Liberia's rising tide of violence and insecurity have precipitated a mounting health crisis within its borders, one that spotlights many of the worst dangers confronting refugees and internally displaced persons (IDPs). Fourteen years of civil war have forcibly displaced an estimated 600,000 Liberians. Beyond the immediate impact of bullets and land mines, the health perils posed by disease, malnutrition, and inadequate shelter are now exacting a deadly toll.
The situation in Liberia illustrates the ways in which governments and humanitarian agencies have worked to meet the health needs of the displaced, even in insecure settings. In Liberia, as with other countries facing humanitarian emergencies, the immediate health risks can be lowered by rapidly addressing water, sanitation, vaccination, nutrition, and shelter needs. What follows is an examination of some of the most typical health threats to the forcibly displaced, as well as strategies used to minimize them, seen through the lens of Liberia's crisis.
Over a decade of violence has left approximately 300,000 Liberians uprooted from their homes within the borders of their homeland, and another 300,000 have fled across international borders to become refugees. Although international attention has focused primarily on the immediate effects of fighting, aid agencies on the scene frequently equate war with disease and death. As the International Rescue Committee (IRC) has observed, violent and non-violent deaths cannot be separated in such a crisis. Within Liberian IDP camps at the end of 2002, IRC figures show that only five percent of deaths were the result of direct violence or accidents, versus 61 percent resulting from diarrhea, malaria, malnutrition, anemia, febrile disease, or respiratory infections.
The death rate of children under five is currently eight per 10,000/day, a figure two to three times higher than that found in Liberia during peacetime, according to the estimates of the non-governmental organization Medicins Sans Frontiers (MSF). Fatal diseases, including diarrheal diseases, respiratory infections, measles, and malaria, are the primary causes of the soaring death rates. These illnesses do not spread in a vacuum. They depend on conditions typically found among displaced populations such as overcrowding, poor water, inadequate shelter, and poor sanitation. At times, these situations are then exacerbated by continuous insecurity and inaccessibility of the population to sources of aid. The UN Office for the Coordination of Humanitarian Affairs (OCHA) has estimated that 70 percent of Liberia's population is currently inaccessible. Without adequate planning and use of resources, epidemics springing from such conditions can quickly strain or overwhelm health safety nets.
Generally, the needs of refugees and IDPs are divided into "emergency" and "post-emergency" phases. The dividing line is grimly calculated in terms of deaths: in the emergency phase, mortality rates exceed one death per 10,000 people/day; a rate far surpassed in present-day Liberia.
Displacement: The Emergency Phase
In the emergency phase, humanitarian agencies focus on two goals: first, to provide protection to those fleeing their homes; and second, to rapidly reduce mortality rates. Providing security typically falls under the mandate of the United Nations High Commissioner for Refugees (UNHCR), though this responsibility is less clear for IDPs. Health responses are frequently coordinated by international organizations, but typically implemented by local government and non-governmental organizations (NGOs).
In recent years, efforts have been made to standardize the response of these agencies to emergencies. The Sphere Project, for example, was a unique collaborative effort by a number of organizations spearheaded by InterAction and the Steering Committee for Humanitarian Response. The project established humanitarian aid standards designed to improve the quality of assistance, identify common risk factors, project disease progressions in emergencies, and structure strategies and standards for prevention. The standards, which were published in 1998, aim to minimize specific risk factors that contribute to the most fatal diseases. There are both past and present examples of how predictably such diseases break out. In Mozambican refugee camps in the late 1980s, 70 percent of deaths of under-fives occurred as a result of measles, diarrheal diseases, respiratory infections, and malaria. The IDPs in Liberia showed similar trends in the fall of 2002, with 53 percent of deaths in the under-fives resulting from these same four diseases. These examples demonstrate the importance of targeting certain diseases and standardizing humanitarian responses with regard to key risk factors. Some of the key areas for attention include:
Assessment and Surveillance. Initial assessment is critical to implementing health programs of sufficient capacity and reach and also to make vital decisions regarding health and nutrition. Evaluating health status, the geography of the site, available resources, and the political and social circumstances are all beneficial components. In the earliest stage of an emergency, information gathering should reach within the displaced population to identify human resources, and develop communication networks to the internal, less visible areas of a camp. These specific steps help to identify problems or outbreaks at the earliest possible moment and also establish relationships with so-called beneficiaries. Surveillance systems are particularly key in settings of displacement where circumstances can change rapidly.
Liberia is a prime example of a continually changing situation, yet assessment has been compromised as a result of insecurity in many regions. Disease-specific mortality rates have not been collected and counts of the displaced are imprecise. The World Health Organization (WHO) usually organizes such health assessment steps, but central locations, such as refugee or IDP camps, must be established before this process can take place. In Liberia, MSF has recently done just this, by establishing new IDP camps within the capital, Monrovia. This should assist the assessment processes.
Water and Sanitation. Establishing water and sanitation systems is one of the most critical health interventions for preventing the spread of disease among the displaced. The inadequate supply of safe drinking water, compounded by poor sanitation systems can lead directly to widespread diarrheal diseases and high mortality rates from dehydration. Typically, these issues are addressed by identifying and securing a clean water source, and building a sufficient number of latrines. In the early days of an emergency, this may involve the chlorination of a water source or the temporary supply of water through trucks or bladders, later evolving to wells and piped sources. Sphere guidelines state that each person should have access to 15 liters of clean water each day. Latrines should also be built for every 20 people, but trenches may be necessary alternatives in the early phases.
The absence of appropriate water and sanitation systems almost inevitably leads to outbreaks of disease. In Zaire, for example, cholera and dysentery spread through a contaminated water source, killing nearly 50,000 Rwandan refugees in 1994. In Liberia, the situation is unlikely to reach such proportions, yet it appears that seasonal rains have combined with overcrowding and poor sanitation to result in smaller cholera outbreaks in nearly all the IDP camps. In July 2003, the WHO reported that 1,630 cases of cholera existed in Liberian IDP camps. Local hospitals have not been able to accommodate the majority of these cases. In response, MSF and Merlin, a British NGO, have set up diarrheal centers for treatment. Other organizations have also begun trucking water and collapsible water tanks to nine of the IDP sites, and are working to revitalize wells. Shortages of supplies and limitations in access, however, have complicated interventions and suggest that many more people are likely to die of this disease before it is brought under control.
Vaccination Campaigns. Vaccination campaigns, specifically for measles, have become a standardized initial response in refugee camps, and in IDP settings when possible. Measles, characterized by a rash and fever, is highly fatal among young children and spreads rapidly when there is overcrowding. Therefore, in refugee camps, measles vaccines accompanied by vitamin A supplements are a high priority and are typically implemented in the first days after arrival. The Sphere Project recommends that such campaigns target all children ranging from six months to five years (frequently extended to 15 years when risk is believed to be unusually high).
Although vaccination campaigns in refugee camps are standardized, fatal outbreaks occur when there are lapses in the system. At the end of 1988, for example, measles outbreaks were identified in eleven Mozambican refugee camps in Malawi as a result of oversights in previous vaccination campaigns. More than 1,200 were infected and 20 percent of the infected children under five died. In the fall of 2002, an outbreak of measles was also seen in Liberian IDP camps. According to the IRC, febrile illness (among which measles is included) accounted for 16 percent of deaths in children under five in these camps. Recently, UNICEF and the WHO have collaborated with local authorities to carry out the first round of measles, polio, and tetanus toxoid vaccines for children under five and women of childbearing age. Supplies have been received for vaccines and storage. There is concern that continued insecurity in the region, however, may threaten the second round of vaccines planned for the fall of 2003.
Shelter and Site Planning. Shelter and site planning help ensure the health of a displaced population by indirectly addressing concerns regarding malaria, respiratory infections, and general resistance to disease. Sphere guidelines state that 3.5 – 4.5 square meters of housing or shelter material should be provided for each individual, but regional climate determines the ventilation necessary for a home, as well as the materials needed for its construction (to ensure appropriate insulation). In addition to shelter qualifications, site selection can address components of overcrowding, ventilation, water, and transport of supplies. Sphere recommends that 45 square meters of land be available for each person in a camp. This space includes what may be necessary for roads, clinics, and other needed structures. In addition, sites should consider location above the water table, drainage and filtration of soil, standing or flooding water, and endemic diseases.
The consequences of unsuitable site selection and shelter become visible in the health of camp occupants. In Ethiopian refugee camps in eastern Sudan, for example, malaria was highly prevalent because there were numerous riverbed pools and forests surrounding the site. Ten percent of the population was infected with malaria as a result. The camp's stick and grass shelters further exacerbated the situation because they were inappropriate for the use of insecticides. Poor shelter and poor health management are the key risk factors for those acquiring these infections, although the fatality rate is largely dependent upon management and nutrition. Within Liberian IDP camps in 2002, the IRC reported that acute respiratory infections (ARI) accounted for 13 percent of deaths. This situation has become much worse since recent violence in the capital forced masses of people to find shelter in open-air stadiums and schools. In response, NGOs working there have attempted to build additional structures and camps to accommodate those in need of shelter.
Food and Nutrition. The provision of food aid is a primary response of aid agencies during an emergency. Food and nutrition can be understood on two levels: first, caloric intake; and second, micronutrient supply. Both are overarching concerns among displaced populations because they affect all other health outcomes, including measles, ARI, and malaria. Children, especially IDPs, deteriorate nutritionally during displacement and they are most vulnerable from nine months to two years of age. Changes in diet and variety, or lack of access to food contribute to nutrient deficiencies. Malnutrition and micronutrient deficiencies are indirect causes of mortality, but also directly contribute to long-term disability (blindness, rickets), longevity of other diseases, and overall child survival. According to Sphere guidelines, individuals must be provided with a minimum of 2,100 kcal/day, with 10-12 percent of calories provided by protein, and 17 percent provided by fat. Other standards are vague, but are meant to ensure that the nutritional needs of a population are met.
Recent history demonstrates the dangers that nutritional deficiencies pose to refugees. In the 1980s, a lack of access to vegetables and fruit among Ethiopian refugees in Somalia led to vitamin C deficiencies, which resulted in scurvy and other ailments. Today, malnutrition is one of the most crucial concerns for those displaced in Liberia. Basic caloric needs are not being met. The inaccessibility of camps to the north of the city, and the ongoing violence within the capital, are both raising great concern. The World Food Program (WFP) has stated that their food trucks cannot reach the camps in the northern suburbs of Monrovia, which currently host 100,000 IDPs. Although high-energy biscuits and oral rehydration salts have arrived in the capital, along with other relief supplies, aid agencies claim that they cannot be distributed amid the current violence.
After the 'Emergency'
Liberia has not yet passed the state of "emergency" and the timing of this change is difficult to predict. It is likely, however, that Liberian displacement, as in many other conflicts, will extend beyond the original crisis.
In the post-emergency phase, mortality rates drop below one per 10,000/day and the basic services previously mentioned are in place. This phase can be seen as fragile, for although the risk of diseases declines, the population is still quite vulnerable. The general health of a displaced population improves as risk factors are addressed, and frequently their health actually surpasses that of local populations as a result of structured and focused interventions. Despite these significant improvements, there remain unique risks. The focus of interventions gradually shifts towards long-term health concerns that include curative, reproductive, and psychosocial services, while maintaining the integrity of previous disease interventions.
Outbreaks of communicable diseases, including TB or meningitis, are still of concern in such situations. In Tanzania, for example, a meningitis outbreak in 2002 threatened the health of refugees in well-established camps on the border with Burundi. This outbreak was identified and monitored as a result of having surveillance systems and protocols in place. In this situation, surveillance systems that were well established in the emergency phase continued monitoring diseases after the crisis, and curative services established in the post-emergency phase assisted in treatment.
Violence in the camps or prior to displacement, whether witnessed or experienced by the forcibly displaced, is a prevalent concern that humanitarian agencies typically address in the post-emergency phase. Rape and sexual violence, for example, increase among displaced communities, where war or movement has shredded social norms and distorted acceptable practice. In addition, trauma resulting from witnessed conflict or family separation may result. Liberia, with its extensive reports of child rape and gender-based violence, exemplifies this type of social breakdown.
To address these issues, reproductive health and psychosocial programs are prioritized in the post-emergency phase. Yet, whenever possible, they are initiated in the emergency phase. Steps are taken, for example, during site design to minimize risks to specific genders, ages or ethnic groups. The involvement of the displaced (including women and other particularly vulnerable people) in the process of identifying the location of water taps, latrines, and fire wood, can help ensure that appropriate safety considerations are made.
In addition, psychosocial interventions appear to be gaining momentum within camps. Psychosocial issues can be addressed through a "Western" model, which focuses on individuals, or through a community strategy. The latter has a broader reach, and should begin in the emergency phase through community involvement in designing aid programs. Allowing people some control and involvement over what has been a traumatic and uncontrollable situation is among the key concepts in trauma recovery. This approach addresses issues of apathy and idleness that are especially prevalent in long-term refugee settings. The establishment of normal routines and systems for the entire population, such as schools, markets, and social activities, is also greatly beneficial.
In Liberia, initial steps towards addressing all of these issues have begun. MSF, for example, is currently establishing counseling and treatment facilities to address rape and gender violence, and programs will also be designed to decrease the vulnerability of children in these settings. These steps are components of both psychosocial and reproductive health programs, which will expand to family planning, counseling, HIV/AIDS programming, and safe obstetric care. All of these measures are essential in Liberia, which has one of the highest maternal mortality rates in the world, extensive incidence of trauma, and HIV rates that were estimated at nine percent even before the current conflict.
Forced displacement, as seen in the case of Liberia and many other refugee and IDP settings, brings unique risks that result in a general decline in health. Previous crises have shown that these immediate risks are reduced when concerns about water, sanitation, vaccinations, nutrition, and shelter are addressed. Standards like those of the Sphere Project have been established to ensure such responses, but standards tend to be more difficult to implement in less-secure settings. In some camps, it has been seen that the involvement of refugees and IDPs from the earliest stages of an emergency may not only improve the ability to meet set standards, but also keep agencies abreast of undercurrents and changes. These steps help to minimize what could otherwise be devastating circumstances.
In Liberia, where constant insecurity has jeopardized humanitarian interventions in recent months, aid agencies are working to ensure responses that meet standards and satisfy the constantly changing needs of the forcibly displaced. Displacement is rarely a short-term situation, however, and a long road is still ahead for humanitarians working with refugees and IDPs in Liberia and beyond.
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