International Refugee Health Policy

International Refugee Health Policy

Maheen Quadri

I. Definitions

II. Statistics

III. UNHCR

IV. Partner Organizations

V. Refugee Health

VI. Specific Health Issues

VII. Special Populations

VIII. Policy Issues

IX. A Successful Organization

This chapter takes a global approach to the refugee health policy topic, for more info about immigrant and refugee health policy in the United States, please see Dr. Jen Edman’s chapter “Immigrant and Refugee Health.”

Definitions

A refugee is defined as one who "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country...."[1]

If formally recognized as a refugee, an individual’s rights as a refugee should be the same as those of a foreign legal resident. This includes personal rights as well as economic and social rights.[2]

Internally displaced persons (IDPs) are similarly afflicted individuals who flee their homes, but remain in their country of origin. They usually do not receive the material assistance and legal protection that is available to most refugees. Although the United Nations High Commissioner for Refugees (UNHCR) attempts to assist IDPs, their situation remains precarious. Countries with large numbers of IDPs are sometimes hostile to outside involvement in their internal affairs, and assistance for the 25 million IDPs worldwide is difficult to secure.[3]

Asylum-seekers are those individuals who are in the process of applying for asylum in the country to which they have fled, in order to be officially recognized as refugees by that country.

Stateless people are those who find themselves with no legal nationality, and therefore have little if any political rights in the country in which they reside. Statelessness often arises in the context of political upheaval, but it can also be due to administrative oversights. Examples of stateless peoples have included: ethnic Eritreans after the Eritrean-Ethiopian war in the 1990s, and Asians living in Uganda forced to leave the country during the 1970s.[4]

Repatriated refugees are those that have returned to their country of origin, while resettled refugees are those that find a new permanent country of residence and citizenship.

The UNHCR is the official international organization that is mandated to protect refugees and their rights, and to coordinate international efforts to help refugees. The UNHCR refers to all the categories of individuals above as “of concern” to the organization.[5]

Statistics[6]

According to UNHCR, at the start of 2005 there were approximately 19.2 million people “of concern” to the organization. This was an increase of 13% from the 17 million people of concern at the start of 2004. However, the number of refugees dropped from 9.7 million to 9.2 million. The drop in total refugees was primarily due to voluntary return of many refugees to Afghanistan and Iraq.

The breakdown of the total population of concern to UNHCR at the start of 2005 is as follows:

Type	Number
Refugees	9,237,000
Internally displaced persons	5,574,000
Asylum-seekers	839,200
Stateless, others of concern	2,053,100
Returnees	1,494,500
Resettled refugees	83,700

Excluding the 4 million refugees from Palestine that are assisted by a different branch of the UNHCR, the largest refugee population at the start of 2005 was from Afghanistan (an estimated 2 million), with most of these refugees currently in Pakistan, Iran, and a few European countries. Other large refugee populations hailed from Sudan, Burundi, Democratic Republic of Congo, Somalia, Palestine, Vietnam, Liberia, Iraq, and Azerbaijan.

Although the UNHCR estimates that there were 25 million IDPs in 2004, the organization was only able to assist approximately 5 million, and therefore only these 5 million fall under the title of “persons of concern” to UNHCR. The countries with the largest populations of IDPs assisted by UNHCR were: Columbia, Sudan, Azerbaijan, Liberia, Sri Lanka, the Russian Federation, Bosnia and Herzegovina, Serbia and Montenegro, Georgia, Afghanistan, and Cote d’Ivoire. The largest total population of IDPs is currently in Sudan (6 million).

The two largest repatriation movements were of Afghans and Iraqis returning home. The top five countries hosting refugees are: Iran, Pakistan, Germany, Tanzania, and the United States. The main countries with large resettled refugee populations include the United States, Australia, and Canada.

United Nations High Commissioner for Refugees

Although vulnerable migrant populations have always been present, their rapid increase in numbers after World War I prompted official international cooperation to address the issue. In response to this crisis, the League of Nations (forerunner of the United Nations) developed an Office of High Commissioner for Refugees in 1921. In 1938 an Intergovernmental Committee for Refugees was established alongside the League of Nations office. Both these organizations focused their efforts on assisting the migrant populations of war-torn Europe. In 1944, both were combined and became the International Refugees Organization under the direction of the United Nations. This organization became the present day United Nations High Commissioner for Refugees (UNHCR) in 1951. The 1951 Convention relating to the Status of Refugees was an important milestone in establishing criteria for refugee status and detailing refugee rights.

Over the years, the UNHCR has come to the assistance of various populations throughout the world, expanding upon its original focus of European refugee issues. The organization advocates for the rights and safety of refugees through its influence on governments. UNHCR also assists in the long-term processes of settlement in host countries and repatriation in refugees’ countries of origin. The organization is also involved in prevention of the very circumstances that lead to displacement, and is constantly monitoring for possible crisis situations.[7]

The UNHCR has won two Nobel peace prizes (1945 and 1981)[8] and is the principle organization charged with protection of refugees. However, the organization has also received criticism because of their gradual change in focus over the past fifty years. Advocating for the human rights of refugees has become gradually superseded by the implementation of specific relief operations. Some critics suggest that the diplomatic power enjoyed by the UNHCR would be put to better use in the continued struggle to protect refugee rights. Another controversial issue is the organization’s focus on repatriation of refugees as the ultimate solution to refugee crises, occasionally resulting in refugees being returned to the same dangerous environments that led to their initial displacement. Despite the criticism, the UNHCR remains a large, successful organization that has done much to draw attention to the plight of displaced persons as well as provide them with material assistance.[9]

Partner Organizations

There are several United Nations organizations that work closely with the UNHCR on the issue of refugee protection. These include the World Food Program, the World Health Organization (WHO), the UN Children’s Fund (UNICEF), the UN Development Program, Office for the Coordination of Humanitarian Affairs, and the UN High Commissioner for Human Rights.

Other important international partners include the International Committee of the Red Cross (ICRC), the International Federation of Red Cross and Red Crescent Societies (IFRC), and the International Organization for Migration (IOM).[10]

There are also many non-governmental organizations (NGOs) that advocate and provide for refugees, internally displaced persons, and asylum-seekers. NGOs raise awareness, advocate, assist in conflict-resolution, and provide humanitarian assistance to displaced persons throughout the world. In recent years, the UNHCR has worked on strengthening its ties with NGOs and coordinating UNHCR-NGO efforts.[11]

Refugee Health

There are many parties involved in assisting refugees or other populations affected by humanitarian emergencies. Although the UNHCR is the principal organization involved, the UN Security Council regulates which UN constituent will be the “lead relief agency” in the event of a humanitarian emergency requiring outside intervention. The lead agency is responsible for coordinating the efforts put forth by all relief organizations, both UN and NGO-related, although individual NGOs sometimes work outside of the lead agency’s direction.

As far as UN-mediated medical assistance, WHO’s Health Action in Crisis department is responsible for coordinating medical care for refugees and other displaced people assisted by UNHCR. They have also published many guidelines as to the essential medicines needed in a crisis, the particular communicable and non-communicable diseases that require special attention, food safety and nutrition issues, and recommendations for special types of medical care (reproductive care, injury prevention/treatment, mental health care).[12]

The previously mentioned ICRC based in Geneva is also an important organization in the area of refugee health, because of both its medical relief assistance and its staunch impartiality and independence. Other NGOs involved in the medical care of refugees include: national Red Cross/Red Crescent societies, religious relief groups, Medicins Sans Frontieres or Doctors without Borders (MSF), and state-sponsored groups.[13]

Specific Health Issues

Health issues of particular importance to displaced populations include obvious problems such as trauma, malnutrition/dehydration, and communicable diseases, but also more subtle and long-term issues such as post-traumatic stress disorder (PTSD) or exacerbation of chronic conditions.

The following issues are of concern in any displaced population, particularly those in refugee camps:

Malnutrition – Food scarcity often afflicts a population before it is even displaced; this predicament is usually in the context of a political and/or economic crisis. Even when in refugee camps or other types of shelters, nutrient needs might not be met because of inadequate resources or inappropriate allocation of resources available. Deficiencies in certain nutrients (iron, iodine, selenium, water and fat-soluble vitamins) will result in characteristic signs and symptoms but not necessarily with a defect in growth. Other deficiencies (zinc, essential amino acids, general energy stores) will result in a growth failure usually accompanied by nonspecific indicators for malnutrition. Specific deficiencies that are common in refugee populations include vitamin A (resulting in pellagra), vitamin C (resulting in scurvy), and iron (resulting in anemia). Screening for malnutrition can be accomplished by measuring mid-upper arm circumference (MUAC), for which certain parameters have been established to diagnose varying degrees of malnutrition.

Measles – In unvaccinated and under-vaccinated populations, measles is a great threat because of its high potential for infectivity and serious complications.

Diarrhea – This condition remains one of the top three causes of death in the type of complex humanitarian emergencies that result in displaced populations. It is especially disabling for children, but the epidemic forms of diarrhea like cholera and dysentery can cause mortality in all age groups.

Acute Respiratory Infections – A major cause of morbidity and mortality, particularly in cold climates like northern Iraq, the Balkans, and former Soviet republics, all regions with substantial displaced populations.

Malaria – Movement of populations to areas of high malaria incidence puts them at substantial risk for infection, but the opposite is not usually true because the disease is mostly vector-driven. Overcrowding, proximity of refugee camps to livestock, and alteration of the surrounding environment when constructing a refugee camp are all factors that can contribute to increased rates of malaria infection.

Meningitis – Although outbreaks of meningitis are not a routine occurrence in refugee camps, the possibility itself is of concern. In an outbreak, mortality is high and patient deterioration is rapid, and the outbreak itself is quite prolonged.

Hepatitis E – This disease is usually spread via fecally-contaminated water, and can have high rates of mortality among pregnant women.

Tuberculosis – TB is another highly infectious disease that is hard to control once introduced into a susceptible population. The close quarters of a refugee camp lend themselves to the spread of TB, which is by a respiratory route. Because of the prolonged and rigid treatment regimen associated with TB, its diagnosis and containment are often given less priority than other, more acute and manageable infections.[14]

HIV/AIDS – The disruption of society often accompanying wide-spread migration can place vulnerable populations at an increased risk of HIV infection, but there is not enough data to support the claim that documented rates of infection increase among displaced populations. An important factor to consider is that many of the countries from which refugees leave or to which they migrate already have a high prevalence of HIV. Prevention of transmission of HIV and other sexually transmitted diseases (STDs) is imperative in the setting of a refugee camp.[15]

Other infectious diseases – The following diseases have less impact than those mentioned above, but are important in the consideration of resource allocation and disease prevention: yellow fever, typhoid fever, relapsing fever, Japanese B encephalitis, dengue hemorrhagic fever, typhus, leptospirosis. It is of note that the diseases that cause the large majority of morbidity and mortality among displaced persons are the same diseases that are the most prevalent in non-emergency situations in low-income countries.

Injury – Much of the turmoil associated with the displacement of large populations causes or involves intentional and accidental injuries. The issue of land mine injuries has received a lot of attention from the international community, and is just one example of possible civilian injuries arising from military conflicts.

Mental Health – The sense of insecurity, threat to personal safety, and substantial loss associated with forced migration can cause short and long-term psychological issues. Some refugees will develop PTSD, often associated with torture or physical/sexual violence. The role of mental health services in the immediate aftermath of migration is debatable, but services have been shown to be helpful in the repatriation/resettlement stages of recovery.

Reproductive Health – Reproductive health is often amongst the second-line of services offered in emergency situations, but it is important for both women and men. It is clearly especially important for pregnant women, and individuals who have been raped or sexually abused. Treatment and prevention of STDs is a key aspect of reproductive health services.

Chronic/“Non-Communicable” Diseases – Chronic conditions such as cardiovascular disease, diabetes, asthma, and malignancies all require frequent interactions with health care workers, active self-management, and availability of medications and technologies that are often scarce in emergency crisis situations. These conditions are difficult to manage even in non-crisis situations, and so require particular attention amongst displaced populations. However, this is understandably very difficult to accomplish in resource-constrained settings and therefore is often given less priority than acute and communicable diseases.[16]

Special Populations

There has been an increased awareness of the particular issues facing “vulnerable

populations” during complex humanitarian emergencies. This category generally includes women, children, the elderly, and disabled. Women and children currently comprise over 80% of all refugees worldwide.[17]

All these groups are at increased risk of acquiring or being affected by many of the health concerns listed in the “Specific Health Issues” section above, due to their vulnerable social position.

Sexual and gender-based violence during conflict is unfortunately a common problem and requires special attention as far as prevention and treatment of affected individuals.

Policy Issues

Facilities and services for refugees and internally displaced persons are usually created in the context of a crisis situation, and therefore it is understandable that long-term sustainability is not of top priority in such a setting. Ideally, refugee camps are meant to be temporary, in the hopes that the factors that result in migration eventually are resolved. Often such factors are not resolved, and refugees or internally displaced peoples find themselves residents of camps for extended periods of time. The toll on the facilities and services available to displaced populations is enormous, and the toll on the host country is often very large as well. Many nations that host large numbers of refugees are low-income “developing” countries that are struggling to provide basic needs to their own citizens. At times, the level of health care available to refugees in an emergency situation is better than the baseline level of healthcare in the host country.[18]

Somalia, host to the largest refugee population in Africa during the 1980s, is one example of such a country. In an article detailing the health policy decisions involved in this example, recommendations to avoid the undue strain and discrepancies mentioned above included: bolstering whatever infrastructure for health care delivery exists, investing in self-sustainable development projects, training refugee health workers, employing foreign health advisers to assist host governments, and fostering a sense of partnership between the host government, international aid organizations, and the refugee population in question.[19]

A Successful Organization

Doctors Without Borders, the Nobel prize-winning humanitarian medical relief organization, is a good example of an NGO that addresses the health care of displaced populations. They have been in operation since 1971, and have maintained their commitment to providing medical assistance to communities in need, while also serving as a powerful voice for the populations they serve. They also are remarkable for their attempts to minimize their administrative costs, and their efforts to develop existing health structures and train health workers in countries in which they operate.[20]

Currently, Doctors Without Borders has added their voice to the many that are speaking out about the massive displacement amid conflict and violence in Sudan. The organization has established several clinics to care for the internally displaced peoples, and although they face many challenges in maintaining funding for these clinics, they continue to have a presence in the region. They also continue to release press reports documenting the affects of the current violence in the region upon civilians.[21]

For more information…

United Nations High Commissioner for Refugees: www.unhcr.org

World Health Organization: www.who.int

Forced Migration Online: www.forcedmigration.org

Migration Information Source: www.migrationinformation.org

US Committee for Refugees and Immigrants: www.refugees.org

United Nations Relief and Works Agency for Palestine Refugees in the Near East: www.un.org/unrwa

US Department of Health and Human Services Office of Global Health Affairs: www.globalhealth.gov

Doctors Without Borders: www.doctorswithoutborders.org

American Refugee Committee: www.arcrelief.org

References