Health programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study

doi:10.1016/S0140-6736(02)11915-5

The Lancet

Volume 360, Issue 9349, 14 December 2002, Pages 1927-1934

https://doi.org/10.1016/S0140-6736(02)11915-5 Get rights and content

Summary

Background

An estimated 35 million people have been displaced by complex humanitarian emergencies. International humanitarian organisations define policies and provide basic health and nutrition programmes to displaced people in postemergency phase camps. However, many policies and programmes are not based on supporting data. We aimed to identify associations between age-specific mortality and health indicators in displaced people in postemergency phase camps and to define the programme and policy implications of these data.

Methods

In 1998–2000, we obtained and analysed retrospective mortality data for the previous 3 months in 51 postemergency phase camps in seven countries. We did multivariate regression with 18 independent variables that affect crude mortality rates (CMRs) and mortality rates in children younger than 5 years (<5 MRs) in complex emergencies. We compared these results with recommended emergency phase minimum indicators.

Findings

Recently established camps had higher CMRs and <5 MRs and fewer local health workers per person than did camps that had been established earlier. Camps that were close to the border or region of conflict or had longer travel times to referral hospitals had higher CMRs than did those located further away or with shorter travel times, and camps with less water per person and high rates of diarrhoea had higher <5 MRs than did those with more water and lower rates of diarrhoea. Distance to border or area of conflict, water quantity, and the number of local health workers per person exceeded the minimum indicators recommended in the emergency phase.

Interpretation

Health and nutrition policies and programmes for displaced people in postemergency phase camps should be evidence-based. Programmes in complex emergencies should focus on indicators proven to be associated with mortality. Minimum indicators should be developed for programmes targeting displaced people in postemergency phase camps.

Introduction

At the end of 2000, an estimated 35 million people had been displaced¹ by complex humanitarian emergencies affecting civilian populations. Such emergencies arise from a combination of war or civil strife, food shortages, and population displacement that generally results in significant excess mortality. During the emergency phase of a complex humanitarian emergency, which is defined as having a crude mortality rate (CMR) of one or more deaths daily per 10 000 people, mortality rates in displaced people are at least double predisplacement baseline levels.2, 3 Most deaths result from preventable and treatable infections, often exacerbated by malnutrition, caused mainly by diarrhoeal disease, respiratory tract infections, measles, and malaria.2, 4 To reduce this excess mortality rapidly, humanitarian organisations prioritise their relief programmes toward the provision of adequate shelter, water, sanitation, food, and public health and curative health programmes. Many populations affected by complex humanitarian emergencies have been displaced for long periods, living relatively settled lives—this postemergency phase is defined as having a CMR of less than one death daily per 10 000 people.2, 3, 4 In this article, we use the term displaced people to refer both to refugees who have crossed international borders and to people who have been displaced from their homes but remain within the internationally recognised borders of their countries.

The Sphere project describes minimum standards for providing basic services to displaced populations in the emergency phase of complex humanitarian emergencies.3 The project evolved from a growing recognition among donors, aid agencies, and recipients that humanitarian assistance needed to become more professional, effective, and accountable.5, 6 These minimum standards were based on scientific data if available or on consensus between experts. Data for service delivery and health outcomes in complex humanitarian emergencies are increasingly being gathered as donors and humanitarian organisations recognise the need to assess interventions to develop an evidence base for policies and programmes.⁷ However, data have mainly been obtained from the acute phase of complex emergencies, in which excess mortality as well as political interest, media attention, and funding is greatest.⁴ The postemergency phase has been little studied, and no comprehensive programme guidelines exist for this phase.

Our results are part of a large study assessing the magnitude and causes of morbidity and mortality in displaced people in postemergency phase camps. We aimed to identify associations between age-specific mortality and health indicators in displaced people in postemergency phase camps, and to describe programme and policy implications for governments, UN agencies, and humanitarian organisations working during the postemergency phase. We also aimed to start a dialogue on minimum standards for displaced people during the postemergency phase of complex humanitarian emergencies.

Section snippets

Population

From November, 1998, to March, 2000, we visited 52 camps for displaced people in seven countries. Our inclusion criteria for camps were: displaced people were residing in the camp during the postemergency phase; stable camp population size, defined as less than 5% change in population size during the 3 months before data collection; camp population at least partly dependent on outside organisations for food aid and health care; and functioning health-information system, defined as those

Results

From November, 1998, to March, 2000, we surveyed 52 of around 80 eligible camps for displaced people during the postemergency phase in seven of 11 countries (table 1). We were unable to visit all camps that met our inclusion criteria because of logistical constraints or lack of government or NGO authorisation. We completed six 6–8-week field trips to the following countries: Azerbaijan (seven camps), Ethiopia (11), Myanmar (three), Nepal (seven), Tanzania (eight), Thailand (five), and Uganda

Discussion

Our results support some policies and programmes that are already being implemented, such as provision of a minimum quantity of water and an emphasis on diarrhoeal disease prevention and treatment.

Additionally, we have identified factors whose importance has not been sufficiently prioritised, such as the number of local health-care workers per person and the distance that camps are situated from a border or area of conflict. Health and nutrition policies and programmes for displaced people in

References (29)

W Van Damme et al.
Effects of a refugee-assistance programme on host population in Guinea as measured by obstetric interventions
Lancet
(1998)
LA Bartlett et al.
Maternal mortality among Afghan refugees in Pakistan, 1999–2000
Lancet
(2002)
World Refugee Survey 2001
(2001)
Famine-affected, refugee, and displaced populations: recommendations for public health issues
MMWR CDC Surveill Summ
(1992)
The Sphere project: humanitarian charter and minimum standards in disaster response
(1998)
MJ Toole et al.
Prevention of excess mortality in refugee and displaced populations in developing countries
JAMA
(1990)
Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July 1994?
Lancet
(1995)
P Salama et al.
Improving standards in international humanitarian response: the Sphere Project and beyond
JAMA
(2001)
N Banatvala et al.
Public health and humanitarian interventions: developing the evidence base
BMJ
(2000)
Medecins Sans Frontières
Refugee health: an approach to emergency situations
(1997)

P Spiegel et al.

The accuracy of mortality reporting in displaced persons camps during the post-emergency phase

Disasters

(2001)

S Becker et al.

Seasonal patterns of deaths in Matlab, Bangladesh

Int J Epidemiol

(1998)

Handbook for emergencies

(1999)

Cited by (77)

Exploring the influence of health management processes on health outcomes among internally displaced persons (IDPs)
2022, Journal of Migration and Health
Citation Excerpt :
The lack of experienced HSPs and absence of health management protocols showed to have contributed to poor IDP health outcomes, e.g. mortality due to delayed access to care. Similar weakness in the healthcare monitoring process and their impact on IDPs have also been reported in previous studies (Onyango et al., 2013, Bruckner and Checchi, 2011, Spiegel et al., 2002, Siddique et al., 1995). Although non-communicable and long-term health conditions like hypertension and diabetes were not reported among the common IDP health conditions, previous studies have also shown they often receive less attention, as evidenced in our study by the lack of support for managing mental health by supporting organisations. (
Despite global action and policy initiatives, internally displaced persons (IDPs) experience poor living conditions and lack healthcare access compared to refugees. This study sought to understand the relationship between health management processes and health outcomes among camp-dwelling IDPs in northern Nigeria.
73 individuals participated in either a focus group (n = 49) or one-to-one interview (n = 24), comprising IDPs (n = 49), camp managers (n = 9), health workers (n = 7) and government administrative authorities (n = 8). Interviews explored IDP health management processes, partners and perceptions around camp management. Data were analysed using an inductive thematic approach.
Four main themes were identified: opinions about healthcare organisation and management, service availability, interventions and information management, and IDP health outcomes. Though many stakeholders, partnerships, and national and international government agencies were involved in the provision of healthcare services, respondents described efforts as disjointed. Reports suggested that the coordination and management of health services and resources were not tailored to the needs of those living in all camps. And because so many national and international agencies were involved, but under weak coordination, access to services was less than optimal and adequate management of critical public health interventions was lacking. Varied allocation of resources such as funding, medication and medically trained staff were viewed as key factors in the availability and the ability to access what was considered as essential healthcare services.
The health of IDPs in camp-like settings was compromised by uncoordinated management, treatment, and control of communicable and non-communicable diseases. Government authorities need to be aware and consider the complexity of the multiagency involvement in the management and provision of IDP healthcare services. Introducing systems to streamline, monitor and support IDP healthcare management could be cost-effective strategies for achieving optimal health care.
Environmental health conditions in the transitional stage of forcible displacement: A systematic scoping review
2021, Science of the Total Environment
Citation Excerpt :
With respect to standards, one study recommended that hygiene standards be developed to prevent Hepatitis A virus (Mellou et al., 2017). Additionally, indicators were recommended for programs that help displaced people (Spiegel et al., 2002). A more specific indicator recommendation was that zone specialists in WaSH offices in Lebanon collect data and send them to the UNICEF office in the capital city, Beirut; these data would presumably then be an indicator of the conditions across Lebanon (UNICEF and Hydroconseil, 2017).
In 2019, 30,000 people were forced to leave their homes due to conflict, persecution, and natural disaster each day. Eighty-five percent of refugees live in developing countries, and they often face underfunded and inadequate environmental health services. Many displaced persons live in camps and other temporary settlements long after the displacement event occurs. However, there is little evidence on environmental health conditions in the transitional phase—defined by the United Nations High Commissioner for Refugees as six months to two years after displacement. To address this gap in research, we conducted a systematic scoping review of environmental health conditions, exposures, and outcomes in transitional displacement settings, as well as reported obstacles and recommendations for improvement. Eighty-eight publications met the inclusion criteria. Water supply was the most frequently discussed environmental health topic. Overcrowding was the most common risk factor reported, Vibrio cholerae was the most common pathogen reported, and diarrhea was the most commonly reported health outcome. Obstacles and recommendations were categorized as institutional, political or implementation-based. Identified knowledge gaps included minimal information on setting logistics and on topics such as menstrual hygiene, oral hygiene and fomite contamination. In order to improve environmental health conditions in transitional displacement settings, all levels of government and non-governmental organizations should increase collaboration to improve resource provision. This study is the first to report on environmental health conditions in this important time of transition between the emergency and protracted stages of displacement.
Understanding the health needs of internally displaced persons: A scoping review
2021, Journal of Migration and Health
Citation Excerpt :
In certain IDP camps in Sudan, violence was also a leading cause of death, particularly among young men (Grandesso et al., 2005; Depoortere et al., 2004). Policies and programmes for IDPs need to be evidence-informed and should focus on minimum indicators associated with mortality (Spiegel et al., 2002). In camp settings, identifying and registering IDPs should allow for the more systematic provision of healthcare and measurement of mortality.
We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.
The humanitarian system is not just broke, but broken: recommendations for future humanitarian action
2018, The Lancet
An unprecedented number of humanitarian emergencies of large magnitude and duration is causing the largest number of people in a generation to be forcibly displaced. Yet the existing humanitarian system was created for a different time and is no longer fit for purpose. On the basis of lessons learned from recent crises, particularly the Syrian conflict and the Ebola epidemic, I recommend four sets of actions that would make the humanitarian system relevant for future public health responses: (1) operationalise the concept of centrality of protection; (2) integrate affected persons into national health systems by addressing the humanitarian–development nexus; (3) remake, do not simply revise, leadership and coordination; and (4) make interventions efficient, effective, and sustainable. For these recommendations to be implemented, governments, UN agencies, multilateral organisations, and international non-governmental organisations will need to put aside differences and relinquish authority, influence, and funding.
Populations at Special Health Risk: Displaced Populations
2016, International Encyclopedia of Public Health
The number of displaced people in the world today – which includes those uprooted by violent conflict, natural disasters, economic development, climate change, and a variety of other causes – continues to grow. Such people face serious risks to their safety and health, related to the causes and effects of the flight itself, acute and chronic diseases, mental illness, and cultural dislocation. Women and children are particularly vulnerable. Responses – both in the countries of origin and internationally – are often inadequate, either because of insufficient resources or a lack of compassion and generosity from the world community. There is a need to rethink the definitions of ‘refugee’ and ‘internally displaced person,’ which are largely obsolete in the era of complex and changing internal and global forces, and to redesign the institutions that have been constructed to deal with the problem.
Associations between Social Support and Subjective Symptoms in Disaster-Stricken Ishinomaki, Japan
2021, Disaster Medicine and Public Health Preparedness

View all citing articles on Scopus

View full text

ArticlesHealth programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Population

Results

Discussion

Lancet

Lancet

World Refugee Survey 2001

Famine-affected, refugee, and displaced populations: recommendations for public health issues

MMWR CDC Surveill Summ

The Sphere project: humanitarian charter and minimum standards in disaster response

Prevention of excess mortality in refugee and displaced populations in developing countries

JAMA

Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July 1994?

Lancet

Improving standards in international humanitarian response: the Sphere Project and beyond

JAMA

Public health and humanitarian interventions: developing the evidence base

BMJ

Medecins Sans Frontières

Refugee health: an approach to emergency situations

The accuracy of mortality reporting in displaced persons camps during the post-emergency phase

Disasters

Seasonal patterns of deaths in Matlab, Bangladesh

Int J Epidemiol

Handbook for emergencies

Articles
Health programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study