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close this bookNew Approaches to New Realities (University of Wisconsin, 1996, 508 p.)
close this folderTheme TWO: Political, Security, Protection, Civil and Human Rights Aspects
View the documentTopic 7 - Protection, Security, Civil and Human Rights
View the documentTopic 8 - Provision of Assistance in Complex Emergencies
View the documentTopic 9 - Special Needs of Vulnerable Groups
View the documentTopic 10 - Support to Urban and Dispersed Populations
View the documentTopic 11 - Repatriation, Return and Reintegration
View the documentTopic 12 - Phasing Out Assistance

Topic 9 - Special Needs of Vulnerable Groups

This paper was prepared by James Good and Sheila Reed of InterWorks. In addition to the resources listed in the paper, the following people provided significant contributions:

Bruce Abramson - is an independent consultant in matters of international law working in Geneva, Switzerland.

Marie Lobo - is a Senior Social Services Officers for the United Nations High Commissioner for Refugees in Geneva, Switzerland.

Gerry Salole - is a Programme Specialist with the Bernard van Leer Foundation in The Netherlands.

John Williamson - is an independent consultant specializing in international social welfare issues.

This paper is a synthesis of the efforts of all of those cited above and as such does not express the viewpoint of any single resource, contributor or organization.

Introduction

Individuals are vulnerable when their physical security or health is at-risk. An individual may be vulnerable as a result of inadequate access to resources, inadequate protection from an external threat, and/or personal limitations in relation to the context in which he or she is living. All human beings require access to vital resources such as clean water, food and the means to prepare it, shelter, clothing, and sanitation. Not adequately meeting their basic mental, emotional or social development needs is an additional risk for children.

· External threats can be from other human beings, epidemic disease, disasters, or other conditions capable of overwhelming normal capacities for survival and health. “Be it earthquake, flood, cyclone or drought, it’s often not the disastrous event itself that causes the highest number of deaths, but the aftermath, when victims are huddled together in overcrowded, inadequate shelter, with insufficient food, contaminated water supplies, and no sanitation. It’s these awful post-disaster conditions that epidemics and disease take their toll - especially of women, children, the sick, and the elderly” (Fieth, 1995, p. 7).

Vulnerability may also be imposed on an individual by others through persecution and abuse based on gender, race, ethnic or political differences. Alternatively, vulnerability may spring from the individual due to personal limitations or weaknesses. Personal limitations that can cause vulnerability include:

· physical limitations - inadequate strength, size, health, capabilities

· social marginality - inability to obtain necessary social protection, cooperation, assistance, or support

· inadequate knowledge or skills

· mental/emotional disabilities - inability to function normally in a given social context

Even in cases of personal disability or limitations, an individual is not considered “vulnerable” if he or she has access to resources and support from family or community adequate to ensure survival, well-being, and basic development. When individuals and families lack access to basic resources, vulnerability is widespread. Ensuring access to adequate basic resources eliminates or greatly reduces the vulnerability of many who are not able to meet their own needs. Consequently, “vulnerable group” categories which are based on personal limitations, are not themselves sufficient to identify those who are vulnerable because they may be too narrow (if resources are generally lacking or there is an overwhelming external threat) or too broad (if families and other groups have adequate access to resources.) They are useful, however, in identifying those people whose vulnerability should be assessed.

Principles

1. Any support to vulnerable groups or individuals should be based on an understanding of the affected community’s strengths, capabilities, and “natural” ways of providing such support.

In order to address effectively the needs of vulnerable groups, it is necessary to recognize and, as appropriate, build upon the traditional coping and care systems of the family, group or community in the emergency settlement. The critical activities needed to support this approach are observation and analysis of the emergency situation and the people’s reactions to it. Ignoring the traditional systems of the affected population undermines the community’s own coping and healing mechanisms and has the effect of absolving people from assuming their own responsibilities.

There is a danger that interventions may deal with the disabled, elderly, separated children, and other vulnerable groups in a piecemeal way - especially when multiple NGOs respond simultaneously in the same emergency settlement. Although this approach may be administratively easier from the point of view of the outside responders, it does not strengthen the community’s own structures for caring for its vulnerable members. From the beginning of an emergency, assistance should be provided in ways that encourage and help families remain together and increase their coping capacities. A community-based approach is recommended for emergency settlement situations because such a response will: be more sustainable for the long-term, be more culturally appropriate, and be more cost-effective than an individual case work approach.

2. An initial assessment of the health, nutritional status and coping capacities of the emergency settlement and family groups within it must be made as soon as possible.

A rapid assessment should be conducted by an interdisciplinary team of experienced professionals to identify:

· those within the population who are at greatest risk,
· measures to increase family and community capacity to meet the needs of those at-risk, and
· direct interventions to protect and ensure the survival of those without family care.

The most vulnerable people will often be the least able to make their needs known. They must be sought out. In an emergency, the most vulnerable will be the first to die. Rapid action is required to identify those who are at greatest risk and to initiate appropriate measures to help ensure their protection, survival and well-being.

3. Measures to address the psychosocial needs of the population can help reduce vulnerabilities and are important from the early stage of an emergency.

It is extremely important to enable members of the emergency settlement to have as much control over their daily lives as possible and to resume as quickly as possible as many aspects of normal daily life as their circumstances permit. Participation and self-management should be basic approaches for achieving this end. Program implementors and those providing psychological counseling or other non-physical support must identify and respect what people are able to do for themselves. A basic goal of interventions should be to strengthen the capacity of people to cope and take care of meeting their own needs. Assistance should reinforce, not supplant these capacities. So far as possible, assistance should be managed by the affected community itself.

Emergency responders should support efforts to re-establish normal economic, social, cultural and religious activities within the community. The dependent position in which emergency survivors are often placed by relief organizations is very damaging. It compounds the effects of trauma and impedes recovery. For children, normalization of daily life is extremely important, including the opportunity to go to school and to see their parents in normal social roles, including those of provider and protector.

4. In assessing the situation and vulnerabilities of a population in an emergency, particular attention must be given to identifying and determining the situation of children without care, children with families other than their own, isolated women (i.e. without the support and protection of a family, but not necessarily single), disabled or elderly persons without family care, and others who may be isolated and vulnerable.

It is appropriate for those responding to situations of emergency settlement to take special care in assessing the needs and resources of those individuals and probable groups of people who are likely to require special assistance in order to survive the situation. The primary response should be to identify and reinforce family and community capacity to provide for their needs, avoiding or minimizing establishment of alternative forms of care. Aid providers should be cautious in the provision of aid which is not needed or which undercuts the affected population’s natural ability to cope.

5. Coordinated procedures must be put in place to ensure that vulnerable individuals are able to receive and make use of physical, psychological, developmental and other assistance in an equitable manner in the specific context of the emergency settlement.

At the beginning of an emergency, in keeping with the principles stated here and policies of UNHCR, UNICEF and other appropriate international bodies, competent authorities should establish and promulgate context specific policies relating to types and levels of service, and methodology and approaches to meeting the needs of vulnerable groups.

6. In an emergency involving displacement, all agencies involved should: anticipate that children will be present who are separated from their parents or guardians, make active efforts to identify and register them, and ensure they immediately receive appropriate care (e.g. keeping siblings together.) Separated children should be placed with a substitute family or, if this is not possible, in emergency care that replicates normal family life so far as possible.

As rapidly as possible, medical screening and interim care in substitute families should be arranged for all separated children. Their well-being should be monitored on an ongoing basis. Except as necessary to ensure their personal security, such care for a child should be arranged within the emergency settlement as close as possible to the place where the child was identified. Separated children should benefit from the same level of assistance, schools and services as other children. The standard application of the “best interest” of the child should be applied in all decisions related to placement of separated children.

As soon as possible after being identified, each child separated from his or her parents or guardian should be documented to record information needed for tracing and immediate care and an active system should be initiated for tracing parents, guardians, other family members or relatives.

7. Preventing the separation of children or disabled dependents from their families must be integrated into all aspects of emergency preparedness and response.

There are many reasons why children or disabled dependents may become separated before an emergency or during the response to it. It is important to determine very quickly how and why separations have occurred so that actions taken do not inadvertently cause additional separations. Especially during the acute stage of an emergency when the general population does not yet have access to basic subsistence requirements or is in physical danger, parents may tell their children or other dependents to present themselves as separated hoping that they will receive assistance or protection. In extreme cases, adults, who lack the resources or capacity to care for all those with them, may abandon children or weaker family members who seem less likely to survive.

Two kinds of actions are needed to minimize such separations. One is to ensure that vulnerable families, such as those headed by women, benefit quickly and fully from any assistance provided to the general population. Special measures may also be needed to ensure their physical safety. In addition, all children or other vulnerable individuals who appear to be on their own must be screened to determine where they have been living and with whom; whether it would be in their best interest to continue living with a parent or previous care provider; and if the provision of a small amount of food, other basic assistance, or better security would make this possible. Such targeted assistance should be phased out as soon as the families concerned are able to benefit from the same assistance provided to the general population. Any assistance provided to children or others who are separated must be at a basic level and provided with minimal public visibility. The screening of those who appear to be separated must be done by individuals of the same background as the affected population who have been trained how to interview children and assess their situation.

8. Any incidents of sexual violence should be carefully investigated in a sensitive way with complete respect for the confidentiality of the survivor. Action should be taken to ensure the survivor’s personal security from further violence.

Unfortunately, rape is often recurrent. The primary response should be investigation of the event to the extent possible to punish those responsible and protect those who have been harmed. Such investigations must be carried out without further endangering the survivor. To this end confidentiality must be ensured. This confidentiality, however, does not preclude the provision of appropriate support. Support should be culturally acceptable and easily accessible. The use of female counselors from the same ethnic group as the survivor will present the fewest barriers to communication and support.

BEST PRACTICES

A key operational issue in an emergency is identifying those individuals who will remain at-risk - even if basic resources are made available to the emergency settlement population - and initiating special measures to reduce their vulnerability and otherwise ensure their survival and growth. So far as possible, such interventions should be through, or in cooperation with their families, if present, and the community. A fundamental strategy in emergency response must be to improve rapidly the capabilities of families and the community to provide adequately for the needs of members, particularly the most vulnerable. In some cases it may not be possible to initiate rapidly enough interventions through families or the community to ensure personal security and/or physical survival. In these situations, direct intervention by outsiders is necessary. This type of intervention, for example centers to care for separated children, should be a last resort, but, where necessary, must be initiated very rapidly.


Assessment of vulnerable groups

Vulnerability is contextually determined. For example, to determine what social or other characteristics might make households headed by women more vulnerable than others, careful, gender sensitive assessment is needed. In other circumstances a particular social group, tribe, or clan might be considered pariahs or enemies and therefore be excluded from normal aid distribution by leaders, thereby making them vulnerable.

To make good and timely decisions about how to intervene to reduce the vulnerabilities of those at greatest risk requires accurate information and understanding of the social and cultural characteristics of the affected population(s) and of the current dynamics and capacities among them. In order to obtain such information quickly, an assessment team must include members with solid understanding of the factors that cause individuals to be vulnerable and the appropriate skills to obtain rapidly essential information from members of the affected population. Gender, cultural background, language abilities, cross-cultural skills and technical knowledge and skills are all significant considerations for putting together an assessment team.

Separated children and others who are vulnerable are often found at feeding centers, medical facilities, churches, military camps and other places where assistance might be available or anticipated. Visiting such sites and interviewing personnel is useful. Leaders, health workers, or teachers among the affected population are often aware of groups that need special assistance. Brief interviews with randomly selected women can often yield useful information about difficulties within the population and groups with special needs. Although it takes at least a few days, training and deploying community social workers is one of the most useful ways to identify groups and individuals with special needs and to determine how to respond to the needs of the most vulnerable members of the population.

Indigenous personnel who are given basic training and ongoing supervision are invaluable in assessing individual and community needs; planning and implementing solutions; and monitoring the situation of those identified, especially any separated children placed in substitute family care. They can be much more effective than outsiders in determining the actual situation of children who are apparently without adult care and determining what sort of intervention may be appropriate. Recruiting, training, supervising and supporting such a group is extremely important. Health care personnel are needed to determine whether vulnerable individuals simply need basic food, shelter and care or require medical treatment. They should be provided with specific protocols for such assessments.

People involved in assessment of vulnerable groups must combine local people’s knowledge with technical skills and analysis. Assessors must be able to see beyond the obvious, have a respect for ordinary people’s knowledge and skills, and most importantly, be able to combine analysis with listening skills to address social and developmental problems without an over-reliance on pre-established methods.


Children

As minors make up the majority of most emergency settlement populations, at least one member of the assessment team should have training and experience in child welfare and development and a very good understanding of the principles and guidelines concerning children. All action concerning children must be guided by the “best interests” principle:

“The most basic element in national and international law guiding action concerning children is the ‘best interests’ principle. It is included in Article 3 of the United Nations Convention on the Rights of the Child. This principle has three essential elements. First, it means putting what is best for the child above all other considerations, political, social, religious or others. Second, it requires that a child be treated as an individual whose particular needs and circumstances must be considered, so placement or other important decisions, cannot be made on the basis of a general formula or without consulting the child. Third, it requires seeking to provide for a child’s developmental needs as well as for basic immediate material needs and security” (Ressler, Boothby and Steinbock, 1988, pp. 228-229).

In general, children are best cared for by their parents. Therefore, agencies involved in responding to emergencies should design programs to help prevent children from being separated from their parents. Since emergency settlement situations uproot families, restoring a sense of normalcy as soon as possible can help prevent families from separating. Single-parent families and families with disabled children may need special attention to their needs to prevent separation or abandonment. In the Rwanda emergency Food for the Hungry International demonstrated the effectiveness of an approach they call ChildWINS. In one camp in Goma they screened children who appeared to be separated and found many could continue to live with a family if some limited support was provided. With a view to preventing separations, they also identified vulnerable families among refugees returning from Zaire and helped them initiate group agricultural activities, secure housing and otherwise be better able to provide for their children’s needs.

When there is early warning of a possible emergency, key operational personnel of the ministry concerned with child welfare, other government personnel with responsibilities in emergencies, and NGO personnel likely to respond should be trained concerning actions required to prevent family separations and to ensure protection and care for separated children and other vulnerable groups in emergencies.

Growth monitoring is also extremely important for children. In addition to well baby and child clinics, community health workers must be trained to identify children in the community who are malnourished. An infant stimulation program connected with a well-baby clinic or feeding program can be very useful in helping infants recover as well as aiding the recovery of mothers who have suffered losses and/or trauma. This type of program promotes positive interactions between mothers and their infants. (See Elizabeth Jareg’s Psychosocial Factors in Relief Work During Famine and Rehabilitation: Field Guidelines listed in the references section for more information.)

Separated children

It is extremely important to define and coordinate policies and procedures concerning vulnerable children. In an emergency, an agency should be designated as responsible for coordinating action in keeping with the operating policies established. Context specific policies must be devised for each of the following:

· Preventing separation of children from their families

· Identifying and registering children without adult care and children with families other than their own

· Arranging age-appropriate emergency care for separated children with substitute families if at all possible

· Documenting the social history, condition and special needs of each child separated from his or her parents or guardian

· Initiating tracing for family members of each child separated from his or her parents or guardian

· Reuniting separated children, as possible and in their best interests

General policies (see for example those of UNHCR (1994(a)) and UNICEF (1986)) may need to be revised for specific emergency settlement populations. For example, institutional type care should generally be avoided. In some situations, however, it may, on an interim basis, be the least harmful option available. A clear, harmonized policy is needed to prevent agencies from establishing forms of care that are inappropriate and to define what actions to take for children without appropriate adult care.

Globally applicable policies, guidelines and principles have been defined (UNHCR, 1994(a); UNHCR, 1994(b); UNICEF, 1986; Williamson and Moser, 1987), but in every emergency, situation-specific policies and procedures must be defined as part of preparedness and contingency planning and the initial response. For example, a clear policy is needed to prevent agencies from establishing forms of care that are inappropriate. In addition, procedures are needed to define what action to take when separated children are identified. The legal guardianship of children separated from their parents or guardians should also be established and made clear to all parties involved in responding to the emergency. Normally guardianship is established by the law of the country in which separated children are residing. Responsibility for guardianship will be with some arm of that country’s government that may choose to retain the responsibility or designate a non-governmental body as the guardian. In cases where no government is prepared to act in the best interests of the separated children de facto guardianships should be established by the international organization directly concerned, for example UNHCR in a refugee situation, or UNICEF in other situations.

As a group, children without family care are the most vulnerable people in an emergency1. As soon as possible after being identified, each child separated from his or her parents or guardian should be registered and provided with immediate care. If possible, substitute family care should be arranged at the outset, but for any children who are placed in other forms of emergency care, substitute families should be arranged as soon as possible within the affected community. Documentation of social histories must be done as soon as possible and active tracing initiated for parents or other surviving family members or relatives.

1 The term “unaccompanied child,” often leads to confusion about which children it includes and what kinds of action is needed for their benefit. Consequently, the term “separated children” has been used in this paper.

Before a separated child is entrusted to an adult requesting family reunification, the relationship with the adult must be verified and appropriate weight given to the wishes of the child. There are risks that must be avoided when making decisions about family reunion for separated children, e.g. placing the child based on an unfounded claim of relationship, placing the child with a parent or relative who may have previously abused or neglected the child, or refusing to make a reunion because a child claims not to recognize the adult requesting reunion. For a variety of reasons a child may say he/she does not recognize a parent or relative, particularly if there has been an extended separation. It may take several interviews before such a child is prepared to accept or admit that the person making the claim is, in fact, who he/she claims to be. At the same time, false claims are a genuine risk and the process of verifying relationships must be done carefully.

Displaced and refugee children should be informed about options and permitted to participate in all important decisions affecting them, such as their placement with a family, movement back to the place or country of origin, local settlement, or third country resettlement. They should be kept informed about the progress of activities undertaken on their behalf, such as tracing or efforts to arrange placement or movement. Long-term placements should seek to maintain significant relationships as well as community ties that a child has established. Weight should be given to the views of the children in keeping with their degree of maturity.


The elderly

“Elderly refugees constitute a particularly vulnerable group as they are often confronted with a number of problems arising from their diminishing physical or mental ability to deal with the requirements of life. It is also evident that the effect of displacement experienced by the aged is more pronounced than on the others” (UNHCR, 1994(c), p. 60).

The number of elderly found in an emergency settlement community is more likely to be related to the location of the emergency settlement community rather than the direct cause of the emergency situation. Those communities which have become emergency settlements without displacement will likely have a very high percentage of vulnerable elderly. This may be due, in large part, to the ability and interest of younger people to move out of the emergency situation, whereas the elderly may have less ability, means, and interest in leaving their long-term home. An assessment of vulnerable groups in the Republic of Georgia undertaken in 1993 ranked “Old Age Pensioners” as the largest vulnerable group in the country (InterWorks, 1993, p. 79). In many instances the vulnerabilities of the elderly in urban situations are also increased due to devaluation of their pensions or other stipends. Those on fixed incomes, without access to wages or other compensation, will be the most vulnerable to economic collapse and widespread failure of urban support systems.

Emergency settlements arising out of displacement, such as those caused by war or widespread hardship, will likely have relatively fewer elderly in the population than stable communities because the elderly may have been unable to make the move with their families due to health, or attitudinal reasons. Also, it is often the case in extreme emergencies, that the elderly, along with the very young are the first to die, and therefore will be under-represented in successive demographic analyses after the initial phase of the emergency.

Assistance programs for the elderly should generally be comprised of remedial, rehabilitative, and developmental services. These services or programs should be incorporated into the national program(s) of the country in which the emergency settlement exists. Since lack of opportunity or access to wages or other subsistence is a primary problem for the elderly in emergency settlement situations, subsistence or living allowances should be considered for this group. Outreach home care services should be provided to those who are constrained (for whatever reason) from access to other public programs of assistance.


Isolated women and households headed by women

“The circumstances that precipitate the flight of refugees from one country to another often result in families leaving at least one member behind; in time of war, it is inevitably the male head of household who is either engaged in battle or has lost his life. This means that the woman is compelled to take on the role of head of household and carry out duties and functions” with which she may be unfamiliar (UNHCR, 1994(c), p. 56). In these situations the factors contributing to the vulnerability of households headed by women are their lack of experience in this role, stress and/or trauma from the loss of a spouse, economic disadvantages due to societal norms and traditions, and their expanded responsibility as provider and protector of their children.

Many women in this situation are also vulnerable to opportunistic abuse by men in positions of power or who control the material support desperately needed by these women and their families. Pressures may be placed on women to provide sex for money, material goods or access to important administrative procedures.

Assistance to households headed by women heads should include the following:

· Activities to enable them to earn the extra money which they need for their families (UNHCR, 1994(c)).

· Provisions to enhance their personal security, e.g. lighting areas used at night, protected areas in which to live

· Mutual support groups among women (UNHCR, 1994(c)).

· Mechanisms through which women are ensured a voice in decision-making concerning the settlement

· Availability of health services with female personnel (UNHCR, 1994(c)).

· Educational and recreational facilities for children (UNHCR, 1994(c)).

· Avenues through which women can report episodes of sexual exploitation (UNHCR, 1994(c)).

· Support of specified men and elders within the community on whom women can count with certainty (UNHCR, 1994(c)).


The physically disabled and chronically ill

The physically disabled may or may not be individually vulnerable. The general approach to disability should address three basic issues. The first is prevention which may be addressed through public health programs and other activities designed to reduce the risk of physical impairment. In the early stage of an emergency it is important to screen the population to identify any individuals having difficulty meeting such immediate survival needs as:

· obtaining food, water or fuel;
· preparing or eating food;
· washing himself/herself;
· washing clothes;
· dressing;
· moving around within his/her living area;
· using sanitary facilities;
· understanding what is said to him/her;
· expressing thoughts, needs and feelings; or
· obtaining basic medical or other essential services (UNHCR, 1991).

Second emergency responders should ensure that the immediate needs of these individuals are met. So far as possible, the needs of people with serious disabilities should be addressed by strengthening their own capacities and those of their families to meet their needs. Their strengths and abilities must be recognized, not just their limitations. Finally, there should be a program of rehabilitation for the disabled and they should be integrated within the general population and enabled to use the same health, educational and other services as other members of the community. Emergency responders providing services for people with disabilities should aim to reach all such individuals.

Programs for people with disabilities should be community-based and incorporated into the overall emergency settlement assistance program. It is important that outreach programs be involved with early detection. Where possible, treatment programs can facilitated by integrating program policies for individuals with disabilities into educational, medical, nutritional, and other community-oriented programs or initiatives. So far as possible, disabled children and adults should be integrated into the same programs, services, and educational, cultural and recreational activities as others in the community.

The following questions are taken directly from the UNHCR “Guidelines on Assistance to Disabled Refugees” (1992, p. 14) and should be asked when new projects are proposed.

Approach

· Will the intervention tend to increase the dignity of the people affected?
· Will it encourage the development of refugee human resources?
· Is it in keeping with refugee’s cultural and religious beliefs?
· Will it result in the better integration and acceptance of the individual?

What

· What strategies will be used?
· What material/equipment are needed - locally devised and prepared?
· What existing channels will be used?
· Will efforts be made to make people independent?

Who

· Who will be the major category of direct care workers? Parents, disabled persons, primary level personnel or professionals?

· How comprehensive is the coverage?

· Who will be the major target group?

(a) a single category of disabled persons?
(b) a single age group? or
(c) all disabled or all age groups?

· How many will be served?

· Are existing organizations being involved?

Where

· Where will the programme/project be mainly conducted? In the refugee camp/settlement? In the home? In a small local centre? In a central city location?

Cost - Per disabled person.

· Is there a multiplier effect?
· What about continuity/sustainability?
· Can indigenous measures be used? What is the most cost effective?
· Would it be feasible to train local/refugees?


The traumatized and mentally disturbed

In emergency settlement situations the daily difficulties of coping with emergency stresses are often compounded by the cumulative stress of crisis events which have already occurred. (For a more detailed discussion, see the Emergency Settlement paper “Social and Psychological Aspects of Emergency Settlement.”) There may be a higher incidence of mental disturbance throughout the population affected by disaster, especially those who have experienced or continue to experience violence. In recent years various types of disasters have demonstrated the importance of psychological assistance and the manner in which it is provided. Psycho-social programs for refugees and displaced persons have been provided in countries as diverse as former Yugoslavia and Sri Lanka (Revel, 1995(a)). Even though such programs needed, the simple provision of service and the establishment of a presence in the emergency settlement does not guarantee effective outreach.

“Violence is part of many refugee situations and its victims should have access to coordinated medical, counseling, material and legal assistance. Furthermore, in addition to immediate access to treatment, field offices should ensure that these refugees are given priority attention for recovery and long-term rehabilitation. In such matters, field staff will need the guidance of qualified experts.

“Depending upon a person’s coping mechanisms, not all will want or need to avail themselves of all these services. However, those working with refugees must be alert to the mechanisms of avoidance and denial, and be sensitive to complaints and the hidden problems behind them. Feelings of rage, despondency, insufficiency, etc. are very often not admitted, or are repressed.

“The process may be further complicated by the suspicions of such refugees of representatives of authority, doctors, compatriots they do not know well (e.g. interpreters) and the fear of betrayal engendered by their experiences. Medical, social and psychological examinations thus may be regarded by some refugees as a threat” (UNHCR, 1992, p.71).

Traumatized persons

Social or community workers who interact directly with the victims of torture or other survivors of violence must proceed with both sensitivity and persistence to provide outreach services to these people. Care must be taken not to further distress those already suffering psychological pressures through the actions of assistance providers.

Survivors of rape

An important starting point in the provision of counseling for the survivors of rape is to use trained female counselors of the same ethnic background as the survivors. It is essential that counselors working with female survivors of sexual violence be women. Appropriate professional training (e.g. social work, psychology) is important as is relevant prior work experience. It is important that counselors receive training specific to dealing with issues of sexual violence in the cultural and social context in which they will be working, even if they are of the same ethnic background as the people in the emergency settlement. For most social issues the best arrangement is generally to have trained workers from the community who do face-to-face work with professional supervision. With the issue of sexual violence, however, there is an advantage to having counselors of the same ethnic background who are not from the same community as those with whom they are working, because maintaining confidentiality is extremely important among the survivors.

“At the beginning of 1993, a world-wide campaign started to help the thousands of women who were systematically raped. Pressure for immediate and obvious action in response was very high. However, it was decided to have a low-key, professional approach to try to avoid another trauma to an already overloaded situation. The rationale for that choice lies in the cultural background: women who would have been seen entering a ‘Centre for Raped and Tortured Women’ would immediately have been labeled as ‘raped’, thus ‘impure’ and therefore not eligible for marriage” (Revel, 1995(b), p.8).

Mentally disturbed persons

The term “mentally disturbed” as used in this discussion refers primarily to those people in the emergency settlement community who have a pre-existing mental disturbance. This group is considered vulnerable as their disturbance will likely hamper their day-to-day survival activities and their ability to access offered support services. The priority areas of intervention are support and improvement of their family situations and normalization of their surroundings. While psychotropic medication is helpful for some cases, in the emergency settlement situations it may not be available, and a qualified physician must be available and capable of managing its use. In all cases the context in which the mentally disturbed are living will dictate priority responses.

“Mental health services are provided in refugee camps in a variety of work settings that range from the most primitive (outside without benefit of an office or private space as in some camps in Hong Kong) to quite attractive space that meets Western criteria (as in Bataan). In the former situation the noise level from the camp population is high, privacy is totally lacking, and the discomfort provided by the elements is disconcerting. Services in the camps generally include social history-taking, limited counseling, psychotropic medication, and the use of traditional healers as found in Khao I Dang and Phanat Nikhom Thailand and in the Philippine Refugee Processing Center (Bataan). Traditional healing includes prescribed rituals, incantations, steam baths, massage, herbs, and other organic materials that are used with apparent effectiveness. In addition a great variety of group activities led by a mental health provider or indigenous paraprofessional are used extensively” (Gong-Guy, Cravens and Patterson, 1991, p. 643).


Public health and community-based interventions in mental health

“Primary prevention has its roots in public health, which adopts a communitywide perspective for addressing health concerns. A public health approach differs from the clinical-psychology/medicine emphasis on one-on-one curative care, its hallmark being community action” (Turshen cited by Williams and Berry, 1991, p.632).

Community-based intervention programs can be very useful in promoting recovery. In the Ukwimi refugee settlement in Zambia the trauma program of the International Catholic Child Bureau (initiated by Margaret McCallin and Shirley Fozzard) was run almost entirely by refugees. It included such measures as an infant stimulation program, structured play groups primarily for children identified as being traumatized, volunteer groups of village counselors, training in trauma-related counseling for selected teachers in the Zambian schools for refugees and in the refugee-run schools, and therapeutic structured activities for children.

The following is an excerpt from a report written for UNICEF immediately after the city of Kigali was taken by the RPF: “At this stage the most important steps to mitigate the effects of trauma on children, separated or not, are as rapidly as possible to promote a normal, peacetime environment for them.” The three most critical needs in this regard are for nurture within a family environment (which underlines the importance of early steps to arrange foster family placements for separated children and to arrange for family reunion), physical security and adequate provision for subsistence needs. The opportunity to play is extremely important for children because this is a principal way that they will psychologically process their experiences and begin to come to terms with them. The resumption of regular school will be very important to the normalization of children’s lives and will eventually provide opportunities for appropriate interventions to address the effects of trauma. Activities such as structured group play, sports, music, singing, handicrafts and cooperative projects can also be beneficial. The ability of parents to resume their normal family economic and community roles are also important to the normalization of children’s lives. Participation in their preferred forms of religious expression can also provide support, and opportunities for emotional release.

Beyond measures to promote the normalization of children’s lives, certain interventions may be appropriate, although none of them should be imposed on children or their families. Research in situations of armed conflict has shown that children’s trauma is most effectively addressed when that of their parents or guardians is addressed as well. The mother’s psycho-social well-being is extremely important to that of her children. Also, any measure to address directly psycho-social trauma must be relevant to the culture and life circumstances of those expected to benefit. The following are examples of interventions that have proven to be beneficial:

· infant stimulation programs
· religious ceremonies for healing
· women’s groups that provide opportunities for social interaction
· school-based measures
· opportunities for expression through making pictures, group discussion or writing
· peace education
· counseling by teachers with special training
· counseling by paraprofessionals who have ongoing professional support

In formulating guidelines about mental services for emergency settlements, one of the key issues is the differentiation between these programs and other, more typical mental health services in non-emergency situations. The following short guideline prepared by Diane Myers (1994, p. 1) was based on the experience of mental health administrators and practitioners who have provided disaster mental health recovery services.

KEY CONCEPTS OF DISASTER MENTAL HEALTH

1. No one who sees a disaster is untouched by it.

2. There are two types of disaster trauma (individual and collective).

3. Most people pull together and function during and after a disaster, but their effectiveness is diminished.

4. Disaster stress and grief reactions are a normal response to an abnormal situation.

5. Many emotional reactions of disaster survivors stem from problems of living brought about by the disaster.

6. Disaster relief procedures have been called “The Second Disaster.”

7. Most people do not see themselves as needing mental health services following disaster and will not seek out such services.

8. Survivors may reject disaster assistance of all types.

9. Disaster mental health assistance is often more “practical” than “psychological” in nature.

10. Disaster mental health services must be uniquely tailored to the communities they serve.

11. Mental health staff need to set aside traditional methods, avoid the use of mental health labels, and use an active outreach approach to intervene successfully in disaster.

12. Survivors respond to active interest and concern.

13. Interventions must be appropriate to the phase of disaster.

14. Support systems are crucial to recovery.


Conclusion

Vulnerability, whether due to age, disability, gender, or severe psychological stress is always an important issue for consideration in the provision of aid to emergency settlement communities. Whether the affected people are refugees, internally displaced, under siege, or impoverished due to natural disaster, there will be categories of vulnerable groups who will present special needs which may not be readily seen or understood by those responding to the emergency. Quick assessment and an understanding of vulnerable groups which are likely to be present will facilitate uncovering and addressing these issues.

The identification of vulnerable groups and the categorization of individuals as belonging to such groups is only important if such a system leads to the establishment of programs or other responses which help the specific groups named. An understanding of these vulnerabilities and situation-specific assessments should provide responders with the insights needed to take appropriate action to address these needs. Based on this understanding, emergency responders should also strive to strengthen overall community structures and facilitate traditional coping mechanisms. The following points are offered as an overall guideline for the implementation of community services for vulnerable groups and are compiled from various sources, but particularly from the Radda Barnen report entitled “Social Work in Refugee Emergencies” (1994).

· Participation of community services coordinators in the earliest stages of the emergency is an important element of emergency response and should be regularized.

· Although there will be short-term difficulties in establishing community-based services for vulnerable groups in the first days of an emergency, community service workers should nevertheless be deployed at this time to conduct assessments and analysis of information that may be used as the situation begins to take shape and community structures begin to solidify.

· An understanding of the groups likely to be at greater risk in emergency situations will facilitate assessment and design of priority interventions.

· Specific areas of concern requiring urgent response often need specialist inputs (for example support for separated minors, survivors of rape, and mentally disturbed).

· The continuity of such community based programs for assisting vulnerable groups should be guaranteed. The problems are long-term, and so must be addressed with a long-term view, even though the programs of support may have been initiated in response to a “short term emergency”.

· Formal and non-formal education should play a larger role in emergency response than at present.

Standards

While standards have not been specifically addressed in this paper, the idea of standards or useful “yardsticks” by which community services can be measured has been brought forward by several of the contributors and reviewers of this document. It is hoped that some of these standards can be discussed and compiled at the Emergency Settlement Workshop and subsequent activities of the Emergency Settlement Project.

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