Institute for Domestic & International Affairs, Inc.
United Nations High Commission for Refugees Public Health in Refugee Camps Director: Ghadeer Hasan
Š 2010 Institute for Domestic & International Affairs, Inc. (IDIA) This document is solely for use in preparation for Philadelphia Model United Nations 2010. Use for other purposes is not permitted without the express written consent of IDIA. For more information, please write us at idiainfo@idia.net
Policy Dilemma ______________________________________________________________ 1 Chronology__________________________________________________________________ 4 10 December 1948 - Universal Declaration of Human Rights _____________________________ 4 1948-1950 - Palestinian Exodus ______________________________________________________ 4 28 July 1951 - Convention Relating to the Status of Refugees _____________________________ 5 11 December 1948 - UN General Assembly Resolution 194 (III) ___________________________ 6 1979 - Médecins Sans Frontières Publishes Manual on ‘Emergency care in catastrophic situations’________________________________________________________________________ 7 1989 - Convention on the Rights of the Child___________________________________________ 8 2004 Geneva Conference on the Humanitarian Needs of Palestinian Refugees _______________ 9 1 August 2008 Neirab Rehabilitiation Project _________________________________________ 10
Possible Causes _____________________________________________________________ 11 Lack of Proper Housing and Infrastructure __________________________________________ 11 Deteriorating Socioeconomic Conditions in the West Bank and Gaza _____________________ 13
Actors and Interests __________________________________________________________ 16 Refugees ________________________________________________________________________ 16 United Nations Relief and Works Agency in the Near East (UNRWA), its Donors, and NonGovernmental Organizations_______________________________________________________ 17 Host States ______________________________________________________________________ 18
Projections and Implications ___________________________________________________ 19 Discussion Questions _________________________________________________________ 22 Bibliography________________________________________________________________ 23 For Further Reading______________________________________________________________ 23 Works Cited_____________________________________________________________________ 24
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Policy Dilemma Refugee camps are temporary camps built to receive an influx of refugees and are designed to provide basic human needs for only a short time. However, long-term problems and conflicts prevent refugees from returning or resettling elsewhere. Consequently, camps have to be considered somewhat permanent settlements.
The
Middle East in particular has a very high number of refugees and as a result many camps. About one-third, or 1.3 million, of registered Palestinian refugees live in 58 recognized refugee camps in Jordan, Lebanon, the Syrian Arab Republic, the West Bank and Gaza Strip.
1
There are, however, a small number of unofficial camps. The United Nations
Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), established in 1949, has played a major role in providing basic services to registered Palestinians in refugee camps. A refugee camp is considered to be a traditional setting in which the UNHCR has worked in the past, since refugee camps are circumscribed areas where refugees can be registered and easily provided with services. One important challenge is ensuring and maintaining good long-term public health in these camps. Public health is simply defined by the Institute of Medicine (IOM) as “what we do as a society to collectively assure the conditions in which people can be healthy.”2 Any public health system involves the activities of governments and the associated efforts of private and voluntary organizations and individuals.3 Public health is meant to maintain the health of a community or population; in this case the population of interest is refugees. Community health is the health status of a defined group of people and the actions and conditions to promote, protect, and preserve their health.4 Good public health measures include health prevention, sanitation and environmental health, health education and surveillance, and
1
“Where Do the Refugees Live?”. UNRWA. http://www.un.org/unrwa/refugees/wheredo.html Institute of Medicine (1988). The Future of Public Health. Washington, DC The National Academies Press. 3 Ibid 4 McKenzie, James F. An Introduction to Community Health. Jones and Bartlett. Sudbury. 2008. 2
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access to proper healthcare. These measures are relevant to all major determinants of health. The lack of resources and investment, and the nebulous authority over refugee camps make it difficult to create the conditions necessary to maintain the health of refugees. While some camps do have proper infrastructure and access to public services, the conditions in most camps have continued to deteriorate to resemble slums. Many of the water and sewage systems are unstable and in need of upgrading; poor sanitation in these camps pose severe health risks. It is not uncommon for refugee camps to have very poor infrastructure, overcrowding, poverty, unemployment, and very limited access to the government’s public health and educational facilities. Often, there is no access to public social services.5 “Palestinian refugee camps are a model of poor environmental conditions and lack of green and planted areas or open spaces lacking.6 Overcrowding of the camps is a severe issue with around 40 percent of households having three or more persons living per room.7 Not only does overcrowding contribute to mental health problems, but it also significantly increases spread of disease. Many of the diseases that afflict refugees in these camps result from poor diets, sanitary conditions, and lack of ventilation. Stress is also a contributing factor, especially in a conflict zone such as Gaza.8 The rates of chronic and non-communicable diseases such as hypertension, diabetes, cancer and cardiovascular diseases have also been on the rise in the refugee camp population; these are most often due to the lack of sufficient nutrition.9 “Birth rates are among the highest in the world and intervals between births are short, thus affecting women’s health.”10 In addition, diarrhea and intestinal parasites,
5
“Refugee Camp Profiles”. UNRWA, http://www.un.org/unrwa/refugees/camp-profiles.html Al-Khatib, Issam A., Arafat, Rania N. and Musmar, Mohamed(2005)’Housing environment and women’s health in a Palestinian refugee camp’,International Journal of Environmental Health Research,15:3,181 — 191 7 Dumper, Michael. The Future of Palestinian Refugees. Lynne-Reinner. 2007. Colorodo (p. 45) 8 Cook, Richard. Palestinian Camps and Refugees in Lebanon: Priorities, Challenges and Opportunities Ahead. American University of Beirut. http://www.aub.edu.lb/ifi/Documents/public_policy/pal_camps/memos/02/ifi_pc_memo02_cook.pdf 9 “Refugee Health Today”. UNRWA. http://www.un.org/unrwa/programmes/health/refugee.html 10 Ibid 6
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particularly affecting children, are highly prevalent due to poor environmental conditions in the camps.11 Needless to say, public health initiatives are sorely lacking. The UNHCR is mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide; the public health of refugees is a priority for UNHCR, although UNRWA remains the main provider of basic health care to the Palestinian refugee community. In addition, host authorities are responsible for certain public health sectors and health services, although refugees do not have proper access. Since its creation, UNRWA has been establishing semi permanent health clinics in refugee camps and tries to ensure access to primary and secondary health service. Preventive health services are also provided, including “vaccination campaigns, health education, safety checks, and home visits to the elderly, nursing women and infants.”
12
However, it is important to realize that lack of donor funding has been undermining the quality of UNRWA’s provisions. It is imperative that the UNHCR address this issue because unlike UNRWA, its mandate extends to refugees outside of the Palestinian territory. It is important to understand the importance of investing in public health. Public health is inextricably interlinked with protection of human rights, and improving the physical and mental wellbeing of refugees can significantly alleviate their conditions. Health is a major marker in development and productivity; communities wouldn’t be sustainable without public health initiatives. Ameliorating the poor health conditions of these camps would allow refugees to better participate in the economic and political life of their communities.
11
Ibid UNRWA Relief, Recovery and Reconstruction Framework 2008-2011. UNRWA. http://www.un.org/unrwa/publications/NBC/NBC_RRR_Framework_6June08.pdf 12
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Chronology 10 December 1948 - Universal Declaration of Human Rights The Universal Declaration of Human Rights (UDHR) was adopted by the UN General Assembly at the Palais de Chaillot in Paris after the events of the Second World War, and represented the first global acknowledgment of the rights to which every human is entitled. Article 25 states “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”13 This reinforces the notion that the right to health is a fundamental part of human rights and is an essential component of a life in dignity. Thus, refugees, like everyone else are entitled to a healthy life and any adequate standard of living must be supported by a good public health system.
1948-1950 - Palestinian Exodus By the spring of 1948, a Jewish state was established over approximately seventyseven percent of Mandate Palestine. This action displaced ninety percent of indigenous Palestinian Arabs from their homes and dispersed across the region. They settled in camps in what became known as the West Bank and Gaza Strip, Transjordan, Syria, and Lebanon, and also established small communities in Egypt, Iraq, and the states of the Arabian Peninsula. About 800,000 Palestinians were uprooted from their homes and became refugees. International organizations such as the International Committee of the Red Cross, the League of Red Cross Societies, and the American Friends Service Committee, first provided assistance to the Palestinian refugees. In November 1948, the UN established the United Nations Relief for Palestine Refugees (UNRPR), which provided relief to refugees and coordinated with NGOs and other UN bodies such as the United Nations International Children’s Emergency Fund (UNICEF), World Health 13
“The Universal Declaration of Human Rights”. United Nations Documents. http://www.un.org/en/documents/udhr/ (accessed 11/21.2009).
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Organization (WHO), Food and Agriculture Organization (FAO), the International Refugee Organization. In December of 1949, the UN established UNRWA under UN General Assembly Resolution 302 (IV), as a UN subsidiary organ. UNRWA’s mandate has been renewed every three years since 1949, and is expected to continue to be renewed pending a just settlement to the refugee problem.14 UNRWA has been heavily involved in the health sector of refugee camps since its establishment. In schools, UNRWA instated nutritional and hygienic programs, which quickly became integral in every day school routines; these measures included hygiene inspections and serving milk. At the beginning of its establishment, UNRWA stressed that providing healthy environments could support large numbers of displaced bodies. Thus, they sponsored public health campaigns, mass immunizations, supplemental feedings at schools and UNRWA stations. UNRWA administered required childhood vaccines at schools and sprayed camps with DDT to prevent the spread of Malaria. It also used public health marketing tactics such as using colorful posters to remind people to take their children for check ups and supplemental feedings.15
28 July 1951 - Convention Relating to the Status of Refugees The Convention Relating to the Status of Refugees was a significant cornerstone in international refugee law. Designed to partly solve the problems of the many refugees that were scattered across Europe due to the Second World War, the Convention Relating to the Status of Refugees clearly spelled out who is a refugee and outlines the legal protection and social rights a refugee should receive. As displacement spread around the globe, the scope of the Convention was increased from the 1967 protocol, which removed geographical and time limits. Under the convention, a refugee is defined as the following: A person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of 14
“History and Establishment of UNRWA”. UNRWA. http://www.un.org/unrwa/overview/qa.html (Accessed 11/21/2009) 15 Peteet, Julie. Landscape of Hope and Despair: Palestinian Refugee Camps. University of Pennsylvania Press. 2005.
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his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return 16 to it.
The Convention requires that refugees should be guaranteed the same rights as other foreign aliens. If states are unwilling or unable to provide the necessary services to refugees, such as the provision of food, shelter, health, and education, international assistance is required. It is important to note that most of the Middle Eastern States that host the majority of Palestinian refugees are not signatories to the 1951 convention; their assistance to refugees is a matter of goodwill and international assistance is provided via the UNHCR. 17
11 December 1948 - UN General Assembly Resolution 194 (III) Folke Bernadotte, who was a Swedish diplomat, was unanimously chosen to be the United Nations Security Council mediator in the Arab-Israeli conflict near the end of the war in 1948. In one of his progress notes, he stressed that innocent people who were uprooted from their homes by the present war have the right to return to their homes. He proposed recommendations to the UN that Palestinian refugees should be allowed to return to their homes in Jewish controlled territory as soon as possible, and that the UN should oversee their resettlement and social rehabilitation. He also proposed that the refugees who chose not to return should be adequately compensated for their property. Soon after, the UN General Assembly passed Resolution 194 in which it expressed appreciation of his efforts and reinforced his recommendations. The 15 paragraph document was named “Palestine Progress Report of the United Nations Mediator” and it was a comprehensive effort to deal with the ongoing problems. The resolution established a Conciliation Commission, which assumed the responsibility of acting as mediator and assisting the governments and authorities 16
1951 Convention and Protocol Relating to the Status of Refugees. UNHCR. http://www.unhcr.org/3b66c2aa10.html (accessed 10/03/2009). 17 “Palestinian Refugee Children: International Protection and Durable Solutions”. Information & Discussion Brief. Issue No. 10. Badil Resource Center. 2007. http://www.badil.org/index.php?page=shop.product_details&flypage=flypage.tpl&product_id=7&category_id=2&v mcchk=1&option=com_virtuemart&Itemid=4
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involved in the conflict to determine the final settlement of all the outstanding questions. The commission was instructed to “facilitate the repatriation, resettlement and economic and social rehabilitation of the refugees and the payment of compensation.” It is important to note that the resolution assumed that the principle of right of return was not in issue and the central point was achieving practical repatriation.”18 Historically, because of the emphasis on the refugees’ right of return and their compensation, there has been hesitation with regard to initiating large-scale projects that encouraged resettlement or established a sense of permanency in camps because this was seen as a violation of Resolution 194. Eventually, due to the wretched conditions of the camps, there were improvements in housing and the public health sector.19
1979 - Médecins Sans Frontières Publishes Manual on ‘Emergency care in catastrophic situations’ Médecins Sans Frontières (Doctors Without Borders) provided a guide for relief workers in the context of a humanitarian emergency such as a refugee situation. This piece of work was a response to the public health consequences of armed conflict and displacement. It provided a guide to front line relief workers who needed to acquire extensive and practical knowledge about water, sanitation, food and nutrition, water and sanitation, immunization, disease control, maternal and child healthcare, and public health surveillance. In an emergency situation, these workers needed to quickly make assessments, to establish public health priorities, and to be able to coordinate with health facilities and personnel and relief organizations.20 “More than 75 percent of the contents were devoted to surgical and resuscitative procedures; the remainder covered epidemiology, nutrition, water & sanitation, and immunization.”21 The guide outlined
18
Mallison, T., & Mallison, S. V. (1980). “The Right of Return”. Journal of Palestine Studies, vol.9, no.3, pp. 125136. Retrieved from http://www.jstor.org/stable/2536553. Accessed: 09/23/2009 19 Farah, Randa.”A Report on the Psychological Effects of Overcrowding in Refugee Camps in the West Bank and Gaza Strip”. International Development Research Centre (IDRC). 2000. http://prrn.mcgill.ca/research/papers/farah_0004_4.htm 20 “Refugee Health: An Approach to Emergency Situations”. Médecins Sans Frontières. http://www.refbooks.msf.org/msf_docs/en/Refugee_Health/RH1.pdf (Accessed 11/21/2009) 21 Ibid.
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operational priorities in emergency situations and following its publication, more technical manuals were written to expand on diagnostic and treatment guidelines, nutrition, and environmental health.22
1989 - Convention on the Rights of the Child In 1989, world leaders recognized the need for an international agreement that would pay special attention to the rights of children due to their increased vulnerability and developmental needs. The Convention on the Rights of a Child (CRC) outlined the special cultural, civil, political, economic, and social rights of children (people under 18 years of age). The four core principles of the Convention are non-discrimination; devotion to the best interests of the child; the right to life, survival and development; and respect for the views of the child. Special protection is granted to a refugee child, who is entitled to “receive appropriate protection and humanitarian assistance”,23 thus any state that receives a refugee or is host to a refugee camp, is responsible for the safety and protection of that child and must provide them with the same level of protection, care and resources as their native counterparts of that state. In addition, Article 24 of the Convention pertains specifically to the child’s right to the highest standard of health and medical care. Therefore, host states must take appropriate measures regarding providing necessary medical assistance, “disease and malnutrition including within the framework of primary health care, through inter alia the application of readily available technology and through the provision of adequate nutritious foods and clean drinking water, and taking into consideration the dangers and risks of environmental pollution.”24 The convention also emphasizes the need for health education regarding “child health and nutrition, the advantages of breast-feeding, hygiene and environmental sanitation and the prevention of accident.”25 Children make up over half of the world’s refugee population (approximately 40 per cent of Palestinian refugees are children) and 22
Ibid. “Convention on the Rights of the Child”. UNICEF. http://www.unicef.org/crc/ (Accessed 11/21/2009). 24 Ibid. 25 Ibid. 23
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these children continue to face gaps in day-to-day protection of human rights.26 UNRWA has been obtaining favorable results with respect to the health of refugee children by investing in maternal healthcare and infant mortality rates among Palestine refugee children are less then half the world average and compare favorably with host authorities. However, there still remains a lack of significant attention, with respect to refugee children, to access to health care, nutrition, mental health and disability rehabilitation.27
2004 Geneva Conference on the Humanitarian Needs of Palestinian Refugees The Swiss Agency for Development and Cooperation (SADC) and UNRWA hosted the first conference in 54 years with the purpose of planning humanitarian and human development strategies for the 4.1 million Palestine refugees. The conference took place in Geneva, Switzerland and was attended by 67 countries and 34 international organizations. The main purpose of the conference was to raise international support for the needs of refugees and focused on the wellbeing of Palestinian refugee children; housing, infrastructure and the environment in refugee camps; the socio-economic development of the refugees and the management and mobilization of resources on behalf of the refugees. Among these issues were the need for the respect for international humanitarian law, freedom of movement for refugees and improved efforts on community development and access to employment.28 The conference also prioritized the needs of the refugees and aimed to meet those needs within five years while renewing financial commitment to UNRWA. One of the main discussions at the conference revolved around the detrimental effects of the environmental components of refugee camps, such as restrictions in camp expansion combined with demographic growth, poor 26
“Palestinian Refugee Children: International Protection and Durable Solutions”. Information & Discussion Brief. Issue No. 10. Badil Resource Center. 2007. http://www.badil.org/index.php?page=shop.product_details&flypage=flypage.tpl&product_id=7&category_id=2&v mcchk=1&option=com_virtuemart&Itemid=4 27 “Promoting the Well-being of the Palestine Refugee Child”. UNICEF. 2004 http://www.un.org/unrwa/genevaconference/english/wg1_dp6may04.pdf 28 “67 Countries and 34 International Organisations Gather for Largest Ever Conference on Palestine Refugees” Press Release. UNRWA. http://www.un.org/unrwa/genevaconference/press_releases/geneva_pr01.pdf. (Accessed 11/22/2009)
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solid waste management, and sanitation problems.
1 August 2008 Neirab Rehabilitiation Project The Neirab camp is the largest and most impoverished Palestinian refugee camp in Syria and was established after the first wave of refugees in 1948. The population density of the camp, which housed over 18,000 refugees, was very high: 89 refugees per 1,000 square meters.29 The total area of the camp is 148,000 square meters and was built around army barracks constructed by the Allied Forces during the Second World War.30 While UNRWA has been able to make essential improvements the barracks, the infrastructure and housing are the most unhealthy and unsafe among all the camps in Syria. Refugees are not protected from the elements and are forced to withstand the freezing winter temperatures as well as the scorching summer heat. Poor sanitation and rodent infestation of the camp have lead to severe public health problems.31 To address these issues, UNRWA and the United Arab Emirates Red Crescent Society are currently implementing the Neirab Rehabilitation Project, which has set has set a precedent in utilizing “an innovative approach to redevelopment work emphasizing community participation in rehabilitating the sixty-year old dilapidated shelters.” 32 In addition to creating new housing units and a new community health clinic, the plan took into consideration both the physical structure and elements of the camp as well as the change in the socio-economic situation of the refugee community. Thus, the project was approached as an integrated urban development plan, addressing health, housing, education, by improving public infrastructure, schools and health facilities, and the socioeconomic needs of the refugees, by of community mobilization and increasing
29
“UNRWA Revamps Northern Syrian Refugee Camp. Brooke Anderso. Special to the Daily Star. 2003. http://www.un.org/unrwa/news/articles/archive/dailystar-oct03.html (Accessed 11/22/2009) 30 “UNRWA Implements Neirab Rehabilitation Project in Aleppo in Syria” Aljazeera 1/10/2009. http://www.aljazeera.com/news/print.php?newid=273732 (Accessed 11/22/2009) 31 “Neirab Refugee Camp”. UNRWA. http://www.un.org/unrwa/refugees/syria/neirab.html 32 “Rehabilitation of 60-year old Shelters Begins With Support From UAE Red Crescent”. UNRWA Press Release. 28 June 2008. http://www.un.org.sy/press/16(UAERC)English.pdf (Accessed 11/22/2009)
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access to development resources and the local job markets.33 The project proved to be unique because it included the active involvement and participation of the community and should be used as model to improve other refugee camps.
Possible Causes Lack of Proper Housing and Infrastructure Refugee camps are often characterized by having poor housing structures. Housing can be defined as a house, shelter, or dwelling and a household is composed of one or more families or individuals. The quality of housing is an important determinant of health in refugee camps. For example, a lack of windows and natural sunlight will prevent exposure to sunrays that provide the necessary ultraviolet rays for the body to utilize vitamin D.34 Inadequate heat insulation, ventilation and excess moisture encourage microorganisms, such as molds, to grow; These molds can be allergenic and attract house mites.35 Other factors that directly affect health that are related to housing are the site of residential area, access to water, sanitation, building materials, and overcrowding. Serious respiratory health risks can occur from factors such as tobacco use, biological organisms, building material, cleaning agents, as well as airborne lead and mercury vapors.36 Overcrowding leads to the spread of communicable diseases and jeopardizes privacy, which can cause mental health problems. For example, in Al-Ein Refugee Camp, which is located the West Bank of the occupied Palestinian territories, family size ranges from 2 to 37 members with the average being 8.06. 40 percent of families live in three rooms or less. Fifty percent of houses only had one window, and two percent had no windows at all. While most of the homes are connected to a sewage system, it still 33
“Neirab Reabilitation Project” United Nations in Syria. http://www.un.org.sy/forms/projects/viewProject.php?id=115 (Accessed 11/22/2009) 34 Al-Khatib, Issam A., Arafat, Rania N. and Musmar, Mohamed(2005)’Housing environment and women’s health in a Palestinian refugee camp’,International Journal of Environmental Health Research,15:3,181 — 191. http://dx.doi.org/10.1080/09603120500105950 35 Ibid. 36 Ibid.
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required upgrading. The housing is generally crowded. 60.4 percent of housing was characterized by having high density while 7.9 percent was considered overcrowded, and 31.7 percent was considered to be low in density.37 In Syria, only one in five are crowded compared to some one in four in Lebanon and one in three in Jordan.38 Refugee camps are prone to overcrowding because only small areas are allotted for refugee settlement; lands allocated for refugee camps in 1949 have not been increased during the past 50 years and in some cases, land was even reduced. Consequently, housing is expanded vertically failing to meet most standards for healthy living.39 Water plays an essential role in sanitation and public health and it is important for drinking water to be adequately treated and monitored. According to the World Health Organization, water that is to be consumed by humans must be free of biological and chemical agents and should be of good quality, colorless, tasteless, and odorless. Numerous diseases are transmitted through water or due to lack of water, such as cholera, typhoid, malaria, dysentery, and hepatitis. Water supplies are often contaminated due to improper handling and poorly planned networks.40 Piped water is often available to refugee camps; however, there is often irregularity in its delivery. For example, in refugee camps in Lebanon, 64 percent of households have piped water while only 50 percent have piped drinking water. Refugees generally have lower access to safe drinking water and many resort to open containers, boreholes, reservoirs, and rain wells, which are potentially unsafe due to the lack of filtration devices and are not always chlorinated. Water service has a tendency to get interrupted and sometimes water is available only during certain hours of the day.41
37
Ibid. Jacobson, Laurie Blome. “The Material and Social Infrastructure, and Environmental Conditions of Refugee Camps and Palestinian Communities in Syria”. Fafo. http://www.fafo.no/ais/middeast/palestinianrefugees/syriapaper04.pdf 39 Zeidan, Ali. Environmental Conditions In Palestinian Camps in Lebanon - Case Study”. FOFOGNET Digest, 5 September 1999. http://prrn.mcgill.ca/research/papers/zeidan.htm 40 Ibid. 41 “Living conditions Among Palestinian Refugees in Camps and Gatherings in Lebanon”. Fafo. 2003. http://www.fafo.no/pub/rapp/409/409.pdf 38
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Another important implication related to environmental health is sewage and waste disposal. Not all refugee camps are connected to a sewer system and many households have septic tanks, most of which are improperly constructed and cause leakages which flow into open rain water systems resulting in water contamination.42 The sewage systems that do exist need upgrading and rehabilitation. Infections associated with poor environmental health, such as viral hepatitis and enteric fevers, are still a public health threat It is important to take into consideration that access to basic infrastructure is largely dependant upon the way camps are linked to national or regional water and sewage systems. For example, in Lebanon, “the government has not allowed refugee camps’ sewage networks to link to those serving nearby municipalities. The isolation of Lebanon camps from national infrastructure systems means that camps have not benefited substantially from the large-scale reconstruction in infrastructure that has taken place in Lebanon during the 1990.”43
Deteriorating Socioeconomic Conditions in the West Bank and Gaza There are 27 refugee camps in the occupied Palestinian territory, which constitute almost half of the total number of Palestinian refugee camps in the West Bank and Gaza,. This it is important to consider the effect of the socioeconomic conditions on the occupied territories that significantly affect public health and access to health services. The combination of expanding settlements and outposts limit the movement of people and goods due to the complex system of physical obstacles and checkpoints. Currently, there is a wall being built that is progressively limiting the possibilities of Palestinian residents of the West Bank to access services, including healthcare.44 Camps and settlements within the West Bank are geographically separated from each other by forms
42
Zeidan, Ali. Environmental Conditions In Palestinian Camps in Lebanon - Case Study”. FOFOGNET Digest, 5 September 1999. http://prrn.mcgill.ca/research/papers/zeidan.htm 43 Ibid. 44 “The Annual Report of the Department of Health” UNRWA 2009.
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of Israeli infrastructure such as settlements, military areas, and outposts and add to the lack of mobility within this area. This lack of mobility on the Gaza Strip, according to the World Health Organization, will result in dire consequences on the health of population residing there and “their right to enjoy the highest attainable standard of health.”
45
Fuel supply has
been significantly reduced to this area, which has a severe impact on water and sanitation services in Gaza, which is placing public health at risk.46 Water well pumps and wastewater management stop functioning due to fuel shortages. Due to border closures, equipment and supplies needed to repair and rehabilitate water and sewage networks have been denied entry.47 In addition, access to adequate quantities of safe water for both drinking and domestic uses has been severely restricted for many people having serious affects on hygiene.48 Untreated sewage is being discharged daily into to the sea, which has potentially harmful implications. “In July 2009, the World Health Organization reported that water samples taken from 7 separate beach areas in the Gaza Strip were contaminated with Fecal Coliforms and Fecal Streptococcus. Seawater contaminated with human and animal waste can contain a variety of bacterial, viral and protozoan pathogens: a danger human health, in particular to bathers and those who consume seafood.”49 Thus, environmental health has been extremely threatened by the closures in Gaza. Another consequence of the deteriorating socioeconomic conditions is a reduced access to health services. “The interruption of energy provision jeopardized primary health care services, medical supply delivery, and, at secondary health care level, had a particularly severe impact on intensive care units, operation theaters and emergency rooms.” 50 Tertiary healthcare services are available only outside the Gaza strip and high45
Ibid. The Impact of the Blockade on Water and Sanitation in Gaza” WASH Advocacy Task Force. UNISPAL http://unispal.un.org/UNISPAL.NSF/0/BBB5C84A39DEBDF785257632004F336E. (Accessed 11/21/2009) 47 Ibid. 48 Ibid. 49 Ibid. 50 “The Annual Report of the Department of Health” UNRWA 2009. 46
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level specialized care is increasingly difficult to access. According to the WHO, “the proportion of patients given permits to exit the Gaza Strip for medical care decreased from 89.3 percent in January 2007 to 64.3 percent in December 2007, an unprecedented low figure.”51 Patients with urgent and life threatening conditions are particularly vulnerable. In 2007, twenty deaths occurred (including five children) due to the lack of access to referral services within a three-month period.52 Patients with chronic diseases, such as diabetes, cancer, and heart disease are unable to receive regular follow up care and treatment because they, as well as health care personnel, are unable to access specialized care centers and health clinics.53 The closure system and separation barrier have significantly hindered UNRWA’s ability to provide health assistant to the refugees. A break down in preventative services has lead to a 10.4 percent increase in the incidence of low birth weights and a 52 percent increase in the stillbirth rate. The reduced and irregular access to primary health care centers, for example, has lead to the significantly increased prevalence of iron-deficiency anemia among pregnant women in the West Bank because they could not seek proper antenatal care during their course of pregnancy. In addition, patients suffering from diabetes and hypertension could not control their conditions. The dire circumstances also hinder the implementation of projects for development of the infrastructure of camps.54 Difficulties in the movement of staff and goods and increases in procurement prices of goods including medicines and food commodities, as well as the problems and complications of logistics and operational costs, are two of the main issues challenging UNRWA’s health programs and services.55
51
“Health conditions in the occupied Palestinian territory, including east Jerusalem, and the occupied Syrian Golan “Report of the director of Health. UNRWA 2007. http://apps.who.int/gb/ebwha/pdf_files/A61/A61_ID2-en.pdf 52 Ibid. 53 “Healing the Wounds”. The Union of Palestinian Medical Relief Committees. 2001. http://www.pmrs.ps/content/publications/2001_newsletter.pdf (Accessed 11/22/2009). 54 “Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine”. WHO. 2002. http://apps.who.int/gb/archive/pdf_files/WHA55/ea55id3.pdf 55 “Health conditions in the occupied Palestinian territory, including east Jerusalem, and the occupied Syrian Golan “Report of the director of Health. UNRWA 2007. http://apps.who.int/gb/ebwha/pdf_files/A61/A61_ID2-en.pdf
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Actors and Interests Refugees The wellbeing of refugees is significantly impacted by the quality of public health in their communities. It affects both their physical and mental health, and consequently their functionality as a whole. Health affects their ability to find employment, provide for their families, educate themselves, and positively contribute to society. The conditions in which refugees find themselves are significantly ameliorated by public health interventions. It is important that the international community plays a role in implementing public health measures and interventions in refugee camps. Infant mortality rates (IMR) are useful indicators for the health and development. The IMRs among Palestinian refugees are 32 in Jordan, 33 in Gaza, 35 in Lebanon, and 29 in Syria.56 To put these numbers in perspective, the infant mortality rate in a developed country such as the United Kingdom is 4.85, while the rate in a developing country such as Mali, is 102.57 However, there is a significant deviation from the infant mortality rates of the countries acting as hosts to these refugees. For example, the infant mortality rates in Jordan, Lebanon, and Syria, are 14.97, 21.82, and 25.87 respectively.58 Thus, it is clear that there is a disparity in the quality of healthcare and public health services that refugees receive in these countries. While all these refugees exist in various social and economic conditions, the preferred policy constitutes voluntary repatriation in a dignified manner to their home state and finding an end to exile and ultimately preserving their identity. However, when repatriation is not a viable option, the optimal outcome is one in which their host state, together with other members of the International community and non-governmental organizations, provide them with adequate public health, which would ultimately ease their reintegration, resettlement, or repatriation. 56
“Infant and child mortality rates among Palestinian refugee populations” H.Madi The Lancet, Volume 356, Issue 9226, Pages 312-312 57 “Country Comparison: Infant Mortality Rates”. CIA World Factbook. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html. (Accessed 11/22/2009) 58 Ibid.
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United Nations Relief and Works Agency in the Near East (UNRWA), its Donors, and Non-Governmental Organizations UNRWA was mandated “to carry out direct relief and works programmes in
collaboration with local governments," to "consult with the Near Eastern governments concerning measures to be taken preparatory to the time when international assistance for relief and works projects is no longer available.”
59
The agency remains essential to all
fields of refugee relief and will remain in operation pending a just settlement to the refugee problem. Most of the funding for UNRWAs work comes from the contribution of donor states, including the United States, United Kingdom, Sweden, European Commission, Japan, Canada, Arab states of the Gulf Cooperation Council, and Scandinavian countries. A small portion of funding comes from NGOs. Organizations such as the WHO and the United Nations Educational, Scientific, and Cultural Organization assist with the staffing of education and health programs. UNRWA forms partnerships with NGOs, such as CARE International and Doctors Without Borders, to work together to run essential services for Palestine refugees, The NGOs are useful in that they offer technical expertise and training. They are generally medical-humanitarian, human rights and development oriented.60 The agency is currently under-funded and the amount of funding is inadequate to sustain the growth of the refugee population as well as their growing needs, which will be very detrimental to the quality of UNRWA’s services. UNRWA is under even more strain due to the current humanitarian crisis in the West Bank and Gaza caused by Israeli closure, causing it to repeatedly launch emergency appeals for emergency food as well as employment and cash assistance. While UNRWA spends a considerable portion of its budget on health and relief services, more than half of its budget is spent on the education
59
“History and Establishment of UNRWA”. UNRWA. http://www.un.org/unrwa/overview/qa.html (Accessed 11/21/2009) 60 Ibid.
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program. UNRWA is dedicated to Palestinian refugees, however, it requires more funding from donors and collaboration from host governments and NGOs.61 Due to the lack of sovereignty and authority that organizations such as UNRWA and NGOs have, they must agree to the will of both refugees and host States. NGOs cannot implement their programs and projects if the host state does not approve. This can be clearly seen in the area of public health infrastructure. NGOs trying to improve the public infrastructure in refugee camps are limited in the sense that it would be most efficient if it were linked to the infrastructure of the host state, which the host government deems undesirable. Thus, it is necessary for NGOs to concede to the will of host states and create projects that are compatible with their policies.
Host States The relationship between refugees and host countries varies widely. For example, Jordan has proved to be a welcoming host by granting refugees citizenship since 1954 and while Syria and Lebanon do not. Syria it allows refugees to work and own property, while in Lebanon, refugees are not allowed to work in most professions can only own property with special permission. Overall, host states view refugees as destabilizing and a threat to political and economic security. Because of the stigma attached to them, many refugees have been unable to benefit from certain basic rights or to integrate into the societies in which they live. While, hosts receive refugees in good will, they sometimes perceive an improvement in the conditions of refugee camps will lead to permanent settlements.62 Host states are usually responsible for the overall infrastructures of the camps and they are to ensure the refugees receive the same quality of health services as their own citizens. Host states spend millions of dollars each year to support refugee camps but also appeal to the international community for support. Host states would prefer to have less responsibility for the refugees and push for their repatriation. Governments sometimes 61
Ibid. Cook, Richard. Palestinian Camps and Refugees in Lebanon: Priorities, Challenges and Opportunities Ahead. American University of Beirut. 62
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limit the refugees’ access to the government’s public health or educational facilities and public social services to prevent a strain on its infrastructure and also to keep refugee communities isolated.
63
The optimal outcome for host states is to receive aid from
international agencies and allow organizations such as UNRWA to administer public health services.
Projections and Implications Refugee camps are meant to be temporary residences to those who were uprooted from homes and seek protection and basic services. Living in a setting that was built in the mindset that its residents would not be staying for very long, and lacking in the proper infrastructure and unstable services, will have serious implications on the physical and mental health of refugees. Such camps will require more comprehensive interventions to support refugees on a long-term basis. The lack of investment in the public health sector will take a large toll on the physical and mental wellbeing of refugees, who are trying to integrate back into society. Health is the foundation upon which refugees will build themselves. A health individual will have a better chance to become educated and employed and ultimately contribute to society. In stable refugee situations, chronic illnesses will become more prevalent than communicable diseases, which will require significant changes to the health care system in these camps. Chronic illnesses and disorders, such as diabetes and heart disease, are long term and require stable, continuous services. Without an emphasis in primary and secondary prevention in refugee camps, chronic diseases will continue to rise.
64
The birthrate in Palestinian refugee camps is relatively high and the population continues to grow while the infrastructure of the camps struggles to support and provide for them. In a conflict ridden area, it is important to address both the immediate humanitarian needs of the population and ensuring long term development of the deteriorated water and sanitation sector, public health and the environment. Without 63 64
“Lebanon Refugee Camp Profiles”. UNRWA. http://www.un.org/unrwa/refugees/lebanon.html “Refugee Health Today”. UNRWA. http://www.un.org/unrwa/programmes/health/refugee.html
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allocating proper funds to organizations that oversee the health of refugees, such as UNRWA, the administration of health in terms of access and quality will also breakdown. Lastly, the current conflict and hostilities, and the feeling of an insecure future all significantly affect the health of the refugees.65
65
Ibid.
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Conclusion The lack of proper public health in refugee camps is an issue that will require the consideration of both the technical aspects and basic principles in public health as will as the bigger political and social environment in which these refugees find themselves. The most immediate cause of poor public health is the lack of proper infrastructure, housing, water, sanitation, and healthcare services. The underlying cause of the problem can be found in the socioeconomic and political scene of the refugee camps, which is greatly influenced by the policies of host states. It is important to realize that organizations such as UNRWA are useful tools in implementing public health interventions and programs; however, their lack of sovereignty is limiting. The greatest implication of poor health will be translated into the decreased social wellbeing and productivity of refugees, which will ultimately determine the fate of any durable solution.
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Discussion Questions • What is UNHCR’s role in administering proper public health? • How can the basic principles of public health be applied to an unusual setting such as a refugee camp? • How does proper public health relate to refugee empowerment and their improved livelihood? • What is the role of host states in ensuring proper public health in refugee camps? • How can public health projects in refugee camps receive proper funding and investment? • How can the infrastructure of refugee camps be improved within the boundaries of host states? • How does the socioeconomic and political scene in the Middle East influence the infrastructure and policies in refugee camps related to health? • What mechanisms and policies could be utilized to rehabilitate refugee camps? • How is public health relevant to the human rights of refugees?
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Bibliography For Further Reading “Refugee Health: An Approach to Emergency Situations”. Médecins Sans Frontières. http://www.refbooks.msf.org/msf_docs/en/Refugee_Health/RH1.pdf This resource is a great outline from Medicins Sans Frontiers, also known as Doctors without Borders. It outlines the top ten public health concerns and elaborates on the solutions proposed today. It also specifically focuses on illnesses associated with diseases in the refugee camps. It is an excellent summary of the major problems that health workers face when trying to address refugees. UNRWA Relief, Recovery and Reconstruction Framework 2008-2011. UNRWA. http://www.un.org/unrwa/publications/NBC/NBC_RRR_Framework_6June08.p df This resource provides good insight into the public health initiatives in the Palestinian Refugee camp Nahr el-Bared in Lebanon. This case study outlines the initiatives that the United Nations is taking in a Palestinian Refugee camp. It helps define the level of involvement that the UN has in refugee camps and helps identify the pitfalls of certain current initiatives. “Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine”. WHO. 2002. http://apps.who.int/gb/archive/pdf_files/WHA55/ea55id3.pdf This resource is an active resolution presented by the World Health Organization on public health measures around the Middle East. Because this is from the perspective of the World Health Organization, the perspectives are largely from health care providers.
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Works Cited 1951 Convention and Protocol Relating to the Status of Refugees. UNHCR. http://www.unhcr.org/3b66c2aa10.html “67 Countries and 34 International Organisations Gather for Largest Ever Conference on Palestine Refugees” Press Release. UNRWA. http://www.un.org/unrwa/genevaconference/press_releases/geneva_pr01.pdf Al-Khatib, Issam A., Arafat, Rania N. and Musmar, Mohamed(2005)'Housing environment and women's health in a Palestinian refugee camp',International Journal of Environmental Health Research,15:3,181 — 191 “The Annual Report of the Department of Health” UNRWA 2009. Dumper, Michael. The Future of Palestinian Refugees. Lynne-Reinner. 2007. Colorodo (p. 45) “Convention on the Rights of the Child”. UNICEF. http://www.unicef.org/crc/ Cook, Richard. Palestinian Camps and Refugees in Lebanon: Priorities, Challenges and Opportunities Ahead. American University of Beirut. http://www.aub.edu.lb/ifi/Documents/public_policy/pal_camps/memos/02/ifi_pc_ memo02_cook.pdf “Country Comparison: Infant Mortality Rates”. CIA World Factbook. https://www.cia.gov/library/publications/the-worldfactbook/rankorder/2091rank.html Farah, Randa.”A Report on the Psychological Effects of Overcrowding in Refugee Camps in the West Bank and Gaza Strip”. International Development Research Centre (IDRC). 2000. http://prrn.mcgill.ca/research/papers/farah_0004_4.htm “The Future of Public Health”. Institute of Medicine. The National Academies Press. Washington, DC. 1988. “Healing the Wounds”. The Union of Palestinian Medical Relief Committees. 2001. http://www.pmrs.ps/content/publications/2001_newsletter.pdf “Health conditions in the occupied Palestinian territory, including east Jerusalem, and the occupied Syrian Golan “Report of the director of Health. UNRWA 2007. http://apps.who.int/gb/ebwha/pdf_files/A61/A61_ID2-en.pdf
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“Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine”. WHO. 2002. http://apps.who.int/gb/archive/pdf_files/WHA55/ea55id3.pdf “History and Establishment of UNRWA”. UNRWA. http://www.un.org/unrwa/overview/qa.html The Impact of the Blockade on Water and Sanitation in Gaza” WASH Advocacy Task Force. UNISPAL http://unispal.un.org/UNISPAL.NSF/0/BBB5C84A39DEBDF785257632004F336 E. “Infant and child mortality rates among Palestinian refugee populations” H. Madi The Lancet, Volume 356, Issue 9226, Pages 312-312 Jacobson, Laurie Blome. “The Material and Social Infrastructure, and Environmental Conditions of Refugee Camps and Palestinian Communities in Syria”. Fafo. http://www.fafo.no/ais/middeast/palestinianrefugees/syriapaper04.pdf “Lebanon Refugee Camp Profiles”. UNRWA. http://www.un.org/unrwa/refugees/lebanon.html “Living condtions Among Palestinian Refugees in Camps and Gatherings in Lebanon”. Fafo. 2003. http://www.fafo.no/pub/rapp/409/409.pdf Mallison, T., & Mallison, S. V. (1980). “The Right of Return”. Journal of Palestine Studies, vol.9, no.3, pp. 125-136. Retrieved from http://www.jstor.org/stable/2536553. McKenzie, James F. An Introduction to Community Health. Jones and Bartlett. Sudbury. 2008. “Neirab Refugee Camp”. UNRWA. http://www.un.org/unrwa/refugees/syria/neirab.html “Neirab Reabilitation Project” United Nations in Syria. http://www.un.org.sy/forms/projects/viewProject.php?id=115 “Palestinian Refugee Children: International Protection and Durable Solutions”. Information & Discussion Brief. Issue No. 10. Badil Resource Center. 2007. http://www.badil.org/index.php?page=shop.product_details&flypage=flypage.tpl &product_id=7&category_id=2&vmcchk=1&option=com_virtuemart&Itemid=4
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Peteet, Julie. Landscape of Hope and Despair: Palestinian Refugee Camps. University of Pennsylvania Press. 2005. “Refugee Camp Profiles”. UNRWA, http://www.un.org/unrwa/refugees/campprofiles.html “Refugee Health: An Approach to Emergency Situations”. Médecins Sans Frontières. http://www.refbooks.msf.org/msf_docs/en/Refugee_Health/RH1.pdf “Refugee Health Today”. UNRWA. http://www.un.org/unrwa/programmes/health/refugee.html “Rehabilitation of 60-year old Shelters Begins With Support From UAE Red Crescent”. UNRWA Press Release. 28 June 2008. http://www.un.org.sy/press/16(UAERC)English.pdf “The Universal Declaration of Human Rights”. United Nations Documents. http://www.un.org/en/documents/udhr/ “UNRWA Implements Neirab Rehabilitation Project in Aleppo in Syria” Aljazeera 1/10/2009. http://www.aljazeera.com/news/print.php?newid=273732 UNRWA Relief, Recovery and Reconstruction Framework 2008-2011. UNRWA. http://www.un.org/unrwa/publications/NBC/NBC_RRR_Framework_6June08.pdf “UNRWA Revamps Northern Syrian Refugee Camp. Brooke Anderso. Special to the Daily Star. 2003. http://www.un.org/unrwa/news/articles/archive/dailystaroct03.html “Where Do the Refugees Live?”. UNRWA. http://www.un.org/unrwa/refugees/wheredo.html Zeidan, Ali. Environmental Conditions In Palestinian Camps in Lebanon - Case Study”. FOFOGNET Digest, 5 September 1999. http://prrn.mcgill.ca/research/papers/zeidan.htm