|Medical Assistance to Self-settled Refugees (Institut Tropical - Tropical Institute, Antwerp, Belgium, 1998)|
Although some 100,000 people are estimated to have died due to the famine, these deaths were caused not by lack of food but by 'health crises'. These health crises consisted in localized outbreaks of disease, particularly measles and the diarrhoeas, which were precipitated by population movements and by lack of sanitation and clean water. It is commonly argued that diseases become more prevalent during famines because people are undernourished and so weak and more susceptible to disease. I am arguing that this is false, at least in the case of Darfur. One important factor in this was the decline in both the quantity and the quality of water. A second was the large-scale movement of people. Large concentrations of people accelerated the rates of transmission of infectious diseases. The new situation was equivalent to a sudden change from a dispersed or rural-type environment to a concentrated or urban-type environment. This also put pressure on water supplies and sanitation facilities in the host communities: the public health environment became degraded, for hosts and migrants alike.2
Alex de Waal
The location of the refugees may range from spontaneous settlement over a wide area, through organised rural settlement, to concentration in a very limited area. Circumstances can make this last possibility unavoidable, but the establishment of refugee camps must be only a last resort. A solution that maintains and fosters the self-reliance of the refugees is always preferable. [...] Whatever the circumstances, the overriding aim must be to avoid artificial, high density, refugee camps.3
UNHCR Handbook for Emergencies
Refugee emergencies are frequent, and the most dramatic Somalias, Gomas and Sudans get wide media coverage. Nowadays, concentration of refugees in camps is often considered an inherent feature of mass migration. The terms 'refugees' and 'camps' are intimately linked, both in collective consciousness and in practice. Most aid workers and relief administrators will acknowledge that refugee camps are a bad thing, while stating that, unfortunately, they cannot be avoided; "there simply is no alternative". There is, in dealing with refugee crises, a big gap between theory - "Whatever the circumstances, the overriding aim must be to avoid artificial, high density, refugee camps"3 - and practice - the almost systematic creation of refugee camps.
Common wisdom has it that refugee camps are a necessary evil. To concentrate large numbers of people in a small and chaotic area is a scenario for catastrophe, but good management of such situations can make a huge difference. Camp management has become a science in which lining up, counting, supplying and organising are important skills. More and more, state-of-the-art camp management has become the norm in refugee assistance. Humanitarian agencies know the craft of bringing relief in refugee emergencies.4-41 Excess mortality can be brought down in a spectacular way in a few weeks. Yet, these interventions are mostly conceived as short-term, although the overwhelming majority of the world's refugees stay in the host country for several years.12-14 This puts most officially recognised refugees for years in chronic refugee camps, and makes them passive recipients of aid. With little or no autonomy, they wait for an ever postponed repatriation, in often miserable 'humanitarian sanctuaries'.15
The living conditions in these camps create an ideal breeding ground for epidemics of infectious and nutrition-related diseases. They also constitute an undesirable social and psychological environment.16,17 Camp life keeps refugees largely dependent on outside help. Consequently, camps are very expensive to maintain, and often the international community is unable to do so on the longer term.18,19
But is there really no alternative? Do the disadvantages of "spontaneous settlement over a wide area" 3 outweigh the disadvantages of camps? Less organised or chaotic dispersion of refugees among the host population occurs in each refugee crisis. A variable proportion of the refugees remain unassisted, some by choice.20 There are always refugees who prefer to self-settle and rely on themselves and the host population, rather than on the aid bureaucracy.17 But in the current approach to refugee assistance, self-settlement almost invariably implies receiving no assistance, and leaves such refugees no other choice but to rely entirely on themselves and their hosts.
Between 1990 and 1996, some 500,000 Liberians and Sierra Leoneans found refuge in Guinea. The situation in Liberia and Sierra Leone remained unstable during many years, which limited prospects for repatriation. The Government of Guinea did not restrict freedom of movement or settlement. Refugees self-settled among the local population; very few were confined to refugee camps. Medical and nutritional assistance to the refugees was adapted to this reality. Rather than forcing refugees to congregate in order to receive assistance, aid followed the refugees in the places where they self-settled. Refugees got access to medical care in existing health facilities, which were upgraded and extended to cope with the additional workload. Many refugees developed a high degree of economic self-reliance, and were thus less dependent on food aid than refugees in camps. This study describes the medical assistance in Guinea in response to the refugee emergency. It analyses the development of the approach, its strengths and weaknesses.
The first three chapters present the context in which the refugee crisis took place. Chapter 1, 'Guinea, Liberia & Sierra Leone', gives some background on the countries. Guinea and Sierra Leone are among the poorest and least developed countries in the world. They are inhabited by a patchwork of ethnic groups, and national borders cut across ethnic divisions. The Forest Region, where the refugees settled, is a remote part of Guinea, but with considerable agricultural potential and low population density.
Chapter 2 describes the 'Health System in Guinea, 1989-96'. When the refugees started arriving, the Guinean health system was in the early stages of its nation-wide transition and expansion. Geographical coverage with health facilities was still very poor, but plans and staff were prepared for their fast expansion.
Chapter 3, 'The Refugee-crisis: Between Self-reliance and Pragmatic Assistance', gives an overview of the dynamics of the refugee crisis: the different waves and settlement patterns. This chapter also describes how the Programme d'Assistance aux Réfugiés Libériens et Sierra-Léonais (PARLS) started and evolved over time between 1990 and 1996.
The following three chapters deal with three key aspects of the assistance provided to the refugees in the context of PARLS. Chapter 4 describes 'Food Aid'. Refugee registration and assessment of the nutritional situation were fraught with difficulties. Food aid covered only part of the needs of the refugees; they were partly self-sufficient. Preconceived ideas and standard strategies - not adapted to the non-camp situation - inspired the approach to food aid more than knowledge of the socio-economic situation of the refugees or hard data.
Chapter 5, 'Control of Epidemics' analyses the epidemics that occurred and how they were controlled. Most epidemic control measures were highly cost-effective - with meningococcal meningitis mass vaccination as a notable exception - but decisions on control of epidemics were not only inspired by the potential burden; fear also played an important role. Bio-demographic burden and psychological impact are indeed both essential dimensions of the epidemic phenomenon.
Chapter 6, 'Health Services for Refugees: between Primary Health Care and Emergency Medical Assistance', analyses the organisation of health services for refugees, integrated in, or as an extension of the Guinean health care system. PARLS managed to give most refugees access to health services, but their utilisation remained low, as refugees were dissatisfied with the quality of care. The approach to health service organisation was too technocratic and top-down, and largely ignored the refugees' demands and perceptions. But thanks to PARLS, the host population in the refugee-affected areas got better access to health services.
A final chapter, Chapter 7, 'Towards a more Balanced Refugee Policy' reviews the policy lessons that can be learnt from the Guinean experience. Refugee assistance should be designed to be complementary to the refugees' own coping mechanisms, and not to replace them. To enable such approach, settlement pattern is crucial. Self-settlement and integration facilitate refugees' self-reliance. But even in camps, the refugees' own initiatives can be supported.
This was the first large-scale refugee situation in which the government of the host country knowingly opted for such a non-directive policy and set up a programme to assist the self-settled refugees in collaboration with the United Nations High Commissioner for Refugees (UNHCR) and other agencies.* No other systematic description or analysis of this kind of experience exists. It is meant to stimulate a rethinking of refugee health care policies.
[* In the 1960s and 1970s Liberia, Sierra Leone and Guinea have been hosts to refugees from neighbouring countries, but these populations were not recipients of international assistance.22]