Refugees Magazine Issue 95 (The international year of the family) - Health care and the refugee family

Refugees (Issue 95, I - 1994)

One of the best ways to help the refugee family as a whole is by helping women, particularly in meeting their health needs.

Women and children constitute more than three quarters of the refugee population. Having to maintain the household and look after the well-being of the children, women tend to bear a disproportionate amount of the suffering and hardship that affect families in exile. Not only do women carry the emotional and physical burden of caring for the whole family under difficult conditions, but in the process they are more exposed to violence and often become victims themselves of inadequate diets and infectious diseases.

Over the years, UNHCR has realized that the best way to help the family as a whole is by helping women, who are almost invariably the backbone of the family, the firm support on which husbands and children rely.

"It is the policy of UNHCR to make special efforts to meet the needs of women because their good health is crucial to the unity and strength of the refugee family," said Serge Male, UNHCR's senior epidemiologist.

Mother and Child Health Care (MCH) programmes were organized over the past several years in an attempt to reduce infant and maternal mortality rates. The MCH programmes have focused on the health aspects of pregnant and lactating mothers and children, and certainly achieved some success. But it is now generally recognized that their scope has to be expanded.

"The trouble with MCH programmes is that they restrict women to the role of mother," Male said. "This is very reductive. What about young girls who may - or may not - one day become mothers? What about women who are past child-bearing age, who in many societies have enormous influence over younger women? Ignore them and you risk diluting the effectiveness of health care and health education programmes."

Programmes targeted not only at adult women but also at teenage girls and elderly women stand a better chance of preventing the spread of a variety of deadly illnesses such as neonatal tetanus, an acute disease that usually occurs through infection caused by cutting the umbilical cord with non-sterile instruments. In 1988, the mortality rate from neonatal tetanus ranged from 100 to 150 per 1,000 live births among refugees in rural areas of eastern Iran. This is an extremely high figure and prompted an accelerated effort to reduce the rate through training of female health workers and traditional birth attendants. At the same time, a massive immunization programme was begun. All of these efforts yielded dramatic results.

It is also important to include older women in health care programmes because in many traditional societies they wield the influence and power to change old ways of thinking and to guide the younger women.

UNHCR has slowly been developing greater respect for local customs, mainly through a process of trial and error. It is now generally recognized that cultural sensitivity can be the key to an efficient programme. Cultural beliefs and traditions must be respected, but people must also understand that they can be harmful. Ritual genital mutilation, unsafe child delivery methods, a tradition of fasting for days after birth and not breastfeeding a newborn during the first 48 hours are all examples of practices that can cause major health problems.

One of the most fundamental cultural issues in many countries concerns the question of gender. In many societies, women are reluctant to consult male doctors. The presence of female health staff can be absolutely essential to the success of a health programme, as was clearly demonstrated in Bangladesh in 1992 when refugee women from neighbouring Myanmar were discovered to be suffering a higher mortality and morbidity rate than males. The main problem? There were no female health workers available.

Simple factors, such as too few or badly positioned health centres can have a devastating effect on families. If a mother has seven children and one falls sick, is she going to walk 5 km to get the sick child to a clinic, and then sit there with it for 24 hours, leaving the other six children on their own, with no one to fetch and cook their food? In such situations, mothers will often feel that the risk of abandoning six children is simply too great, and as a result the sick child may die.

"It is extremely important to take health care to the refugees - to have an outreach programme," said Mohamed Warsame Dualeh, UNHCR's senior public health officer. "It has to be easily accessible."

Dualeh noted that in 1988, in Hartisheik, Ethiopia, the mortality rate for children under five years of age was extremely high - 152 deaths per 1,000 people. The rate was caused by several factors, including inadequate food rations, water and sanitation, and the poor design and layout of the camp itself which made it difficult for people to obtain health care. As a result, health care services were decentralized and an outreach programme was begun. Women were encouraged to bring their children to feeding centres early enough, and refugees were trained as health workers and birth attendants. Improving access allowed mothers to take care of all pressing family needs, ranging from gathering firewood to seeking medical help for the children.

A fundamental characteristic of health care is that it is an essential service but not sufficient on its own. There is a clear need, particularly in emergency situations, for better coordination, in particular closer linkage with other vital sectors such as water, sanitation and food provision. The malnutrition and terrible sanitation conditions suffered by Burundi refugees in Rwanda, Tanzania and Zaire in the autumn of 1993 helped make them extremely vulnerable to diseases such as dysentery, anaemia and related illnesses. The result was a catastrophic average mortality rate of 8.6 per 10,000 per day (4.3 times the acceptable rate) among Burundi refugee children. For families who have already experienced the horrors of massacres, ethnic cleansing and wholesale destruction of their villages and livelihoods the emotional impact of the additional loss of children through malnutrition and disease in refugee camps can be devastating.

In a worst-case scenario, women lack an adequate diet and become susceptible to anaemia, which makes them more prone to other illnesses. Because they are sick, they are unable to take proper care of themselves and their children, who themselves then become malnourished and ill. Because of the poor diet, women also give birth to premature or underweight babies who have a low chance of survival. Moreover, these new mothers lack the additional energy and protein required by lactating women. In most UNHCR refugee programmes, pregnant and lactating women receive extra food.

The question of mental health is both extremely relevant to refugees and particularly hard to deal with satisfactorily. A whole set of health problems are simply manifestations of emotional disturbances. "Vulnerable groups" such as single parents, unaccompanied minors and physically or mentally handicapped all have to deal with a second layer of social disadvantages on top of the whole range of difficulties brought about by the simple fact of being a refugee. Not surprisingly, such situations often lead to psychological traumas which have physical repercussions, often disastrous to the family as a whole.

If UNHCR's mandate is to save lives, the pivotal role of the woman is obvious. Efforts to meet the needs of refugee women - and through them their families - will surely help UNHCR to fulfil its mandate.

Source: Refugees Magazine Issue 95 (1994)