
Basic services in place
– Food supply
– Water
– Sanitation
– Health care
– Shelter
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Repatriation Phase
Return home is usually spontaneous
– Refugees make their own decisions
– Most refugees return unassisted
Continued
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Repatriation Phase
Role of NGOs
– Can provide information to inform decisions
– Assist refugees returning
– Rehabilitate essential services in country
of origin
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Key Indicators
Crude mortality rate or death rate is one of
the key indicators of health status in all
phases
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Estimated Excess Mortality
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What are Health Needsin Emergencies?
Priorities vary with phases of the emergency
– Protection/security
– Food
– Water
– Sanitation
– Shelter
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Health Care Objectives:Emergency Phase
Treatment of common diseases
Prevention of epidemic diseases
– Particularly malaria
– Excess loss of life
– Tying up resources
Continued
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Health Care Objectives:Emergency Phase
Prevent endemic diseases
– Tick-borne typhus, scabies, lice
Prevent injuries
– From hostilities or household
Continued
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Health Care Objectives:Emergency Phase
Care of the vulnerable
Mental health services
Reproductive health services
Surveillance health information system
Continued
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Health Care Objectives:Emergency Phase
Services based on PHC principles
– Community-based services
Social and educational services
– Needs of adolescents
Need for information
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Health Concerns in Emergency Phase
Most deaths from five conditions
– CFR↑
Continued
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Health Concerns in Emergency Phase
Risk of meningitis
– Frightening but not often large-scale
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Health Concerns of MiddleDevelopment Countries
New problems in former Soviet bloc
– Some epidemic diseases, e.g., head lice, typhoid
– More concern with chronic diseases – e.g., diabetes, hyper-tension, heart disease
Continued
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Health Concerns of MiddleDevelopment Countries
Lack of medication and specialized care
– Difficulty with existing health care protocols
Hypothermia among the aged who cannot
move
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Priorities in Emergency Phase
General health priorities
– Water (quantity more important than quality)
– Short-term sanitation provisions, including
soap
Continued
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Priorities in Emergency Phase
General health priorities
– Food distribution
– Shelter
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Priority Health Activities
Disease prevention and control
– Epidemic diseases – e.g., measles, shigella, cholera
– Less common diseases – e.g., typhus,
relapsing fever, conjunctivitis
May require special feeding programs
Continued
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Priority Health Activities
Immunization against measles
Basic PHC with outreach to increase
Coverage
Basic health information system as early as
possible
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Late Emergency Phase
Death rates generally decline
– Both the Crude Mortality Rate and Case
Fatality Rate drop
Threats from epidemic disease may cause
increases in death rates
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Programs Reachingfor Basic Standards
Food 2,100 kcal/person/day
(Be alert for micronutrient deficiencies)
Water Availability
15–20 Liters/person/day
Sanitation 1 latrine/20 persons or
1 latrine/family (better)
Health Care Death rates <2/10,000/day
Continued
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Programs Reachingfor Basic Standards
Solid Waste Appropriate disposal, includes safe disposal of medical waste
Space 30m2/person in settlement
3m2/person in shelters
Fuel Adequate fuel at hand, i.e.,
1kg fuel wood/person/day
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Late Emergency Phase Concerns
Concern over security increases
Infrastructure-building activities
Continued
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Late Emergency Phase Concerns
Community-based activities
– Community health workers
– Community mobilizers
Continued
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Late Emergency Phase Concerns
Standard case definitions established
– Standard treatment protocols
Information system should expand
– Good idea of denominators
Increased concern for vulnerable population
Continued
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Late Emergency Phase Concerns
Promotion of community structure
– Entails risks, how to control?
Schools linked with health care
Continued
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Late Emergency Phase Concerns
Introduce income-generating activities
– Especially for women
Promote gardens
Continued
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Maintenance orPost-Emergency Phase
Defined by death rates
– Approaching pre-flight or host community
levels
– Below 1 /10,000 persons/day
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Late Emergency Phase Concerns
Health services integrated with host country
health services (if possible)
– Using local referral system
– Using host country essential drug program
and treatment protocols
May be oriented toward country of origin
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Health promotion and preventive services
functioning well
Services pitched at level of host or country of
origin
Maintenance Phase:Approach to Health Services
Continued
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More refugee health personnel involved
Increasing concern for health of host country
community
Maintenance Phase:Approach to Health Services
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Maintenance Phase:More Specialized Programs
Implementation of more specialized health
care programs
– Control of tuberculosis and leprosy
– Reproductive health care, including control
of STI, and HIV/AIDS
– Mental health programs for persistent
mental disorders
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Emphasis on improving efficiency and
effectiveness of program
Increasing concern about damage to the
environment
Maintenance Phase:Other Concerns
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Moving out of Program (Closure)
Handing over of services from relief
organizations
– National NGOs
– “Development-oriented” NGOs
– Community-based organizations
– Reliance on refugees for sustainability
– Training to promote repatriation
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Section B
Public Health Issues to Consider
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Population Distribution ofIDPs and Refugees
Population distribution usually skewed
Increase in vulnerable populations
Protection issues
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Women and Children
Health services to address needs
Gender roles change
Unaccompanied minors or separated children
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Food and Nutrition
Feeding refugees
– Food sources and preferences
– Logistics and distribution
– Targeting populations
– Composition of general rations
– Special feeding programs?
– Monitoring for micronutrient deficiencies
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Environmental Concerns
Water
Latrines
Solid waste
Vector control
Environmental damage
– Fuel wood
– Shelter
– Planting
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Emotional stress
Dealing with stress
Pre-existing mental illness exacerbated
Psychosocial Issues
Continued
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Psychosocial Issues
Resettlement/repatriation stress
Adolescent issues
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Mental Health Services
Low priority in acute settings
Single episodes of emotional disorders common
Community efforts major resource
Violence and delayed social development
Role of traditions and cultural activities
Use of refugee resources
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Security and Protection Issues
Raids from country of origin
Recruitment by insurgents
Exploitation by host country
Protection of vulnerable
Protection of relief workers
Prevention of forced repatriation
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Psychosocial Issues
Create dependency by contracting provision
of essential services
– Food, health care, environmental health
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Psychosocial IssuesOr enabling community to meet needs
– Community organization
– Community power structure
– Volunteer vs. incentive vs. pay
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Principles of Health Careto Consider
Displaced camp Own house
Camp Self-settled
Dependent on rations Growing some food
Treatment at home Treatment in health
facilities
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How a Health System Should Be
Nature of health care system
– Integration
– PHC-based
– Nature of illness
– Health care workers
– Curative vs. preventive care
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