Refugee Health Care: Top 10 Priorities in Emergency Intervention

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Refugee Health CareTop 10 Priorities in
Emergency Intervention

• COL David Crudo
• Pacific Regional Medical Command
• Tripler Army Medical Center
• Hawaii

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Refugees and Displaced Populations

• Massive influx of refugees creates an enormous
  burden
• Economic, social, ecologic
• Effective aid always dependent upon rapid
  international response
• Poor resources leads to high mortality
• Prompt relief needed
• Priority to measures likely to have swift impact
• Mortality reduced when efforts well organized and
  coordinated

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Refugees and Displaced Populations

• Emergency Phase
• Mortality rates higher than those prior to
  displacement
• CMR gt 1 per 10,000 per day
• Post Emergency Phase
• Mortality level with surrounding population
• Basic needs have been addressed

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Refugees and Displaced Populations
Host Origin Period CMR Refugee CMR Host
Thailand Cambodia Oct 1979 31.9 0.7
Sudan Chad Sep 1985 24.0 1.7
Ethiopia Somalia Feb 1989 6.6 1.9
Kenya Somalia Mar 1992 22.2 1.8
Zimbabwe Mozambique Aug 1992 10.5 1.5
Crude Mortality Rates (deaths per 1,000 per month)
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Emergency Phase - Top 10 Priorities

1. Initial assessment
2. Measles immunization
3. Water and sanitation
4. Food and nutrition
5. Shelter and site planning

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Emergency Phase - Top 10 Priorities

1. Health care in the emergency phase
2. Control of communicable diseases and epidemics
3. Public health surveillance
4. Human resources and training
5. Coordination

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Emergency Phase - Top 10 Priorities

• Initial Assessment
• Required to ensure fast, effective, and
  appropriate response
• Objectives
• intervention? feasibility?
• priorities of intervention
• implementation
• strategies, resources needed, time frame
• pass on information to international community
  and donors

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Emergency Phase - Top 10 Priorities

• Initial Assessment
• Rapid completed within 3 days
• Geo-political
• Description of population
• Characteristics of environment
• Major health problems
• Human and material resource requirements
• Presence of IO / NGOs

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Emergency Phase - Top 10 Priorities

• Initial Assessment
• Geo-political
• Cause of displacement
• Duration of displacement
• Situation in country of origin
• Situation in the host country
• Security situation in settlement site

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Emergency Phase - Top 10 Priorities

• Initial Assessment
• Description of refugee population
• Demography
• total, age-group, gender
• Socio-cultural characteristics
• leadership, customs, religion
• Vulnerable groups
• unaccompanied minors, female-headed households,
  elderly, disabled

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Emergency Phase -Top 10 Priorities

• Initial Assessment
• Environment
• Physical characteristics
• Water supply
• Accessibility
• Shelter use and availability
• General hygiene
• Presence of disease vectors

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Emergency Phase - Top 10 Priorities

• Initial Assessment
• Major health problems
• Mortality rates and causes
• Morbidity of common diseases
• measles, diarrhea, ARI, malaria
• Presence of potential epidemics
• cholera, shigella, meningitis
• Prevalence of acute malnutrition

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Emergency Phase - Top 10 Priorities

• Initial Assessment
• Resource requirements
• Food availability
• reserves, rations distributed, cooking utensils
• Water availability
• access, containers
• Shelter
• Fuel
• Health facilities

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Emergency Phase - Top 10 Priorities

• Measles immunization
• Serious health problem in refugees
• Leading cause of mortality
• fatality rate can exceed 10
• Preventable
• Mass immunization coupled with vitamin A
  supplementation
• target 90 - 100 of 6 mo to 12 - 15 yr olds
• pregnancy only contraindication

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Emergency Phase - Top 10 Priorities

• Water and sanitation
• Ensure a sufficient QUANTITY of water
• Large amount poorer quality water preferable to
  small amount good quality drinking water
• 5 L / person / day minimum for survival
• drinking, cooking
• 15 20 L / person / day
• personal hygiene and dish / clothes washing
• Availability
• distribution points, yields, containers

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Emergency Phase - Top 10 Priorities

• Water and sanitation
• Improving water QUALITY
• Surface and near-surface water considered
  contaminated
• Chlorination
• Pre-treatment of turbidity
• Consumable water should contain lt
  10 fecal coliforms / 100 ml

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Emergency Phase - Top 10 Priorities

• Water and sanitation
• Sanitation and hygiene
• Reduce environment-related diseases
• Excreta control
• defecation fields
• 1 trench latrine / 50 100 people
• 1 durable latrine / 20 persons or 1 per family

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Emergency Phase - Top 10 Priorities

• Water and sanitation
• Sanitation and hygiene
• Waste water control
• Solid waste control
• Disposal of the dead
• Personal hygiene
• adequate water and detergent
• Vector control

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Emergency Phase - Top 10 Priorities

• Food and nutrition
• Food shortages and nutritional problems frequent
  in refugees
• High prevalence rate of malnutrition
• massive / sudden reduction in food availability
  and accessibility
• impaired health environment
• Associated high mortality rate
• PEM, nutrient deficiencies

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Emergency Phase - Top 10 Priorities

• Food and nutrition
• Highest priority to ensure distribution of
  adequate rations to entire population
• 2100 kcal / person / day minimum with adequate
  nutrients
• Selective feeding programs as indicated
• prevalence of acute malnutrition in children lt 5
  yrs indicator of population as whole
• reduce prevalence of malnutrition
• reduce mortality
• prevention in at-risk groups

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Emergency Phase - Top 10 Priorities

• Shelter and site planning
• Poorly planned site very pathogenic environment
• Minimize overcrowding 30 m2 / person
• Safe zone for security
• Water availability
• Accessibility in all seasons
• Appropriate drainage
• Avoid tensions with local population

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Emergency Phase - Top 10 Priorities

• Shelter and site planning
• Shelter provision
• Adequate space - 3.5 m2 per person
• Single family shelter preferable
• Construct own shelter using provided local
  materials, tools, technical assistance
• Include roof may need groundsheet, blanket,
  heating

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Emergency Phase - Top 10 Priorities

• 6. Health care
• Provide curative treatment for common killers
• diarrhea, malaria, measles, ARIs, malnutrition
• 50 - 95 of mortality
• Reduce suffering
• Cope with high demand for curative services
• Combine curative and preventive services
• Surveillance and active case finding
• Flexible

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Emergency Phase - Top 10 Priorities

• Health care
• Referral hospital
• local host nation (reinforced) or field hospital
• Central health facility
• one per 10 - 30,000 refugees
• 24 / 7 for emergencies, 20 30 in-patient beds
• Peripheral health facilities
• one per 3 5,000 refugees, outpatient
• Outreach activities
• Essential drugs kit

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Emergency Phase - Top 10 Priorities

• Control of communicable diseases and epidemics
• Sources in refugees
• brought from home environment
• no immunity to diseases in new location
• overcrowding, poor sanitary conditions in camp
• Diseases easily spread and more severe
• cholera, dysentery, meningitis, typhus

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Emergency Phase - Top 10 Priorities

• Control of communicable diseases and epidemics -
  General measures
• Improved environment and living conditions
• Immunizations
• Early case detection and active screening
• Rapid deployment of health care facilities
• Early and appropriate response

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Emergency Phase - Top 10 Priorities

• Control of communicable diseases and epidemics -
  Preparedness
• Surveillance
• Protocols for prevention, diagnosis, Rx
• Sources of vaccine identified
• Reserves of material and medical supplies
• Identified treatment sites
• Accessibility to care
• Trained health care workers

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Emergency Phase - Top 10 Priorities

• Public health surveillance
• Information for action
• extreme vulnerability to risks
• sudden changes can occur
• need quantitative data to communicate with
  partners
• Determine priorities, guides programs, provides
  early warning
• Evaluates effectiveness
• CMR best indicator of gravity of situation

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Emergency Phase - Top 10 Priorities

• Public health surveillance
• Keep system simple
• Cover principle problems that can and will be
  acted upon
• Analysis at field level translate into action
• Data

• demography
• mortality
• morbidity

• basic needs
• program activities

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Emergency Phase - Top 10 Priorities

• Human resources and training
• Major factor and principal constraint in
  programming is availability of trained staff
• Remoteness and security issues may hinder
  recruitment
• Objective is to find capable people and organize
  efficiently
• Goal is effective implementation of top 10
  priorities

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Emergency Phase - Top 10 Priorities

• Human resources and training
• Determine required staff and qualifications based
  on needed activities (not
  the other way around!)
• Manpower needs highest when infrastructure being
  set up
• Pool of professionals available on short notice
  from relief organizations

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Emergency Phase - Top 10 Priorities

• Coordination
• Importance usually underestimated
• Establish clear leadership
• Create a coordinating body
• Ensure priorities are shared by agencies
• Prevent program duplication and ensure all needs
  are covered
• Create common standards and use standard
  guidelines