WUNRN
WOMEN, WAR, PEACE & DISPLACEMENT
The often-cited statistic that as many as 80 per cent of displaced populations are women and children fails to convey the complete devastation that displacement visits upon women and communities. Leaving homes, property and community behind renders women vulnerable to violence, disease and food scarcity, whether they flee willingly or unwillingly. Internally displaced women face additional dangers as they are often invisible to the international community within the context of violent conflict. Camps for refugees and the internally displaced have been criticized for not addressing women’s needs and concerns in their design and procedure. Failure to account for women’s security and health needs can make a camp that was intended to provide refuge a dangerous and deadly place for women and girls. Fortunately, the UN, governments and civil society organizations that serve displaced women are beginning to rise to the challenge of including women and a gender perspective at every stage of policy-making and implementation.
Specific challenges faced by female displaced persons include but are not limited to:
- Increased vulnerability to human rights abuses
including sexual harassment, gender-based violence and severe sex
discrimination, which are also reasons many women and girls flee their
homes in the first place. more...
- Increased risk of HIV infection as wars and conflicts
often force them to flee to areas where the virus is prevalent. Women and
girls are also exposed to factors that facilitate transmission when they
flee, including poverty, the disruption of health services and social
structure and increases in sexual violence. more...
- The “protection gap” that results from the
international aid community’s focus on providing food and shelter to the
displaced while largely overlooking their security and protection
concerns. more...
- Obstacles to reintegration and repatriation in the
aftermath of a conflict. Abducted women and girls are often forced to
serve as sex slaves, porters or soldiers in enemy militias and are therefore
seen as accomplices and rejected by the community after the conflict is
resolved. more...
Refugee: The 1951 Refugee Convention defines a refugee as any person who:
"... Owing to 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 or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it." The 1967 Protocol extended the application of the Convention to the situation of "new refugees"; more... The convention's definition of "refugee" excludes gender-based persecution as a legitimate claim for asylum. more...
Internally Displaced Person (IDP): According to UNHCR, an internally displaced person (IDP) is someone who, like a refugee, has been displaced by crisis or conflict but, unlike a refugee, has not crossed an international border. In other words, IDPs are displaced within their own home countries. This can make assistance and protection much more difficult. Of the estimated 25 million IDPs around the world, “UNHCR currently helps over 5.6 million of those internally displaced, and a lively international debate is underway on how to more effectively help this group." more...
Asylum Seeker: Often confused with the term "refugee," UNHCR defines an asylum seeker as "a person who has left their country of origin, has applied for recognition as a refugee in another country, and is awaiting a decision on their application."
________________________________________________________________
http://www.thelancet.com/journals/lancet/issue/vol375no9711/PIIS0140-6736(10)X6110-4
The
Lancet, Volume
375, Issue 9711, Pages 341 - 345, 23 January 2010
HEALTH-CARE NEEDS OF PEOPLE AFFECTED
BY CONFLICT:
FUTURE TRENDS AND CHANGING
FRAMEWORKS
In past decades, much
progress has been made in responding to health-care needs of conflict-affected
populations. The evidence base for interventions addressing excess morbidity
and mortality has expanded. Motivated by a disastrous response to the
Governments, UN
agencies, and international organisations have been slow to adapt to changes in
their operating environments. Present priorities and practices for health-care
provision in conflict settings1 are still broadly
based on a model of humanitarian relief that was developed during the last two
decades of the Cold War, when conflict was usually synonymous with overcrowded
refugee camps sheltering young populations from developing countries. These
camps had very high mortality rates during the acute phase—mainly fuelled by
epidemics (eg, cholera, shigella, and measles), exacerbation of endemic infectious
diseases, and acute malnutrition. Thereafter, conditions progressively improved
as basic health services, often parallel to host-country services, were
established. In many circumstances, health care provided to refugees was better
than was care for the surrounding host community—sometimes resulting in
tensions. Accordingly, a linear progression from the acute to postemergency
phase was the frequently used model.3
Recent changes in
conflicts have introduced much complexity. Although the overall number of
conflicts has decreased,4 most contemporary wars
are of protracted duration, intrastate, fought by irregular armed groups, and
fuelled by economic opportunities and ethnic rivalry. Direct armed clashes are
often infrequent, but violence against civilians, including rape, is pervasive.
This violence takes place against a backdrop of increasing urbanisation and
ageing populations. Beginning with the Balkan and
During the past decade,
increasing numbers of intrastate conflicts have swelled the number of internally
displaced people, whereas the refugee population has gradually decreased (figure 1).2 Camp situations have always been more rare
for internally displaced people than for refugees. An increasing number of
forcibly displaced people seek refuge in cities—the largest proportion of
refugees now resides in urban environments rather than in camps (figure 2). The urban displaced
often live informally alongside residents and economic migrants, forming a type
of mixed migration (eg, Iraqis in
Figure
1 Full-size image (31K)
Estimated
populations of refugees and internally displaced people,* 1993 to 20085—8
*Dashed
line from 1993 to 2001 shows that population data for internally displaced
people (IDP) were inconsistently recorded. Data are combined Internal
Displacement Monitoring Centre (IDMC) and UN High Commissioner for Refugees
(UNHCR) estimates. IDMC figures were used when two numbers for the same country
were reported for both sources, because UNHCR reports for only IDPs for whom
they have responsibility. The midpoint was used if IDMC figures provided a
range for population size.
Figure
2 Full-size image (48K)
Number
of refugees living in camp-like, urban, or rural and dispersed settings,
1996—2008*
*Only
major refugee populations recorded by UN High Commissioner for Refugees (UNHCR)6, 8 (generally >50 000 people) are
included; thus, numbers do not represent total refugee population. Definitions
of major populations used by UNHCR varied by year (≥10 000 in 1993
and 1994, not stated in 1995, ≥100 in 1996 and 1997, ≥1000 in 1998,
≥100 in 1999 and 2000, ≥5000 in 2001—05, no limit stated in 2006—08).
Before 1999, refugees were mainly registered in camps, and data for those in
urban or rural and dispersed localities were mostly not recorded, and are only
shown for years since 1999.
Absolute excess
mortality rates of people affected by conflict are generally higher outside
than they are within camps, and are higher for internally displaced people than
for refugees,2 showing poor access to
services and the absence of mandate and funding for one agency to assume
decisive responsibility for non-refugee populations. High coverage of health
interventions outside of camp settings is especially challenging because of
poor security, intermittent accessibility, and the incapacity of fragile states
to effectively provide services to their own populations or to those who are
displaced. Health-system issues, previously not addressed in the context of
parallel services for displaced people in camps, are becoming of great
importance. These issues include health financing in protracted crises;
barriers to access because of user fees; and the need to integrate services
within the formal health system, partly to prevent inequity between
beneficiaries and host populations when both have similar needs and
vulnerabilities.
The profile of countries
affected by conflict is gradually shifting towards higher baseline incomes and
life expectancies than previously, as shown by data from refugees (figure 3)
with the human development index (HDI) as a classification method.9 Some camp-based
populations in protracted refugee situations now have longer life expectancies
than in past decades. However, country-level indicators might mask inequalities
within different regions in a country—Sudan is in the medium HDI category but
those people living in Darfur and southern Sudan are assumed to have far lower
life expectancies than the country average. Thus, the specific conflict
setting, rather than the country as a whole, needs to be taken into account.
Figure
3 Full-size image (60K)
Number
of refugees* by human development index category (low versus medium to high) of
country of origin†, 1993—2008
*Only
major refugee populations recorded by UN High Commissioner for Refugees (UNHCR)6, 8 are included; numbers
do not represent total refugee population. Definitions of major populations
used by UNHCR varied by year (≥10 000 in 1993 and 1994, not stated
in 1995, ≥100 in 1996 and 1997, ≥1000 in 1998, ≥100 in 1999
and 2000, ≥5000 in 2001—05, no limit stated in 2006—08). Total population
sizes per year differ from figure 2
because of differences in types of data gathered. †Human development index
(HDI) is a composite index computed from life expectancy, income per head,
adult literacy rates, and school enrolment. The cut-off between low and
medium-to-high HDI is 0·5.
As the profile of
conflict-affected populations changes over time, so does the burden of disease.
Infectious diseases and neonatal disorders remain the largest cause of excess
mortality in conflict settings of low incomes and life expectancies. However,
burgeoning, overcrowding-related epidemics (eg, cholera, shigella, and measles)
might be arising less frequently than previously because an increasing number
of populations live in non-camp-like settings. Furthermore, scaled up malaria
and measles control programmes seem to be having a substantial effect.
Conversely, neonatal disorders, pneumonia, and endemic diarrhoea continue to
cause substantial mortality and morbidity in underserviced, insecure regions of
sub-Saharan Africa and
Non-infectious chronic
diseases are becoming increasingly prominent in conflict settings because of
improved recognition of their importance, possible increases in their
prevalence in some long-term refugee camps, and because conflicts in
middle-income populations that affect older populations seem to be increasing
relative to those in low-income countries (although conflict in low-income
countries is still most predominant). This pattern will probably continue as
populations age further and incomes increase. Furthermore, evidence12, 13 from conflicts and natural disasters shows
that much excess morbidity and mortality results from exacerbation of existing
non-infectious diseases (eg, hypertension, diabetes, and cancer).
In view of these
patterns, approaches to preventive and curative health responses from primary
to tertiary care in conflicts need to evolve substantially. To assist with
orientation of future health strategies, policies, and interventions, we
propose a matrix of three types of settings (camp-like, urban, and
rural-dispersed) and two income and life-expectancy categories (low and medium
to high; table).
As with any classification, categories are not always mutually exclusive and
different settings could coexist within the same conflict area. On the basis of
this framework, we outline four key areas in which we believe new policies and
practices are needed, with related key recommendations (panel).
TableTable
image
Matrix
of conflict settings according to income and life expectancy, with demographic
and epidemiologic profiles and key future challenges
Panel
Proposed
health policies and interventions to address four key areas in future conflict
settings
Delivery
of health services to inaccessible conflict-affected people
- Radically expand range of
mass-delivered interventions, including new or underused interventions
for:
- maternal and neonatal health
(eg, presumptive antimalarial treatment and tetanus vaccination of
pregnant women)
- airborne droplet diseases (eg,
Haemophilius influenzae type B, Streptococcus pneumoniae,
influenza vaccinations, and zinc supplementation)
- diarrhoeal diseases (eg,
rotavirus, typhoid, and cholera vaccinations)
- neglected tropical diseases
(eg, deworming)
- malnutrition (eg, lipid-based
ready-to-use foods, micronutrient spreads and powders)
- Offer these interventions in
integrated mass campaigns; if necessary repeat at epidemiologically
appropriate intervals to maintain adequate coverage and herd immunity
- Expand use of negotiated
ceasefires; previously used successfully for polio vaccination in several
conflict settings (eg,
Address
chronic diseases in conflicts
- Include systematic registration
of prevalent cases of locally treatable chronic disease (at least
tuberculosis, HIV/AIDS, diabetes, and cardiovascular disease) as one of
the top priorities during any emergency health response, and develop rapid
case-identification methods, eg, with key informant-driven or
respondent-driven referral
- Develop simplified home-based
care guidelines for diabetes and heart disease and treatment kits for use
in settings of insecurity and restricted health-facility coverage
- Investigate effectiveness and
harm-to-benefit ratio of new, adherence-promoting ways to offer
tuberculosis and AIDS treatment with reduced laboratory and health-system
contact needs, and safe treatment discontinuation strategies in case of
permanent patient departure from programme catchment area
- Systematically include chronic
disease care as part of public health training modules for humanitarian
staff
- Anticipate increased costs attributable
to expensive tests and treatments, long disease duration, and specialist
consultations in financial planning
Improve
health services for conflict-affected people in urban areas
- Integrate services into
existing national health services through reinforcement of health-care
personnel, centres, medicines, and equipment and through capacity building
- Ensure primary and emergency
health-care services are established before concentrating on secondary
health care—tertiary health care should then be established if sufficient
funds are available
- Develop context-specific
standard operating procedures for secondary and tertiary referral care,
including development of referral-care committees to adjudicate complex
and expensive cases
- Plan finances appropriately,
especially before committing to fund expensive and complex diseases (eg,
renal dialysis and cancers)
- Address barriers to access of
national health systems, including issues related to user fees, and
consider innovative strategies such as the possibility of negotiating
favourable premiums for health insurance and finding donors and
international organisation that can pay for the most vulnerable part of
the population
Changes
in surveillance, assessment, and monitoring of conflict-affected populations
- Include systematic population
estimation as one of the top priorities in emergency response, and
institute donor-funding mechanisms that create incentives for agencies to
accurately and transparently estimate population figures on a regular
basis
- Develop highly simplified
methods for community surveillance of mortality and other key health
outcomes
- Adapt population estimation and
survey methods for complex urban settings through simulation and field
testing of novel sampling designs; develop these methods into guidelines
- Greatly expand capacity of
agencies to undertake demographic and epidemiological surveillance and
decision makers to rationally commission and interpret data through a
global programme of targeted field training
First, new strategies
are needed to deliver health services to dispersed, intermittently accessible
populations in low-income settings with a continuing high burden of infectious
diseases and neonatal disorders. Mass delivery of interventions, currently
restricted mainly to measles vaccine, vitamin A, and sometimes
insecticide-treated materials and meningitis vaccine, is especially appropriate
for these settings, and could be greatly expanded to target maternal and
neonatal health diseases. For example, where routine WHO Expanded Programme on
Immunization services fail because of insecurity, isolation, and poor
infrastructure, implementation of repeat rounds of integrated mass vaccinations
could maintain adequate coverage while simultaneously delivering other
preventive interventions.
Second, chronic diseases
should be addressed more systematically in all conflict settings than they are
at present, irrespective of income and life expectancy. These diseases include
tuberculosis, HIV, and common, manageable non-infectious disorders, such as
diabetes and hypertension.13, 14 In settings with
high incomes and life expectancies, complex disorders such as renal and
cardiovascular disease, complex surgeries, and cancer need to be more equitably
managed than they are now.15 Treatment continuation is essential—both to
save lives and reduce development of drug resistance (eg, for tuberculosis and
HIV). Such treatment continuation will be easiest in camp-like situations, but
might also be achieved with increased resources and concerted efforts in urban
settings, rural and dispersed communities, and even within active conflict
zones, in which lulls in fighting should be used as an opportunity to provide
patients with chronic disease with home-based management and lasting drug
supplies.
Third, creative
approaches to ensure adequate health coverage and access for conflict-affected
people living in urban settings should be developed. In Jordan and Syria, the
UN High Commissioner for Refugees (UNHCR) and other agencies work together to
ensure Iraqi refugees have access to outpatient and inpatient health care that
is similar to that of host communities. Rather than establishing parallel
health services, this process entails subsidising beneficiaries' access to
government and Red Crescent facilities, facilitating referrals, and creating
referral committees to make decisions about expensive surgeries.15 This programme is
UNHCR's costliest health programme per beneficiary. As similar situations arise
in the future, increased costs should be anticipated and innovative strategies
explored to ensure that affected populations have adequate health care in
situations in which they do not have access to national health systems or face
financial barriers.
Fourth, crucial
challenges in measurement and surveillance need to be addressed. Estimation of
total numbers of people affected, including vulnerable groups (eg, children,
pregnant women, and people with chronic disease), is crucial to establish the
true size of populations in need and monitor intervention coverage and
effectiveness.10, 16 Relief interventions
rarely have a target coverage, partly because population estimation and
registration is non-existent, and thus effects of interventions cannot be
measured. Although surveillance is feasible in stable camp situations, affected
urban populations are generally hidden, and often only the vulnerable seek
assistance. Similarly, estimates of the size of conflict-affected populations
living in dispersed rural settings are difficult or impossible to obtain. In
non-camp settings, population-based sample surveys have proved difficult,
politically controversial, and bias-prone, and some of these methods still need
validation. Prospective, community-based surveillance of mortality, nutritional
status, and other key health events is a more useful approach in many
situations but is rarely done, perhaps showing a failure of imagination and
funding rather than insurmountable technical difficulties.
In the past decade,
recognition of the effects of conflict on mental and reproductive health has
improved. These areas need serious reinforcement. Essential mental health
interventions should be expanded beyond populations traditionally covered (eg,
medium-to-high income settings), and research to assess their effectiveness
needs to be expedited.17 Interventions
include consensus measures such as so-called psychological first aid, provision
of essential psychotropic drugs, and promotion of community participation (eg,
through schooling, cultural events, and religious worship). Reproductive health
requirements for those affected by conflict (both internally displaced and
non-displaced people) need increased investment, particularly in settings of
protracted conflict. Despite the cost and logistical difficulties, emergency
obstetric and neonatal care should remain a priority while other especially
neglected interventions, such as family planning, should be prioritised.18
Health policies and
interventions have not kept up with the profound global changes in conflict
settings during past decades. Old paradigms for developing countries with
large, camp-based refugee populations with infectious diseases and malnutrition
do not address the complexity of present and future conflicts. Similarly,
coexistence of crises of differing natures and intensities in the same region
renders the traditional classification of emergencies in linear phases
increasingly irrelevant. In the next few years, impending threats might alter
the worldwide trend of a decline of conflicts. The present financial crisis is
predicted to increase political instability and social unrest, especially in
fragile states.19 In the long term,
climate change is expected to increase risk of conflict through environmental
displacement and heightened competition for resources.20 As humanitarians and
health professionals, we have a collective responsibility to anticipate these
new challenges, understand the increasingly complex environment in which we
work, and adapt our interventions accordingly.
Contributors
PBS, SC, FC, and EP
developed the idea for this Viewpoint and contributed to writing and reviewing
of the report.
Conflicts of
interest
We declare that we have
no conflicts of interest.
Acknowledgments
The views expressed by
the authors do not necessarily represent those of their organisations.
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