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1. The Magnitude of the phenoaenon add its geographical distributionThe number o f re fugees throughout the w o r l d has been rising

substan tially over the last twenty years . According to official estimates ofthe High Commissioner fo r Refugees (Refugees , 1989) , twenty years ago therefugee population stood a t just under 2 .5 million . By 1980 it had risen to8 .2 million (Figure 1 and 2 ) . A t the beginning o f the nineties , the numbero f official refugees falling under UNHCR 's responsibility is approaching 15million . The large m ajority o f them are living in developing countries ,mainly in As ia and Afr ica . If we in f ac t look at the refugee population bycontinent (Figure 3) , we see that in Asia there are 6 .776 .000 refugees andin Afr ica 4 .587 .000 ; 1.380 .000 refugees live in Canada and the USA while inC e n t r a l and Latin A me r i ca ( including Mexico) there are approximately1.197 .000 refugees . Finally in Europe live 745 .000 refugees .

Look ing a t th e number o f refugees in se lec ted countries o f eachcontinent , we can see that in Asia , Pakistan and Iran are hosting thela rgest refugee population o f the wor ld , with respect ive ly 3 .257 .00 0 and2 .850 .00 0 Afghan refugees ; Thailand and ' Malaysia follow with substantiallysmaller numbers o f refugees ( 107 .000 and 104 .00 0 respect ive ly) (Figure 4 &5 ) .

In A f r i c a , S omal i a ( 8 3 4 .000 r e fu g e e s) , Sudan ( 745 .000 refugees ) ,Ethiopia ( 679 .000 refugees) , Malawi ( 628 .000 refugees ) and Zai re ( 34 0 .000

refugees ) are the most a f f e c te d countries (Figure 6 & 7) ; it should be notedthat some o f these countries are among the poores t o f the world . In Afr icaover the last 12 months only the number o f refugees has risen by around6 5 0 .0 0 0 ; in the last fe w months 150 .000 Liberians have fled into theneighbouring countries o f Cote d ' lvoire and Guinea . Presently one out o f


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every five African migrants is arefugee . Especially frequent in Africa is

border migration , with huge numberso f refugees crossing international

borders every day without any formality . In Africa70% o f the burden is

borne by 12 countries , and a o f the 16African countries among the least

developed in the world are affected by the refugeeproblem . An estimated 60%

o f the African refugees receive no assistance .

In North America , there are 1.000 .000refugees lving in the United

States , and 380 .000 in Canada (Figure 8).In Central America there are 278 .000 refugees

in Costa Rica , 237 .000 in

Honduras and 223 .000 in Guatemala (Figures9 & 10) .

In Europe , for a total number of refugeesapproaching 745 .000 people ,

184 .000 refugees live in France , 150 .000in West Germany , 139 .00 0 in Sweden

and 1 .000 in Ialy (Figures 1 & 12) .Even Europe has had to face sudden

and substantial increases in the numberso f refugees who flee : for instance ,

between June and September 1989 more than300 .000 Bulgarians crossed the

border into Turkey . Since 1983Western Europe as a whole has

received

700 ,000 asylum applicants . Host of them- some 300 .000 - have come from

Asia

and the Middle East .And even these figures do not include

over two mion Palestinians who

are assisted by UNRWA (the UN Reliefand Work Agency ) and the over 300 .000

Khmer displaced people assisted by UNBRO(the UN Border Relief Operations );

moreover they re fer only to thosepeople who have received the official

status o f refugees and who are coveredby the 1951 UN Convention relating

to

the status o f refugees and by thesubsequent protocol drafted in 1967 . They

do not incude the huge numbers o fso -called internally displaced

people and

migrants . Just to give an idea of themagnitude of these two phenomena , it


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is sufficient to remember that in Europe there are now some 20 millionimmigrants , and 35% o f them come from developing countries (Figure 13 )(Refugees , 1990) . The proportion o f foreign -bom in many European countriesamounts to between 10 and 15% , compared to 6% in USA and 16% in Canada . Lastyear there were more than 1.2 million arrivals from the East to the West .The year 1989 marked a turning point : if we consider refugees , asylumseekers , foreign workers , sett lers from the east , and family members , morethan 3 million people arrived in 1989 , twice as many as in previous years .

In the last tw o decades , nine million people have left the semi - developedcountries on the Southern side o f the Mediterranean sea to take up work inthe industrialized Nor t h . Accord ing to some demographers , a possiblescenario involving the depar ture o f some 25 million people during the nextfour dec ades cannot b e exc luded ( R i c c a, 1989 ) . Finally , as regardsmigration , it should be said that immigration to western European s ta tes ,taken t o g e t h e r , is presently bigger than immigration to North America(R e f u g e e s, 1 9 9 0) . Fac tua l l y speak ing , Europe has b e e n th e l ead ingimmigration area since the 1970s. A t the same time to tal unemploymen t inEurope runs a t a level o f some 20 million , and currently nearly 20% o f allforeign workers are unemployed .

As regards displaced people , in Afr ica an estimated 35 million live

ou t s i de their own count ry . In Ce n t ra l America , a part from officialrefugees , there is a total number o f around tw o million people displaced .According to some estimates , people fleeing from environmental degradationnow make up the largest class o f displaced people in the world , and theycould be in excess o f 10 million people worldwide . The degradation o fagricultura l and especially is currently displacing more people than any


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other form o f environmental degradation . Otherepidemiologieal estimates ,

obtained on the basis of the data collected bythe U.S . Off ice o f Foreign

Disaster Assistance (Agency for International Development , 1989) concerningthe major disasters which occurred worldwide

from 1900 up to 1988 , indicate

that , in these 9 decades , some 47 mion people became homeless because ofnatural disasters ; the large m ajority o f them were subsequently

displaced .

As for refugees , the displaced victims o f naturaldisasters are mainly made

up o f people living in the poorest countries andbelonging to the lowest

socioeconomic classes : as stated in the U.N.D.R.O . Manualon "

Disaster

Prevention and Mitigation " (1986) , "The smallestand poores t countries are

a f f e c t e d m o s t severely by natural disasters , and the poores t and mostdisadvantaged members o f a disaster a f fec ted community are likely to

experience the most serious consequences " .In general terms , the current refugee problem can be considered a

typical twentieth - century problem : it has been estimatedthat up to 140

million people have been forcibly uprooted in this century (Figure 14 )

(Harrel - Bond , 1988) .An important new characteristic o f the current

refugee situation to be

considered is that while in the past refugee emergenciestended to occur one

at a time , now refugee emergencies are occuringsimultaneously , on widely

scat tered fronts and often without warning .In terms o f sociodemographic characteristics o f the

refugee population ,

it is important to remember that half o f theworld refugee population is

made up o f children (Refugees , 1988) ; nearlyquarter o f a million o f them

suffer from acute malnutrition . Nearly 8 mionrefugees living in camps

and settlements now depend almost entirely onfood aid . Mortality rates in


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these populations during the acute phase o f displacement has been extremelyhigh , up to 60 times the expected rates (Toole & Waldman , 1990) . Displacedpopulations in Northern Ethiopia and southern Sudan have suggered thehighest mortality ra tes .

2 . MENTAL HEALTH AMD PSYCHOSOCIAL NEEDS OF REFUGEESThese f i gu res underscore the importance o f the overall phenomenon

currently represented by refugees and displaced populations ; however , until' recently , the mental health and psychosociai needs o f these people had been

neglected area o f investigation and act ion. It was felt tha t the basicneeds o f these populations were to be me t essentially in terms o f providingsh e l t e r , f o o d, sanitation and immunization aga ins t epidemics ; theirpsychosociai needs were seen as something too secondary to a t t rac t theattention o f relief agencies and relief workers . But over the last few years

different trend has become visible , and there is now wide recognition o fthe f ac t that refugees and displaced people represent populations at risk o fsuffering from various psychological s t ress- re la ted disorders ( (Miserez ,1987 ; W illiam s & Wes termeyer , 1986) .

The mental health needs o f refugees r e f l e c t the problems o f uprootedpersons and the traumatic experiences encountered during their refugee -

seeking course . As a minimu m they include the following : 1) the e f f e c t so f conditions causing the person to f lee from his or her homeland ; 2)vicissitudes during flight ; 3 ) adjustment in the country o f first asylum ;and 4 ) problems arising in the land of resettlement which could indeed meanrepatriation . If unre leved, psychological problems occurring in one phaseaccumulate with those that emerge in subsequent phases .


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As regards the process o f fleeing one 's own country , it can be said

that when people are violently uprooted , placed in a alien and overcrowdedenvironment , or removed from the basic activities that give meaning andpurpose to their lives , there will inevitably develop psychological andadaptational problems . For example , those refugees who have made a last-minute decision to flee often exhibit gu , or conversely a feeling o finvulnerability and aggression . The guilt derives from the l oss o f loved

ones who might have survived had the decision to flee been made earlier .

Camp e x p e r i e n c e, when it o c c u r s , becomes the next stage o f thetraumatic adjustment which the refugee undergoes upon arrival in the countryo f asylum , and it enahances the development o f dependency attitudes . Thecamp r e f u g e e can b e seen as someone facing a pas t world o f l oss , an

uncertain future , and a present sense o f being controlled (Figure 15 ) . The

main psychological consequences are the inability to make predictions , and a

sense o f incompe tence . Psychosocial adaptation in the host country becomesmore o r l e s s difficult depending on f a c to r s pertaining to the refugee

himself , to his country o f origin , and to those in the host community . As tothe first , the very process o f exile engenders in the refugee feelings o fgrief , bereavement , anxiety and fears , which have to be dealt with before asat i s fac to ry adjustment can be made . In the refugee situat ion one ob jec tloss becomes complicated by other l osses, and the result is a multiplebereavement which easily assumes pathological characteristics (Kohn & Levav ,1990) .

Where torture has been experienced , the psychological scars are deeper

and require treatment (Goldfield e t al . , 1988 ; Mollica e t al ., 1987) . In thehost or resettlement country , problems of accommodation , unemployment , and


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isolation f rom cultural and ethnic groups , as well as the degree o frejection within the local communities , and the length o f stay in camps insome countries , all a f fec t the refugee 's ability to integrate and to engagein meaningful activities and interpersonal relationships . Roles and statuschanges of ten occur in the country o f exile causing marital and familyproblems . Moreover , fo r many refugees camp life means a change from a ruralto an urban life- style, with related adaptationai problems . Where thecountry o f origin is characterized by large cultural dif ferences with thehost country , s t ress reactions are more severe . Therefore cultural factorsneed to be taken into account in counseling and in providing mental healthservices .

In Figure 16 the most common psychological disorders to be found amongcamp refugees are shown. These include depression and anxiety ; moreover , thespeci f ic features o f the severe s t r e sse s suf fe red by many refugees - such as

starvation , deprivation , witnessing killings or torture , physical injuriesand loss o f significant others - are likely t o produce a high number o fp o s t - traumatic s t r e s s disorders , Somatization disorders are very common aspeople in developing countries of ten express psychological i -health insomatic rather than in psychological terms (Goldberg & Bridges , 1988) . Thishas been confirmed by WHO collaborative studies carried out in differentdeveloping countr ies (Harding e t al. 1980) . Neurasthenia , which is adiagnostic category included in the ICD- lOth Edition, is another disorderparticularly f requent among some r e f u g e e populations , such as Asianpopulations .

Y et , despite the magnitude o f the problem , we do not know much aboutthe percentage o f refugees suffering from speci f ic psychological disorders


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such as PTSD. The few existing studies havebeen carried out among refugees

lving in resettlement countries (Barudy , 1989; Beiser & Fleming , 1986 ;

Beiser e t al . , 1989 ; Berry & Blondell , 1982;Boehnlein , 1987 ; Kroll e t al .,

1989 ; Krupinsky e t al . , 1973 ; Ln e t a . , 1979 ;Ngyen 1982; Westermeyer ,

1985 , 1987 , 1988) , and their findings arehardly generalizable to refugees

living in crowded camps , often in staggeringlypoor conditions (de Girolamo

e t al . , 1989; Mollica Sc Jalbert , 1989; Urrutia ,1987) . Refugees fled to a

reset t lement country may represent anexceptionally healthy population ,

self - s e l e c t e d for the same f a c t o f havingbeing able to flee to a

resettlement country . Nor do we know about thenatural history and outcome

o f these disorders when they are untreated, and how the cultural norms and

beliefs o f the refugee populations couldhave a moderating e f f e c t on them .

Finally , it should be noted that therate of refugees attending PHC

centres and showing various degrees ofpsychological distress is often very

high : even if we do not have reliable data fromspecific surveys carried out

in refugee camps , we can take note that in amajor WHO collaborative study ,

carried out in PHC facilities in very poor areasin 4 developing countries ,

rate ranging from 1% up to 18% of attenderswere found to be suffering

f r om a significant psychiatric disorder(Harding e t a . , 1980) . If we

consider the exceptional st ress which them ajority o f refugees have endured ,

we can easily conclude that this percentagewill certainly be higher .

3 . MENTAL HEALTH PREVEKTIOH AND CAKE OF REFUGEES :WHO PROGRAMMES AND PRIORITIES

WHO has always been deeply involvedin providing health care fo r

refugees through the Emergency PreparednessProgramme , and is increasingly


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i nvo lved now t h r o u g h th e newly established Relief Programme . The maina c t i v i t i e s have t o do w i t h technical advice and support to other UNa g e n c i e s , such a s UNHCR ; w i t h making h e a l t h a s s e s s m e n t s of refugeesi tuat ions and providing sp ec i f i c recommendations in order to improve theheal th s ta tus of these populations ; and f ina l ly with monitoring th e mostimportant hea lth indicators of the refugee populations (WHO , 1987 , 1989a ,1989b , 1989c , 1989d) .

In view of the recognit ion of th e importance of th e mental heal th and

psychosocial needs of re fugees , WHO has become more and more involved inthese issues as we l l . A number o f p r o j e c t s a re underway : f o r instance , WHOhas been asked by UNBRO t o make an assessment of th e mental heal th andpsychosocial problems of Khmer displaced people l iving in border encampmentson the Thai -Kampuchean border , and to make recommendations f o r improving th es i t u a t i o n o f these popula t ions (de Girolamo e t al . , 1989 ) ; two missions havetaken place to chat area . Another p r o j e c t has been i n i t i a t e d jo in t ly withth e Rel ie f Programme f o r all disabled Afghan refugees and displaced people ,and a mission has recent ly taken place both in Pakistan r e fugee camps and inAfghanis tan < E1 Fawal , 1990) ; another mission was organized to look a t them e n t a l h e a l t h n e e d s o f Namib i an p o p u l a t i o n s s h o r t l y b e f o r e t h e i rindependence (Aboo -Baker & Chikara , 1990) .

Specific programmes can play a very important role in the prevention ofmental heal th and psychosocial problems among re fugee populations . Theseprogrammes should address in the f i r s t place high - r i s k , vulnerable groups ,such as children , women , elder ly and physical ly handicapped . The exist ings o c i a l n e t w o r k , su c h as s c h o o l s , communi ty o r g a n i z a t i o n s, religiousorganizations , self -help groups can play a crucia l role in this respect .


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Fundamenta l is the organization of work and activity programmes , becausenothing restores self -confidence and worth more than daily efforts at someuseful work or activity .Mental health care should be fuly integrated into the existing networkof general health care , and should not function as a separate system . Thereare a number of reasons for this :1) in developing countries , and in the refugee camps located there , theresources devo ted to mental health are often inadequa te to meet even theroutine needs ; the primary health care system is the first and often theonly health network available for socioeconomically deprived individuals ;2) Many potential users do not come to a facility which is openlylabeled as a mental health service , since they do not see themselves aspeople needing speciali zed help but consider themselves only as victims ofextreme adversity .

3) As s ta ted above , the m ajority of people in developing countries tendto e x p r e s s psychological distress in -somatic terms , and therefore thep r i m a r y health c a r e worker represents the crucial locus for theintervention . Moreover , it is well known that the large majority of cases ofpsychological distress among attenders of health centres go unrecognized , donot receive a proper care and represent an important burden for the heal thservices . Better and prompt recognition and management of these disorders ,including PTSD, can improve their outcome and reduce the burden on thehealth services .4) Finay , the primary health care network , thanks to its centralposition in the community , can guarantee proper follow -up of victims andheir families for as long as they need.


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Therefore , the training ofprimary health care workers

to give

treatment to people attendinghealth centres and showing

emotional distress deservesmaximum priority (Lima , 1986;

Lima e t al . ,

1989 ); such tranng represents one of theman preparedness activities

. The

training of health workersshould include basic

knowledge o f the

.psychological featuresassociated with the condition

o f being a refugee;

basic knowledge o f themost common psychological

and stress - related

disorders to be found amongrefugee populations ;

understanding and knowledge

of how to deal with themain psychosocial needs of

these populations ; and

dissemination o f simple and ef fective skillsto be used for the

recognition

and treatment of psychologicallydistressed refugees (interviewing

skis ,

counselling, brief and simplepsychotherapeut ic methods , t a rge ted

pharmaco therapy , group therapy , etc . ) .The training of local health

workers in dealing with psychosocial

problems related to thecondition of being a refugee

must be mandatory even

for socio -cultural reasons , as it isvery important that

assessment be

carried out by personnelwho are acceptable to

refugees (in terms of

language , religion , ethnici ty ,sex , etc . ) . Ths training

can also be an

important tool in fostering autonomyand self - reliance (List ,

1987 ; Simmonds

et a . , 1985) .

The traini .Tl Of healthworkers in mental health seems

to be effective

and long- lasting . I thecontext of a WHO collaborative

Study 111 SIX

developing coun tries , above mentioned, general health workers were

assessed

18 months after trainingaimed at improving their

knowledge , attitudes ,

sks and capacity o f managementin mental health care ; it was

shown that

the improvement was stvisible and was o f equa

magnitude in a


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countries (Ignacio e t a ., 1989) .In this framework , the role o f the specialized mental health teamshould essentially be one o f supervision and training , and only especially

difficult cases should be referred for direct treatment .While an adequate intervention fo r refugees

who have been victims of

violence is important , it should be borne in mindthe danger o f labelng

al victims as i for the possible induction o f a sick role (Harding , 1981)

and the "creation o f a stigmatizing 'victim status ' "(Hueting , 1986) .

Attent ion should also be paid to the mental healthneeds o f the care

givers themselves , who are faced with heavy demandsand who are themselves

exposed to a substantial risk o f stress - related disorders .As for service planning , it must be

remembered that services should be

provided on the basis o f the actual needsrather than on the basis o f the

demand o f the population : this applies both to the timing and magnitude o f

the interventions (Ross & Quarantelli , 1976) .Because o f the crucial importance o f the training

fo r health workers ,

WHO is preparing together with the HighCommissioner for Refugees a training

manual fo r relief workers dealing with refugeesfo r the identification and

management o f most common psychological andpsychosocial problems to be

encountered among refugees and displaced populations .

4 . CONCUJSIOHS iRefugees have generally been seen as a burden

for host communities and

as a threat for soc ie t ies . On thecontrary they can be an essential

component o f important development programmesin poor areas ; they can foster

the capacity o f the h o s t community to respond to difficult local


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circumstances , and they can also represent also a challenge for WHO , NGOsand various clinicians who have to meet the complex needs o f these specialpopulation groups , and have to plan and implement specific programmes in thearea o f mental health .


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Programme 1989 - 1991. Geneva : PCO/EPR/ 89 .5 .World Healh Organization (1989c) . Emergency preparedness and response :Consultative meetings fo r programme development 1986- 1989 . Geneva :PCO/EPR/89 .7 .Wor ld Heal th Organization ( 1 9 8 9 d) . WHO a c t i o n in emergenc ies anddisasters : WHO Manual revision. Geneva : PCO/EPR/ 89 .6 .


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Figure 1 Changes in world refugeepopulations over time (1970-90),8 -1' _ 15_^\ / A f14 412 ! 8.2^\ ^^^^^^^^^^^^^^^^^^^^^^^

1970

1980 CZ3 1990

Source:UNHCR


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Figure 3

World Refugee Population By Continentas of 31 December 1989 (X 1.000)

6 .773_ ^ ^ ^ ,_ i 4 .587^^^^^^^^^\


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Tr-.n Thailand and Malaysia )

^K'BS'S^SST 7 !?^ W^^ '^f l i ^


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Figure 6 Countries hosting the largest refugee population in Africa (omalia, Sudan , Ethiopia , Malawi and Zaire)


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Figure 9 Countries hosting the largest refugee population in Central America (Costa Rica , Honduras and Guatemala )

fttBJBHJ.j-s..Mtaa~tai S&B-i3"-r-aSi.yB*.BBi5 S J-J-i J - -. - .^,... . . . . i


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Figure 13

Europe some 20 mion immigrants

5% from developing countries

I 1989 more than 3 mion arrivalsom Eastern countriesIn Central America 2 mion

people


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Figure 14

In this century up to 140 mionforcibly uprootedBetween 1900 -1988 47 mion becomebecause of natural disastersHalf of the world refugee population

made up by children and adolescents14 of a mion suffer from acutemalnutritionIn Africa 35 mion live outside their

own country


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Figure 15

PSYCHOLOGICAL FEATURES OFREFUGEE LIFE IN CAMPSPast -world of lossFuture uncertain lifePresent sense of being controlledInability to make predictions andsense of inco mpetence

Loss of self -respect and trust in othersD e v e l o p m e n t o f a 'dependency

syndrome '


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Figure 16

ost common psychological disorderso be found amongrefugees in camps

DepressionAnxietyPosttraumatic stress disordersSomatization disordersNeurastheniaIn a major WHO study carried out in 4developing countries , 11 -18% of primarycare attenders w er e ' suffering from apsychiatric disorder


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Figure 16

Mental health care fully integratedthe existing network of generalcare because of:a) shortage of resourcesb) somatic presentation ofsymptomsc ) reluctance to use 'mentalhealth services 'd) proper follow -up by the PHCnetwork

Training of PHC workers deservespriorityDevelopment o f a WHO /UNHCRManual in mental health forworkers

Mental Health and Psychosocial Problems

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