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In mid-2016, the United Nations refugee agency and Ugandan officials made a horrific discovery. Cholera was being introduced in a migrant settlement by refugees from South Sudan who were fleeing the extreme violence in their imploding country.
In barely six weeks, beginning last July, 80,000 South Sudanese had arrived in Uganda when the outbreak of cholera was detected in reception centers and nearby settlements, causing fear and hostile reactions from Ugandan residents toward people already steeped in misery.
Quick intervention by the UN High Commissioner for Refugees and Ugandan health authorities largely stemmed the outbreak, but the story does not end there.
On May 9 this year, another cholera warning was issued, this time for Yemen. Doctors Without Borders/Médecins Sans Frontières sent an alert saying there had been a “drastic” increase in cholera cases around the country, the poorest in the Arab world, where a civil war, fueled by outsiders, began in 2015 over territorial and political power. Doctors Without Borders fears the cholera could get out of control, as numerous hospitals no longer function in Yemen.
The world knows how fast an epidemic can happen with catastrophic results, after troops from Nepal, where cholera is endemic, brought the disease to Haiti, which has no functioning public health system. The Nepalese were working in Haiti as UN peacekeepers after the cataclysmic earthquake in 2010.
“Refugee health is a public health crisis of this century,” two experts reported in the British medical journal The Lancet recently, after working in a clinic for refugees in Thessaloniki in Greece. The center helped people from the Middle East who had crossed the Mediterranean to seek asylum in Europe.
PassBlue, in this latest article in a series of surveys of data and research on global topics, looks at the grim roster of diseases that can strike refugees and people displaced by war, famine, natural disasters and, recently, climate-change effects. Apart from cholera, there are other diarrheal illnesses — caused by contamination of food and water or poor sanitation — as well as respiratory infections, measles, malaria, meningitis, hepatitis A, yellow fever and polio cases, all demanding immediate attention and treatment.
Vaccinations are not always available, especially among displaced people in their own countries. Among the worst cases are the Rohingya in northwestern Burma, or Myanmar — Muslims who are ostracized and assaulted by ethnic Burmese Buddhists, whom Aung San Suu Kyi, the Burmese leader, has not been willing to stop, despite international outcry. Most Rohingya are cut off from aid and off-limits to humanitarian agencies and reporters.
Then there are psychological and psychiatric breakdowns with long-term consequences, especially for children. Disabled people’s needs and chronic conditions among migrants are not always given high priority in the chaos of displacement on a vast scale, requiring huge resources. A manual and power-point presentation designed for raising awareness of women in leadership positions and training aid workers who deal specifically with women who are disabled has been published by the Women’ss Refugee Commission.
Early this year, Medical Teams International, a Christian aid agency based in northwestern Oregon in the US, which works in Uganda among South Sudanese and Burundian refugees, who are escaping political violence in that collapsing nation, estimated that about 3,500 refugees a day are entering Uganda. Many have endured — or barely survived — long treks in severe hunger and thirst that have made them especially vulnerable to infectious diseases. That includes cholera, which ravages the body with severe diarrhea and vomiting and can lead to complete dehydration. It is often fatal.
By UN calculations, there are 65.3 million people in the enormous, turbulent world of refugees and the displaced, the majority of whom abandon their homes in poor and troubled countries only to land in nations as stressed as the places they are fleeing. Uganda may have absorbed as many as 500,000 refugees and displaced people in the last few years, the majority of them women and children from neighboring countries, according to Medical Teams International.
This year, the organization received an $850,000 grant from the Bill & Melinda Gates Foundation to expand its work there and elsewhere around the world.
The UN refugee agency is declaring an emergency in Uganda as a storm season approaches and an urgent need for shelter and other necessities arise, like cooking equipment and lamps that do not depend on electricity. Basic clinics are essential.
“Refugees are generally high users of health-care resources because of acute illness and the high prevalence and poor management of chronic diseases, mood disorders, post-traumatic stress disorder, schizophrenia, and non-affective psychotic disorders,” the researchers who volunteered in Thessaloniki — Quratulain Syed, professor of medicine at Emory University, and Tamin Mobayed, a postgraduate student in psychology at Queen’s University in Belfast, Northern Ireland — wrote in the correspondence section of The Lancet in response to articles on refugee care.
“Because the political crises leading to the displacement of refugees generally last for decades, health-care systems in the host countries will hold the burden of refugees for years to come,” they wrote. “The treatment of communicable diseases is generally prioritized to prevent an outbreak in the host countries. However, chronic medical and mental health disorders, including trauma and stressor-related disorders, as non-communicable diseases . . . are not give the same priority.”
Because children often form the largest age cohort in concentrations of refugees and displaced people, their needs for health care and protection loom large. The International Organization for Migration (IOM) says that in Yemen, the child population includes both local children who may have already been homeless or living as beggars on city streets and unaccompanied minors from outside the country. They account for a quarter of the children in trouble.
“They are mainly Ethiopian boys between the ages of 14 and 17, who are in need of urgent life-saving assistance and protection, having travelled from Ethiopia overland through Djibouti, and sometimes Somalia, and crossed the sea to Yemen,” an IOM blog reported. “More often than not they have been abducted, injured or shot, held captive, abused, exploited, and robbed, while on their journey.”
Many children escaping poverty in large Ethiopian families with no land for new generations to work, try to reach Saudi Arabia to find jobs. If they want to give up and go home, even to a dismal future, the migration organization offers help.
The IOM, now part of the UN family, established 31 child-friendly spaces in the Yemen cities of Aden and Sana to provide psychological support to conflict-affected children and families, where 37,382 boys, girls, men and women have received help from IOM psychologists.
Ironically, and perhaps tragically, among the supporters of child protection and assistance in Yemen has been the US State Department, which is now pressured by the Trump administration to cut foreign-aid programs. IOM’s psychosocial support for children, in particular, has been funded by the US Office for Foreign Disaster Assistance.
Given the growing understanding that women hold societies together, from the family to the community and beyond, how they are assisted, encouraged and, when possible, empowered within a refugee setting can prepare them for a more productive life when and if a crisis ends and they can return to home. Thousands of women arrive pregnant and dangerously malnourished in refugee camps and settlements. Many women have been victims of violence at home, worsened by conflict.
Women and girls are also sexually assaulted on the way to what they hope will be safe havens — a situation that continues even inside camps.
Most women of reproductive age, including teenagers, may also arrive with children, either their own or others entrusted to their care when they flee conflict, famine and natural disasters. Their reproductive health needs are urgent, from prenatal care to birth of a child. They have access to information on breast-feeding, nutrition and contraception to delay or avoid future unwanted pregnancies.
The UN has adopted very liberal rules for helping women and girls, including prescribing emergency contraception for victims of rape and occasionally performing abortions or treatment after botched abortions. That occurs only in places where abortions are safe and legal.
The UN refugee agency has formulated reproductive health guidelines for emergencies as well as a comprehensive survey of available reports and data for aid workers and others to consult.
The Zaatari refugee camp in Jordan, near the border with Syria, has often been held up as a model for its totality of services it offers to women. Almost 80,000 people have sought refuge there, making it the world’s largest camp. Clinics operated by the Jordan Health Aid Society — with support from the UN Population Fund, which the Trump administration has just withdrawn its share of contributions — have been dedicated to helping women since 2012.
Zaatari has been described by visitors as a small city that has developed ad hoc with the help of UN agencies and nongovernmental organizations. There are neighborhoods, fast-food services, educational and vocational training opportunities and medical facilities working around the clock. Thousands of babies have been delivered safely and in good health. Because the population is almost half male and half female, which is not the case in many refugee camps now, families can more often stay together. The key has been Jordan’s active involvement in making it all work.