Better Sanitation and Deeper Relationships: Lesson Learned from Past Health Crises in Refugee Camps.
Written by: Eirene Smith
With the first case of COVID-19 confirmed in the infamous Moria refugee camp on the North Aegean Island of Lesvos, it is absolutely vital that more attention is given to the complex and precarious health and sanitation conditions in refugee camps. This article by guest blogger Eirene Smith examines the sector’s response to three different communicable disease outbreaks in similar conditions. It also raises the question of greater contributing factors to these outbreaks: systemic injustices, neglect of undoubtedly vulnerable populations, and apathy from the global community to demand better.
Refugees are in unique situations. Displaced from their homes and often separated from their families, they are perpetually stuck in limbo, hoping someone will help them. Usually, the agency tasked with that responsibility is the Office of the United Nations High Commissioner for Refugees (UNHCR). The UNHCR and its partner organizations provide shelter, food, water, education, legal aid, and healthcare for refugees in refugee camps all over the world.
Refugees face a myriad of healthcare challenges. They are often malnourished and dehydrated when they arrive at a camp, exhausted from sometimes months of travel. Their immune systems are then put to the test in the camp itself, because they are forced into a confined space with thousands of other people with limited access to sanitation, which is a perfect breeding ground for all kinds of diseases.
This article examines three health crises in refugee camps to draw conclusions about methods the UNHCR could employ to hopefully limit the spread of COVID-19 in refugee camps in the coming months. The three case studies highlighted are the Dadaab refugee complex in Kenya and the 2015 cholera crisis, the PTP refugee camp in Liberia and its experience with Ebola, and the Yida refugee camp in South Sudan and its high numbers of malaria cases. Conclusions from the case studies are that UNHCR and its partner agencies should provide clean water, handwashing facilities, and toilets to refugees. They should also think about expanding the size of camps to accommodate growing families. It is also important that concerned organisations create relationships with refugees, to facilitate awareness campaigns, and that healthcare providers focus on both preventative measures and case management. COVID-19 will inevitably negatively impact refugees and refugee camps, and only time will tell if the measures that the UNHCR has taken and will take can actually reduce the likelihood of a full-blown health crisis in refugee camps.
According to the UNHCR a refugee is a person who “has been forced to flee his or her country because of persecution, war, or violence.” They have a “well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group” so that “they cannot return home or are afraid to do so” (What is a Refugee, 2020). The UNHCR estimates that 25.9 million people were classified as refugees in 2018, with the majority of those people coming from Syria, Afghanistan, South Sudan, Myanmar, and Somalia (Refugee Statistics, 2020).
"... they are forced into a confined space with thousands of other people with limited access to sanitation, which is a perfect breeding ground for all kinds of diseases."
2.6 million of the 25.9 million people live in refugee camps. Refugee camps are “temporary facilities built to provide immediate protection and assistance to people who have been forced to flee due to conflict, violence, or persecution.” A camp must be a safe distance from a state’s border, should have “easy access to water supplies,” be located in an area with good “waste management capabilities,” and should provide each refugee with at least 480 sq. ft. of space. Each camp is designed to provide refugees with shelter, emergency relief items, clean water, food, legal aid, and, most important for the purposes of this paper, healthcare. The UNHCR says they work “with local authorities to ensure refugees have access to essential healthcare services” like “basic medical care, immunization programs, psychological support” and “prevention and control of communicable diseases and epidemics” (Refugee Camps, 2020).
Dadaab Refugee Complex, Kenya, and Cholera outbreak.
Dadaab is the third largest city in Kenya and businesses in that city generate an annual turnover of roughly US$25 million. The city also hosts refugees at Dadaab Refugee Complex, located in south-eastern Kenya near the Somalian border. In March 2020 the complex had 217,511 registered refugees residing there. A large influx of refugees came to Dadaab in 2011,mostly from Somalia fleeing civil war, drought and famine (Dadaab Refugee Complex,2020). The complex comprises three camps, the first of which was set-up in 1991. The Kenyan government has strict encampment policies, which prevent refugees from settling outside the camp. This limits the rights and freedoms of refugees who live there, and the population in the complex continuously increases which also causes damage to the Kenyan environment(The refugee camp that became a city,2019).
The UNHCR reported in December 2015 that cholera, a fatal, diarrheal, water-borne illness, broke out in the Dadaab complex, infecting roughly 1,000 people and killing ten. Officials thought that the outbreak was connected to pooling groundwater caused by El Niño rains. To curb the rate of infection, four cholera-specific clinics were set up by the UN and its partner agencies. The same agencies spearheaded a hygiene promotion campaign through soap distribution, house and toilet disinfection, and education, which seemed to be somewhat effective (Nasrullah, 2015). The head of Médecins Sans Frontières (MSF), Kenya disagreed with the above assertion. Regarding the outbreak, he said, “The fact that this…has occurred further highlights the dire hygiene and living conditions in the camp.” Citing funding cuts from donors as cause for poor upkeep of sanitation facilities, he continued, “there are insufficient latrines for the population size, and they have not received soap for the last two months” (Cholera outbreak spreads to Dadaab refugee camp, 2015).Qabale et al. reported that significant risk factors for contracting cholera were “open defecation, visible human and solid waste, and eating from a shared plate” (2018). Additionally, they noted that Dadaab did not possess an adequate number of handwashing facilities. These conclusions echo those of Cowman et al., who found that cholera cases in Kenya could be linked to a higher prevalence of open defecation, lack of clean water supply, and poverty (2015).
Access to clean water, handwashing facilities, toilets, and awareness of germs could have limited the cases of cholera in Dadaab. In their Emergency Handbook, the UNHCR recommends providing refugees with “full access to essential health services,” and to “ensure safe access to water, sanitation and hygiene in the camps” (Health in the camps; WASH in the camps, 2018). Yet, their guidelines do not require toilets for every household until after an emergency is over (WASH in the camps, 2018). The UNHCR recommends that camps are never constructed with permanent in mind (Camp planning standards (planned settlements), 2018). But, Kennedy holds that many camps, including Dadaab, have housed residents for decades (2005, pg. 46). Households could thus live in a camp for generations and never obtain a toilet for themselves. They would then either share a toilet with others, or defecate in the open, which increases the likelihood of cholera transmission.
“there are insufficient latrines for the population size, and they have not received soap for the last two months”
UNHCR guidelines do not take into account that families will require more space and resources now than they did when they were originally settled in Dadaab. The camp is only growing, and with Kenya’s strict rules, there is no end in sight for when the refugees could return home. This gap between the handbook and realities on the ground partially explains the lack of sanitation facilities afforded to Dadaab refugees, and why they suffered from cholera for an extended period of time, even though it is easily preventable.
PTP Refugee Camp, Liberia, and Ebola
In March 2014, the World Health Organisation (WHO) reported the cases of the Ebola Virus Disease, or EVD, in south-eastern Guinea. This marked the beginning of the West Africa Ebola epidemic. While the initial cases and deaths occurred in Guinea, poor public health infrastructure, weak surveillance systems, and migration across borders meant the virus quickly spread to Guinea’s neighbours—Liberia and Sierra Leone. EVD eventually infected over 28,000 people and killed over 11,000 across all three states. Liberia was not declared fully Ebola-free until June 2016 (2014-2016 Ebola Outbreak in West Africa, 2019; Ebola outbreak 2014-2016, 2017).
The largest refugee camp in Liberia is called PTP Camp and is located in the north-west part of the country, near the Côte d’Ivoire border. The camp was established in 2011 to hold Ivorian refugees following civil unrest due to an election. As of March 2018, the camp held over five thousand refugees, with another thousand people living in the surrounding county (Liberia- PTP Refugee Camp (Grand Gedeh County), 2018). Given that the PTP Camp is operated by the UNHCR, it is reasonable to assume it is similar in construction and layout to Dadaab Camp in Kenya, though it holds a much smaller population
Examining Ebola in Liberia from a political economy perspective, Benton and Deionne show how the trans-Atlantic slave trade, colonialism, structural adjustment policies, civil wars, and foreign aid dependency all contributed to the state uniquely suffering from EVD (2015, pg. 225). In particular, they emphasize how a history of ill-led government interventions made Liberians mis-trust health and government authorities, unfortunately resulting in the further spread of the disease (pg. 228). This was further complicated by a high reliance on international organisations who were disorganised in their attempt to limit Ebola’s spread and who inevitably ran out of resources (pg. 229-230). The structural and historical factors highlighted by Benton and Deionne’s political economy approach showcases why Liberia suffered so acutely and for such a lengthy period of time.
Considering the condition of the state as a whole, it is a shock that the PTP refugee camp remained Ebola free. However, an Ebola Regional Response Plan from the UNHCR credited “strong community mobilization and medical protocols implemented by the UNHCR and its partners” as reasons for why the camp remained healthy even when the surrounding countries were suffering (2015, pg. 5). As mentioned previously, most Liberians did not trust government or health officials due to historical and structural issues. The UNHCR, on the other hand, had deep ties with the refugees who resided in PTP. They relied on social mobilization to spread public health centered messaging to refugee camps, which the refugees trusted to be accurate information because of their pre-established relationship (pg. 7, 13). Resources were also put towards creating early detection and surveillance systems, into establishing Community Care Centers with isolation units, and for the upkeep of essential services including shelter, food, and water (pg. 7-8). In addition, even though PTP is located in Liberia, the residents of the camp were not Liberian. Thus, Benton and Deionne’s political economy analysis does not apply to the refugees. Combined with the strong relationships mentioned previously, the PTP camp avoided Ebola.
Yida Refugee Camp, South Sudan and Malaria
As of 30 April, 2020, over 1 million refugees and asylum-seekers were registered as living in South Sudan. Almost 80% of these refugees came from Sudan, fleeing civil war. The cities of Khartoum, White Nile, and Kassala hold the highest populations of refugees. Of those, the highest number of refugees and asylum-seekers live in Khartoum—the city holds almost 400,000 people (Sudan: Population Dashboard, 2020). The WHO considers Sudan a “high-burden and high-risk” country for malaria. Challenges to decreasing malaria cases are integrating surveillance for malaria into the pre-existing disease surveillance system and increasing the availability of tests to people who are suspected to have the disease (Sudan: Malaria control and elimination, 2012).
In May 2012, there was an influx of refugees into the Yida refugee camp in South Sudan, a wetland area 12km from the Sudanese border. Around 430 refugees arrived every day throughout the month of May due to increased tensions in the Sudanese Nuba mountains, according to one UNHCR representative. This increased the population of the camp from a few thousand to more than 35,000 refugees. Public health as a whole is always at risk when large masses of people migrate, but risk of contracting malaria especially is high when that migration takes place during the start of the rainy season, and when the refugee camp is situated in a wetland area. At the end of May 2012, the UNHCR reassured the press that they had “conducted distributions of plastic sheets, mosquito nets, sleeping mats and blankets to more than 12,700 people” and were going to begin distributing these services to all refugees, not just those considered “vulnerable” (Fleming, 2012). Two months later, MSF reported that Yida, designed to hold 15,000 refugees, was now holding 63,500. They reported that the refugees arriving were in “extremely poor health,” made more complicated by the beginning of the rainy season, and insufficient water supply and sanitation (Deteriorating health situation for refugees in Yida camp, 2012).
Rowland and Nosten hold that malaria thrives in situations of complex emergencies and amongst refugees due to the breakdown of health services, malnourishment, and the placement of camps in areas prone to mosquito breeding (2001, pg. 742). Refugees arriving at Yida were already malnourished and in poor health conditions due to lack of health services and food in Sudan, and Yida is located in a wetland area which is perfect for mosquito breeding. Based on both UNHCR and the MSF reports, it seems that all wrong conditions occurred at the wrong time resulting in drastically high numbers of malaria cases.
Rowland and Nosten go on to say that health providers for refugee camps should not only focus on case management but must also provide preventative measures (2001, pg. 742). Both the UNHCR and MSF tried to prevent as many malaria cases as possible by providing refugees with mosquito nets and increasing their capacity for clinics and resources for staff on the ground. But, there is only so much preventative work to be done when the camp itself is located in a wetland area, and tragically, many people died.
Conclusions and Implications for COVID-19
Looking at each of the public health crises that the Dadaab, PTP, and Yida camps suffered through, a number of suggestions can be put forward in order to better handle COVID-19. Refugee camps should be provided with adequate amounts of clean water, handwashing facilities, toilets, and space for each refugee family in proportion to the length of time they are residing in the camp. Dadaab and the PTP case studies show the importance of spreading reliable information about hygiene through trusted channels, and that fostering relationships between the refugees and the refugee camp officials is vital to maintaining a healthy space. From Yida, we can learn that preventative measures are as important as case management. In the case of COVID-19, that translates to increasing the space of the camp itself to allow for social distancing, and to increasing sanitation precautions.
Preston points out that “refugee camps across the globe are notoriously ill run” with sanitation, and availability of food and medicine as central issues (2015, pg. 88). Preston further points out that the root cause is a lack of clarity surrounding which non-profits and agencies are responsible in certain areas. (2015, pg. 107). Ebola cases in Liberia are a good example of what happens when there is a lack of clarity regarding an organisation’s responsibility in refugee camps. Too many actors and not enough direction resulted in lots of different messages to the same people, which ultimately meant chaotic healthcare provision and more Ebola cases.
The UNHCR is trying to limit the number of COVID-19 cases in refugee camps, because they understand that refugees are at a significant risk of contracting the disease, given their often poor sanitation conditions. They are advocating for states on the African continent to include refugees in their COVID-19 response plans, and mobilizing with other healthcare organisations to spread awareness, prevention, and treatment through “community groups….telephone hotlines, flyers, posters, bulk SMS…messaging, radio announcements, focus group discussions, leaflets, billboards and mural drawings.” They are also working on increasing access to sanitation resources, especially soap, and constructing new isolation wards for refugees. The UNHCR asked for US$255 million for healthcare interventions related to COVID-19, and $15 million is allocated to the East and Horn of Africa. (Baloch, 2020). Time will tell if that amount, and the measures proposed, will be enough.
2014-2016 Ebola Outbreak in West Africa. (2019-08-03). Centers for Disease Control and Prevention. Retrieved June 2, 2020, from https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html.
Benton, A. & Dionne, K. Y. (2015-04-16). International Political Economy and the 2014 West African Ebola Outbreak. African Studies Review, 58(1), 223-236. 10.1017/asr.2015.11.
Baloch, B. (2020-07-04). UNHCR stepping up coronavirus prevention measures for displaced across East, Horn, and Great Lakes region of Africa. UNHCR. Retreived June 9, 2020 from https://www.unhcr.org/en-us/news/briefing/2020/4/5e8c28c44/unhcr-stepping-coronavirus-prevention-measures-displaced-across-east-horn.html.
Camp planning standards (planned settlements). (2018). UNHCR. Retrieved June 1, 2020, from https://emergency.unhcr.org/entry/45581/camp-planning-standards-planned-settlements#4,1591064955152
Cowman, G. A., Otipo, S., Njeru, I., Achia, T., Thirumurthy, H., Bartram, J., & Kioko, J. (2017-03-10). Factors associated with cholera in Kenya, 2008-2013. The Pan African Medical Journal, 28(101). 10.11604/pamj.2017.28.101.12806
Cholera outbreak spreads to Dadaab refugee camp. (2015-12-17). Médecins Sans Frontières. Retrieved May 29, 2020, from https://www.msf.org/kenya-cholera-outbreak-spreads-dadaab-refugee-camp.
Dadaab Refugee Complex. (2020). UNHCR. Retrieved May 29, 2020, from https://www.unhcr.org/ke/dadaab-refugee-complex.
Deteriorating health situation for refugees in Yida camp. Médecins Sans Frontières. Retrieved June 8, 2020 from https://www.msf.org/south-sudan-deteriorating-health-situation-refugees-yida-camp.
Ebola outbreak 2014-2016. (2017). World Health Organization. Retrieved June 2, 2020 from https://www.who.int/csr/disease/ebola/en/.
Ebola Regional Response Plan. (2015). UNHCR. Retrieved June 2, 2020 from https://reliefweb.int/sites/reliefweb.int/files/resources/Ebola%20Regional%20Response%20Plan%20Jan-Dec%202015%20-%20March%202015.pdf.
Fleming, M. (2012-25-05). South Sudan: UNHCR expands aid operations in Yida as population passes 35,000. UNHCR. Retrieved June 8, 2020, from https://www.unhcr.org/en-us/news/briefing/2012/5/4fbf622a9/south-sudan-unhcr-expands-aid-operations-yida-population-passes-35000.html.
Golicha, Q., Shetty, S., Nasiblov O., Hussein, A., Eliud, W., Obonyo, M., Macharia, D., Musyoka, R. N., Hussein, A., Ope, M., Joseph, R., Kabugi, W., Kiogora, J., Munawwar, S., Waqo, B., Galgalo, T., Lowther, S. A., Juma, B., Mugoh, R…Burton, J. W. (2018-31-08). Cholera Outbreak in Dadaab Refugee Camp, Kenya—November 2015-June 2016. Morbidity and Mortality Weekly Report, 67(34), 958-961. Retrieved June 1, 2020 from https://www.cdc.gov/mmwr/volumes/67/wr/mm6734a4.htm.
Health in camps. (2018). UNHCR. Retrieved June 1, 2020, from https://emergency.unhcr.org/entry/54565/health-in-camps#2,1591064967352.
Kennedy, J. (2005-05). Challenging camp design guidelines. Forced Migration Review, 23, 46-47. Retrieved June 1, 2020 from https://www.fmreview.org/sites/fmr/files/FMRdownloads/en/europe.pdf.
Liberia- PTP Refugee Camp (Grand Gedeh County). (2018-03). UNHCR. Retrieved June 2, 2020 from https://data2.unhcr.org/en/documents/download/62981.
Nasrullah, A. (2015-12-31). UNHCR battles cholera at world’s largest refugee complex. UNCHR. Retrieved May 29, 2020 from https://www.unhcr.org/en-us/news/latest/2015/12/5685137c9/unhcr-battles-cholera-worlds-largest-refugee-complex.html.
Preston, G. (2015). No Safe Haven: How the Chasm between the Laws Governing Refugees and Mass Gatherings Has Contributed to Health Crises. Journal of Biosecurity, Biosafety and Biodefense Law, 6(1), 87-108. 10.1515/jbbbl-2015-0011
Rowland, M. & Nosten, F. (2001). Malaria epidemiology and control in refugee camps and complex emergencies. Annals of Tropical Medicine & Parasitology, 95(8), 741-754. 1080/00034980120103405.
Refugee Camps. (2020). UNHCR. Retrieved May 29, 2020, from https://www.unrefugees.org/refugee-facts/camps/.
Refugee Statistics. (2020). UNHCR. Retrieved May 29, 2020, from https://www.unrefugees.org/refugee-facts/statistics/.
Sudan: Malaria control and elimination. (2012). World Health Organization. Retrieved June 3, 2020, from http://www.emro.who.int/sdn/programmes/malaria-sudan.html.
Sudan: Population Dashboard. (2020-04-30). UNHCR. Retrieved June 3, 2020, from http://reporting.unhcr.org/sites/default/files/Sudan%20All%20Refugees%20Dashboard_April%202020.pdf.
The refugee camp that became a city. (2019). Africa Renewal, United Nations. Retrieved May 29, 2020, from https://www.un.org/africarenewal/news/refugee-camp-became-city.
WASH in camps. (2018). UNHCR. Retrieved June 1, 2020, from https://emergency.unhcr.org/entry/39929/wash-in-camps.
What is a Refugee?. (2020). UNHCR. Retrieved May 29, 2020, from https://www.unrefugees.org/refugee-facts/what-is-a-refugee/.