A review of water and sanitation provision in refugee camps in association with selected health and nutrition indicators - the need for integrated service provision

The first global overview of basic water and sanitation indicators in refugee camps is presented (using data from 2003–2006) and compared with selected health and nutrition indicators. This demonstrates that average levels of water and sanitation provision are acceptable at camp level but many refugee operations are suffering from gaps that cross-cut these sectors; e.g. typically poor sanitation provision is corresponding with low per capita availability of water. These findings were confirmed at household level with two household surveys undertaken in African refugee camps; households reporting a case of diarrhoea within the previous 24 hours collect on average 26% less water than those not reporting any cases. In addition, typically higher levels of morbidity of one infectious agent are also reflected across other infectious agents; this is reinforced by comparing the relationship between morbidity and nutrition status from selected camps. The importance that hygiene, environmental conditions and local settings have on health (both of refugees and also local communities) is underlined. Interventions to improve indicators across the water, sanitation, health and nutrition sectors rely not only on increased and sustained resources but must entail an integrated approach to simultaneously tackle short-comings across all these vital sectors.     

Quantifying the burden of disease associated with inadequate provision of water and sanitation in selected sub-Saharan refugee camps

A WHO methodology is used for the first time to estimate the burden of disease directly associated with incomplete water and sanitation provision in refugee camps in sub-Saharan African countries. In refugee camps of seven countries, containing just fewer than 1 million people in 2005, there were 132,000 cases of diarrhoea and over 280,000 reported cases of malaria attributable to incomplete water and sanitation provision. In the period from 2005 to 2007 1,400 deaths were estimated to be directly attributable to incomplete water and sanitation alone in refugee camps in Ethiopia, Kenya and Tanzania. A comparison with national morbidity estimates from WHO shows that although diarrhoea estimates in the camps are often higher, mortality estimates are generally much lower, which may reflect on more ready access to medical aid within refugee camps. Despite the many limitations, these estimates highlight the burden of disease connected to incomplete water and sanitation provision in refugee settings and can assist resource managers to identify camps requiring specific interventions. Additionally the results reinforce the importance of increasing dialogue between the water, sanitation and health sectors and underline the fact that efforts to reduce refugee morbidity would be greatly enhanced by strengthening water and sanitation provision.     

Public health in the Calais refugee camp: environment,health and exclusion

The ongoing emergency for refugees is having profound and hidden health consequences for thousands of displaced persons who live in informal ‘makeshift’ camps across Europe. This interdisciplinary paper reports the results of the first environmental health assessment in such a location, in what was Europe’s largest informal refugee camp in 2016, in Calais, northern France. We detail the lack of facilities for sanitation, safe provision of food, water and shelter, demonstrating how conditions fall short of agreed international standards for formal refugee camps. Rather than the notion of migrants being the cause of health problems, this paper critically reveals the hidden materiality of bodily injury caused by poor health conditions, where the camp itself produces harm. Drawing upon theories of biopolitical exclusion, the paper concludes by (i) emphasising the empirical and conceptual themes that tie refugee politics and biologies together and (ii) makes a call for increased attention to makeshift camps as key sites of health exclusion in Europe and beyond.     

Equity implications for sanitation from recent health and nutrition evidence

Recent evidence points to the possible underestimation of the health and nutrition impact of sanitation. Community sanitation coverage may first need to reach thresholds in the order of 60% or higher, to optimize health and nutrition gains. Increasing coverage of sanitation to levels below 60% of community coverage may not result in substantial gains. For example, moving Indonesia from 60% to 100% improved sanitation coverage could significantly reduce diarrhoea in children under 5 years old (by an estimated 24% reduction in odds ratio for child diarrhoea morbidity) with gains split equally by reaching underserved communities and the unserved within communities. We review the implications of these results across three levels of program implementation – from micro level approaches (that support communities to achieve open defecation-free status), to meso level (sub-national implementation) to macro level approaches for the national enabling environment and the global push to the Sustainable Development Goals. We found significant equity implications and recommend that future studies focus more extensively on community coverage levels and verified community open defecation free status rather than household access alone. Sanitation practitioners may consider developing phased approaches to improving water, sanitation and hygiene in communities while prioritizing the unserved or underserved.     

Alternatives for safe water provision in urban and peri-urban slums

In response to rapid urbanization throughout the global South, urban and peri-urban slums are expanding at an alarming rate. Owing to inadequate financial and institutional resources at the municipal level, conventional approaches for safe water provision with centralized treatment and distribution infrastructure have been unable to keep pace with rapidly growing demand. In the absence of alternatives to centralized systems, a global public health emergency of infectious water-related diseases has developed. Alternative decentralized water treatment systems have been promoted in recent years as a means of achieving rapid health gains among vulnerable populations. Though much work with decentralized systems, especially in urban environments, has been at the household level, there is also considerable potential for development at the community level. Both levels of approach have unique sets of advantages and disadvantages that, just as with treatment technologies, may make certain options more appropriate than others in a particular setting. Integrating community, government and other relevant stakeholders into the process of systems development and implementation is essential if the outcome is to be appropriate to local circumstances and sustainable in the long term.     

With the help of one's neighbors: externalities in the production of nutrition in Peru

Both public and private resources contribute to the nutritional status of children. In addition, the investments made by one household may contribute to the health of other households in the neighborhood through improvements in the sanitation environment and through increases in shared knowledge.This paper measures the externalities of investments in nutrition by indicating the impact of the education of women in Peruvian neighborhoods on the nutrition of children in other households, after controlling for the education and income of those households. We find that in rural areas this shared knowledge has a significant impact on nutrition, with the coefficient of an increase in the average education of women in the neighborhood being appreciable larger than the coefficient of education in isolation.In addition, we indicate the impact of the water and sanitation environment in the neighborhood, again controlling for the household's own access to sanitation and water. In both urban and rural areas, we observe externalities from investments in such household level infrastructure with the evidence particularly strong for sanitation made by neighboring households.     

Environmental health criteria for disaster relief and refugee camps

The very subjective nature of most environmental health criteria for disaster relief and refugee camps makes interpretation of minimum quantities of potable water and separation distances from sources of pollution difficult, even for the trained environmental health professional. A review of the literature and a survey carried out with international environmental health professionals were conducted to summarize both the least‐preferred and most‐preferred parameters for enhanced environmental health services in such camps. The survey was conducted using a form of decision analysis, modified from the Simple Multiattribute Rating Technique. A campsite evaluation form was prepared using the selected criteria, after converting them to utilities. The form was used to evaluate existing refugee camps in Thailand. Camp environmental health scores were then compared to selected environmentally‐associated diseases. Results of that evaluation suggest that the environmental health criteria and the camp rating methodology suggested are valid, at least for camps in hot, moist climates.     

Incidence and risk factors for Malaria, pneumonia and diarrhea in children under 5 in UNHCR refugee camps: A retrospective study

Background

United Nations High Commissioner for Refugees (UNHCR) refugee camps are located predominantly in rural areas of Africa and Asia in protracted or post-emergency contexts. Recognizing the importance of malaria, pneumonia and diarrheal diseases as major causes of child morbidity and mortality in refugee camps, we analyzed data from the UNHCR Health Information System (HIS) to estimate incidence and risk factors for these diseases in refugee children younger than five years of age.

Methods

Data from 90 UNHCR camps in 16 countries, including morbidity, mortality, health services and refugee health status, were obtained from the UNHCR HIS for the period January 2006 to February 2010. Monthly camp-level data were aggregated to yearly estimates for analysis and stratified by location in Africa (including Yemen) or Asia. Poisson regression models with random effects were constructed to identify factors associated with malaria, pneumonia and diarrheal diseases. Spatial patterns in the incidence of malaria, pneumonia and diarrheal diseases were mapped to identify regional heterogeneities.

Results

Malaria and pneumonia were the two most common causes of mortality, with confirmed malaria and pneumonia each accounting for 20% of child deaths. Suspected and confirmed malaria accounted for 23% of child morbidity and pneumonia accounted for 17% of child morbidity. Diarrheal diseases were the cause of 7% of deaths and 10% of morbidity in children under five. Mean under-five incidence rates across all refugee camps by region were: malaria [Africa 84.7 cases/1000 U5 population/month (95% CI 67.5-102.0), Asia 2.2/1000/month (95% CI 1.4-3.0)]; pneumonia [Africa 59.2/1000/month (95% CI 49.8-68.7), Asia 254.5/1000/month (95% CI 207.1-301.8)]; and diarrheal disease [Africa 35.5/1000/month (95% CI 28.7-42.4), Asia 69.2/1000/month (95% CI 61.0-77.5)]. Measles was infrequent and accounted for a small proportion of child morbidity (503 cases, < 1%) and mortality (6 deaths, < 1%).

Conclusions

As in stable settings, pneumonia and diarrhea are important causes of mortality among refugee children. Malaria remains a significant cause of child mortality in refugee camps in Africa and will need to be addressed as part of regional malaria control and elimination efforts. Little is known of neonatal morbidity and mortality in refugee settings, and neonatal deaths are likely to be under-reported. Global measles control efforts have reduced the incidence of measles among refugee children.     

Cost-effectiveness of oral cholera vaccine in a stable refugee population at risk for epidemic cholera and in a population with endemic cholera.

Recent large epidemics of cholera with high incidence and associated mortality among refugees have raised the question of whether oral cholera vaccines should be considered as an additional preventive measure in high-risk populations. The potential impact of oral cholera vaccines on populations prone to seasonal endemic cholera has also been questioned. This article reviews the potential cost-effectiveness of B-subunit, killed whole-cell (BS-WC) oral cholera vaccine in a stable refugee population and in a population with endemic cholera. In the population at risk for endemic cholera, mass vaccination with BS-WC vaccine is the least cost-effective intervention compared with the provision of safe drinking-water and sanitation or with treatment of the disease. In a refugee population at risk for epidemic disease, the cost-effectiveness of vaccination is similar to that of providing safe drinking-water and sanitation alone, though less cost-effective than treatment alone or treatment combined with the provision of water and sanitation. The implications of these data for public health decision-makers and programme managers are discussed. There is a need for better information on the feasibility and costs of administering oral cholera vaccine in refugee populations and populations with endemic cholera.     

Occupational health provision in UK universities

BACKGROUND: Very few studies have been done of occupational health provision across an entire employment sector and universities are particularly understudied. The British government published updated guidance on university occupational health in 2006. AIM: To describe the occupational health services to all the universities in the UK. METHODS: All 117 universities in the UK were included. Detailed surveys were carried out in 2002, 2003 and 2004 requesting self-completed information from each university occupational health service. This paper presents information on general characteristics of the service, staffing, services provided and outcome reporting. RESULTS: There was variation in the type of occupational health provision; half the universities had an in-house occupational health service, 32% used a contractor, 9% relied on the campus primary care or student health service and 9% had ad hoc or no arrangements. In all, 93 of the 117 (79%) universities responded to the detailed questionnaire, the response rate being higher from in-house services and from larger universities. There was a wide variation in staffing levels but the average service was small, staffed by one full-time nurse with one half-day of doctor time per week and a part-time clerical or administrative member of staff. A range of services was provided but, again, there was wide variation between universities. CONCLUSIONS: It is unclear if the occupational health provision to universities is proportional to their needs. The wide variation suggests that some universities may have less adequate services than others.     

The refugee crisis in Africa and implications for health and disease: a political ecology approach

Political violence in civil war and ethnic conflicts has generated millions of refugees across the African continent with unbelievable pictures of suffering and unnecessary death. Using a political ecology framework, this paper examines the geographies of exile and refugee movements and the associated implications for re-emerging and newly emerging infectious diseases in great detail. It examines how the political ecologic circumstances underlying the refugee crisis influences health services delivery and the problems of disease and health in refugee camps. It has four main themes, namely, an examination of the geography of the refugee crisis; the disruption of health services due to political ecologic forces that produce refugees; the breeding of disease in refugee camps due to the prevailing desperation and destitution; and the creation of an optimal environment for emergence and spread of disease due to the chaotic nature of war and violence that produces refugees. We argue in this paper that there is great potential of something more virulent than cholera and Ebola emerging and taking a big toll before being identified and controlled. We conclude by noting that once such a disease is out in the public rapid diffusion despite political boundaries is likely, a fact that has a direct bearing on global health. The extensive evidence presented in this paper of the overriding role of political factors in the refugee health problem calls for political reform and peace accords, engagement and empowerment of Pan-African organizations, foreign policy changes by Western governments and greater vigilance of non-governmental organizations (NGOs) in the allocation and distribution of relief aid.     

Effectiveness of emergency water treatment practices in refugee camps in South Sudan

Objective

To investigate the concentration of residual chlorine in drinking water supplies in refugee camps, South Sudan, March–April 2013.

Methods

For each of three refugee camps, we measured physical and chemical characteristics of water supplies at four points after distribution: (i) directly from tapstands; (ii) after collection; (iii) after transport to households; and (iv) after several hours of household storage. The following parameters were measured: free and total residual chlorine, temperature, turbidity, pH, electrical conductivity and oxidation reduction potential. We documented water handling practices with spot checks and respondent self-reports. We analysed factors affecting residual chlorine concentrations using mathematical and linear regression models.

Findings

For initial free residual chlorine concentrations in the 0.5–1.5 mg/L range, a decay rate of ~5x10^-3 L/mg/min was found across all camps. Regression models showed that the decay of residual chlorine was related to initial chlorine levels, electrical conductivity and air temperature. Covering water storage containers, but not other water handling practices, improved the residual chlorine levels.

Conclusion

The concentrations of residual chlorine that we measured in water supplies in refugee camps in South Sudan were too low. We tentatively recommend that the free residual chlorine guideline be increased to 1.0 mg/L in all situations, irrespective of diarrhoeal disease outbreaks and the pH or turbidity of water supplies. According to our findings, this would ensure a free residual chlorine level of 0.2 mg/L for at least 10 hours after distribution. However, it is unknown whether our findings are generalizable to other camps and further studies are therefore required.     

Safe water for Africa

Most morbidity in Africa is linked to unsafe water supplies and a lack of adequate sanitation facilities. According to official government statistics, only 57% of Africans had access to safe water in 1990. The treatment of contaminated water sources or the development of alternative, cleaner water sources is insufficient. The provision of community water points must be integrated with latrine construction and intensive hygiene education based on traditional cultural activities. In rural areas, where people generally collect water from surface sources or shallow wells, intensive education is required to convince community members of the health benefits of improved sources (e.g., protected wells or bore holes with hand pumps), especially when these sources are more distant. In high-density urban areas, even water from the taps and public standpipes is often contaminated and household treatment of drinking water must be promoted. Greater emphasis is being placed on selecting equipment that can be maintained with local technical and organizational capacities and strengthening local maintenance and repair capacities through training village-based mechanics and establishing networks of spare parts suppliers.     

Maternal health services for refugee populations: Exploration of best practices

ABSTRACT

The full scope of women’s health needs is not necessarily addressed in refugee camps and after resettlement, particularly pregnancy and postnatal services. The aims of this research are to examine the maternal care services provided to refugee women in camps and after resettlement to the United States, and to analyse organisational successes and challenges in service provision. With this understanding, policies can improve service delivery for refugee women. We interviewed respondents from five organisations, ranging from local non-profits to international non-governmental organisations. Most of the organisations do not provide direct medical care, but rather education and social service support to clients, and in some cases midwife training. Their success stemmed from a focus on client capacity building, individualised support, effective partnerships, and cultural competency. Respondents described the need for physical resources, effective leadership, and additional personnel, especially with linguistic capabilities. The dialogue in the interviews supports themes of education as empowerment and client self-sufficiency. Respondents emphasised the importance of funding and policies that support their work. This knowledge can lead to improved models of service delivery and inform the development of best practices and policies in maternal and reproductive health for refugee women.     

Monitoring progress of the role of integration of environmental health education with water and sanitation services in changing community behaviours

The health benefits of clean water, improved sanitation and better hygiene are now more recognized than ever before. The objective of the present study focused on monitoring the progress of behavioural changes towards appropriate behaviours related to water, environment and sanitation (WES). This was achieved through assessing the baseline community behaviours towards WES, exploring to what extent community hygienic behaviours had changed towards desirable and sustainable behaviours, through monitoring progress. The expected behavioural changes are results of an integrated package; safe water supply, sanitation, and hygiene education interventions produced by governmental and non-governmental organizations. The monitoring progress consisted of three household surveys that were administered over three years in four Egyptian districts within three Governorates; Fayoum, Beni Suef, and El-Menia. Behavioural changes were detected through special observation checklist indicators. These indicators were 7, 6, and 9 indicators each for personal hygienic behaviours, proper handling of drinking water, and proper use and maintenance of simple constructed sanitary latrines. The results from the baseline to mid-term and final surveys suggested improvement in the majority of the household behaviours towards the desirable behaviours. The proportions of the householders who practiced desirable behaviours were not to the same levels in the four districts. The results provide support to the concept that integrated interventions can produce a significant sustainable improvement in health promotion.     

Iron and vitamin A deficiency in long-term African refugees

Five cross-sectional surveys were conducted in African refugee camps to assess the level of iron deficiency anemia and vitamin A deficiency in populations dependent on long-term international food aid and humanitarian assistance. The prevalence of anemia in children [hemoglobin (Hb) <110 g/L] was high, with >60% affected in 3 of 5 camps. Iron deficiency [serum transferrin receptor (sTfR) >8.5 mg/L] was also high, ranging from 23 to 75%; there was also a strong ecological correlation between the prevalence of iron deficiency and anemia among different camps. Within camps, sTfR predicted the concentration of Hb with adjusted R(2) values ranging from 0.19 to 0.51. Although children were more affected, anemia was also a public health problem in adolescents and women. The effect of recent recommendations on Hb cutoff values for African populations was assessed and found to produce decreases in the prevalence of anemia of between 5 and 21%; this did not affect the public health categorization of the anemia problem within the most affected camps. Mean serum retinol in children, after adjustment for infection status, ranged from 0.72 +/- 0.2 to 0.88 +/- 0.2 micromol/L in the 4 camps assessed and vitamin A deficiency (<0.7 micromol/L) was present at levels ranging from 20.5 to 61.7%. In areas in which vitamin A capsule distribution programs were in effect, coverage ranged from 3.5 up to 66.2%. The high level of micronutrient deficiencies seen in long-term refugees argues in favor of further enhancements in food aid fortification and the strengthening of nutrition and public health programs.     

Nutritional situation among Syrian refugees hosted in Iraq,Jordan, and Lebanon: cross sectional surveys

Background

Ongoing armed conflict in Syria has caused large scale displacement. Approximately half of the population of Syria have been displaced including the millions living as refugees in neighboring countries. We sought to assess the health and nutrition of Syrian refugees affected by the conflict.

Methods

Representative cross-sectional surveys of Syrian refugees were conducted between October 2 and November 30, 2013 in Lebanon, April 12 and May 1, 2014 in Jordan, and May 20 and 31, 2013 in Iraq. Surveys in Lebanon were organized in four geographical regions (North, South, Beirut/Mount Lebanon and Bekaa). In Jordan, independent surveys assessed refugees residing in Za’atri refugee camp and refugees residing among host community nationwide. In Iraq, refugees residing in Domiz refugee camp in the Kurdistan region were assessed. Data collected on children aged 6 to 59 months included anthropometric indicators, morbidity and feeding practices. In Jordan and Lebanon, data collection also included hemoglobin concentration for children and non-pregnant women aged 15 to 49 years, anthropometric indicators for both pregnant and non-pregnant women, and household level indicators such as access to safe water and sanitation.

Results

The prevalence of global acute malnutrition among children 6 to 59 months of age was less than 5 % in all samples (range 0.3–4.4 %). Prevalence of acute malnutrition among women 15 to 49 years of age, defined as mid-upper arm circumference less than 23.0 cm, was also relatively low in all surveys (range 3.5–6.5 %). For both children and non-pregnant women, anemia prevalence was highest in Za’atri camp in Jordan (48.4 % and 44.8 %, respectively). Most anemia was mild or moderate; prevalence of severe anemia was less than or equal to 1.1 % in all samples of children and women.

Conclusions

Despite the ongoing conflict, results from all surveys indicate that global acute malnutrition is relatively low in the assessed Syrian refugee populations. However, prevalence of anemia suggests a serious public health problem among women and children, especially in Za’atri camp. Based on these findings, nutrition partners in the region have reprioritized response interventions, focusing on activities to address micronutrient deficiencies such as food fortification.

     

Evaluation at the local level: the roles of outsiders and the community

This paper summarizes the findings of a study designed to evaluatewhether primary health care (PHC) was being implemented in oneof the poorest, most remote Tibetan refugee settlements in Indiasome time after the main international aid donations and projectshad ended. There have been too few comprehensive or specificevaluations of relief aid in general and refugee health in particular.The findings highlight the feasibility and desirability of undertakinga combination of participatory and technical methods of evaluation,and illustrate how ‘outsiders’ working with thecommunity can be partners in an evaluation. The implicationsthis has for undertaking an evaluation at the local level arediscussed. A lack of an institutional memory seems evident from recentrefugee experiences where the international community all toocommonly seems to have a half-hearted approach to creating ‘tolerable’camps in the anticipation that they are only a ‘temporary’phenomenon. Such camps are creating more chaos and problemsthan they solve. The development philosophy as applied to theTibetans has illustrated that rhetoric can become reality andthat PHC, as opposed to the provision of solely acute medicaland surgical services, is feasible. The evaluation revealedthe inadequacy of evaluations that focus solely on the restructuringof the health care system to support PHC activities. While sucha focus is of course very important, the main concern of therefugees was for economic and environmental improvements.     

Household income and health status in children and adolescents in Britain

BACKGROUND: Mortality, health, and well-being across the lifespan are associated with socioeconomic position (typically operationalised as occupational status). There is some evidence that adolescence represents a period of 'relative equalisation' of health inequalities. Our aim was to examine the association between inequalities in household income and health in childhood and adolescence. METHODS: Cross-sectional survey using multistage stratified random sample of households in Britain. Information was collected on 10438 children aged 5-15 years. RESULTS: Low levels of equivalised household income was associated with poorer health for 13 out of the 22 indicators examined (odds ratio P < 0.05 for > or =1 income quintile). Multivariate analyses controlling for child characteristics, parental socioeconomic status and household composition indicated that low levels of equivalised household income increased the odds of poor health for 9 out of the 22 indicators examined. There was little evidence of any systematic differences in the extent of health inequalities across age groups (5-10 and 11-15 years). CONCLUSION: Household income is related to a range of health outcomes for children and adolescents, even when other indicators of socioeconomic status are taken into account. We found little evidence that adolescence represents a period of relative equalisation of health inequalities.