Displaced populations and long term humanitarian assistance
http://www.100md.com
《英国医生杂志》
Leonard Cheshire Centre of Conflict Recovery, University College London, London.
Introduction
Conflicts and disasters—whether manufactured or natural—often result in the wide scale displacement of people. This may be as a result of destruction of homes and environment, religious or political persecution, or simply economic necessity. Some remain internally displaced within the borders of their own country, if not their own region or homeland. Others will cross international borders as refugees. (A refugee is legally defined as someone who has crossed an international border to escape actual or potential persecution.)
Whatever the reason for displacement, the resulting mass of vulnerable people, most of whom may be women and children, must be accommodated somewhere, be it in tented camps, semipermanent or permanent collective centres or settlements, or even private residences.
Camp for refugees and internally displaced people
For healthcare professionals contributing to humanitarian missions and projects in the acute phase of population displacement, an awareness of some of the factors that can influence the long term outcomes can be of great benefit for understanding project implications and sustainability.
Potential causes of displacement
Issues in humanitarian responses
Humanitarian responses can be considered under the phases of early or emergency, post-emergency or intermediate, and resettlement or long term (these phases overlap and are not necessarily sequential). This article focuses on continued responses in the long term resettlement phase.
Changes in humanitarian response and responsibility over time
Responsibilities
While the United Nations High Commission for Refugees (UNHCR) is legally bound by international statute to assist and protect refugees, this is not so for internally displaced people—though the commission often does take responsibility for them, as set out in its Guiding Principles on Internal Displacement.
Statistics for internally displaced people
Other agencies that share responsibility for refugees and internally displaced people include the International Committee of the Red Cross (although its mandate ceases when conflict ends), the UN children's fund Unicef, and many smaller non-governmental organisations with varying specialties.
Responsibilities change with time, and the duty of care to internally displaced people in settlements and camps often will, and should, eventually shift back to the host government. However, several closely related factors affect this decision.
Duration of displacement
Displacement may be for a considerable time, which raises questions about living conditions, the possibility of resettlement, the availability of land and houses, and ongoing security issues, including fear of persecution and physical and psychological trauma experienced during conflict. It also brings into question the role of governments, international agencies, and non-governmental organisations in these processes.
Resolution of displacement
A host of factors affect resolution of displacement.
Political—Will of the international community or host government; political influence of the displaced group; issues of responsibility for the displaced people
External funding—Influenced by the political factors above; the strategic importance of the affected region; and media interest in the crisis
Resources in affected region—State of the economy; level of infrastructure and housing; level of economic growth or poverty
Friction—Attitude of indigent population to incomers; protracted conflict; ethnic or nationalist tensions
Role of aid agencies—Risk of creating "aid dependency" and a society functioning on handouts that loses the ability to manage and care for itself; conditions for sustainable development or regeneration.
Human security issues of displacement
The UN Development Programme (UNDP) in 1994 highlighted seven human security indicators, which act as a useful benchmark for the long term provision of care to displaced people.
Internally displaced people living long term in abandoned railway carriages
Economic security (assured basic income)
Many aspects of this are beyond health workers' jurisdiction as it is related to overall infrastructure development. But remember that good general health, including rehabilitation from conflict related injuries, enables people to seek employment.
Long term management of conflict related injuries, such as these deliberate amputations, can allow displaced people to seek employment
Food security (physical and economic access to food)
After the initial emergency phase of displacement, which incorporates therapeutic feeding programmes and provision of food supplies, a health worker's role may shift from the more practical to the dispensing of nutritional advice.
Health security (relative freedom from disease and infection)
Swift resumption of primary care services after a crisis can be more beneficial for the health of the affected population than intensive emergency medical and surgical aid. This means integrating displaced people into local healthcare structures and informing them about the care provided.
As a humanitarian response moves from the early phase, health care will shift in emphasis from managing acute problems to treating chronic disabilities and conditions
Health issues will inevitably shift in emphasis from acute problems to chronic conditions and from curative to preventive medicine. This raises questions about funding and provision, and whether treatments are available, accessible, sustainable, and affordable. Caution is necessary when starting a treatment (from simple dressings to drugs or psychosocial work) that may be difficult to continue once a non-governmental organisation has ceased to provide aid.
Health workers should be particularly aware of long term problems among the most vulnerable populations—elderly or disabled people, women, and children.
Environmental security (access to clean water and air and non-degraded land)
Environmental issues, such as a functioning sewerage system, electricity, running water, and refuse collection have an obvious impact on living standards and health. Such services are often unavailable or severely disrupted immediately after a disaster or conflict and may not be a priority in terms of long term infrastructure repair.
They may also not be seen as a priority by the displaced population if it is given responsibility to organise and pay for these public utilities, as happened in Bosnia. After eight years of providing subsidised utilities, the municipalities decided to charge the beneficiaries. Unaccustomed to paying bills, the beneficiaries in one camp let the debt accumulate until their electricity supply was finally cut off.
Common long term medical problems in internally displaced communities
Personal security (security from violence and threats)
The threat of land mines, unexploded ordnance, and gunfire affect both personal and environmental security and pose a considerable challenge to regeneration after conflict. Both internally displaced people and returnees face fear and intimidation from opposing political or ethnic groups in many post-conflict zones. Women and children in particular face harassment and danger in camps and centres, not only from opposition groups but also from members of their own communities.
In Bosnia, as in many places round the world, new generations of internally displaced people are growing up never having known a homeland or a settled way of life
Community security (security of cultural identity)
Loss of a homeland can lead to a loss of cultural identity. Cultural and ethnic groups may be dispersed and segregated after displacement. Security, dignity, and freedom to be educated and to practise cultural and religious beliefs are essential to preserving a sense of identity. Religious or community leaders often act as spokespeople in camps, and so an understanding of sensitive cultural issues is vital. Health care may also offer a neutral ground for reconciliation between communities.
Azerbaijan resettlement camp, one of the possible ways of ending displacement
Political security (protection of basic human rights)
Internally displaced people have the right to be treated with the same respect and dignity afforded to all citizens of their country. These rights continue if and when displaced people return home.
Resolving displacement
There are three possible resolutions to displacement: return and repatriation, resettlement, or asylum in another country. Each option has its own problems and requires a great deal of support.
The decision to end internal displacement should be voluntary, and depend on legislative, political, economic, and social reforms and the successful transition to peace or a return to "normality." The return process can be difficult to monitor and assess, however, as it is usually the responsibility of the host country. Displaced people should not feel forced to return, but the issues that militate against a return are often the same as those against remaining. These include infrastructure, security, employment, land, health care, and housing.
Many humanitarian projects cease when displaced people return home, but many returnees continue to need support, particularly in areas such as health care and education, for which the infrastructure is often still in the early phase of regeneration.
Conclusion
In a humanitarian response, aid agencies must consider their long term goals. Over an extended period, some internally displaced populations can and do adapt to their circumstances, creating their own conditions for coping, and even becoming self sufficient. However, many others become increasingly vulnerable and socially excluded.
The end of displacement is invariably a gradual process, requiring continued and sustainable support. This is particularly important for health care. Health professionals work in tandem with many other agencies and specialists in the field and have a vital role in the continuing care, assessment, and treatment of long term displaced populations.
Further reading
? Global IDP Project. Internal displacement: a global overview of trends and developments in 2003. www.idpproject.org/global_overview.htm
? Weiss Fagen P. Looking beyond emergency response. Forced Migration Review 2003;17: 19-21
? The Sphere Project. Humanitarian charter and minimum standards in disaster response. www.sphereproject.org/
? Ryan J, Mahoney PF, Greaves I, Bowyer G, eds. Conflict and catastrophe medicine—a practical guide. London: Springer-Verlag, 2002
? Médecins Sans Frontières. Refugee health—an approach to emergency situations. London: Macmillan, 1997
? International Committee of the Red Cross. www.icrc.org/
? UNHCR: the UN refugee agency. www.unhcr.ch/
This is the eighth in a series of 12 articles
Maria Kett is research fellow, Leonard Cheshire Centre of Conflict Recovery, University College London, London.
The photograph of a Ugandan girl with amputated hands was taken by Chris Steele-Perkins and supplied by Magnum Photos.
The ABC of conflict and disaster is edited by Anthony D Redmond, emeritus professor of emergency medicine, Keele University, North Staffordshire; Peter F Mahoney, honorary senior lecturer, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham; James M Ryan, Leonard Cheshire professor, University College London, London, and international professor of surgery, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD USA; and Cara Macnab, research fellow, Leonard Cheshire Centre of Conflict Recovery, University College London, London. The series will be published as a book in the autumn.(Maria Kett, research fellow)
Introduction
Conflicts and disasters—whether manufactured or natural—often result in the wide scale displacement of people. This may be as a result of destruction of homes and environment, religious or political persecution, or simply economic necessity. Some remain internally displaced within the borders of their own country, if not their own region or homeland. Others will cross international borders as refugees. (A refugee is legally defined as someone who has crossed an international border to escape actual or potential persecution.)
Whatever the reason for displacement, the resulting mass of vulnerable people, most of whom may be women and children, must be accommodated somewhere, be it in tented camps, semipermanent or permanent collective centres or settlements, or even private residences.
Camp for refugees and internally displaced people
For healthcare professionals contributing to humanitarian missions and projects in the acute phase of population displacement, an awareness of some of the factors that can influence the long term outcomes can be of great benefit for understanding project implications and sustainability.
Potential causes of displacement
Issues in humanitarian responses
Humanitarian responses can be considered under the phases of early or emergency, post-emergency or intermediate, and resettlement or long term (these phases overlap and are not necessarily sequential). This article focuses on continued responses in the long term resettlement phase.
Changes in humanitarian response and responsibility over time
Responsibilities
While the United Nations High Commission for Refugees (UNHCR) is legally bound by international statute to assist and protect refugees, this is not so for internally displaced people—though the commission often does take responsibility for them, as set out in its Guiding Principles on Internal Displacement.
Statistics for internally displaced people
Other agencies that share responsibility for refugees and internally displaced people include the International Committee of the Red Cross (although its mandate ceases when conflict ends), the UN children's fund Unicef, and many smaller non-governmental organisations with varying specialties.
Responsibilities change with time, and the duty of care to internally displaced people in settlements and camps often will, and should, eventually shift back to the host government. However, several closely related factors affect this decision.
Duration of displacement
Displacement may be for a considerable time, which raises questions about living conditions, the possibility of resettlement, the availability of land and houses, and ongoing security issues, including fear of persecution and physical and psychological trauma experienced during conflict. It also brings into question the role of governments, international agencies, and non-governmental organisations in these processes.
Resolution of displacement
A host of factors affect resolution of displacement.
Political—Will of the international community or host government; political influence of the displaced group; issues of responsibility for the displaced people
External funding—Influenced by the political factors above; the strategic importance of the affected region; and media interest in the crisis
Resources in affected region—State of the economy; level of infrastructure and housing; level of economic growth or poverty
Friction—Attitude of indigent population to incomers; protracted conflict; ethnic or nationalist tensions
Role of aid agencies—Risk of creating "aid dependency" and a society functioning on handouts that loses the ability to manage and care for itself; conditions for sustainable development or regeneration.
Human security issues of displacement
The UN Development Programme (UNDP) in 1994 highlighted seven human security indicators, which act as a useful benchmark for the long term provision of care to displaced people.
Internally displaced people living long term in abandoned railway carriages
Economic security (assured basic income)
Many aspects of this are beyond health workers' jurisdiction as it is related to overall infrastructure development. But remember that good general health, including rehabilitation from conflict related injuries, enables people to seek employment.
Long term management of conflict related injuries, such as these deliberate amputations, can allow displaced people to seek employment
Food security (physical and economic access to food)
After the initial emergency phase of displacement, which incorporates therapeutic feeding programmes and provision of food supplies, a health worker's role may shift from the more practical to the dispensing of nutritional advice.
Health security (relative freedom from disease and infection)
Swift resumption of primary care services after a crisis can be more beneficial for the health of the affected population than intensive emergency medical and surgical aid. This means integrating displaced people into local healthcare structures and informing them about the care provided.
As a humanitarian response moves from the early phase, health care will shift in emphasis from managing acute problems to treating chronic disabilities and conditions
Health issues will inevitably shift in emphasis from acute problems to chronic conditions and from curative to preventive medicine. This raises questions about funding and provision, and whether treatments are available, accessible, sustainable, and affordable. Caution is necessary when starting a treatment (from simple dressings to drugs or psychosocial work) that may be difficult to continue once a non-governmental organisation has ceased to provide aid.
Health workers should be particularly aware of long term problems among the most vulnerable populations—elderly or disabled people, women, and children.
Environmental security (access to clean water and air and non-degraded land)
Environmental issues, such as a functioning sewerage system, electricity, running water, and refuse collection have an obvious impact on living standards and health. Such services are often unavailable or severely disrupted immediately after a disaster or conflict and may not be a priority in terms of long term infrastructure repair.
They may also not be seen as a priority by the displaced population if it is given responsibility to organise and pay for these public utilities, as happened in Bosnia. After eight years of providing subsidised utilities, the municipalities decided to charge the beneficiaries. Unaccustomed to paying bills, the beneficiaries in one camp let the debt accumulate until their electricity supply was finally cut off.
Common long term medical problems in internally displaced communities
Personal security (security from violence and threats)
The threat of land mines, unexploded ordnance, and gunfire affect both personal and environmental security and pose a considerable challenge to regeneration after conflict. Both internally displaced people and returnees face fear and intimidation from opposing political or ethnic groups in many post-conflict zones. Women and children in particular face harassment and danger in camps and centres, not only from opposition groups but also from members of their own communities.
In Bosnia, as in many places round the world, new generations of internally displaced people are growing up never having known a homeland or a settled way of life
Community security (security of cultural identity)
Loss of a homeland can lead to a loss of cultural identity. Cultural and ethnic groups may be dispersed and segregated after displacement. Security, dignity, and freedom to be educated and to practise cultural and religious beliefs are essential to preserving a sense of identity. Religious or community leaders often act as spokespeople in camps, and so an understanding of sensitive cultural issues is vital. Health care may also offer a neutral ground for reconciliation between communities.
Azerbaijan resettlement camp, one of the possible ways of ending displacement
Political security (protection of basic human rights)
Internally displaced people have the right to be treated with the same respect and dignity afforded to all citizens of their country. These rights continue if and when displaced people return home.
Resolving displacement
There are three possible resolutions to displacement: return and repatriation, resettlement, or asylum in another country. Each option has its own problems and requires a great deal of support.
The decision to end internal displacement should be voluntary, and depend on legislative, political, economic, and social reforms and the successful transition to peace or a return to "normality." The return process can be difficult to monitor and assess, however, as it is usually the responsibility of the host country. Displaced people should not feel forced to return, but the issues that militate against a return are often the same as those against remaining. These include infrastructure, security, employment, land, health care, and housing.
Many humanitarian projects cease when displaced people return home, but many returnees continue to need support, particularly in areas such as health care and education, for which the infrastructure is often still in the early phase of regeneration.
Conclusion
In a humanitarian response, aid agencies must consider their long term goals. Over an extended period, some internally displaced populations can and do adapt to their circumstances, creating their own conditions for coping, and even becoming self sufficient. However, many others become increasingly vulnerable and socially excluded.
The end of displacement is invariably a gradual process, requiring continued and sustainable support. This is particularly important for health care. Health professionals work in tandem with many other agencies and specialists in the field and have a vital role in the continuing care, assessment, and treatment of long term displaced populations.
Further reading
? Global IDP Project. Internal displacement: a global overview of trends and developments in 2003. www.idpproject.org/global_overview.htm
? Weiss Fagen P. Looking beyond emergency response. Forced Migration Review 2003;17: 19-21
? The Sphere Project. Humanitarian charter and minimum standards in disaster response. www.sphereproject.org/
? Ryan J, Mahoney PF, Greaves I, Bowyer G, eds. Conflict and catastrophe medicine—a practical guide. London: Springer-Verlag, 2002
? Médecins Sans Frontières. Refugee health—an approach to emergency situations. London: Macmillan, 1997
? International Committee of the Red Cross. www.icrc.org/
? UNHCR: the UN refugee agency. www.unhcr.ch/
This is the eighth in a series of 12 articles
Maria Kett is research fellow, Leonard Cheshire Centre of Conflict Recovery, University College London, London.
The photograph of a Ugandan girl with amputated hands was taken by Chris Steele-Perkins and supplied by Magnum Photos.
The ABC of conflict and disaster is edited by Anthony D Redmond, emeritus professor of emergency medicine, Keele University, North Staffordshire; Peter F Mahoney, honorary senior lecturer, Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham; James M Ryan, Leonard Cheshire professor, University College London, London, and international professor of surgery, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD USA; and Cara Macnab, research fellow, Leonard Cheshire Centre of Conflict Recovery, University College London, London. The series will be published as a book in the autumn.(Maria Kett, research fellow)