Refugees and Displaced Persons

8/13/2019 Refugees and Displaced Persons

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Refugees andDisplaced PersonsWar, Hunger, and Public HealthMichael J. Toole, MD, DTM&H, Ronald J. Waldman, MD, MPH

Thenumber of refugeesandinternallydisplacedpersonsinneedofprotectionandassistance has increased from 30 million in 1990 to more than 43milliontoday.War and civil strife have been largelyresponsible forthisepidemic of mass mi-grationthathasaffectedalmosteveryregionof theworld,includingEurope. Since1990, crude death rates(CDRs)during theearly influx ofrefugees who crossedinternational borders have been somewhat lower than CDRs reported earlieramongCambodian andEthiopianrefugees.Nevertheless,CDRs amongrefugeesarrivinginEthiopia,Kenya,Nepal,Malawi,andZimbabwesince1990rangedfromfive to 12 times the baselineCDRs in the countriesof origin.Amonginternallydis-

placed populations in northern

Iraq, Somalia,andSudan, CDRs were

extremelyhigh,rangingfrom 12to 25timesthebaselineCDRsfor thenondisplaced.Amongboth refugeesand internallydisplaced persons, death rates amongchildren lessthan 5 yearsof age werefarhigher than amongolder childrenandadults. In Bang-ladesh,the death ratein femaleRohingyarefugees was severaltimeshigher thanin males. Preventable conditions such asdiarrhealdisease, measles, and acuterespiratory infections,exacerbatedoftenbymalnutrition,caused mostdeaths.Al-though relief programs for refugees have improved since 1990, the situationamongtheinternallydisplacedmay haveworsened.Theinternationalcommunityshould intervene earlier in the evolution ofcomplex disastersinvolving civil war,human rightsabuses, foodshortages, and massdisplacement. Relief programsneed to be based on sound health and nutrition information andshouldfocus ontheprovision ofadequate shelter, food, water, sanitation, andpublic health pro-

gramsthat

preventmortalityfromdiarrhea,measles,andother communicabledis-

eases, especially among young children and women.(JAMA. 1993;270:600-605)

ALTHOUGH the end of the cold warbroughtpromises of a newworldorder,dozensof wars havegenerated a cycleofviolence,hunger, mass migration, anddeaththataffects millionsof civilians inseveral continents and provides one ofthe greatpublichealthchallengesof ourtimes. Images of Somalis starving industy, makeshift camps, of Kurds huddled in snow-coveredmountains,and o fBosnian civilians

trapped in their be

sieged citiesdominate the world's television screensandnewspapers.The m edia haveselectively focused on afew ofthesehuman emergencies, but these represent a small sample of a global epidemicof masshumandisplacementthatshows no signs ofabatement.

From the International Health Program Office, Cen-tersforDiseaseControland Prevention,Atlanta, Ga (DrToole), and theDivisionof Diarrhoeal and Acute Res-piratory Disease Control, World Health Organization,Geneva, Switzerland (Dr Waldman).

Reprint requests to International Health ProgramOf-fice, Centersfor Disease Control an d Prevention, Mail-

stopF03, Atlanta, GA 30333

(DrToole).

In1990, wedescribedthehighmortality associated with mass population displacements in developing countries andproposed preventive strategies.1 Sincethen, the number ofrefugees andinternally displaced persons has grownby 40%fromapproximately 30 million to 43 million.23 We describe herein the publichealth impact of mass migrations thathave taken placesince1990,assess the ad

equacyofthe international

community'sresponse, and suggest approaches for protecting affected populations from themostlypreventable conditions that havecausedhigh deathrates in the past. Wefocus on the prevention ofmortality inacuteemergencies whilerecognizing thatothercritical issues affecting the longer-termwell-beingof displaced communities warrant serious attention.

REFUGEES

Refugees are defined as people whohave crossedinternationalbordersflee

ing war or

persecution for reasons of

race, religion, nationality, or membership in particular social and politicalgroupsand are protectedby severalinternational conventions.4 Since 1990,morethan6.9 millionrefugeeshavebeenaccordedsuchprotectionandassistanceby theinternational community,of whom2 million have returned to their countriesof originand lessthan100000 havebeen resettled inthirdcountries(Table1).

Approximately4 .5 million remain in

relief camps,bringingthe totalnumberofdependent refugees worldwide to almost 19 million.5

During the 1970s and 1980s, most ofthe world's refugees fled developingcountries such as Afghanistan, Cambodia, Ethiopia, Mozambique, and Vietnam, that ranked amongthe poorest inthe world. However, since 1990, anincreasing numberofrefugees haveoriginated in relatively moreaffluent countries such as Armenia, Iraq, Kuwait,and the former Yugoslavia. Approximately 1 million refugees have soughtasylum in one or another of the newrepublicsthat oncecomprisedYugoslavia;in addition, morethanhalf amillionrefugees from the former Yugoslaviahavesought asylumin various countriesin Western Europe.6 The warbetweenArmeniaandAzerbaijan overcontrol ofthe enclave ofNagorno-Karabakh hasgenerated morethan500 000 refugees.5Theinternationallyaccepted definitionofrefugees excludes large numbers of"economic" refugees, such as EasternEuropeansandNorth Africanswho havemigrated toWesternEurope, and Cen

tral Americans and Haitians who havesought better lives in theUnitedStates.While many people fled the general

violenceofwar, mostsoughtrefugebecause they were specificallytargetedbyarmed forces. Muslim Rohingyas wholeftMyanmar for the refugee camps ofBangladesh were victims of religiouspersecution by their government; ethnicNepalis were harassedbyBhutaneseauthorities;Liberians wereattacked ormurderedbecauseof their ethnicity;andCroats, Serbs, and Bosnian Muslimswere victims of ancient ethnic and re

ligiousfeuds. Womenin the formerYu-

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Table 1.Refugees Arriving in the Countries ofAsylum Between January 1990 andApril 1993*

Country of Origin Country o f AsylumYear ofArrival

Estimated RefugeePopulation

Liberia Guinea 1990 300 000

Liberia Cte d'Ivoire 1990 200 000

Somalia Djibouti 30 000

Somalia Ethiopia 1990-1991 200 000

Sudan EthiopiaKuwait/I raqt Jordan 1990 750 000

Mozambique Malawi

Azerbaijan Armenia 1990-1992 300 000Armenia Azerbaijan 1990-1992 200 000

Iraq* Iran 1991 1 100000

Iraqi Turkey 1991 450 000Sierra Leonell Guinea 1991 185 000

Ethiopian Sudan

Somalia Kenya 1991-1992 320 000Croatia/

Bosnia-HerzegovinaAll republics of

former Yugoslavla# 1991-1993 1 000 000Former Yugoslavia Countries of Western Europe*

Georgia Russia 1991-1992 10000 0

Somalia Yemen 50 000

Ethiopia Kenya 1992 80 00 0Sudan Kenya 1992 20 00 0

Mall/Niger Algeria 1992 40 000Myanmar BangladeshBhutan Nepal 1992 75 000

Mozambique Zimbabwe 1992

Tajikistan Afghanistan 1993 60 000

Togo Ghana

Togo Benin 1993 130 0 00Burundi

Total 6 901 400

*Data from United Nations High Commissioner for Refugees (unpublished data, 1992, 1993) a nd the US Committeefo r Refugees.5

tMajority were guest workers from Asian countries and were repatriated within 6 months.^Majority had returned to northern Iraq by December 1991.Majorityof Kurdishrefugees were either on the Turkish border orjust inside Iraq.

jllncludes many Liberian refugeeswho had previouslysoughtasylum i n Sierra Leone and who then fled to Guineain 1991.

TIEthiopianmilitary and their dependents; most were repatriated to Ethiopia by the end of 1991.Numberof refugeesarrivingby republic wereasfollows:Serbia,390 000;Croatia, 365 000;Bosnia-Herzegovina,

93000; Slovenia, 70 000; Montenegro, 51 000; and Macedonia, 31 000.**Number of refugeesarriving by country as follows: Germany, 220 000; Sweden, 74 000; Austria, 73000;

Switzerland, 70 000;Hungary, 40 000;Turkey,20 000; Italy, 17 000; Denmark,7000;the Netherlands,7000; UnitedKingdom, 4900; Spain, 4600; France, 4200; Norway, 3700; Belgium, 3400; Finland, 1800; Czech Republic andSlovakia, 1700; Luxembourg, 1600; and Poland, 1500.

goslavia and among the Rohingya minority in Myanmar have been the targets of organized sexual violence.Drought and famine, while often citedas primary causes ofpopulation movements, are usuallyonlycontributing factors. For example, although a severe

droughtduring 1992 affected food

production in all countriesofsouthern Af

rica, only in war-torn Mozambique didhundredsof thousandsof hungryinhabitantsmigrate toneighboringcountriesinsearchof food.Likewise,drought exacerbated rather than initiated the flightof refugeesfromthecivil war inSomaliaintoKenyaduring 1992.

INTERNALLY DISPLACED PERSONS

Refugees are clearly definedby internationallegalconventionsand,therefore,are entitled toprotection and assistancebytheUnitedNationsHighCommission-

erfor Refugees (UNHCR). In contrast,persons who flee their homes for the samereasonsas refugees but who remain insidetheir own countriesenjoy no such legalstatus. These"internallydisplaced" persons arein a particularlyprecarious situation becausethey areoftenbeyond thereach ofinternational

agencies,which

relyon the cooperation of national governments to deliver reliefaid. The principle ofsovereignty, enshrined inthe UnitedNations(UN)charter,protects therightofnational governmentsto control accesstotheir territory. Although the GenevaConventions guarantee thebasic humanrights of civilian victimsof war,theInternationalCommitteeof theRedCross,thecustodianof theconventions,is oftendenied access to thesepopulationsby governments orrivalpoliticalorganizations.

There are currently an estimated25 million internally displaced persons

worldwide, an increase of 9 million since1990; ofthese,approximately 16 millionlive in Africa.5Some have been forcibly relocatedby theirgovernments, for example, more than 4 million into the blackhomelands of South Africa and 500000into the resettlement areas ofEthiopia.Themajorityhave fledtheirhomesto escape warand persecution and to searchforfood and shelter. More than 1 million

people are

internallydisplacedin each of

the following: Mozambique, Philippines,Sudan,Somalia,and the formerYugoslavia. In addition, Angola, Liberia, Peru,Rwanda, and the former Soviet Unioneach have morethan half a million inter

nallydisplacedpersons.5

PUBLIC HEALTH CONSEQUENCES

Increased MortalityDuringthe acutephase of mass popu

lationdisplacements,the most specificindicatorofpublichealth impact is the crudedeath rate (CDR). Since 1990,mortalitysurveillance systems have been established routinely inmostof theworld's refugeepopulationsby either the UNHCRor private voluntary organizations. Insome cases, information gathered bythese systems has been augmented bypopulation surveys. The collection o finformation on mortality ininternally displacedpopulationshasbeenlesscompletebecause access tothe affected communities is oftendifficult;however,mortalitysurveys were performedin selected displaced communities in Liberia (1990),northern Iraq (1991), Somalia(1992 and

1993), and southernSudan (1993).Refugees.In our 1990 JAMA article, CDRs were cited among refugeesduring the early influx that ranged ashigh as 45 times the baseline CDRs intheircountry oforigin.1 In this report,CDRs are expressed as the number ofdeathsinallagesper 1000populationpermonth, unless otherwise specified, andarenot age-adjusted. Since 1990, CDRsamong refugeeshave generally beenlower thanthose reportedearlier among refugeesin Thailand(1979),Somalia(1980),and Sudan (1985). Nevertheless, since

1990, CDRs between five and 12 times

the baseline rates have been reportedduring theearly influx amongrefugeesinEthiopia, Kenya, Malawi,Nepal, andZimbabwe (Table 279). Death rates returnedto baselinelevels within3months

amongBhutaneserefugeesinNepalandMozambicanrefugeesin MalawiandZimbabwe.However, improvement was slower amongSudaneseand Somalirefugees,who were housed in large camps in remote areas ofEthiopia and Kenya, respectively,where watersupply was ofteninadequate and thelogistics of fooddelivery was problematic.



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Table 2.Crude Monthly Death Rates* for Refugee Populations BetweenJuly 1990 a nd August 1992

Date Host CountryCountry

of OriginBaseline Crude

Death Rate12Refugee Crude

Death Rate

July 19907 Ethiopia Sudan 6.9June 19917 Ethiopia Somalia 14.0March 1992t Kenyan Somalia 22.2

April 19928 Nepal Bhutan

June 1992 B angladesh Myanmar 4.8June 19929 Malawil Mozambique

August 1992s ZlmbabweH Mozambique 1.5 10.5

"'Deaths p er 1000 population. Baseline crude death rates are from countries of origin. (-Unpublished data, Carol Collins, MD, Nairobi, Kenya, February 1992.

jcrude death rate fo r refugees in Ifo camponly.Unpublished data, Brent Burkholder, MD, Atlanta, Ga, August 1992.llCrude death rate for refugees in Llsungwe refugee camponly; openedJanuary 1992.HCrude death rate for refugees in Chambuta camponly.

Table 3.Crude Monthly Death Rates* for Internally Displaced Populations Between January 1990 andMarch 1993

Date CountryLocation

Within CountryBaseline Crude

Death Rate Internally Displaced Persons,

Crude Death Rate

January-December 1990" Liberia Monrovia

March-May 199110 Iraq Zakho 0.7 12.6

April 1991-March 1992" Somalia Merca

April-November 1992,: Somalia Baidoa 2.0 50.7

April-December 1992'= Somalia AfgoiApril 1992-March 1993" Sudan Ayod 1.6 23.0

April 1992-March 1993'4 Sudan Akon

April 1992-March 1993'= Bosnia Zepa 3.0

*Deathsp er 1000 population. Baselinecrude death rates are from countries of origin.

Refugeesoften arrive in the countryofasylum after a prolonged period ofdeprivation andrequire focused attention toaddress their healthproblems, asis illustrated by the high death ratesamongnewlyarrivingMozambicanrefugees. During July and August 1992,the mean

daily CDR

among Mozam

bicane whohad been in the Zimbabwean camp of Chambuta for less than 1month was0.8 per 1000. This was fourtimes the death rate ofrefugees whohad been in the camp between 1 to 3

months, and 16 times the ratereportedfornondisplacedpopulationsin Mozambique."

In Guineaand Coted'Ivoire, mortalityrates among Liberianrefugees maynot have been elevated, although surveillance information from these countriesis incomplete.Theserefugeesmayhave been spared excessive mortalitybecause many were housed in local villages,avoidingtheproblemsassociatedwith crowded and unsanitary camps.MortalitydatafromrefugeepopulationsinArmenia,Azerbaijan,Yemen,andtheformerYugoslavia arenot available.

Internally Displaced.Civil warsin Bosnia-Herzegovina, Iraq, Liberia,Mozambique, Somalia, and Sudan haveled to widespread violence, food shortages, population displacement, and unusually high death rates (Table 31,H6).Crude death rates amonginternally displaced populations in Liberia (1990) and

northern Iraq (1991) were six and 12 times

theCDRs,respectively,fornondisplacedpopulations inthosecountries.lluur>In Somalia,seriously diminished foodproduction, continued fighting between rivalwarlords, and widespread looting andbanditry led to extensivehungerand thedisplacement ofup to 2 million civilians.

Population surveys conducted in

Merca,Qorioley,12Baidoa,Afgoi,13Bardera, andNorthMogadishufoundthatthe averageCDRs among internally displacedpopulations between April 1991 and January1993 ranged from 14 to 51 per 1000 permonth, sevento25 times the baseline rateoftwo per 1000 per month (unpublisheddata, Centers for Disease Control andPrevention and United Nations Children's Fund [UNICEF], Mogadishu, Somalia, 1993).

Since1990,increasedfightingand foodshortages in southern Sudan have led todisplacement of large numbers of persons.Population surveys conducted in March1993 at threesites,Ame(EasternEqua-toria region), Ayod (Upper Nile), andAkon (Bahr el Ghazal), found averagemonthly CDRs for the previous12 monthsof 19.5,23.0,and 13.7per 1000,respectively,comparedwithmonthlyCDRs reported in nonfaminetimes in the Horn ofAfrica of 1.7 to 2.0 per 1000.1416

SinceApril 1992, morethan 1 millionpersons have beeninternallydisplacedin Bosnia-Herzegovina. Death ratesamong the displaced have not been directlyestimated;however,there arein

directindicators of thepublichealthim-

pact ofdisplacement in this war-ravagednation.Forexample,inthe centralBosnianprovinceo fZenica,whosepopulation has been swollen by displacedMuslims from easternBosnia, theperinatal and childmortality rates doubledbetween 1991 and 1992.15 Inthe easternBosnianenclaveof Zepa,where theprewar population of 7000 increased to33000 as a result of an influx of dis

placed Muslims, the annual CDR between April 1992 and March 1993 was36per1000,four timesthe prewar deathrate in Yugoslavia.15

High-RiskGroupsConsistent with earlier reports, most

deaths among refugees andinternally displaced persons during the past 3 yearshave occurred among young children.

Sixty-threepercentof deaths amongdisplacedKurdsinnorthernIraq occurredinthe 17%of thepopulationyounger than5years.10 Death rates among Somali chil

dren in displaced-persons camps wereamongthehighest everrecorded. In onecampin Baidoa,70% ofchildrenyoungerthan 5 years ofage may have died in an8-monthperiod.13At the time ofthe survey,only8%of theremainingpopulationconstituted children younger than 5

years,comparedwiththe normal 18% to20% found in most African populations.Thesurveillancesystemin refugeecampsinBangladeshprovided raredata on sex-specificmortality. InGundhum II camp,the death rate among Rohingya girlsyounger than 1 year of age was almosttwice that for

boys.Among refugeesolder

than 5 years, the death rate among femaleswas 3.5 times that for males(unpublished data, UNHCR, Cox's Bazaar,Bangladesh,1992).

Communicable Diseases

Since 1990, the most common reported causes ofdeath amongrefugeesandinternallydisplacedpersonsduringthe early influxphase have been diar-rhealdiseases, acute respiratory infections,measles,and otherinfectious diseases.7-810 While measles wascited as amajor cause ofdeathpriorto 1990,fewermeaslesepidemicshavebeen reportedamong refugeepopulationsinthepast3 years. However, measles outbreakswere reported among new refugees incamps inMalawi,Nepal,andZimbabwe,contributingto high death rates. InSomalia, extensive measles epidemics occurred. Surveys indicated that 23% to50% of deaths inBaidoa,Afgoi,and Bard-era in 1992 were causedby measles.1:i

Epidemics o f severediarrhealdiseasehave been increasingly common since1990. Cholera has occurred in refugeecampsin Bangladesh,Iraq,Malawi, Ne

pal,Turkey, Swaziland, and Zimbabwe.



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In addition, outbreaks ofdysentery causedbyShigelladysenteriae type 1 havebeenreportedin Bangladesh, Kenya, Malawi,Nepal, and Somalia, andby Escherichiacoli 0:157 in Swaziland.17 Among displacedKurds on theTurkey-Iraqborder,74% ofdeaths were associatedwith diarrhea anddehydration.1" Morbiditydatafrom someKurdishcamps indicatedthat almost70%of clinicoutpatients inearly April 1991

presented with diarrheal illness. In Somalia during1992,between22% and56%ofdeaths in Baidoa,Afgoi, and Barderawere reported to be due to diarrhea.111Malaria was reported as a major causeofdeath in camps in westernEthiopia andMalawi.711Refugeesin campsinthe HornofAfrica continue to be at risk ofhepatitis E outbreaks.7

Malnutrition

Malnutritionhas often been a majorcontributing factor to high death ratesamong refugeesandinternally displaced

persons. Prevalencerates o facute malnutrition were reported in childrenyounger than5yearsof age as Sudanese

refugees arriving inEthiopia during1990(45%, unpublished data, Rita Bhatia,MSc, Addis Ababa, 1990); 29% amongSomalirefugees in Kenya in 1991 (unpublisheddata,Carol Collins,MD,Nairobi, February 1992); and 48% amongMozambicanrefugees arriving in Zimbabwe in 1992. Malnutrition rates remained high in some Kenyan refugeecampsduring late 1991and the firsthalfof 1992. High prevalence ofacute malnutrition has not

always been associ

ated with foodshortages. Forexample,in 1991, the malnutrition prevalenceamongKurdishrefugeechildrenyounger than 5 years was only 4% after 2months ofdisplacement;however,amongchildren 12 to 23 months of age the ratewas 13.5%.10 This elevated rate wasalmostcertainlyassociated withthe highincidenceofdiarrhealdiseasein thisagegroup during time spent in mountaincampswherewaterandsanitation were

inadequate.18The highest malnutrition rates have

been reported among internally dis

placedpopulationsinSomaliaandsouthernSudan. InSomalia, acute malnutrition prevalence rates (mid upper-armcircumference less than 12.5cm) in displacedchildrenrangedbetween47%and75%during 1992.12 In March 1993, population surveys ofinternallydisplacedcommunities inAme andAyodin southern Sudan found prevalences (weight-for-height score less than -2) of81%and75%,respectively.14Since1990,therehavebeenfewerreports ofmicronutri-ent deficiencydisease outbreaks. However, sporadic cases ofpellagra were

reported among Mozambican refugees

inMalawiandZimbabweduring1992.Asevere outbreak of scurvy occurred

among demobilized Ethiopian soldiersin Sudan in 1991.19

InjuriesWar-related trauma has also caused

many deathsamong certain internally displaced populations. In Somalia, an estimated 14000 residents of Mogadishuwerekilledduringbattles thatraged between December 1991 and March 1992.2"A survey of Merca and Qorioley foundthat approximately 10% of deaths betweenApril 1991 and March 1992 werecaused by war-related injuries.12 Refugees andinternallydisplaced persons intheformerYugoslaviahaveperhapssuffered most from intentional injuries inflictedduring the course of bitter inter-ethnicfighting. TheBosnia-Herzegovinagovernment estimates that more than130000 people have died inthatcountryduringthe last2 yearsof conflict.21 Inad

dition, reports o fsexualviolenceagainstdisplaced womenhave been common.Onestudy in January 1993 estimated that12000 rape incidentsinvolvingCroatian,Muslim, andSerbian womenhadoccurredsince the war began.22WORLD'S RESPONSESINCE 1990

New and renewed conflicts have ledto a cycle ofviolence, hunger, and displacement in many parts oftheworld,including Europe. In some countries,such as Bosnia-Herzegovina, Liberia,andSomalia,governmentshavebecome

literally nonfunctional. Millions of

peoplein thesecountrieslackthe mostbasic protection and services usually affordedby a government. The internationalresponsetothesesituations needsto include timely political decisions bydonor governments toprovideadequateresources,followedbytechnicallyeffective interventions implemented by internationalandnongovernment relief organizations. The response to recentemergencies is reviewed below.

Technical ResponseEmergency relief programs must ad

dressthecriticalneedsof refugeesand internally displaced personsadequatefood,water,shelter, sanitation,andpublichealth programs that preventmortalitydue tomeasles,diarrhea,and other communicable diseases.Since the1980s, therehas been an increasedrecognition amongmajor relief agenciesof theimportanceofcertain basic public health programs.First,thecollectionof healthinformationhas improved; standardized mortalitysurveillance hasbeen instituted relativelyearly during recent refugee influxes inBangladesh,Ethiopia, Malawi,Nepal, and

Zimbabwe.Armenia hasrecently estab-

lished an emergency public health surveil-lancesystem that includes the collectionof data from refugee communities.21 Inothersituations,such asin Kenyaand onthe Turkey-Iraq border,surveillance wasestablished promptly only in certaincampsby experienced aidagencies. Theestablishment of standardized publichealth surveillance of internallydisplacedpopulations in war zonessuch asSomaliaand Bosnia-Herzegovina has been difficultand sometimesdangerous.

In some countries,timelyanalysisanddisseminationo fsurveillance datahavebeen obstructed by host country governments that are wary ofthe politicalimplicationsofthe data. Toooften,keydecision makers in relieforganizationsand governmentagenciesfailtorespondin a timelyfashionto healthinformationgeneratedby field workers. In Nepal,appropriatepublichealthprograms werenot implemented until a measles epidemic among Bhutanese refugees was

well established. Adequate water andsanitationprograms in some KenyanandZimbabweancamps werenotdevelopeduntil some time after extensive outbreaks of enterically transmitted diseases had occurred.

International consensus has beenreached on the minimal nutritional requirements ofrefugees, in terms of bothmacronutrients and micronutrients.24Population surveys of nutritional statususing standardized methods have beenroutinely performed in refugee campsmanagedby the UNHCR.However, the

timelydeliveryof

adequatequantitieso f

all food items listed inrefugee rations isproblematic in some settings,especially inAfrica.Theproblem lies partly with theambiguousdivisionof responsibilities betweenthe UNHCR and the World Food

Programme. While the UNHCR has themandate ofensuring thatrefugee needsare adequatelymet,theWorldFoodProgramme physically delivers and distributesfood onbehalf of donor governments.There is no clear accountability for thequantity and quality of foodactually received and consumedby refugees.Thus,when nutritional deficiencies are identi

fied in refugee communities, the channelthrough which a response should bemounted is often unclear.Also, there isstill n odurable solutionto theproblemofincludingadequate niacin and vitamin Cinrefugee food rations.

Prompt provisionofadequateclean waterand sanitation need tobetoppriorities for relief plannersinorder topreventdiarrhea and otherenterically transmitteddiseases thatroutinely causebetween30% and 50% ofdeathsin displacedpopulations.Technicalstandards are alreadywell defined25; however, the remote lo

cations ofmany camps and the difficult



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logistics in many refugee-hosting countries are genuineconstraints. In 1992,forexample,the amountofclean waterthatcouldbe trucked totheNyangombecamp,on the Zimbabwe-Mozambique border,providedlessthan5L per person per dayforall purposes,comparedwiththe 20 Lrecommended by the UNHCR.25 In an8-monthperiod in 1991,only 3 to 5 L ofwaterper personperday wereavailablein the Kenyan camp of Liboi during atimewhen1700 casesof hepatitisE werereported,causing63 deaths.7

Awarenessoforalrehydrationtherapy as aneffectivetreatmentof dehydration has grown. Nevertheless, manyreliefagenciesrely on traditional clinic-basedservices.Busyhealthstaffare un able to supervise aggressive oralrehydration therapy and frequently rely onunnecessary and potentially dangerousintravenoustherapy orissuepackets oforalrehydration salts to mothers without adequate explanations.Integrated re

hydration and nutritional managementof thedehydratedchildisstill rare.Moreover, the rapid spread ofmultidrug-re-sistant Shigella dysentery has createdserious problems because the effectivemanagementof thisdiseaseusing affordable antibiotics is no longerfeasible.

The major relieforganizations recognizethe criticalimportanceof vaccinatingchildrenagainstmeaslesimmediatelyafterthey arrive in a camp. Nevertheless,since1990,relatively severeoutbreaksofmeasles occurred in refugee camps inZimbabwe andNepal andamong internal

lydisplaced Somalis,causing many preventabledeaths.Thereremains a gapbetween recognition of the problem andprompt implementationof an effective immunization program. In some emergency-relief programs,effortsfocusalmostsole

ly on theprovision offood, with insufficient attention to providing measlesvaccineand associatedvaccinationequipment. This was evident on the Turkey-Iraq border in 1991. In earlyApril, theweek after the arrival of Kurdish refu

gees,appeals weremadefrom the field formeasles vaccine and equipmentthroughtheUNHCR,UNICEF,and USgovernment agencies, including the armedforces. NotuntilearlyMay did completesupplies arrive, even though the campsbordered on a European country. Problemsexperiencedwithall aspectsof vaccine and equipment supply could havebeenavoided if a plannedsystem of procurement, transport, and storage hadbeen inplace.

Other communicable diseases remain

significant problems in some displacedpopulations. Malaria is increasingly difficultto managebecauseexistingcontrolprogramshavecollapsedin several war-

affectedcountries,andwidespread chlo-

roquineresistancehasnecessitated moreexpensivedrugs for treatment.Infectionby the human immunodeficiency virushasbeen recognizedbytheUNHCRandsomegovernments as a problemthataffectsboth refugees and surrounding localpopulations.The UNHCRhasimplemented innovativeprojectsthat seek toprovide humanimmunodeficiency virusprevention services tobothrefugeesandlocal residents inEthiopia and Sudan.Anenduringproblem is the failure todetect and adequately respond to sudden, unexpected changes in the healthsituationofrefugees and internally displacedpersons.New influxesof refugeesand epidemicsof communicablediseasessuch as cholera and meningitis are themost commonof theseemergencies.Forexample, in 1991, a sudden influx ofapproximately 40000 Sudaneserefugeesoccurred in the otherwise stable camp ofItangin westernEthiopia.Therefugeeswere in a poor state ofnutrition andquick

ly succumbed to communicable diseasessuch as diarrhea andmalaria.Death ratesremained higherthan among other refugeesin the camp for at least6 months;adaptation of the existing camp healthcaresystemto the new emergency conditions wasslow.Emergencypreparedness plans need to beintegral elementsof a refugee health program.

Political ResponseTheworld's response to massmigra

tionis mostprompt andadequatewhenrefugees crossinternational borders and,

therefore, are

protectedbyinternation

allegal conventions.In the caseof morecomplexemergencies involving civil war,famine, nonfunctioning governments,and mass internal displacement, theworld has been slower to respond. Inthe caseof Somalia,existing early warning systems provided adequate information on theevolving disaster in late1991. However, the international community didnot respond fully to thescopeofthe crisis until 1 yearlater. Currently, in southern Sudan, internally displacedpersons are experiencing amongthehighestmalnutritionrates everdoc

umented14; however, the world's responsehas sofar beenquiteinadequate.It is notsurprising that internally displacedpopulations,such asthose in SomaliaandSudan, haveexperienced thehighestmortality rates.

Whilethe UNHCRhas clearresponsibilitiesforthe careof refugees, nosuchorganizationhas a clearlymandated roleincaringfor theinternallydisplaced.TheUNhas takendifferentsteps to addressdifferent emergencies related to internallydisplacedpersons.Sometimes,special humanitarian assistancecoordinators

havebeenappointed(eg,inEthiopia,So-

malia, and Iraq). On otheroccasions,thehead of an existing UN agencyhas beendesignated to lead assistance efforts(eg,thedirector ofUNICEF toleadOperation LifelineSudan,andthe UNHCR toruntheassistanceprogramintheformer

Yugoslavia).The currentUNsecretary-general has

takensteps to addressthisinconsistency with the creation of theDepartmentof Humanitarian Affairs to oversee internationalassistance topeople affectedby all mannerofdisasters,includingwaranddisplacement.TheDepartmentof Humanitarian Affairs will only be useful if itsucceedsinreducing interagencycompetitiveness,clarifyingorganizationalroles,andminimizing bureaucraticdelays in mounting an emergency response.Hopefully, decisive action by the Departmentof Humanitarian Affairs wouldprevent situations such as that whichoccurred during the early days of theKurdish crisis when there was a vacu

um of leadership. The InternationalCommittee ofthe Red Cross has madecommendableeffortsto reach internallydisplaced persons in war zones, but itsresources arelimited and itsdelegateshave recently beenunable to ensuresafeaccess to affectedpopulations(eg,inBosnia-Herzegovina).Althoughciviliansaffectedby war are protected bytheGeneva Conventions, the international communityhas notalwaystaken an activiststanceinensuring their well-being.Nevertheless,in recent years,bold new stepshave been taken in some instances.

A new

development common to the

disasters in Kurdestanand Somalia wasthe appearance of UN-mandated militaryforces whoserole wasto ensure security and toprovide logistical supportto the relief programs. However, theseforceful actions disguise an underlyingsense of confusion within the internationalcommunity.Whenand how shouldthe international community, eitherthrough the UN or through unilateralaction,forcibly ensure that humanitarian assistance reaches the needy whengovernmentsand armies intentionally obstruct reliefefforts? What is the role o f

militaryforcein thisprocess?What criteria should be used in deciding whereand when to intervene?Military forcesundoubtedlyhave major logistical advantages overconventional reliefagencies;however, theirdeployment ispoliticallydetermined and extremely expensive.The useofmilitaryfirepowerand logistics inKurdistanandSomaliarepresentsan importantprecedentfor interventionby theworldcommunity on behalf of war-affected civilians trapped within theircountry.However, current ambivalenceby western governmentstowardthepro

tectionof Bosniancivilianssuggeststhat



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suchactionisby no means afirm internationalprinciple.

CONCLUSIONS

Refugee camps arethe emergencydepartments of internationalpublic health.Overthe past few years, the emergencydepartmentshavefilled andpatients arelining up for admission. Death ratesamongrefugees andinternallydisplacedpopulationshaveremainedunacceptablyhigh, and the most common causes ofdeathremainlargelypreventable. However,lesspreventableinjuriesand deathscausedbyarmedconflicthavebecomeincreasingly common. We cannot expectthat mass migrationswilldiminish in theyears to come; we must be preparedfor them to increase in number and in

scope.In the absenceof worldpeacethemost desirable preventive measuretechnicallyeffective,well-managedreliefprograms may limit the intolerable excessmortality thatresultsfrom war,hunger,

and displacement.Epidemiologie data have identifiedthose healthproblems thatconsistentlycausemostdeathsand severe morbidity.Inaddition,youngchildrenand,in somesettings, women aremost atriskof theseadverse outcomes. Reliefprogram managers, therefore, mustchannel all available resources toward addressing measles, diarrheal diseases, malnutrition,acuterespiratory infections,and, in somecases,malaria,especially among womenand youngchildren. Inaddition, newso lutionstorecurringproblemsneed to be

explored. Refugees and

internally dis

placed persons will continue to find refuge in remoteregions where theprovision of basic needs requires innovative

References

1. Toole MJ, Waldman RJ. Prevention of excessmortality inrefugee and displaced populations indeveloping countries. JAMA. 1990;263:3296-3302.2. United Nations High Commissioner for Refu-gees. Focus: emergency. Refugees. 1992;91:4-35.3. RefugeePolicyGroup. Internally DisplacedPer-sonsin Africa:AssistanceChallengesand Oppor-tunities. Washington, DC: Refugee PolicyGroup;1992:5-21.4. Conventionand ProtocolRelatingto the Statusof Refugees. Geneva, Switzerland: United Nations

High Commissioner for Refugees; 1968. Publica-tion HCR/INF/29/Rev 3 .5. USCommittee for Refugees.World Refugee Sur-vey, 1993.Washington,DC: USCommitteefor Ref-ugees; 1993.6. United Nations High Commissioner for Refu-gees. UNHCRImplementation in1992: Provision-al Reportfor Former Yugoslavia. Geneva, Swit-zerland: United Nations High Commissioner forRefugees;February 10, 1993.7. Centers for Disease Control and Prevention.Famine-affected,refugee,anddisplaced populations:recommendations forpublichealth issues. MMWRMorb Mortal Wkly Rep. 1992;41(RR-13):1-25.8. Centers for DiseaseControland Prevention.Sur-veillance of the health status of Bhutanese refu-gees\p=m-\Nepal,1992. MMWRMorb MortalWklyRep.1993;42:14-17.

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approaches. Therefore, there is an urgentneedforsystematic operationalandevaluation research in the areas of nutrition, water supply,anddiseasecontrol.

Theplanninganddesign ofreliefprograms need strongerinput fromexperiencedtechnicalspecialists,andemergency management decisions need to bebased on sound technical information.

Timely public health and nutrition dataneedtobe more widelydisseminated.Forexample, a routine "State ofthe World'sRefugees"reportissuedatregularintervalsmightbe auseful toolin monitoringhealth trends in these populations, andmightmakerelief organizations more ac countable for the effectiveness of their

programs. Relief programs need to be

systematicallyevaluated, notmerely fortheirquantity and content, but for theirimpact and effectiveness. Greater resourcesneed tobe allocatedtopersonneltraining, emergencypreparednessplanning,andthe maintenanceof regionalr eserves

ofessentialreliefsupplies. Theseactivitiesneedto includegovernmentandnongovernment agencies in developingcountrieswhereemergencies are likely tooccur.

The international community needsto addressurgently the issue of accesstointernallydisplacedandwar-affectedciviliansin countries wherethe government either has ceased to function ef

fectively or intentionallyobstructs aidefforts. An international agency shouldbe designated to provide both protection and assistance to internally dis

placedpopulationsin the same

way

thatthe UNHCR has a mandate to protectand assistrefugees.

War and public health are incompati-

tality amongnewlyarrived Mozambicanrefugees,Zimbabwe andMalawi, 1992.MMWRMorbMortalWklyRep. 1993;42:468-469, 475-477.10. Centers for Disease Control and Prevention.Public health consequences of acute displacementof Iraqi citizens: March-May 1991. MMWR MorbMortal Wkly Rep. 1991;40:443-446.11. Hildebrand K, Durand A. JointNutrition andMortalitySurvey,Monrovia, Liberia\p=m-\1990.Mon-rovia, Liberia: M\l=e'\decinssans Fronti\l=e`\resandUnited Nations Children's Fund;January 1991.

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ble.Despitethe factthattheprovisionofhealth careto refugeesand internally displaced populations has generally improved overthe pastfew years, shifts inthe geopolitical balance of power haveresulted in a substantial increase in the

magnitudeof theproblem.Asis too oftenthe casein areasof publichealth,onlythesymptoms,not the root causes, are beingadequatelyaddressed.Arguments can bemade that the solutions lie primarily inthe realm ofpolitics and economics, andare beyondthe scopeof publichealth action. Wedisagree forthree reasons: (1)public healthpractitioners areoftenabletodocumentthemagnitudeof a disasterusing scientifically rigorous methods,therebydrawingthepublic'sattentiontothe situation with credible information;(2) once access to an affectedpopulationhas beenachieved, much excess mortality may be preventedby implementingfocused,technically effective public healthprograms;and (3)ensuring accessto ad

equate health care

shouldbeconsidereda basic human right for all people, nomatterwhat the circumstances.

Until there is moreeffectiveadvocacyby public health officials at the highestlevels for increasedprotection ofhumanrights, including the development ofguidelines for international interventionwherever and whenever gross abusesare occurring, thechallengeof providingcareandhope to millionsof refugeesandinternallydisplacedpersonsin every cornerof theworld will remain.

We thankthe following individuals for their assistance in thepreparation of themanuscript: RitaBhatia, MSc, MarianiClaeson, MD, Mohamed Dualen,MD, PatDisket,MSc,StevenGalson,MD,andSerge Male, MD.

18. YipR,SharpTW. Acute malnutritionandhighChildhood mortality related to diarrhea. JAMA.1993;270:587-590.19. Toole MJ. Micronutrient deficiencies in refu-

gees. Lancet. 1992;339:1214-1215.20. Physicians for Human Rights, Africa Watch.No Mercy in Mogadishu. New York, NY: Physi-cians for Human Rights;July, 1992:3.21. Sudetic C. Leader of Bosnia denounces newalliedplan to limitfighting. New York Times.May24, 1993:A7.

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TeamofExperts on Their Mission to Investigate Alle-gations ofRape in the Territory of the FormerYugoslavia. Brussels,Belgium:European Commu-nity; February 4, 1993. Publication E/CN.4/1993/50.23. Centers for Disease Control and Prevention.Emergency public health surveillance in responseto food and energy shortages\p=m-\Armenia, 1992.MMWR Morb Mortal WklyRep. 1993;42:69-71.24. Refugee Studies Programme. Responding tothe Nutrition Crisis Among Refugees: The Needfor New Approaches: Report of an InternationalSymposium, Oxford, 17-20 March 1991. Oxford,United Kingdom; 1992.25. United NationsHigh Commissioner for Refu-gees. Handbookfor Emergencies. Geneva, Swit-zerland: United Nations High Commissioner for

Refugees; 1982.

Refugees and Displaced Persons

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