Module 3: Food, Water, Sanitation, and Housing in Refugee Camps

Food

“I spent years in a refugee camp in Ethiopia, and there I watched two young boys, perhaps twelve years old, fighting so viciously over rations that one kicked the other to death. He had not intended to kill his foe, of course, but we were young and very weak.” (1) This quote from a refugee highlights the realities of living in a refugee camp, where there is not enough food in the camps. Chronic malnutrition makes refugees fragile and more susceptible to a variety of diseases and illnesses. Most refugee camps do not have sufficient food to provide to their populations, and refugees are frequently dependent entirely on humanitarian aid. The United Nations High Commissioner for Refugees (UNHCR) recommends that each refugee receive more than 2,100 calories per day, but often camps fall short of this standard. For example, in 2005 and 2006, the daily amount of distributed food in Tanzanian refugee camps was 1,700 and 1,460 kilocalories per person, respectively.(2) A 1987 study in the largest refugee camp on the Thai side of the Thailand-Cambodian border found that 30% of the population was chronically malnourished.(3) In addition, a joint UNHCR and WFP review conducted in 2006 discovered unacceptable rates of acute malnutrition in many protracted refugee camps, most notably in Kenya, Ethiopia and Sudan.(4) Even if a refugee receives the recommended amount of calories per day, caloric intake is further reduced as refugees tend to sell food rations for other non-food goods. Moreover, it is not only the quantity of food that is insufficient. The lack of food variety, fruits, and vegetables causes many refugees to suffer from deficiencies in essential vitamins and minerals, which can lead to a variety of diseases. For example, chronic deficiencies of vitamin A can lead to xeropthalmia and blindness in childhood, while iron deficiency can lead to anemia, vitamin C deficiency leads to scurvy, niacin deficiency causes pellagra, and thiamin deficiency results in beriberi.(5) Meheba refugee camp in Zambia, mentioned in Module One, is more of a permanent settlement and therefore refugees are encouraged to grow their own food in small gardens, cutting down on malnutrition and ensuring the consumption of some fruits and vegetables. These gardens serve as a supplement to UNHCR food rations given out monthly and individuals are not allowed to grow and sell surplus of food for economic benefit. Many refugees there complain that monthly rations are not adequate and children and adults are left hungry, cutting down on their productivity and ability to work. At the Meheba camp clean water pumps have been installed that are within walking distance of every part of the settlement, decreasing the chances of disease spread through water contamination and pollution.(6)

Coping Mechanisms

In some refugee camps in Bangladesh, refugees use farming patches to produce vegetables, garlic and spices to enhance the taste and nutrition of the rations that they receive.(7) Unfortunately, most camps either do not let refugees participate in agriculture or there is not enough rainfall or water to do so. Thus, refugees have developed innovative mechanisms for obtaining more food. One of the main ways that refugees obtain more food is through a process called recycling in which they leave the camp and reenter under a new identity, thereby gaining an extra ration card.(8) Recycling in itself is a dangerous process and also contributes to the presence of a black market in many refugee camps.

Water

It is essential for refugees to receive an adequate quantity of good quality water because water has an impact on so many vital sectors of society, including nutrition, health, education and sanitation. The UNHCR estimates that more than half of the refugee camps in the world are unable to provide the recommended daily water minimum of 20 liters of water per person per day.(9) Ensuring that the refugees receive an adequate quantity of water is an important public health issue because lack of clean water is correlated with the presence of diseases such as diarrhea and cholera. A 2005 study carried out in Kakuma Refugee Camp in Kenya found that there were 11 cholera cases among the households who had access to 110L/day. Meanwhile, there were 32 cases of cholera among the households who had access to 44L/day. Cholera affected 163 people amongst households with access to only 37L of water per day.(10) Similar trends were found regarding diarrhea. A study carried out between 2005 and 2006 in Kenyan and Ghanaian refugee camps found that the households who reported a case of diarrhea within the previous 24 hours collected 26% less water on average than those households who did not report any cases.(11)

Though it is important to provide adequate quantities of water, the water quality and hygiene is also of the utmost importance. Even if the water that is provided is not contaminated, the transfer of water between vessels, the storage of water in the home, and touching the inside of water vessels with the hands are risk factors for contamination. In order to attempt to control contamination, public health initiatives focus on hygiene education and the distribution of an “improved bucket”, which has been used in Nyamithuthu Refugee Camp in southern Malawi. The improved bucket is a 20-liter container that has a constraining lid to dissuade hand entry, as well as a spout for easy pouring. These improved buckets had fecal coliform values that were 53.35% lower than the control vessels.(12) The use of water purification tablets that dissolve in water can also help to decrease diarrheal diseases and can be used for large quantities of water depending on the size of the tablet.(13)

It is also important for the water to be readily accessible, and the taps should be centrally located. If the water taps are far away, children might have to interrupt their schooling to collect water for their families. In addition, if the water taps are very far away, the physical burden of water collection grows immensely. For example, if a person draws water for all of their family’s needs (around 80L) from a well located 200 meters from their home, they may use up to 1/6 of their rationed calories for the day on this one task.(14) The UNHCR therefore recommends that all households have access to a water tap that is less than 200 meters away. Unfortunately, many refugee camps do not meet this standard. Refugee camps in Uganda, for example, have particularly poor access to water. Only 43% of the population has access to water taps that are within 200 meters. In addition, there are over 450 people per water tap, far exceeding the UNHCR standard of 200 persons per water pump.(15)

Sanitation

The provision of adequate sanitation services is crucial to prevent communicable diseases and epidemics while ensuring good health and dignity. Though the importance of having adequate latrines is well documented, still 30% of refugee camps do not have adequate waste disposal services or latrines.(16) A study conducted in refugee camps in Bangladesh found that camps that provided sanitation facilities had cholera rates of 1.6 cases per 1,000 people, while camps that had no such facilities had cholera rates that were almost three times greater (4.0-4.3 cases per 1,000 people).(17) In addition to providing latrines and sanitation services, it is also important to provide the population with sufficient resources to curb diseases and epidemics. A study in a Kenyan refugee camp found that sharing a latrine with 3 or more households was found to be a significant risk factor for cholera due to an increase in the fecal-oral transmission of the disease.(18) By promoting the importance of cleanliness in communal bathing and latrine areas, refugees can be made aware of the dangers associated with dirty and contaminated water.

Housing

“It is argued that a safely built environment, including adequate housing conditions, is one of the most elemental human needs. Nonetheless, around one billion (one-sixth) of the world’s population currently live in slums and squatters and a large proportion of refugees reside in inadequate shelters.”(19) Housing in refugee camps is often overcrowded and of inferior quality. In Sri Lankan refugee camps, a typical house is a small wooden one-room hut with a corrugated iron roof. The houses are poorly ventilated, overcrowded, and have no chimney.(20) A study of houses in Jalazone, a Palestinian refugee camp, documented the poor housing conditions and found that dampness was present in 72.5% of the houses, while 50.5% had mold, 37% had leaks, and only 41.5% were exposed to the sun.(21) In addition, in Jalazone, 61% of the households had 3-5 people per room, while 16.5% of the households had over 5 people per room.(22)

Malaria poses a huge threat to adults and children alike in refugee camps, especially where refugees live en masse in close quarters, without window screens or solid doors. When refugees first flee across their borders into camps, they are sometimes provided with mosquito nets, tarps, grass mats, and blankets. However, insecticide-treated nets (ITNs) usually lose their effectiveness after 3-5 years, and must be replaced.(23) The ‘Nothing but Nets’ Campaign partners with UNHCR to deliver mosquito nets to prevent malaria, especially among children, but malaria is still rampant, infecting 200 million every year.(24)

It is essential to provide safe homes that are free of physical hazards.(25) The presence of dampness and mold is associated with a range of symptoms and illnesses, including aches and pains, digestive disorders, and respiratory tract infections.(26) Crowded, cramped conditions have also been associated with acute respiratory infections, and poor mental health among children.(27) A study done in Sri Lanka demonstrated the poor housing conditions in refugee camps and found that living in a transitional camp as compared to a permanent house was a significant risk factor for coughs, stomach ailments, headaches, and generally feeling unwell.(28) Poor housing also is correlated with an increased presence of rodents, which causes an increased incidence of Lassa fever in West African countries.(29) Inadequate housing is also an important public health issue because it can lead to anxiety, stress and even high blood pressure.(30)

Footnotes

(1) Eggers, D. What is the What; the Autobiography of Valentino Achak Deng. (New York: Random House, 2006), 9.

(2) Bruijn, B. “Human Development Research Paper 2009/25. The Living Conditions and Well-being of Refugees.” United Nations Development Programme. (2009).

(3) Reedy, J. (2007). The Mental Health Conditions of Cambodian Refugee Children and Adolescents (Doctoral dissertation, The Ohio State University).

(4) Bruijn, B. “Human Development Research Paper 2009/25. The Living Conditions and Well-being of Refugees.” United Nations Development Programme. (2009).

(5) Prinzo, Z., and de Benoist, B. “Meeting the challenges of micronutrient deficiencies in emergency-affected populations.” Proceedings of the Nutrition Society. 61 (2002): 251-257.

(6) FORGE Refugee Camps.https://www.forgenow.org/content/forge-refugee-camps.

(7) Bruijn, B. “Human Development Research Paper 2009/25. The Living Conditions and Well-being of Refugees.” United Nations Development Programme. (2009).

(8) Eggers, D. What is the What; the Autobiography of Valentino Achak Deng. (New York: Random House, 2006), 387.

(9) UNHCR. “Water, Sanitation and Hygiene (WASH).” https://wash.unhcr.org/what-we-do/.

(10) UNHCR, “Access to Water in Refugee Situations.” https://www.un.org/waterforlifedecade/pdf/unhcr_water_brochure.pdf.

(11) Cronin, A. et al., “A review of water and sanitation provision in refugee camps in association with selected health and nutrition indicators – the need for integrated service provision.” Journal of Water and Health. 6.1 (2008).

(12) Roberts, L., et. al., “Keeping clean water clean in a Malawi refugee camp: a randomized intervention trial.” Bulletin of the World Health Organization. 79.4 (2001): 280-287.

(13) Tesfaye, F. Ethiopia: New Water Purification Tablet Launched. Daily Monitor. 19 October 2008. https://allafrica.com/stories/200810220628.html.

(14) UNHCR, “Access to Water in Refugee Situations.” https://www.un.org/waterforlifedecade/pdf/unhcr_water_brochure.pdf.

(15) Bruijn, B. “Human Development Research Paper 2009/25. The Living Conditions and Well-being of Refugees.” United Nations Development Programme. (2009).

(16) UNHCR, “Access to Water in Refugee Situations.” https://www.un.org/waterforlifedecade/pdf/unhcr_water_brochure.pdf.

(17) Cronin, A. et al., “A review of water and sanitation provision in refugee camps in association with selected health and nutrition indicators – the need for integrated service provision.” Journal of Water and Health. 6.1 (2008).

(18) Shultz. A, et. al. “Cholera Outbreak in Kenyan Refugee Camp: Risk Factors for Illness and Importance of Sanitation.” The American Journal of Tropical Medicine and Hygiene. 80.4 (2009): 640-645.

(19) Habib, R., Basma, S., and Yeretzian, J. “Harboring illnesses: On the association between disease and living conditions in a Palestinian refugee camp in Lebanon.” International Journal of Environmental Health Research. 16.2 (2006): 99-111.

(20) Turner, A., Pathirana, S., Daley, A., and Gill, P. “Sri Lankan tsunami refugees: a cross sectional study of the relationships between housing conditions and self-reported health.” BMC International Health and Human Rights. 9.16 (2009).

(21) Al Khatib, I. A., & Tabakhna, H. (2006). Housing conditions and health in Jalazone Refugee Camp in Palestine. EMHJ-Eastern Mediterranean Health Journal, 12 (1-2), 144-152, 2006.

(22) Ibid.

(23) Lorenz, L., et al. “Investigating mosquito net durability for malaria control in Tanzania—attrition, bioefficacy, chemistry, degradation and insecticide resistance (ABCDR): study protocol.” BMC Public Health. 14.1266 (2014).

(24) Nothing but Nets. https://nothingbutnets.net/.

(25) National Center For Healthy Housing. “Where We Live Matters for our Health: The Links Between Housing and Health.” Robert Wood Johnson Foundation. 2008. https://nchh.org/resource/rwjf_where-we-live-matters-for-our-health_the-links-between-housing-and-health/.

(26) Turner, A., Pathirana, S., Daley, A., and Gill, P. “Sri Lankan tsunami refugees: a cross sectional study of the relationships between housing conditions and self-reported health.” BMC International Health and Human Rights. 9.16 (2009).

(27) Habib, R., Basma, S., and Yeretzian, J. “Harboring illnesses: On the association between disease and living conditions in a Palestinian refugee camp in Lebanon.” International Journal of Environmental Health Research. 16.2 (2006): 99-111.

(28) Turner, A., Pathirana, S., Daley, A., and Gill, P. “Sri Lankan tsunami refugees: a cross sectional study of the relationships between housing conditions and self-reported health.” BMC International Health and Human Rights. 9.16 (2009).

(29) Bonner, P. et. al. “Poor Housing Increases Risk of Rodent Infestation and Lassa Fever in Refugee Camps of Sierra Leone.” The American Society of Tropical Medicine and Hygiene. 77.1 (2007): 169-175.

(30) Al Khatib, I. A., & Tabakhna, H. (2006). Housing conditions and health in Jalazone Refugee Camp in Palestine. EMHJ-Eastern Mediterranean Health Journal, 12 (1-2), 144-152, 2006.