Displaced populations have occurred throughout the history of humankind. A large population can be displaced by a number of events. These include, but are not limited to, natural disasters (e.g., floods, famine, earthquakes, hurricanes, monsoons, and volcanoes), persecution, conflict, and war. As seen in the Haiti earthquake of 2010, populations that are displaced face many difficult challenges. They are forced to leave their home, possessions, and occupations and be separated from their family and friends. These disasters can have direct effects on the physical and mental health of these populations and expose them to violence stemming from social inequalities. Displaced persons experience fear of the unknown and loss of control and self-identity. These populations are vulnerable to abuse on many levels, including human rights and gender-based crimes. Although the burdens of any displaced population may be similar, generally they fall into one of two broad groups: refugees and internally displaced populations.
For a person to be considered a refugee, he or she must cross a border into another country. Certain displaced persons are not considered refugees: war criminals, persons who commit acts of terrorism, criminals who have a fair trial and seek refuge to avoid incarceration, soldiers, and economic migrants (those who leave their country of their own will to better their lives). The United Nations High Commissioner for Refugees (UNHCR), through the 1951 Convention Relating to the Status of Refugees, defines a refugee as a person 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.” UNHCR estimates that by the end of 2011, there were approximately 43.3 million refugees worldwide “due to either conflict or persecution,” and the largest refugee camp in the world, Hagadera Camp in Dabaab Kenya, held approximately 138,000 people. These enormous numbers reflect the ever-growing need for worldwide attention to this problem. The needs of displaced populations at such numbers are vast. In addition, it has been found that at least 1 in 5 displaced women in refugee camps is a victim of sexual predation and violence. The role of UNHCR is to protect and act as an advocate for this population.
An important principle of refugee law is nonrefoulement , which is “a concept which prohibits States from returning a refugee or asylum-seeker to territories where there is a risk that his or her life or freedom would be threatened on account of race, religion, nationality, membership of a particular social group or political opinion.” This works in theory, however, either by force or voluntary action, some refugees continue to return to still unsafe situations in their homelands.
Refugee status is often considered to be a temporary matter, when in reality it can go on for years to decades. Whole new generations have been born in refugee camps, having no identification with their original country. Generally, there are three options for a refugee’s destiny: to repatriate to his country, to resettle in the country where he has sought refugee status, or to be resettled to a third country.
Internally displaced persons
Internally displaced persons (IDPs) are those who have been forced to flee their homes to escape armed conflict, generalized violence, human rights abuses, or natural or human-made disasters. They differ from refugees in that they stay within the borders of their home country. It is estimated that the number of IDPs increased to 28.8 million in 2012, with much of that increase due to the conflict in Syria. Because they exist within the borders of a potentially hostile home country, they lack the services and protections available to refugees.
Priorities for a displaced population
Although events that lead up to a movement of a large population may differ, there are certain principles that generally apply. Many different actors may be involved in these movements: governments (including multiple countries, states, or localities), military units, and nongovernmental organizations. Whenever possible, members of the local community should be involved in the decision to move. This includes government officials, professionals (e.g., public health, health care providers, engineers), and the local workforce. These groups can be an invaluable resource in understanding the population needs, potential challenges, infrastructure, and cultural issues. Box 58-1 lists the top priorities of a displaced population. The remainder of this chapter will go through the priorities of the initial management of a displaced population.
Water and sanitation
Food and nutrition
Shelter and site planning
Health care in the emergency phase
Control of communicable diseases and epidemics
Public health surveillance
Human resources and training
There should be a clear understanding of the context and the event that led to the movement of the population being evaluated. The effects of war or genocide will require very different resources and management than those of a hurricane or earthquake. Even though the initial assessment might be difficult, one should try to consider the potential length of time that this population may be displaced. Historically, the time frame is often much longer than one would expect. Remember that there are refugees who have been displaced for decades from their original home, and two thirds of refugees are still living in camps 5 years after the initial event. The well-being and security of both the population and those responding to the situation need to be of utmost importance. Unfortunately, at times, this important concept has gone underappreciated or poorly understood. We are seeing evidence of this now in postearthquake Haiti, and postconflict Sudan.
It is of great value to learn the demographics of the population that has been displaced. With a better understanding of things such as work experience, education, and language skills, trauma-related psychological pathology, social relationships, and perceived quality of life can be dramatically affected. This information can be obtained by initial registration of the population, census information, health records, sample surveys, and speaking with local authorities. Basic essential data include the size, sex, and age distribution of the population; family members; cultural makeup (e.g., religion and ethnicity); medical health, disease prevalence, and vaccine status; and the identification of potential vulnerable groups. The region where the population is relocating to also needs to be well understood. What resources are available to the population? Is there an adequate water supply, and to what extent can it be used? Will proper sanitation be available, and for how long? What amount of food is available locally, and what kind of stores are available? Is the land suitable for living on? What local supplies are available for constructing shelter? What medical care and provisions are available locally? How secure are all of these items? What infrastructure is available to bring in further supplies? Are there suitable roads? What size vehicle can the roads accommodate? Are there facilities to repair vehicles that encounter mechanical problems? Are there train stations in close proximity? Where is the closest landing strip, and what is the maximum size aircraft that can land there? Where is the nearest port? If goods are to be shipped in, where can they be stored, and can these items be secured? What are the options to distribute water, food, and supplies in an orderly and safe manner?
Measles and tuberculosis
Refugee camps are small, close-quartered communities, often with poor sanitation and health care. This type of living condition is prone to many forms of infectious diseases, particularly organisms spread by droplets and aerosolization. Many health care providers are often very surprised to learn that measles continues to be a major cause of morbidity and mortality throughout the world, and outbreaks are often seen in refugee camps. The pediatric population is at highest risk, and mass vaccination should be highest priority in children from 6 months to 15 years of age. Measles is an RNA paramyxovirus that is highly contagious and spread through secretions in the respiratory tract. Approximately 90% of susceptible persons will contract the disease after exposure to an infected person. It should be noted that vitamin A deficiency can cause cases of measles that are more severe and complicated. All refugee populations should be vaccinated for measles, and vitamin A should be distributed when vaccinating.
Tuberculosis continues to be a concerning infectious disease, representing a leading cause of death in the developing world. The disease burden seen in these areas is exacerbated and heightened by the complex nature of refugee camps, consisting of displaced populations from developing countries. Data have shown that tuberculosis morbidity and mortality correlates with the existence and quality of identification and treatment programs. The data speak to the need for early establishment of screening and treatment facilities in refugee camps and displaced populations.
Clean water should be top priority in any disaster situation. It is the cornerstone of any emergency response involving refugee care. Water is not only a necessity for life but also for basic hygiene. In the initial response, the quantity of water is more important than the quality. The absolute minimum requirement of water is 5 L/person/day; this should be increased as soon as possible to reach a level of 15 to 20 L/person/day. Other things to consider about water include the source, accessibility, location, availability of carrying containers, and security considerations.
Water can be a source of disease on many different levels, as evidenced by the cholera outbreak months after the earthquake in Haiti. Even though it was most likely brought into the country by an aid worker, it flourished in the standing water and poor sanitation seen in and around the tent cities. Contaminated water, as shown in Table 58-1 , contributes significantly to global morbidity and mortality. Freshwater can act as the home for the intermediate hosts that cause schistosomiasis and guinea worm infection. These infections commonly occur when a person stands in water as he or she is collecting it. A lack of water or contaminated water can also contribute to trachoma, which is a major cause of blindness and skin infections. Finally, water can act as the home to insect vectors that cause malaria, dengue fever, filariasis, onchocerciasis, and African trypanosomiasis. Adequate ways to filter and purify water should be made available.