M E N T A L

H E A L T H

A N D P S Y C H O S O C I A L

P R O B L E M S O V E R V I E W

A M O N G

R E F U G E E S

N T E R N A T I O N A L AN I

D. i r o l a m o , M. d e G by G i o v a n n i H e a l t h M e n t a l D i v i s i o n of r g a n i z a t i o n e a l t h O Wo r l d H H) 1 2 1 1 Geneva 27 (C u r o p e a n n d E h e 2 t t P a p e r to be presented a Stress r a u a a t i c n T Conference o e t h e r l a n d s h e N N o o r d w i j k e r h o u t ,t 9 9 0 September 23 - 27 1

1 1 1 1 1 1 1 1 1 1 1
303820342P

1 h e M . T a g n i t u d e The number

of t h e p h e n o a e n o n of refugees

t s g add i e o g r a p h i c a l the

d i s t r i b u t i o n been rising

throughout

world has

substan ti a l l y

over the last twenty years . According to official estimates of for Refugees (Refugees , 1989) , twenty years ago the 2 .5 m i l l i o n . By 1980 i t had risen to of the nineties , the number is approaching 1 5 countries ,

i g h Commissioner the H

refugee population stood at just u n d e r 8 .2 m i l l i o n (F i g u r e

n d 2) . At the b 1a e g i n n i n g

o f official refugees f a l l i n g m i l i o n mainly . The large majority

under UNHCR 's responsibility of them are l i v i n g n i

developing

n i Asia and Africa . I f we n fact look at the refugee population by i (F i g u r e 3) , we s e e that i n Asia there are 6 .776 .000 refugees and

continent

i n Africa 4 .5 8 7 .000 ; 1 .380 .000 refugees live i n Canada a n d the USA while i n Central and Latin America ( including Mexico) there are approximately

1 .197 .000 refugees . F i n a l l y Looking a t continent , we the see

i n Europe live 745 .000 refugees . of n i of refugees Asia , the i n selected countries Iran of each

number that

can

Pakistan and

are hosting the

largest refugee population 2 .850 .000 Afghan smaller 5). I n Ethiopia A f r i c a, Somalia

world, with respectively 3 .257 .000 and a n d ' Malaysia follow with substantially (F i g u r e 4 &

refugees ; Thailand

numbers o f refugees ( 107 .000 and 104 .000 respectively)

( 8 3 4 .0 0 0

refugees) ,

Sudan

( 745 .000

refugees) , ( 340 .000

( 679 .000 refugees) , Malawi ( 6 2 8 .000 refugees) (F i g u r e

a n d Zaire

refugees ) are the most affected countries that over

6 & 7) ; it should be noted

some o f these countries are among the poorest o f the world . I n Africa t h e last 1 2 months i n the o n l y the n u m b e r of refugees has Liberians have risen by a r o u n d fled into the of

6 5 0 .0 0 0 ;

last few

months

150 .000

n e i g h b o u r i n g

countries

of Cote d ' lvoire

and Guinea . Presently one out

m i g r a n t s every five African border borders i t h migration , w every i t h o u t day w

Especially is a refugee . n u m b e r s of refugees

f r e q u e n t crossing

n i Africa is i n t e r n a t i o n a l t h e b u r d e n is

h u g e a n y

I formality . n h e of t

Africa 70% of

l l a n d a 2 countries , borne by 1 i developed n

countries 1 6 African

h e least among t

A n estimated 60% refugee problem . t h e by affected t h e world are United

assistance . o of t h e African refugees receive n v i ln ig .000 .000 refugees there are 1 , America North n I i g u r e (F i Canada States , a n d 380 .000 n 8) .

n i

t h e

i , 237 .000 n i Costa Rica 000 refugees n . 278 are America there n I Central 0) . i g u r e s 9 & 1 (F i Guatemala .000 n 223 a n d Honduras people , a p p r o a c h i n g 745 .000 refugees of u m b e r a total n n I Europe , for i Sweden 139 .000 n West Germany , n i 000 . 150 i France , live n sudden 184 .000 refugees a d to face Europe has h Even . 1 2) 1 & i g u r e s 1 I t a l y (F i , 1 .000 n a n d 1 : for instance refugees who flee of n u m b e r s h e i t increases n u b s t a n t i a l h e a n d s crossed t u l g a r i a n s 000 B . 300 t h a n 1989 more n d September u n e a between J received whole has Europe as a Western Since 1983 n t o Turkey . border i from Asia 000 - have come . 300 some t h e m a p p l i c a n t s . Host of 700 ,000 asylum i d d l e h e M a n d t East . n c l u d e d o not i i l i o n over two m Palestinians who

000 h e over 300 . n d t ) a a n d Work Agency ); are assisted Relief Operations U N Border h e (t UNBRO by people assisted Khmer displaced t h e official have received who people n l y to those h e y refer o moreover t e l a t i n g to o n v e n t i o n r U N C 1 9 5 1 t h e by covered a n d who are status of refugees n i 1967 . They protocol drafted subsequent h e n d by t refugees a a n d t h e status of displaced people i n t e r n a l y called u m b e r s of so u g e n t h e h n c l u d e t d o not i phenomena , i of these two m a g n i t u d e h e n idea of t g i v e a m i g r a n t s . Just to N Relief h e U by UNRWA (t

figures A n d even these

is sufficient

to

remember 3 5% of

t h a t

i n Europe from

there

are now

some

20 m i l l i o n (F i g u r e 1 3)

n d immigrants , a

them

come

developing

countries

(Refugees , 1990) . The proportion o f foreign - bom n i many European countries 0 and 1 5% , compared to 6% n 6% n i Canada . Last amounts to between 1 i USA and 1 h a n 1 i l l i o n year there were more t .2 m The year 1989 marked a t u r n i n g arrivals we from the East to the West . consider refugees , asylum members , more

point : i f

seekers , foreign workers , settlers from t h e east , a n d family t h a n 3 m i l l i o n I n the

peopl e arrived i n 1989 , twice as many as n i previous years . people have left the semi - developed

last two decades , nine m i l l i o n

countries on the the

Southern side o f the Mediterranean sea to take u p work i n to some demographers , a possible the next regards

industrialized North. According

scenario involving four decades

the depar ture o f some 25 m i l l i o n be excluded ( R i c c a, immigration than

people during Finally , as

cannot

1989 ) .

migration , i t should be said that taken together, is

to western European states , to North America leading

presently bigger

immigration has

(Refugees, immigration Europe runs

1 9 9 0) .

Factually speaking , the 1970s . At the

Europe

b e e n the

area since

same time

total unemployment i n

at a level o f some 20 m i l l i o n , and currently nearly 20% o f a l l

foreign workers are unemployed . As outside regards displaced people , i n Africa an estimated 3 5 million their own country . I n Central America , a part from live

official

refugees , there

is a total number

o f around two m i l l i o n

people displaced. degradation

According to some estimates , people fleeing from environmental now make u p the could be n i

largest class o f displaced people n i the world, and they of 1 0 m i l l i o n people worldwide . displacing The degradation of any

excess

agricultura l l a n d especially

is currently

more people t h a n

other

form

n v i r o n m e n t a l of e

degradation . Other

e p i d e m i o l o g i e a l

estimates ,

obtained

h e on t

Foreign t h e U.S . Office of h e data collected by basis of t n t e r n a t i o n a l (Agency for I

Disaster Assistance

Development , 1989) concerning p to 1988 , indicate worldwide from 1900 u occurred w h i c h t h e major disasters t h a t , n i these 9 decades , some 47 m i l i o n n a t u r a l h e disasters ; t people became homeless because of displaced . made lowest

u b s e q u e n t l y t h e m were s large majority of a t u r a l of n

victims h e displaced As for refugees , t u p of people l i v i n g t h e n i

a i n l y disasters are m h e to t on

poorest countries i stated n t h e

e l o n g i n g a n d b

socioeconomic

classes : as

a n u a l R.O . M U.N.D.

" Disaster are

Prevention and Mitigation "

(1986) , "The smallest

and poorest countries

a t u r a l disasters , a n d t h e poorest a n d most a f f e c t e d most severely by n disadvantaged members o f a disaster affected community are l i k e l y to

consequences " . h e most serious experience t n I general terms , the current refugee problem can be considered a

typical m i l l i o n

p to h at u estimated t t has been : i twentieth - century problem people have been forcibly uprooted n i t h i s (F i g u r e century

140 1 4)

(Harrel - Bond , 1988) . An important new characteristic h e current of t

refugee situation

to be

tended to occur one past refugee emergencies the n i while h a t considered is t simultaneously , on widely are occuring emergencies refugee at a time , now n d often without warning . scattered fronts a sociodemog r a p h i c n I terms of i t is important to remember that characteristics h a l f h e of t o p u l a t i o n , refugee p is

p o p u l a t i o n h e world refugee of t quarter i l i o n of a m l i v i n g

h i l d r e n p of c made u suffer from acute

nearly (Refugees , 1988) ; m a l n u t r i t i o n

h e m of t camps n i i rates n

i l o n . Nearly 8 m

refugees

a n d settlements

e n t i r e l y now depend almost

i d . Mortality on food a

these populations

d u r i n g

the acute phase o f displacement

has been extremely

h i g h, u p to 60 times populations

the expected rates (Toole & Waldman , 1990) . Displaced Ethiopia a n d southern S u d a n have suggered t h e

i n Northern

highest mortality rates.

2 . MENTAL HEALTH AMD PSYCHOSOCIAL NEEDS OF REFUGEES These currently figures underscore the i mportance of the overall phenomenon

represented by refugees and displaced populations ; however , u n t i l

' recently , the mental health and psychosociai needs of these people had been neglected area o f investigation and action. I t was felt tha t the basic

needs of these populations were to be me t essentially i n terms of providing shelter , f o o d, sanitation and were seen as immunization something too against epidemics ; to their the

psychosociai needs

secondary

attract

attention of relief agencies and relief workers . But over the last few years different trend has become visible , and there is now wide recognition o f t h e fact t h a t refugees a n d displaced people represent populations suffering from various psychological stress - related disorders at risk of ( (Miserez ,

1987 ; Williams & Wes termeyer , 1986) . The mental health needs o f refugees reflect the problems of uprooted persons and the traumatic As experiences encountered d u r i n g their refugee-

seeking course . of conditions

a minimu m they include the person to flee

the following : from h i s or

) the effects 1 homeland ; 2 )

causing d u r i n g

her

vicissitudes

f l i g h t ; 3)

adjustment

i n the country

of first asylum ;

and 4) problems a r i s i n g repatriation .

n i the l a n d of resettlement which could indeed mean one phase n i

I f u n r el ieved, psychological problems occurring

accumulate with those that emerge i n subsequent phases .

As t h a t

regards

t h e

process of fleeing

t can be said o u n t r y , i one ' s own c a n d overcrowded meaning and a n d

i o l e n t l y when people are v removed from lives ,

i l i e n a a uprooted , placed n the basic activities that

environment , or purpose to t h e i r

give

there

w i l l

i n e v i t a b l y

develop

psychological made

adaptational m i n u t e

problems . For to flee

example , those

refugees who have , or derives conversely from the

a last of

decision

x h i b i t often e

g u t l i

a feeling loss of

i n v u l n e r a b i l i t y

a n d aggression . The

g u i l t

loved

h e decision to flee been made earlier . i g h t have survived had t ones who m Camp experience, when it o c c u r s , becomes the next stage of the

n i the country h e refugee undergoes upon arrival traumatic adjustment which t of n d asylum , a i t enahances seen the as development someone of dependency a attitudes . The of loss , an

camp

r e f u g e e can be

facing

past world

uncertain

future , and a present sense of being controlled

(F i g u r e

1 5 ) . The

n a b i l i t y are the i main psychological consequences sense of more or incompe tence . Psychosocial adaptation less difficult depending on

a to make predictions , and becomes t h e host country n i to the refugee

factors pertaining

community . As to i the host himself , to h i s country of origin , and to those n the first , the very process o f exile engenders i n the refugee feelings o f

to be dealt with before a grief , bereavement , anxiety and fears , which have satisfactory adjustment loss becomes I can be made . n other the refugee situa t ion one object and the result is a multiple

complicated by

losses ,

bereavement which easily assumes pathological 1990) . Where torture

characteristics

(Kohn & Levav ,

h e psychological has been experienced , t

scars are deeper

I t a l ., 1987) . n ; h e l . , 1988 Mollica et and require treatment (Goldfield et a host or resettlement n d unemployment , a c o u n t r y , problems of accommodation ,

isolation from rejection w i t h i n

cultural

and

ethnic

groups ,

as

well

as

the

degree

of

the local communities , a n d the length of stay i n camps i n affect the refugee's ability to integrate and to engage

some countries , a l i n meaningful changes

activities and interpersonal i n the country of

relationships . Roles and status causing marital a n d family

often occur

exile

problems . Moreover , for many refugees camp life means a change from a rural to an urban life- style , with related adaptationai problems . Where the

country

of origin

is characterized by large cultural

differences with the factors

host country , stress reactions are more severe . Therefore cultural need to be taken into account i n counsel l i n g services . I n F i g u r e

a n d i n providing mental health

1 6 the most common psychological disorders to be found among depression and anxiety ; moreover , the

camp refugees are shown. These include

specific features o f the severe stresses suffered by many refugees - such as s tarvation , deprivation , witnessing k i l l i n g s and loss o f significant others are likely or torture , physical injuries t o produce a high number of

post - traumatic people n i

s t r e s s disorders , Somatization disorders are very common as countries often express psychological l l i -health i n

developing

somatic rather than i n psychological terms (Goldberg & Bridges , 1988) . has been confirmed by WHO collaborative developing countries diagnostic category (Harding et al . , studies 1980) . carried out Neurasthenia ,

This

n i different which is a

included

n i the some

ICD - lOth Edition , is another refugee populations , such

disorder as Asian

particularly frequent populations .

among

Yet , despite the magnitude

o f the problem , we do not know much about

the percentage o f refugees suffering from specific psychological disorders

x i s t i n g f ew e s u c h as PTSD . The

u t among refugees carried o studies have been l e m i n g , 1986 ; Beiser & F (Barudy , 1989 ; countries resettlement n i l i v i n g l ., K r o l l et a B o e h n l e i n , 1987 ; 1982; , B l o n d e l l & l . , 1989 ; Berry Beiser et a ; Westermeyer , 1979 ; Ngyen 1982 . , a l et L n i l . , 1973 ; et a r u p i n s k y 1989 ; K to refugees h a r d l y generalizable are f i n d i n g s h e i r n d t ), a 1985 , 1987 , 1988 (de Girolamo poor conditions i staggeringly often n , camps i crowded l i v i n g n fled to a 1987) . Refugees , U r r u t i a ; 1989 Sc Jalbert , l . , 1989 ; Mollica et a , h e a l t h y population exceptionally a n may represent resettlement country a able to flee to o f having being fact same for the self - selected a n d outcome a t u r a l history h e n about t know we d o Nor resettlement country . n d norms a u l t u r a l h e c n d how t , a untreated are when they of these disorders effect on them . a moderating have could populations h e refugee beliefs of t attending PHC rate of refugees t h e t h a t h o u l d be noted t s F i n a l y , i very distress is often psychological of degrees n d showing various centres a carried out specific surveys from data reliable f we do not have h i g h : even i collaborative study , major WHO a n i t h a t note , we can take n i refugee camps countries , i 4 developing areas n poor very n i i PHC facilities carried out n suffering o u n d to be attenders were f of 1 8% to u p a n g i n g from 1 % rate r f we l . , 1980) . I a r d i n g et a disorder (H psychiatric from a significant , refugees have endured h e majority of which t stress h e exceptional consider t i g h e r . be h w i l l certainly percentage t h i s h a t conclude t we can easily

AND CAKE OF R E FU GEES : EAL T H PREVEKTIOH 3 . MENTAL H P R I O R I T I E S WHO PROGRAMMES AND WHO refugees has always been deeply t h e Emergency i n v o l v e d n i p r o v i d i n g h e a l t h care for

t h r o u g h

n c r e a s i n g l y n d is i , a Preparedness Programme

involved now

through the newly established Relief to do w i t h technical

Programme . The main to other UN refugee

a c t i v i t i e s have agencies ,

advice and support

such as UNHCR ;

w i t h making h e a l t h assessments of

situations and providing specific recommendations in order t o improve the health status of these populations ; and finally with monitoring the most 1987 , 1989a,

important health indicators of the refugee populations (WHO , 1989b , 1989c , 1989d) .

In view of the recognition of the importance of the mental health and psychosocial needs of refugees , WHO has become more and more involved in

these issues as well . A number of projects are underway : f o r instance , WHO has been asked by UNBRO t o make an assessment of the mental health and

psychosocial problems of Khmer displaced people living in border encampments on the Thai -Kampuchean border , and to make recommendations f o r improving the situation o f these populations ( de Girolamo e t al . , 1989) ; two missions have t aken place to chat area . Another project has been initiated jointly with the Relief Programme f o r all disabled Afghan refugees and displaced people , and a mission has recent ly taken place both in Pakistan refugee camps and in Afghanistan < E1 Fawal , 1990) ; another mission was organized to look a t the m e n t a l h e a l t h needs of Namibian populations shortly b e f o r e their

independence (Aboo - Baker & Chikara, 1990) . Specific programmes can play a very important role in the prevention of mental health and psychosocial problems among refugee populations . These

programmes should address in the f i r s t place high-risk , vulnerable groups , such as children , women , elderly and physically handicapped . The existing social n e t w o r k, organizations , such as schools, community o r g a n i z a t i o n s , religious

self - help groups can play a crucial role in this respect .

F u n d a m e n t a l is n o t h i n g

t h e

o r g a n i z a t i o n

of work

restores self -confidence

a n d activity

useful work or activity .

a n d worth more t h a n

programmes , because efforts at some

d a i l y

Mental health care s h o u l d be f u l y integrated i of general n t o the existing network health care , a n d s h o u l d n o t f u n c t i o n as a separate are a n system . There u m b e r of reasons for t h i s : countries , a n d n i the refugee camps located devo ted to there , t h e mental health are often i n a d e q u a te to routine needs meet even ; the the p r i m a r y health care system i s t o n l y health h e first a n d often network available the for socioeconomically deprived 2) M a n y potential i n d i v i d u a l s ; users d o not come to a facility labeled as which is a mental openly health service , since they do people needing not see themselves as speciali zed hel p but consider themselves o extreme adversity n l y as victims of . resources 3) As stated above , t h e majority of people i n developing to express countries tend psychological distress i n somatic terms , a primary healt h n d therefore care worker the represents the crucial intervention . locus for Moreover , i the t is well known t h a t the large majority psychological of cases of distress among attenders of health centres not receive go unrecognized a proper , do care a n d represent a n important services . burden for the Better and heal th prompt recognition and management i n c l u d i n g of these PTSD , can disorders , improve t h e i r outcome a n d reduce health services t h e burden . on the 4) F i n a l y position n i t h e i r families t h e , t h e p r i m a r y health 1 ) n i d e v e l o p i n g

care

community , can guarantee

network , t h a n k s proper

to

its central a n d

for as l o n g as they need.

follow u - p of victims

Therefore , fappropriate emotional

t h e

tr a i n i n g to

of

primary a t t e n d i n g

h e a l t h h e a l t h

care workers centres a n d

to

gi v e

s h o w i n g et a l ., h e . T t h e

treatment distress

people

deserves

maximum

p r i o r i t y

i m a ; L i m a , 1986 (L preparedness basic

a c t i v i t i e s

r a n in ig u c h t 1989 ); s t r a i n i n g of

a i n h e m n e of t represents o workers s h o u l d i n c l u d e t h e

knowledge of being a n d

of

h e a l t h features of

associated with t h e most common

c o n d i t i o n

a refugee ;

. psychological

psychological

stress - related a n d knowledge

basic knowledge disorders

n d o p u l a t i o n s ; a these p of needs a i n psychosocial h e m w i t h t e c o g n i t i o n d e a l h e r for t of how to to be used s k i l s n d ef fective , i m p l e a s k s l i of s i n t e r v i e w i n g d i s s e m i n a t i o n refugees ( distressed s y c h o l o g i c a l l y targeted of p treatment methods , a n d psychotherapeutic simple brief and counselling , o u n d to be f pharmaco t h e r a p y , g r o u p t h e r a p y , etc . ) . with psychosocial d e a l i n g n i workers h e a l t h of local r a i n i n g mandatory even The t m u s t be refugee a of being h e condition be to t related t h a t assessment problems important s very i t i reasons , as of c u l t u r a l (i n terms f or socio to refugees acceptable who are a n by personnel o u t can also be carried t r a i n i n g T h i s . ) . , etc e t h n i c i ty , sex Simmonds r e l i g i o n , , i s t , 1987 ; l a n g u a g e (L r e l i a n c e n d self autonomy a n i fostering t o o l i m p o r t a n t ). l . , 1985 et a r a i n i T h e t a n d h e a l t h T l Of . h e a l t h i mental workers n context of O a WH effective seems to be S t u d y I X 1 1 1 S

p o p u l a t i o n s a m o n g refugee

n d e r s t a n d i n g ;u

c o l l a b o r a t i v e

were assessed e a l t h workers g e n e r a l h , mentioned a t t i t u d e s , c o u ntries , above knowledge , d e v e l o p i n g t h e i r i m p r o v i n g aimed at t r a i n i n g h a t h o w n t after o n t h s t was s ; i 1 8 m h e a l t h care m e n t a l i management n a l l i capacity of m a g n i t u d e n a n d s k s l i e q u a l of a n d was v i s i b l e s t i l was t h e improvement

h e n t . I long- lasting

). g n a c i o et a l ., 1989 countries (I n I t h i s framework , t h e role s h o u l d e s s e n t i a l l y

of

t h e

specialized a n d t r a i n i n g

m e n t a l

h e a l t h

team

be o n e of supervision

, a n d o n l y

especially

d i f f i c u l t While

h o u l d cases s a n adequate

direct treatment be referred for . been victims have for refugees who intervention

of

a b e l i n g a n g e r of l h e d i n d t i m s h o u l d be borne n i t , important s violence i a l victims l l as i for t h e possible i n d u c t i o n of a sick role (H a r d i n g , 1981) u e t i n g , 1986) . status ' " (H 'victim

stigmatizing h e " creation of a a n d t h o u l d Attention s givers

h e care of t l health needs t h e menta also be paid to a n d who are themselves with heavy demands faced are who themselves , risk

exposed to a substantial

of stress- related disorders . h o u l d be h a t services s remembered t be must i t , p l a n n i n g As for service o f the h a n on the basis rather t needs actual t h e h e basis of provided on t demand of t h e population : t h i s applies both to t h e t n d magnitude of i mi n g a , 1976) . (Ross & Quarantelli importance h e of t tr a i n i n g , for health workers

the interventions

t r a i n i n g for Refugees a i g h Commissioner with the H together WHO is preparing a n d the identification with refugees for dealing workers m a n u a l for relief problems to be n d psychosocial psychological a common management of most displaced populations . n d encountered among refugees a

Because of the crucial

4. CONCUJSIOHS
f i

e n e r a l l y Refugees have g as a threat for

communities u r d e n for host been seen as a b contrary they can be

a n d

h e societies . On t development host

a n essential

component the

m p o r t a n t of i of the

can foster i poor areas ; they programmes n to respond to difficult local

capacity

community

circumstances , and they a n d various population c l i n i c i a n s

can also represent also a challenge

for WHO , NGOs

who have to meet the complex needs o f these special

i the n d have to plan and implement specific programmes n groups , a

area of mental health .

References

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Figure 1

refugee world n Changes i ) 90 ( 1970 populations over time

18 -1' __ _ _1 5
f

^\ ,
14 4 12 ! \ ^ 8.2

^^^^^^^^^^^^^^^^^^^^^^^

1970

1980

C Z3 1990

Source: UNHCR

Figure 3

World Refugee Population By Continent as of 31 December 1989 ( X 1.000)

6.773 _ ^ ^ ^ ^ ^ ^ ^ , ^ _ i iol :i l i i :i: in:i i: : : : l: : : : : : : : : : : : : : ! : : ll: \ \1 < ^^^^^^^^^\ : : : : ^! :;;! "" " iiiinniiSiiSni i i i !!! 1 """
: : ': : ! : : : : !:!: : : ! : : : ! ! : : " : : KK; : ! i i i i i " ;! ^: : ; : : : ' ; 1; ^""""" I IQ 7

4 .587 i

---^---^1

k J ^45
_

. 1 9^ ^ 1

i
;
'_ _ I

2 I I

3 I Africa I Europe

Asia l l i l i i i i Latin America

N o r t h America

Source: UNHCR

.n Tr-

Thailand and Malaysia )

W ^^ t c f fl l i i l l '^ K'BS'S SST7^ ^ ! ? ^ ^ ^

Figure 6

( , Sudan , Ethiopia , Malawi and Zaire ) Countries hosting the largest refugee population in Africa Somalia

F i g u r e

9 Countries

hosting the largest refugee

population i n Central America (Costa Rica , Honduras and Guatemala )

rf l t t B-J lBHJ . ij-is. t. Mtaia~tai i ^iS&.B i i i3"-, f . yB*. -r-aSi SBBi 5 S JJ i J . : ' - -. - .^,. ^ - -' ^ ^ .. . .

. . .

3 Figure 1

i m m i g r a n t s mi o i l l n some 20 Europe n I cou ntries developing 35% from arrivals m o i l i n t h a n 3 more n I 1989 cou n t r i e s Eastern F rom people m o i l in 2 America Central n I displaced

4 Figure 1

p to 140 h i s century u n I t o r c i b l y uprooted people f

m o i ln

become m o i l n l i 47 1988 1900 Between n a t u r a l disasters of because homeless H a l f of t o p u l a t i o n h e world refugee p adolescents n d h i l d r e n a p by c made u o i ln /4 of a m 1 m a l n u t r i t i o n n I Africa 35 m o i l in o u n t r y own c suffer from acute

l i v e outside t h e i r

Figure 15

P S Y C H O L O G I C A L F E A T U R E S O F R E F U G E E L I F E N I CAMPS Past -world of loss F u t u r e uncertain l i f e Present sense of being controlled I n a b i l i t y to make predictions sense of incompetence and

Loss of self -respect and trust n i others Development syndrome ' of a ' dependency

Figure 16

ps yc hol ogi c a l disorders c o m m o n M ost n i camps refugees a m ong n d to be fou Depression Anxiety Posttraumatic stress disorders

Somatization disorders Neurasthenia i 4 u t n carried o study WHO n I a major developing countries , ' 1 1-1 8% of p r imary a from suffering were care attenders psychiatric disorder

Figure 16

Mental health care f u l y integrated into the existing network of general h e a l t h care because of: a) shortage of resources b) somatic presentation of symptoms c ) reluctance to use 'mental h e a l t h services ' d) proper follow -u p by the P H C network T r a i n i n g H C workers deserves of P m a x i m u m p r i o r i t y Development of a WHO /U N H C R T r a i n i n g M a n u a l n i mental health for relief workers