Refugee Health

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Lily Bullitt

Contents

Introduction

There are currently 42 million displaced people in the world (8). Figure one shows the countries that most of these people are displaced. Many of these people are living in camps set up for refugees or Internally Displaced People. Unsanitary conditions and a lack of resources in these camps cause many of the residents to suffer from health conditions that they otherwise might not have suffered from.
Figure 1. Refugee home countries in 2007. (22).
Health statistics reported from refugee camps are much worse than those reported from their non-displaced counterparts (6). Basic needs such as food and water are often difficult to obtain. The United Nations Refugee Agency (UNHCR) has stated that “in any refugee camp, a good, reliable source of clean water must be available. But sometimes, refugee camps end up on impossibly poor sites” (11). These camps are located all over the world including Thailand, Kenya, Iraq, Colombia and numerous other sites. This means that every camp has a unique health profile and has different needs, but there are a few public health aspects that affect the majority of camps. Displaced people from all over the world are more at risk of suffering from malnutrition and obtaining infectious diseases and parasites.


Malnutrition

Malnutrition is when a body is not absorbing enough nutrients or enough of the right kind of nutrients. This is important to a person’s health because malnutrition weakens the immune system making that person more susceptible to disease. Many diseases in turn keep the body from absorbing nutrients, making them even weaker. Malnutrition and disease form a vicious cycle that can be fatal to many displaced people living in camps (1). Malnutrition is increasingly becoming a problem in refugee and IDP camps. At three refugee camps in Darfur, acute malnutrition was reported to have a prevalence rate of 14.1%, 23.6%, and 10.7% respectively.
Figure 2. Normal blood cell movement and sickle cell composition movement. (14).
Many displaced people depend on international food aid as their only source of food. International food aid has been declining in the past years meaning that displaced people have not been receiving enough food and malnutrition is increasing in camps (13). Some forms of malnutrition such as Marasmus or Kwashiorkor can improve if the patient improves his or her diet. But other more serious forms of malnutrition such as Cachexia do not improve with increased intake of nutrients and lead to muscle, bone, and fat loss.


If patients are lacking certain micronutrients, known as micronutrient deficiency, it can lead to serious long-term effects such as the stunting of mental and physical development and a lowered intellectual potential (1). This occurs often in residents of refugee or IDP camps because diets are not varied enough to supply everyone with sufficient micronutrients. In Bangledesh and Nepal, many displaced people are lacking in Vitamin B. In Kenya and Algeria, many displaced people are lacking iron, leading to anemia (13). Sickle cell anemia is also very common in Liberia. Those with Sickle Cell anemia have inherited it from both parents. Sickle Cell anemia causes red blood cells to form in a crescent shape rather than a disc shape. Figure two shows that crescent shaped blood cells cause blood clots that are extremely painful and can delay physical growth of the patient (2) (14). There is no cure for sickle cell anemia, but there are ways to reduce the pain it can cause. These techniques however, are fairly high-tech and expensive and are not available to refugees or IDPs who are still trying to access the most basic health necessities such as food.


Because the main cause of malnutrition is a lack of diversity of food, the best way to combat malnutrition is through a balances diet. Unfortunately, this is extremely difficult to provide to people living in refugee and IDP camps. Camps are mostly built in previously uninhabited areas and they were uninhabited for a reason, one of those reasons being that the land is usually not very fertile. This makes it extremely difficult to camp occupants to grow their own food and they mostly rely on food aid, mostly from the international community. Food aid is not reliable as it relies largely on how much money the government and private donators are willing to give. Recently food aid has been minimal due to rising food prices and the financial crisis. Some food programs have been experiencing “a severe funding crisis” (27) which puts thousands of people at risk of malnutrition everyday.

Infectious Diseases

Displaced people are susceptible to the same disease that their non-displaced counterparts are susceptible to, except that they are more likely to contract these diseases due to poor environmental conditions and lack of health care and basic necessities. Hepatitis A is an infectious disease that can spread quickly in refugee camps because it is transmitted through the consumption of contaminated water or food (1). It can also be transmitted if any amount of fecal matter is consumed. In camps, residents may not have access to the proper decontamination tools or even to know at all to decontaminate their food and water and to wash their hands after using the bathroom because health education is often non-existent or weak in camps (15). A vaccine exists for the immunization of Hepatitis A, but many refugees do not receive this.


Hepatitis B is also quite prevalent in some refugee camp. Burmese refugees are estimated to have a 13% prevalence of chronic Hepatitis B. This means that they are infected but do not excrete the virus and live with it in their bodies for the rest of their lives. This leads to permanent liver damage and possibly liver cancer.


Malaria is an infectious disease caused by a parasite that is transmitted through a mosquito bite (17). This affects refugee and IDP camps that are established in malaria zones, such as Sub-Saharan Africa, Thailand, and Pakistan. Many inhabitants of malaria-zones develop a resistance to the disease. In some cases, if they are living in a refugee camp that is not in a malaria zone and they later return home and contract malaria, they can die because they have lost their resistance (16). Bed nets to sleep under at night greatly reduce the risk of malaria, but these are rare in camps. In 2008, the UNHCR and the UN Foundation started a campaign called “Nothing But Nets” to provide 630,000 nets to refugees in Sudan, Tanzania, Kenya, and Uganda (18).


Tuberculosis is another large health concern for crowed camps. Tuberculosis is caused by a bacteria that targets the lungs. It spreads through the air if a person with the bacteria in their lungs breaths it out and other person breaths it in (19). This can occur quite often in crowded areas like refugee and IDP camps. 85% of refugees in southeast Asia come from or move to an area of high TB burden (20). Tuberculosis alone can be fatal, but in refugee camps where the overall health of the population is weak, means that Tuberculosis is much more harmful, especially in conjunction with other diseases such as HIV.


HIV can rapidly spread through a refugee or IDP camp because of the lack of resources available to the camps. Most camps do not have the materials to test for HIV or to screen blood that could be used in a transfusion. Health education is limited in refugee camps so many people are unaware of the cause of HIV and prevention methods. Dirty needles are sometimes used if they are the only ones available for health practices, which can spread HIV (21).


Numerous other infectious diseases are present in refugee camps such as leptospirosis, mycetoma, trachoma, typhoid fever and others. Usually they are caused by lack of contamination and environmental health risks, such as lack of access to water. They are easily preventable if the proper resources are available, such as vaccines and bed nets. But refugee and IDP camps are limited and usually do not have vaccines or bed nets available to them. This means that the most likely preventative measure that will stop the spread of infectious disease is education. If more camp inhabitants are aware of how these disease spread of what they can do to protect themselves and their families, they will lower their chances of being infected.

Parasites

Figure 3. Hookworm lifecycle. (22).

Parasites are a type of infectious disease. Refugees and IDPs are at high-risk because of their poor living conditions. The hookworm is a good example of how conditions can lead to parasites. Larvae are transmitted from the soil through the skin and eventually reach the small intestine, lungs, and throat, where it is swallowed and develops into an adult ringworm in the small intestines (1). Eventually they are excreted in the human feces. Eggs hatch and once again can infect another human who comes in contact with them. Figure three shows this progression. Often in refugee and IDP camps, bathroom facilities and human waste is not very contained and the ground can become very unsanitary so parasites like hookworm can spread quickly. This is harmful because hookworm can cause serious side effects. Because hookworm causes blood loss it can lead to anemia. Children may suffer from protein deficiency and development delays (1).


Cryptosporidiosis is another parasite common in refugee camps. It enters the body when humans come in contact with contaminated water (24). Because clean water is in short supply at many camps, many people come into contact with Cryptosporidiosis. Cryptosporidiosis causes diarrhea, which in turn causes dehydration. Dehydration, if untreated, can be fatal. In Sudanese IDP camps, diarrheal disease cause between 25% and 47% of deaths (4). The UNHCR has stated “ diarrhea, often the product of the consumption of poor quality water, is one of the main causes of morbidity that results in . Malnutrition contributes to almost 60% of deaths of under five year olds in developing countries and has been a major concern in refugee situations” (10). Many other parasites are the cause of diarrhea and are due to lack of sanitation in refugee and IDP camps. A simple way to reduce the prevalence of parasites is to increase the level of knowledge of sanitation. If more people are aware that washing their hands after using the bathrooms will drastically reduce their chances of getting a parasite, they are more likely to wash their hands. Also if the layout of the camp is geared toward sanitation, then health will increase. For example is the bathrooms are located far away from where the eating, cooking, and cleaner are done then parasite prevalence will decrease. There are many simple ways to increase sanitation and therefore decrease the number of parasites.

Conclusion

Displaced people all over the world suffer more health issues when they are living in camps. The conditions in the camps cause diseases to spread easily. A lack of health resources means that it is very difficult to treat these diseases and difficult to spread information on how to prevent them. The World Health Organization has created a special program called Emergency and Humanitarian Action (EAH), which aims to “ease the impact of natural and manmade disasters on the health of millions of people around the world” (26). A large part of the EAH’s efforts are focused on getting necessary health care to those who need it in refugee camps. While this is very important, it will not stop many health issues from being a problem. Parasites will continue to plague residents of refugee camps if preventative measures are not taken. There are steps that camp directors can take to be more sanitary and public health oriented. Site planning is very important when it comes to creating a camp. The UNHRC has issued guidelines and regulations about how a camp should be set up. These include a minimum distance from shelters to the bathrooms and a maximum distance from shelters to the water supply. They insist that the water supply be continually tested. They urge facilitators to push education and to use their medical supplies wisely (3).


While this situation would be ideal, many camps do not have the money, the infrastructure, the time, or the manpower to implement all of these regulations so many camps are still unsanitary and people are still getting sick and dying. There are few ways to help those who are sick because resources are short, which is why facilitators need to focus on prevention rather than treatment. If the actual campsite becomes more sanitary and the people living there take up sanitary habits, such as washing his or her hands after using the bathroom will greatly decrease the amount of disease. While health in refugee camps is weak, a few preventative measures could save thousands of lives.

References

1) “Background on Potential Health Issues for Burmese Refugees.” ¬HHS.gov. January 21, 2009. U.S. Department of Health and Human Sources. Accessed December 3, 2008.

http://www.globalhealth.gov/refugee/refugees_health_burmese.html

2) “Background on Potential Health Issues for Liberian Refugees.” ¬HHS.gov. January 21, 2009. U.S. Department of Health and Human Sources. Accessed December 3, 2008. http://www.globalhealth.gov/refugee/refugees_health_liberian.html

3) “Communicable disease control in emergencies.” Connolly, MA and The World Health Organization. 2005. Accessed December 6, 2009. http://whqlibdoc.who.int/publications/2005/9241546166_eng.pdf

4) Grandesso, Francesco et al. “Mortaliity and Malnutrition Among Populations Living in South Darfur, Sudan.” The Journal of the American Medical Association. March 23/30 2005. Vol 293. Accessed December 6, 2009. http://jama.ama-assn.org/cgi/content/abstract/293/12/1490

5) Salama, Peter et al. “No Less Vulnerable: the Internally Displaced in Humanitarian Emergencies.” The Lancet. May 5, 2001. Vol 357 Issue 9266. Accessed December 7, 2009 http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4313NW5-1B&_user=7774802&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1126277064&_rerunOrigin=scholar.google&_acct=C000062877&_version=1&_urlVersion=0&_userid=7774802&md5=370a2c73d2ca7b71e1b00d346d222c73

7) Mourad, Abu. “Palestinian refugee conditions associated with intestinal parasite and diarrhea: Nuseirat refugee camp as a case study.” Science Direct. March 2004. Volume 118, Issue 2. Accessed December 6, 2008. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B73H6-4B8X3FV-1&_user=7774802&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1126308074&_rerunOrigin=scholar.google&_acct=C000062877&_version=1&_urlVersion=0&_userid=7774802&md5=00a3b2cf96c1c4a88d0a8d72f0add9d1

8) “2008 Global Trends: Refugess, Asylum-seekers, Returnees, Internally Displaced and Stateless Persons.” United Nations Refugee Agency. June 16, 2009. Accessed December 7, 2009. http://www.unhcr.org/4a375c426.html

10) “Access to Water in Refugee Situations.” United Nations Refugee Agency. Accessed December 6, 2009. http://www.un.org/waterforlifedecade/pdf/unhcr_water_brochure.pdf

11) “Water: Nary a drop to drink.” United Nations Refugee Agency. Refugees Magazine, September 1, 1996, Issue 105. Accessed December 7, 2009. http://www.unhcr.org/publ/PUBL/3b582bc08.html

13) “UN Agencies highlight dangers of increasing malnutrition in refugee camps.” United Nations Refugee Agency. News Stories October 7, 2005. Accessed December 6, 2009. http://www.unhcr.org/cgi-bin/texis/vtx/news/opendoc.htm?tbl=NEWS&id=4346ac9a4

14) “Sickle Cell Amenia.” NIH.gov. National Heart Lung and Blood Institute. August 2008. Accessed December 7, 2009. http://www.nhlbi.nih.gov/health/dci/Diseases/Sca/SCA_WhatIs.html

15) “Hepatitis A Transmission.” NIH.gov. National Institute of Allergy and Infectious Diseases. October 2, 2009. Accessed December 7, 2009. http://www3.niaid.nih.gov/topics/hepatitis/hepatitisA/transmission.htm

16) Bates, Drimelda et al. “Vulnerability to malaria, tuberculosis, and HIV/AIDS infections and disease. Part II: determinants operating at environmental and institutional level.” The Lancet, June 2004, Vol 4, issues 6. Accessed December 6, 2009. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W8X-4CG913M-V&_user=7774802&_coverDate=06%2F30%2F2004&_rdoc=1&_fmt=full&_orig=search&_cdi=6666&_sort=d&_docanchor=&view=c&_searchStrId=1126872455&_rerunOrigin=scholar.google&_acct=C000062877&_version=1&_urlVersion=0&_userid=7774802&md5=1779599d0dee82f9d185eceac4708c4b#SECX2

17) “Malaria: Topic Home.” CDC.gov. Centers for Disease Control and Prevention. Accessed December 7, 2009. http://www.cdc.gov/malaria/

18) “A UN safety net for refugees in Africa.” United Nations Refugee Agency. News Stories September 29, 2008. Accessed December 7, 2009. http://www.unhcr.org/48e0d8cf4.html

19) “Tuberculosis.” CDC.gov. Centers for Disease Control and Prevention. June 1, 2009. Accessed December 7, 2009. http://www.cdc.gov/tb/topic/basics/default.htm

20) “TB in Special Situations.” WHO.int. World Health Organization, Regional Office for South-East Asia. April 27, 2006. Accessed December 6, 2009. http://www.searo.who.int/en/Section10/Section2097/Section2106_10684.htm

21) “HIV transmission risks and AIDS among refugees in developing countries.” NIH.gov. NLM Gateway. Accessed December 6, 2009. http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102206421.html

22) “MAP: Main source countries of refugees, end of 2007.” Thomas Reuters Foundation. UNHCR MAPS. July 17, 2008. Accessed December 7, 2009. http://www.alertnet.org/thefacts/satelliteimages/12162876974.htm

23) “Hookworm.” NIH.gove. Medline Plus. November 30, 2009. Accessed December 7, 2009. http://www.nlm.nih.gov/medlineplus/ency/article/000629.htm

24) “Crypto-Cryptosporidiosis.” CDC.gov. Centers for Disease Control and Prevention. Accessed December 6, 2009. http://www.cdc.gov/crypto/

25) “Hookworm.” DCD.gov. Laboratory Indentification of Parasites of Public Health Concern. Accessed December 7, 2009. http://www.dpd.cdc.gov/dpdx/HTML/Hookworm.htm

26) "Emergency and humanitarian action." WHO.int. World Health Organization. Accessed December 19,2009. http://www.who.int/mediacentre/factsheets/fs090/en/

27) Dugger, Celia W. "Zimbabwe:Food Rations Reduced Amid Shortfall." The New York Times. November 12, 2008. http://query.nytimes.com/gst/fullpage.html?res=9502E0D8103CF931A25752C1A96E9C8B63

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