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Spring World Health Organization Background Guide I. II. Combating the growing health concerns among refugees and within refugee settlements Developing rapid response mechanisms to infectious disease outbreaks. Evan Cotreau, Head Chair [email protected] Mai Nagabayashi [email protected] 17 World Health Organization (WHO) What is the WHO, and what do they do The World Health Organization’s underlying goal is to build a healthier future for people all over the world. WHO works in offices in over 150 countries, working side by side with governments and other partners to ensure the ability to provide healthy living conditions for people throughout the world. In conjunction WHO strives to combat diseases and infectious diseases. We help mothers and children survive in conflict areas. We ensure the air people breathe is safe, the water they drink is clean, and the food they eat isn’t rotten. WHO is also committed in providing medicines and vaccines to areas that need them. Where WHO Works WHO supports countries to attain their health goals, by working within the established national policies and strategies at combating health problems. WHO assists countries by establishing collaborative efforts amongst multiple sectors of government and partners including, bi- and multilaterals and funds and foundations. WHO also encourages civil society organizations and bodies within the private sector to help in achieving these goals. Committee Information The ultimate agenda of the WHO is for “the attainment by all people of the highest possible level of health,” with responsibilities ranging from providing leadership in global health epidemics and research to monitoring trends and offering support within countries. As such, the: WHO fulfills its objectives through its six core functions: ● Providing leadership on matters critical to health and engaging in partnerships where joint action is needed; ● Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; ● Setting norms and standards and promoting and monitoring their implementation; Articulating ethical and evidence-based policy options; ● Providing technical support, catalyzing change, and building sustainable institutional capacity; and ● Monitoring the health situation and assessing health trends The governing forum of WHO is the World Health Assembly (WHA). The WHA is composed of the health ministers of all 194 member states of WHO, and is the world’s highest health policy setting body. Resources ● ● ● ● World Health Organization: http://www.who.int/en/ CIA World Factbook: https://www.cia.gov/library/publications/the-world-factbook/ World Health Organization http://www.who.int/about/en/ Constitution of the World Health Organization http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1 Topic 1: Combating the growing health concerns among refugees and within refugee settlements Refugees are a tragic reminder of the wars, oppression and famine that continue to taint our rapidly changing world, forcing millions of uprooted people into exile and focusing international attention onto forgotten conflicts and isolated, little-known countries. The United Nations High Commissioner for Refugees (UNHCR) has reported that in 2015, there are a total of 65.3 million who are forcibly displaced, 21 million of whom are refugees and 10 million are stateless people.1 The conflict in Syria transitioned from an insurgency to a civil war during the summer of 2012. For the first year of the conflict, Bashar al-Assad relied on his father’s counterinsurgency approach; however, his campaign failed to put down the 2011 revolution and accelerated the descent into civil war. As the Assad regime lost its counterinsurgency campaign, Syria falls into a civil war killing 450,000 civilians2 From the fall of the Assad regime to the ongoing threat of ISIS, Syria remains the center of attention in the media. As such, the highest number of refugees are in Syria with a total of 4.8 million refugees, almost 1.4 million Syrians fled the country in 2015, UNHCR says.3 As many of them are settled in neighboring countries, including Turkey (2.7 million), Lebanon (1.05 million), Jordan (655,000), and Iraq (247,000). The vast majority of Syrian refugees remain in the Middle East with little or no medical nor health care. The seriousness of this issue is intensified by the increase in diseases, injuries, mental and psychological wellness concerns as a result from the traumatic outcomes of war that added to the underlying decrease in the accessibility of health social insurance. Amongst other issues include the need for cooperation and funding from developed nations, intergovernmental organizations (IGOs) and non-governmental organizations (NGOs). There are a number of health concerns amongst refugees and refugee settlements. While many suffer from physical illness, some also suffer face mental concerns due to post traumatic stress disorder (PTSD) from recent experiences as many they may have lost relatives and friends, and they have certainly been forced to abandon homes and possessions, and a way of life. While mental health is a main concern for many refugees, the physical health concerns and needs of refugees and IDPs is of the utmost importance, as diseases are plagued around war-torn countries4 Food Concerns 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.5 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. As 170,000 refugees flee their home country in Sudan to escape conflict, many are faced with food insecurity in two refugee camps in 1 UNHCR, Figures at a Glance: http://www.unhcr.org/en-us/figures-at-a-glance.html I AM SYRIA, Death Toll: http://www.iamsyria.org/death-tolls.html 3 http://www.unhcr.org/en-us/news/press/2015/7/559d67d46/unhcr-total-number-syrian-refugees-exceeds-fourmillion-first-time.html 4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231133/ 5 http://www.unhcr.org/45fe62642.pdf 2 South Sudan. New epidemiological data shows that refugees are suffering from malnutrition and also mortality.6 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 xerophthalmia 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 beriberi7 The Dzaleka refugee camp is located in the central region of Malawi and hosts refugees mostly from the Great Lakes and Horn of Africa regions. Due to the lack of funding, the World Food Programme (WFP) has been forced to reduce rations. Ration cuts mean that refugees are only receiving 40 percent of the recommended minimum daily kilocalories, compromising longstanding efforts to achieve food security in Dzaleka camp. Currently, the refugees are only receiving three of the five planned foods – and even then a lot of their food are served in half the initial amount. The WFP would require a sum of US$2 million to continue the provision of full rations for the next months. In order for refugees to be well-nourished, it is recommended that each refugee must obtain 2100 calories a day to be fit and healthy. As such, there needs to be 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 a more balanced diet. Water Concerns According to the UNHCR, 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. The lack of clean water is correlated with the presence of diseases such as diarrhea and cholera, therefore, it is an important public health issue to ensure that refugees receive an adequate quantity of water. 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.8 In 2005, there were 11 cholera cases amongst the households who has access to 110L per day in the Kakuma refugee camp in Kenya. Meanwhile, Cholera has affected 163 people amongst households with access to only 37L of water per day. 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. It is also vital for 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. In order for refugees to be able to get access to clean water, it is 6 Doctors Without Borders, Catastrophic Malnutrition in Refugee Camps: http://www.msf.ca/en/article/catastrophicmalnutrition-refugee-camps 7 https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition-growth.html 8 Refugee Camp Water: https://www.alws.org.au/media/wysiwyg/discovermore/schools/awareness_week_2015/Refugee_Camp_Water_1.pdf important that there are readily available water nearby camps so refugees do not have to travel afar. The UNHCR therefore recommends that all households have access to a water tap that is less than 200 meters away. In addition, the use of water purification tablets that self-dissolve in water, often chlorine-based can also help to decrease diarrhoeal diseases and can be used for large quantities of water depending on the size of the tablet. 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. Sanitation Concerns 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. 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 four times greater (4.0-4.3 cases per 1,000 people)9 In addition to providing latrines and sanitation services, it is also important to provide the population with sufficient resources to curb diseases and epidemics. As the number of refugee constantly increases day by day, this creates a more pressing issue on infrastructural housing and sanitation. In 2013, at a camp for Syrian refugees in Iraq, aid agencies say overcrowded living conditions in Domiz (Duhok Province) - built for 25,000 refugees but now accommodating almost twice that number - have put refugees’ health at risk.10 At the same time, this is putting a strain on water contamination that could lead to various of other diseases as well. Diarrheal disease, the second leading cause of death in children under the age of 5, is preventable if appropriate water, sanitation and hygiene infrastructure and practices are in place. 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.11 The key to a good hygiene and sanitation program is creating positive behavior change so that infrastructure that is developed is used and maintained. 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. Mental Concerns 9 UNHCR, A review of water and sanitation provision in refugee camps in association with selected health and nutrition indicators – the need for integrated service provision: http://www.unhcr.org/enus/protection/environment/4add71179/review-water-sanitation-provision-refugee-camps-association-selectedhealth.html 10 IRIN News, Containing disease in a Syrian refugee camp in Iraq: http://www.irinnews.org/report/98349/containing-disease-syrian-refugee-camp-iraq 11 NCBI, Cholera outbreak in Kenyan refugee camp: risk factors for illness and importance of sanitation: https://www.ncbi.nlm.nih.gov/pubmed/19346392 While living in their home country, refugees often experience traumatic events and adverse situations such as sexual violence, genocide, torture, political persecution, the loss of loved ones, and forced child soldiering, which frequently prompt them to escape from their country of origin. Similarly, violence often characterizes the would-be safe haven of the UNHCR refugee camps in the immediate aftermath of the refugees’ flight. Following the Rwandan genocide of 1994, much of the Hutu tribe escaped into neighboring Democratic Republic of Congo and other bordering countries, as the Tutsi tribe took over power and enacted revenge on those Hutus they believed were responsible for the 1994 genocide. However, amongst the fleeing ‘refugees’ were war criminals, who used the refugee camps in the Democratic Republic of Congo as a base and cover to launch attacks against those now in power in Kigali, Rwanda’s capital. These Hutu militiamen used fear tactics and propaganda to keep the refugees complicit in order to recruit allies and fighters. These tactics furthered violence in the area and severely affected the psychological health of refugees who were already recovering from a ghastly genocide. However, it is not only traumatic events or experiences that affect the mental health of refugees. Recent work has shown that the daily hassles of living in refugee camps, such as waiting in line at the water tap, also negatively impact mental health. refugees have witnessed and experienced many traumatic events, as well as multiple and chronic adversities, they have a high risk of developing mental health problems and have a higher prevalence of psychological disorders, in particular depression and post-traumatic stress disorder (PTSD). PTSD is an anxiety disorder which often occurs after witnessing or experiencing an event that is personally threatening. It is important to address the mental health of refugees because mental illness severely impacts the functioning of a person in many different ways and can also contribute to poor physical health. For example, mental illness often negatively impacts the ability of an individual to engage in economically productive activities, to benefit from educational opportunities, and also makes one more prone to experiencing addictive substance abuse and a dysfunctional family life. Thus, in order to ensure the refugees’ successful adaptation and functioning after resettlement, it is critical to identify and treat mental health illness. Questions to Consider in Your Research ● Myanmar’s Rakhine State: What is the current health concern within the Rohingya refugee settlement? ● Where is the funding coming from? ● What are the concerns within host countries? I.E. spread of diseases ● What is your country doing specifically regarding this issue? Resources Healthcare Access and Conditions in Refugee Camps: https://www.cdc.gov/immigrantrefugeehealth/profiles/congolese/healthcareaccess/index.html Migration and Health: Key Issues: http://www.euro.who.int/en/health-topics/health-determinants/migration-andhealth/migrant-health-in-the-european-region/migration-and-health-key-issues#292936 Doctors Without Borders: http://www.doctorswithoutborders.org/country-region/syria Health Care in Refugee Camps and Settlements: http://www.uniteforsight.org/refugee-health/module1#_ftn5 Current Research on Mental Health of Syrian Refugees: https://www.apa.org/international/pi/2015/09/noor-baker.pdf The Ongoing Humanitarian Emergency in Myanmar’s Rakhine State: http://www.doctorswithoutborders.org/news-stories/field-news/ongoing-humanitarianemergency-myanmars-rakhine-state Rohingya Face Health Care Bias in Parts of Asia, Study Finds: https://www.nytimes.com/2016/12/05/world/asia/rohingya-myanmar-health-care.html Topic 2: Developing rapid response mechanisms to infectious disease outbreaks. We live in a world today, rapidly increasing in globalization and industrialization. With the increased mobility of individuals, international trade, deforestation, and the impacts of urbanization not only rapidly changing the world we live in, but linking us together more and more. Add to this the rapid adaptation of microorganisms, which has brought forth the return of many old communicable diseases and the emergence of new ones. Antimicrobial resistance has caused many curative treatments to be less effective in a wide range of diseases. This has lead to many scenarios where a communicable disease in one country can be a concern for other countries. In industrialized countries, communicable disease mortality has decreased greatly in recent years. The concern now lies in preventing the resurgence of past disease epidemics and preventing the outbreak of new ones. In developing countries, the biggest concern is detecting communicable disease outbreaks, and preventing them from spreading. This has to be done by responding to outbreaks early and stopping the spread of the disease before it has a major impact on public health, trade, and tourism. Both developing and industrialized countries share one major means of addressing these health concerns, and it is by developing a strong surveillance system to measure risk. In order for this to be fully effective, it would be in the best interest of nations developing national surveillance systems to develop global partnerships.12 What are Infectious Diseases Infectious diseases are caused by pathogenic microorganisms, including bacteria, parasites, fungi, and viruses. These diseases can be spread both, directly or indirectly, from person to person. Zoonotic diseases are infectious diseases of animals that can cause disease when transmitted to a human.13 Some examples of infectious diseases are Tuberculosis, Influenza, Measles, Malaria, Meningitis, Yellow Fever, HIV/AIDS, Ebola virus disease, Cholera, and Sever acute respiratory syndrome. ca Communicable Diseases A communicable disease is an infectious disease transmissible by direct contact with an affected individual or the individual's discharge or by indirect means. Factors that increase the spread of communicable diseases can derive from environmental, socioeconomic, and behavioral sources, and can spread by international travel and migration. Vaccine-preventable, foodborne, 12 World Health Organization Global Infectious Diseases Surveillance: http://www.who.int/mediacentre/factsheets/fs200/en/ 13 World Health Organization Infectious Diseases: http://www.who.int/topics/infectious_diseases/en/ zoonotic, health care-related and communicable diseases pose significant threats to human health and may sometimes threaten international health security. WHO has developed standards and guidelines, with cooperation of governments, to help countries implement effective disease prevention and control programs and to address risk factors.14 It is important to note that many communicable diseases can also be considered as an infectious disease. The distinguishing factor that determines if a disease is communicable is if it can be spread by direct contact with an infected individual or bodily fluids. Some communicable disease to consider are Ebola virus disease, Flu, Hepatitis B, HIV/AIDS, Measles, MRSA, Rabies, West Nile Virus, Zika, Tuberculosis, and Sexually Transmitted Diseases. Emerging Diseases As defined by the WHO, “an emerging disease is one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic region.”15 In December of 2015, public health experts and scientist were brought together by WHO to meet in Geneva to discuss emerging pathogens that are most likely to cause an outbreak in the foreseeable future, and to assess what current medical countermeasures exist in treating these diseases. They developed a list of diseases that are of the most concern, that will become the focus on WHO’s future research and development projects to help control the possibility of future outbreaks. The following list reflects the disease priorities needing urgent research and development Crimean Congo hemorrhagic fever Ebola virus disease Lassa fever MERS SARS Marburg Rift Valley fever Nipah This list provided the foundation for the WHO Blueprint for R&D preparedness, which focuses on accelerating research and development on emerging dangerous pathogens, which have the most potential to create an epidemic. The Blueprint also advocates for allocating initial resources to research and development in order to help generate diagnostics, vaccines and treatments for all the diseases within the list. This Blueprint demonstrates WHO’s commitment to providing effective and efficient treatment in the potential case of an epidemic of these emerging diseases. 14 WHO Regional Office for Europe Communicable Diseases: http://www.euro.who.int/en/healthtopics/communicable-diseases 15 WHO Emerging Diseases: http://www.who.int/topics/emerging_diseases/en/ Chikungunya, severe fever with thrombocytopenia syndrome, and Zika were determined to be serious emerging diseases, that will require action by WHO in order to promote research and development, but not to the severity of the other diseases within the Blueprint. It was also found that HIV/AIDS, Malaria, Avian influenza, Dengue, and Tuberculosis all have epidemic potential. The reasoning behind why they were not included in the Blueprint was due to the vast disease control and research networks that already exist for these infectious diseases.16 WHO’s Role in the Surveillance of Diseases From 1992 on, there has been growing concerns over emerging and re-emerging diseases. This has resulted in several national and international initiatives to improve and restore the surveillance and control of communicable diseases. In 1995 the World Health Assembly produced a resolution urging all Member States to strengthen surveillance for infectious diseases in order to detect the emergence of previous diseases and to identify new infectious diseases. The Assembly recognized that in order for this resolution to be successful, it would depend on the ability to obtain information on infectious diseases and the willingness of sovereign nations to communicate the information nationally and internationally. Improving the detection and surveillance of re-emerging and new infectious diseases, will lead to better prioritization of public health efforts both nationally and internationally. WHO has utilized a global surveillance system which links together existing local, regional, national and international networks of medical centers and labs to create a super surveillance network. This network is being constructed with the 191 WHO Member States and other partners, that includes the European Union-United States Task Force on Emerging Communicable Diseases and the US-Japan Common Agenda. 17 WHO’s Alert and Response Operations In order to protect the population from emerging epidemics, WHO continuously dedicates resources to track evolving infectious diseases. This allows for the spread of information amongst countries that will allow for appropriate responses when needed to protect the health of their people. Since June of 2007, the International Health Regulations have been enforced, with four main areas of focus, protect, prevent, control, and provide a public health response. All of these areas of focus must work in synergy in order to protect the populations at risk from the international spread of disease. The IHR provides a framework for WHO alert and rapid response activities that are already implemented, and strengthens countries abilities to control international outbreaks, while simultaneously strengthening international public health 16 WHO WHO publishes list of top emerging diseases likely to cause major epidemics: http://www.who.int/medicines/ebola-treatment/WHO-list-of-top-emerging-diseases/en/ 17 World Health Organization WHO’s role in disease surveillance: http://www.who.int/mediacentre/factsheets/fs200/en/ security. It is important to note that the regulations within the IHR must consider international traffic within affected countries, especially in regards to trade, in order to not hurt the country’s economy. The context of the IHR provides a cohesive guideline for all the countries involved, with respect to national sovereignty. The IHR (2005) introduce new operational concepts including: Specific procedures for disease surveillance, notification and reporting of public health events and risks to WHO by countries Requests by WHO for verification of public health events occurring within countries Rapid collaborative risk assessment with and assistance to countries Determinations as to whether an event constitutes a public health emergency of international concern Coordination of international response18 Questions to Consider in Your Research ● What diseases, both infectious and communicable, are affecting your country? ● Does your country already have systems in place for handling disease outbreaks? ● Where do many of these infectious diseases originate from? What does your country do to assist in the countries of origin? ● Is your country a party to the International Health Regulations? If so how does your country implement its guidelines into its government structure? Resources 18 WHO, Alert and Response Operations: http://www.who.int/csr/alertresponse/en/ WHO Regional Office for Europe Communicable Diseases http://www.euro.who.int/en/health-topics/communicable-diseases WHO Alert and Response Operations http://www.who.int/csr/alertresponse/en/ WHO facts and information on Infectious Diseases http://www.who.int/topics/infectious_diseases/en/ WHO Global infectious disease surveillance http://www.who.int/mediacentre/factsheets/fs200/en/ International Health Regulations http://apps.who.int/iris/bitstream/10665/246107/1/9789241580496-eng.pdf?ua=1 State Parties to the International Health Regulations http://www.who.int/ihr/legal_issues/states_parties/en/