UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
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| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
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This document is being made available by the Population
Information Network (POPIN) Gopher of the United Nations Population
Division, Department for Economic and Social Information and Policy
Analysis, in collaboration with the United Nations Population Fund
Emergency Relief Operations. For further information, please
contact Dr. Daniel Pierotti, Senior Advisor, UNFPA Emergency Relief
Operations, 9, chemin des Anemones, 1219 Chatelaine, Geneva,
Switzerland.
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Inter-agency Symposium
on
Reproductive Health in Refugee Situations
June 28-30, 1995
Geneva, Palais des Nations
Background note
The explosion of ethnic conflicts that has marked the 1990s, as the
Cold War's end unfreezes long-dormant disputes, has created
humanitarian crises whose number and magnitude seem to increase
dramatically every year. In 1994, the scale and geographical spread
of such violent upheavals reached proportions that have few
parallels in recent history. In tiny Rwanda, in less than four
months, between half and two thirds of the country's population was
killed, died from epidemic diseases, or fled. It was the largest
and most catastrophic exodus the the international community has
witnessed since WW II.
Today, UNHCR estimates that 49 million refugees and internally
displaced people have been forced to leave their homes because of
conflict, massive human rights abuse, or the direct effects of
conflict, such as famine and lawlessness. In other words, one out
of every 113 people on this planet has been forced to leave his or
her home. Statistics on refugees and asylum seekers are rarely
broken down by gender, but as a rule of thumb, roughly
three-quarters of those destitute displaced people are likely to be
women and their dependent children. In areas of the world often
deeply scarred by suffering, exploitation and ill-health, these
refugee women and children -- deprived, by definition, of the
protection of their state -- are hard-hit by the violence and
uncertainty of displacement. Many have already survived situations
of extreme pain. They are among society's most vulnerable members.
While food, water, shelter, sanitation and preventive health care
do remain a priority, reproductive health-care is among the crucial
elements that can give refugees the basic human welfare and dignity
that is their right. The key issues are safe and adequate maternity
care; access to family planning and child spacing; treatment and
prevention of sexually transmitted diseases (including HIV/AIDS);
prevention of -- and response to -- sexual violence; gynecological
care; and prevention and treatment of complications arising from
the genital mutilation of girls.
The range of reproductive health services required by refugees are
similar to those needed by any other population. The difference:
refugees' needs are likely to be more influenced by trauma, in part
because, amid the chaos of displacement and exile, refugees are
more vulnerable to abuse. Compared to those of other populations,
the reproductive health-care needs of refugees are therefore likely
to be both more urgent and more acute.
The current symposium will unite field officers accustomed to
working with the realities of refugee situations and experts
specialized in reproductive health issues. Together, they will be
discussing the most effective and practical ways to cut down
sexually transmitted diseases, improve community education and
access to family planning, and make maternity safer in refugee
camps. They will be shaping the content of new reproductive health
services for refugees and developing refugee-specific tools that
can be easily implemented in the field. Finally, a field manual,
grounded in the practical experience of hundreds of refugee
aid-workers, will define what reproductive health services will be
implemented, how and where. It will be written following this
symposium and delivered to field offices before the end of 1995.
Reproductive Health For Refugees Today
Many refugees do have access to some degree of reproductive
health-care services. In virtually every refugee camp the world
over, maternity and ante-natal care at least equals the level
available to local populations. In addition, in many camps -- from
Afghanistan to Zaire -- refugee women have access to services that
include some availability of contraception and counselling.
Nonetheless, most health services in refugee camps are currently
confined to curative and maternal and child care. Prevention is
rare, and -- with a few exceptions -- there has been no systematic
strategy to offer basic reproductive health services to refugee
women, even in stable refugee situations. Other than childbirth,
reproductive health issues are often poorly addressed. Post-natal
care, family planning information and services, prevention of
unsafe abortion, prevention and treatment of the genital mutilation
of girls, prevention and management of assaults and rape -- and
even contraception and initiatives to prevent the spread of
sexually transmitted disease -- are far from systematic in refugee
health-care. In the vast majority of refugee situations, much of
the direct work of health-care is undertaken by international
agencies and non-governmental organizations. UNHCR essentially
operates as a contractor: administering, coordinating and
monitoring. WHO (World Health Organization), UNICEF (United Nations
Children's Fund), UNDP (United Nations Development Program) and
other UN agencies play a variety of technical and operational roles
that vary from case to case. UNFPA has recently become more
actively engaged in refugee issues, recognizing the urgent need to
protect the reproductive rights of populations in areas of crisis,
and has approved three projects in the Rwanda/Burundi crisis area,
totalling just over US$1 million. Countless non-governmental
organizations, including those present at the symposium, are also
active in refugee health-care.
The humanitarian organizations that together struggle to assist and
protect refugees the world over urgently need more effective
guidance on providing reproductive health care to refugees. They
need well-designed models that can swiftly introduce or improve the
coverage, quality, and coordination of such services in refugee
situations. UNHCR field staff need to be equipped with monitoring
and management information systems, so that they can oversee and
guide the work of other health-care teams. The refugees need
appropriate, culturally acceptable community education. Finally,
all the international agencies and non-governmental organizations
who work in refugee situations, whether alongside UNHCR or under
UNHCR supervision, need more effective co-ordination and a clear,
joint commitment to this work.
These agencies are meeting to make a public and detailed
commitment to giving refugees access to effective reproductive
health-care, as rapidly as possible. Clinics in refugee camps -- as
elsewhere -- should offer counselling and treatment of sexually
transmitted disease, AIDS awareness and prevention; ante- and
post-natal consultations; infant immunization and preventive
personal hygiene; family planning, including condoms; gynecological
treatment; treatment of incomplete abortion; advice on nutrition
and breast-feeding; and counselling on rape.
The Basic Building Blocks, from Emergency To Repatriation
Even among the chaos and trauma of mass exodus, basic reproductive
care can -- and should -- be delivered to refugees, as part of
every minimum health-care package. As the emergency stabilizes,
reproductive health-care should be upgraded to meet the minimal
standards of human well-being.
If such standards exceed local conditions, agencies should see this
as an opportunity to improve existing health services to local
populations. Similarly, our work for refugees should be extended to
their repatriation. UNHCR and other agencies already operate
numerous small-scale projects to improve the health-care facilities
available to refugees who return home, but such efforts are
neccessarily limited. UNFPA, WHO, UNICEF and other agencies will
play a vital role in assisting governments to reinforce (or create)
reproductive health services.
Safe Motherhood
In any refugee population, some 20% of adult women may be pregnant
at any given time. The fear and hardship of their flight increases
the likelihood of spontaneous miscarriage or other birth
complications. In addition, at least 15% of women who do give
birth at term are likely to develop some complication and may need
more sophisticated medical care, including surgical intervention.
Access to this care should be considered a priority.
In most refugee situations, the majority of births are likely to
take place in the community. Clean delivery is critical to the
safety of both mother and child. No emergency should be without
provision for clean delivery -- including supplies of gloves,
needles, syringes, and essential drugs. Even in the first few days
of a refugee crisis, and despite the often overwhelming
difficulties that emergency teams typically face, some provision
needs to be made for births -- some normal, some complex --
miscarriage, and rape. These measures should be constantly
upgraded as a refugee emergency moves into more stable phases.
Sexual Violence
Rape is a horrifyingly common element in the pattern of
persecution, terror or "ethnic cleansing" that drives refugee
families from their homes, as civilians increasingly become the
targets -- rather than the accidental victims -- of warfare.
Subsequently, the road to asylum is itself paved with sexual
violence and exploitation. The perpetrators may be bandits,
smugglers, border guards, police, military and irregular forces on
both sides of the border, or elements of local populations taking
advantage of defenseless arriving refugees. The need to cross
military lines or regions affected by anarchy or civil war to reach
safety puts women and girls at particular risk. Once in exile,
women and girls are still subject to sexual violence or
exploitation, by camp officials or other refugees.
UNHCR has already developed formal guidelines on preventing and
responding to sexual violence, based on detailed recommendations
by field workers experienced with the rape and piracy attacks on
Vietnamese boat-people, rapes of Somali women in Kenya, and the
'ethnic cleansing' rapes of women in Bosnia. The guidelines aim to
provide field workers with practical, non-specialist advice on the
medical, psychological and legal ramifications of sexual violence.
They are also intended to dispel the discomfort of many refugee
workers with such acts -- or any tendency to dismiss them as an
inevitable by-product of social breakdown. Protection from rape,
prevention of rape and appropriate response to rape is the duty of
every government and humanitarian agency. Counselling and adequate
medical services should be open to every refugee, along with the
appropriate legal and protection measures.
AIDS and Sexually Transmitted Disease
Similarly, refugees need adequate care and prevention techniques
for sexually transmitted disease. The HIV/AIDS pandemic --
particularly in Rwanda/Burundi emergency, where prevalence is
particularly high -- has brought this issue to the fore. To date,
according to WHO, at least 18 million people worldwide have been
infected with the virus that causes AIDS. HIV spreads fastest in
conditions of poverty, and social instability: in other words, in
refugee emergencies and refugee camps. Condoms and equipment to
ensure safe blood transfusion should be part of any minimum
health-care package.
Family Planning and Child Spacing
As refugee situations stabilize, an increasingly broad range of
appropriate contraceptive techniques should be made available.
Studies have suggested that the large number of unwanted
pregnancies in refugee camps result mainly from lack of access to
proper contraception. Such situations often lead to unsafe
abortion, sepsis, hemorrhaging, infertility and even death.
Refugee women should not have to die for lack of contraception.
Women in refugee camps may be under pressure -- or may themselves
desire -- to replace lost relatives and children. Still, family
planning can be important in allowing women free choice; in
preventing maternal and newborn deaths; and (particularly for
condoms) in preventing disease.
More Effective, More Accessible, More Appropriate Care
In September 1994, the International Conference on Population and
Development in Cairo recognized that "reproductive health care and
family planning are vital human rights." Refugees share those
rights. UNHCR, UNFPA and their sister and partner agencies are
committed to facilitating them.
This will, necessarily, be a multi-sectoral approach. Reproductive
health programs need to be integrated within primary health-care,
but they also extend to community services and legal, protection
activities. The refugees themselves will be a valuable resource in
this effort. Many refugees are qualified and experienced in a wide
range of professions. They can offer their skills as field workers,
health visitors and community distributors. In addition, they can
offer their advice. Only the refugees themselves can tell
health-care providers about their particular needs.
No reproductive health programs can work without the help and
support of an entire community. They must be acutely sensitive to
social and cultural beliefs, and to the refugees' right to be fully
informed and to exercise free choice. Similarly, these programs
must be consistent with national laws, as well as with universally
recognized human rights. They must be practical, rapid,
compassionate -- and above all, effective.