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No less vulnerable: the internally displaced in humanitarian emergencies
REFUGEES
No less vulnerable: the internally displaced in humanitarian emergencies Peter Salama, Paul Spiegel, Richard Brennan The US Committee for Refugees estimated that, in 1999, campaigns in the acute phase of humanitarian there were 14 million refugees and 21 million internally emergencies. However, major measles outbreaks, resulting displaced persons (IDPs) worldwide. Refugees are defined in high mortality rates, have been reported among IDPs in as people who have crossed international borders and have Ethiopia and the Democratic Republic of Congo during special status under international law. Furthermore, the the past 2 years because of delays in initiating vaccination United Nations High Commissioner for Refugees has an campaigns. international mandate to protect the rights of refugees and This pattern of high mortality among IDPs has also to coordinate provision of basic services. IDPs, however, become apparent during emergencies in more-developed who may flee their homes for the same reasons as refugees regions. During the Kosovo crisis in 1999, CMRs in but have not crossed internationally recognised borders, refugee camps in Macedonia and Albania remained cannot invoke the same legal extremely low at a daily rate of protections as refugees. less than 0·1/10 000. Among Additionally, no specific those people in Kosovo itself, Rights were not granted to include international humanitarian however, the CMR peaked in this image in electronic media. agency is responsible for April, 1999, at 1·1/10 000; providing them with protection war-related mortality acPlease refer to the printed journal. and humanitarian assistance. counted for 63% of deaths. The distinction between Older men, rather than men of refugees and IDPs has military age, had the highest important public-health age-specific mortality rates, implications. partly because younger men The health status of IDPs is were more likely to flee across one of the key public health the border and seek refugee issues presently facing the status.2 humanitarian community. Data on morbidity among Whereas health data for IDPs IDPs are more scarce than is generally less comprehensive those for mortality. There is than that for refugees, some of some evidence to suggest that, the highest crude mortality in certain situations, rates of rates (CMRs) in humanitarian morbidity might also be higher emergencies have been among IDPs than refugees. recorded among IDPs during When compared with food the past decade. In the early distributions in refugee camps, 1990s, CMRs in parts of the provision of an adequate Sudan and Somalia surpassed food ration to IDPs is often the emergency threshold more complicated because of of one death per unstable security environments 10 000 people per day and and because such populations reached a daily rate of about eight per 10 000 and 17 per are dispersed over large geographical areas. Not 10 000, respectively.1 surprisingly, therefore, some of the highest malnutrition prevalence rates recorded in recent years have been in IDP Unfortunately, these high mortality rates among IDPs, populations during famine. According to Médecins Sans caused by a confluence of political and environmental Frontières (MSF), in Ajiep, southern Sudan, prevalence factors (including recurrent drought), have reccurred rates for severe acute malnutrition were 36% during the recently. During the famine in the Somali region of famine in July, 1998. Although frequent in the past, Ethiopia in 1999–2000, daily CMRs of about six deaths micronutrient deficiency outbreaks are now less per 10 000 were recorded. Major outbreaks of vaccinecommonly reported in acute refugee crises. However, in preventable diseases such as measles have been Angola in 2000, niacin was not a component of the general uncommon in refugee camps since the late 1980s because food ration, and MSF documented a large outbreak of of the high priority afforded to mass measles vaccination pellagra with attack rates among IDPs more than twice those of the non-displaced population. In Kosovo during Lancet 2001; 357: 1430–32 1999, IDPs suffered more traumatic events than refugees; events such as forced isolation, torture or abuse, lack of Epidemic Intelligence Service (P Salama MBBS), and International Emergency and Refugee Health Branch (P Salama, P Spiegel MD), shelter, and forced separation from family members were National Center for Environmental Health, Centers for Disease more commonly reported by IDPs than refugees, were Control and Prevention, Mail Stop F48, Atlanta, Georgia 30341, experienced for a longer period and were associated with USA; and Health Unit, International Rescue Committee, New York, higher levels of psychological morbidity.3 USA (R Brennan MBBS). To address the shortfalls in the protection of the rights of IDPs, non-binding legal principles on internal Correspondence to: Dr Peter Salama (e-mail: [email protected]) displacement, which draw on existing humanitarian and
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THE LANCET • Vol 357 • May 5, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
REFUGEES
human rights law as well as on analogous refugee law, have now been developed and disseminated.4 These principles list the important essential services that IDPs are entitled to: food, potable water, sanitation, shelter, and medical services. However, responsibility for the protection of and provision of basic services to IDPs still rests with national governments, many of which may be unwilling to prioritise the delivery of services to IDPs, or lack the technical capacity to coordinate or monitor the programmes of international humanitarian organisations during emergencies. There is an urgent need for a specific international humanitarian agency to be given the mandate for providing such services so that tangible improvements in the health and welfare of IDPs to be attained. The designation of such agency responsibility will represent an important step in preventing excess morbidity and mortality among IDPs and in providing them with the basic human rights and dignity now afforded to most refugees. Measles vaccination campaigns and adequate
food rations have become a standard component of health services for refugees and such basic services should be systematically extended to IDPs. However, no matter which lead agency is ultimately chosen for this task, access by the humanitarian community to emergency-affected populations, when sovereign nations are reluctant to accept foreign interventions, will remain the key obstacle to improving health status among IDPs. References 1 2 3
4
Toole MJ, Waldman RJ. Refugees and displaced persons: war, hunger, and public health. JAMA 1993; 270: 600–05. Spiegel P, Salama P. War and mortality in Kosovo: an epidemiological testimony. Lancet 2000; 355: 2204–09. Lopes Cardozo B, Vergara A, Agani F, et al. Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA 2000; 284: 569–77. Deng F. Guiding principles on internal displacement. New York: United Nations Office for the Coordination of Humanitarian Affairs, 1999: 1–14.
Military involvement in refugee crises: a positive evolution? Fiona Terry Military involvement in refugee relief operations has impartial in conflicts, compromising the image, and hence undergone a remarkable evolution during the past decade, the effectiveness, of aid organisations that associate with from providing logistical support to aid organisations in them. Few aid organisations will accept an escort from the Kurdistan in 1991 to leading relief efforts for Kosovan UN peacekeeping force in Sierra Leone since its belligerent refugees in 1999. Some aid organisations have welcomed stance against the Revolutionary United Front (RUF) this development, and increasing attention is being paid to hinders access to civilians in RUF-held areas. Moreover, issues of civil-military cooperation. However, although few civilian lives are put at risk through mixing humanitarian would contest that military forces possess logistical and military actions. The presence of NATO troops in capacities unmatched in the aid community, important Kosovan refugee camps undermined the civilian and questions remain as to the appropriateness of an increased humanitarian character of the camps, and those in northern military presence beside humanitarian organisations in the Albania were shelled by the Yugoslav forces as a field. consequence. First, the motivation of the Third, the military lacks the “In Kigali, Kibeho, and Srebrenica, technical competence to respond to military is different from that of troops stood by helplessly and withumanitarian organisations, even the needs of refugee populations. nessed the slaughter of civilians if the intervention is couched Military forces are trained and in “humanitarian” terms. equipped to provide medical care because their mandate did not Humanitarian action is premised on and facilities to a predominately extend to such a role . . .” the equal worth of all human beings, male, adult, healthy population. yet military interventions since Many of the essential medicines Somalia have been selectively undertaken by governments used in emergency settings, such as oral rehydration salts with direct national interests: the French in Rwanda, the and vaccines, are lacking in sufficient quantity in military USA in Haiti, the Russians in Georgia, the Australians in supplies, and facilities are not adapted to the needs of East Timor, NATO governments in Kosovo, the Nigerians refugees. The French army hospital in Goma in 1994, for in Liberia, and the British in Sierra Leone. Conflicts that example, provided excellent care to some refugees, but pose no threat to powerful nations, either through security given the scale of the cholera epidemic that began soon concerns, lost investments, or potential refugee flows, are after their arrival (some 50 000 deaths in a matter of largely overlooked, despite the human misery they generate. weeks), it was an inappropriate use of resources. Instead, The massive offensive undertaken in defence of Kosovar the allocation of one helicopter to transport potable water refugees contrasts starkly with the cynical indifference could have alleviated the supply problem caused by the shown towards Sierra Leonean and Liberian refugees under congestion of roads with refugees. siege from rebel forces in Guinea today. Can we accept that But the most serious shortcoming of military the lives of some human beings are worth more involvements in relief operations of the past decade does than the lives of others? not concern what they do, but what they do not do. Second, outside military forces are rarely perceived as Protection from violence is the most vital need of refugee and displaced populations today, and is a task that humanitarian organisations are unable to assume. Yet most Lancet 2001; 357: 1431–32 military forces have been deployed with a humanitarian Médecins Sans Frontières, Paris 75011, France (F Terry PhD) mandate aimed at providing or protecting relief supplies. (e-mail: [email protected]) This mandate gives governments an image of doing
THE LANCET • Vol 357 • May 5, 2001
1431
For personal use. Only reproduce with permission from The Lancet Publishing Group.
No less vulnerable: the internally displaced in humanitarian emergencies Peter Salama, Paul Spiegel, Richard Brennan The US Committee for Refugees estimated that, in 1999, campaigns in the acute phase of humanitarian there were 14 million refugees and 21 million internally emergencies. However, major measles outbreaks, resulting displaced persons (IDPs) worldwide. Refugees are defined in high mortality rates, have been reported among IDPs in as people who have crossed international borders and have Ethiopia and the Democratic Republic of Congo during special status under international law. Furthermore, the the past 2 years because of delays in initiating vaccination United Nations High Commissioner for Refugees has an campaigns. international mandate to protect the rights of refugees and This pattern of high mortality among IDPs has also to coordinate provision of basic services. IDPs, however, become apparent during emergencies in more-developed who may flee their homes for the same reasons as refugees regions. During the Kosovo crisis in 1999, CMRs in but have not crossed internationally recognised borders, refugee camps in Macedonia and Albania remained cannot invoke the same legal extremely low at a daily rate of protections as refugees. less than 0·1/10 000. Among Additionally, no specific those people in Kosovo itself, Rights were not granted to include international humanitarian however, the CMR peaked in this image in electronic media. agency is responsible for April, 1999, at 1·1/10 000; providing them with protection war-related mortality acPlease refer to the printed journal. and humanitarian assistance. counted for 63% of deaths. The distinction between Older men, rather than men of refugees and IDPs has military age, had the highest important public-health age-specific mortality rates, implications. partly because younger men The health status of IDPs is were more likely to flee across one of the key public health the border and seek refugee issues presently facing the status.2 humanitarian community. Data on morbidity among Whereas health data for IDPs IDPs are more scarce than is generally less comprehensive those for mortality. There is than that for refugees, some of some evidence to suggest that, the highest crude mortality in certain situations, rates of rates (CMRs) in humanitarian morbidity might also be higher emergencies have been among IDPs than refugees. recorded among IDPs during When compared with food the past decade. In the early distributions in refugee camps, 1990s, CMRs in parts of the provision of an adequate Sudan and Somalia surpassed food ration to IDPs is often the emergency threshold more complicated because of of one death per unstable security environments 10 000 people per day and and because such populations reached a daily rate of about eight per 10 000 and 17 per are dispersed over large geographical areas. Not 10 000, respectively.1 surprisingly, therefore, some of the highest malnutrition prevalence rates recorded in recent years have been in IDP Unfortunately, these high mortality rates among IDPs, populations during famine. According to Médecins Sans caused by a confluence of political and environmental Frontières (MSF), in Ajiep, southern Sudan, prevalence factors (including recurrent drought), have reccurred rates for severe acute malnutrition were 36% during the recently. During the famine in the Somali region of famine in July, 1998. Although frequent in the past, Ethiopia in 1999–2000, daily CMRs of about six deaths micronutrient deficiency outbreaks are now less per 10 000 were recorded. Major outbreaks of vaccinecommonly reported in acute refugee crises. However, in preventable diseases such as measles have been Angola in 2000, niacin was not a component of the general uncommon in refugee camps since the late 1980s because food ration, and MSF documented a large outbreak of of the high priority afforded to mass measles vaccination pellagra with attack rates among IDPs more than twice those of the non-displaced population. In Kosovo during Lancet 2001; 357: 1430–32 1999, IDPs suffered more traumatic events than refugees; events such as forced isolation, torture or abuse, lack of Epidemic Intelligence Service (P Salama MBBS), and International Emergency and Refugee Health Branch (P Salama, P Spiegel MD), shelter, and forced separation from family members were National Center for Environmental Health, Centers for Disease more commonly reported by IDPs than refugees, were Control and Prevention, Mail Stop F48, Atlanta, Georgia 30341, experienced for a longer period and were associated with USA; and Health Unit, International Rescue Committee, New York, higher levels of psychological morbidity.3 USA (R Brennan MBBS). To address the shortfalls in the protection of the rights of IDPs, non-binding legal principles on internal Correspondence to: Dr Peter Salama (e-mail: [email protected]) displacement, which draw on existing humanitarian and
1430
THE LANCET • Vol 357 • May 5, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
REFUGEES
human rights law as well as on analogous refugee law, have now been developed and disseminated.4 These principles list the important essential services that IDPs are entitled to: food, potable water, sanitation, shelter, and medical services. However, responsibility for the protection of and provision of basic services to IDPs still rests with national governments, many of which may be unwilling to prioritise the delivery of services to IDPs, or lack the technical capacity to coordinate or monitor the programmes of international humanitarian organisations during emergencies. There is an urgent need for a specific international humanitarian agency to be given the mandate for providing such services so that tangible improvements in the health and welfare of IDPs to be attained. The designation of such agency responsibility will represent an important step in preventing excess morbidity and mortality among IDPs and in providing them with the basic human rights and dignity now afforded to most refugees. Measles vaccination campaigns and adequate
food rations have become a standard component of health services for refugees and such basic services should be systematically extended to IDPs. However, no matter which lead agency is ultimately chosen for this task, access by the humanitarian community to emergency-affected populations, when sovereign nations are reluctant to accept foreign interventions, will remain the key obstacle to improving health status among IDPs. References 1 2 3
4
Toole MJ, Waldman RJ. Refugees and displaced persons: war, hunger, and public health. JAMA 1993; 270: 600–05. Spiegel P, Salama P. War and mortality in Kosovo: an epidemiological testimony. Lancet 2000; 355: 2204–09. Lopes Cardozo B, Vergara A, Agani F, et al. Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA 2000; 284: 569–77. Deng F. Guiding principles on internal displacement. New York: United Nations Office for the Coordination of Humanitarian Affairs, 1999: 1–14.
Military involvement in refugee crises: a positive evolution? Fiona Terry Military involvement in refugee relief operations has impartial in conflicts, compromising the image, and hence undergone a remarkable evolution during the past decade, the effectiveness, of aid organisations that associate with from providing logistical support to aid organisations in them. Few aid organisations will accept an escort from the Kurdistan in 1991 to leading relief efforts for Kosovan UN peacekeeping force in Sierra Leone since its belligerent refugees in 1999. Some aid organisations have welcomed stance against the Revolutionary United Front (RUF) this development, and increasing attention is being paid to hinders access to civilians in RUF-held areas. Moreover, issues of civil-military cooperation. However, although few civilian lives are put at risk through mixing humanitarian would contest that military forces possess logistical and military actions. The presence of NATO troops in capacities unmatched in the aid community, important Kosovan refugee camps undermined the civilian and questions remain as to the appropriateness of an increased humanitarian character of the camps, and those in northern military presence beside humanitarian organisations in the Albania were shelled by the Yugoslav forces as a field. consequence. First, the motivation of the Third, the military lacks the “In Kigali, Kibeho, and Srebrenica, technical competence to respond to military is different from that of troops stood by helplessly and withumanitarian organisations, even the needs of refugee populations. nessed the slaughter of civilians if the intervention is couched Military forces are trained and in “humanitarian” terms. equipped to provide medical care because their mandate did not Humanitarian action is premised on and facilities to a predominately extend to such a role . . .” the equal worth of all human beings, male, adult, healthy population. yet military interventions since Many of the essential medicines Somalia have been selectively undertaken by governments used in emergency settings, such as oral rehydration salts with direct national interests: the French in Rwanda, the and vaccines, are lacking in sufficient quantity in military USA in Haiti, the Russians in Georgia, the Australians in supplies, and facilities are not adapted to the needs of East Timor, NATO governments in Kosovo, the Nigerians refugees. The French army hospital in Goma in 1994, for in Liberia, and the British in Sierra Leone. Conflicts that example, provided excellent care to some refugees, but pose no threat to powerful nations, either through security given the scale of the cholera epidemic that began soon concerns, lost investments, or potential refugee flows, are after their arrival (some 50 000 deaths in a matter of largely overlooked, despite the human misery they generate. weeks), it was an inappropriate use of resources. Instead, The massive offensive undertaken in defence of Kosovar the allocation of one helicopter to transport potable water refugees contrasts starkly with the cynical indifference could have alleviated the supply problem caused by the shown towards Sierra Leonean and Liberian refugees under congestion of roads with refugees. siege from rebel forces in Guinea today. Can we accept that But the most serious shortcoming of military the lives of some human beings are worth more involvements in relief operations of the past decade does than the lives of others? not concern what they do, but what they do not do. Second, outside military forces are rarely perceived as Protection from violence is the most vital need of refugee and displaced populations today, and is a task that humanitarian organisations are unable to assume. Yet most Lancet 2001; 357: 1431–32 military forces have been deployed with a humanitarian Médecins Sans Frontières, Paris 75011, France (F Terry PhD) mandate aimed at providing or protecting relief supplies. (e-mail: [email protected]) This mandate gives governments an image of doing
THE LANCET • Vol 357 • May 5, 2001
1431
For personal use. Only reproduce with permission from The Lancet Publishing Group.