Mental health of refugees, internally displaced persons and other populations affected by conflict

Mental Health in general and Mental Health of Refugees in particular are priorities of the work of the World Health Organization. Intensified efforts are being made by WHO in order to respond to the mental health needs of one of the most vulnerable groups of today' s world.

In January 1999, it was estimated that there were some 50 million refugees and displaced persons worldwide. To ease discussion the term "refugee" as used herein includes asylum seekers, refugees, internally displaced and repatriated persons, and other non-displaced populations affected by war and organised violence. Of the 50 million refugees only 23 million are protected and assisted by the Office of the United Nations High Commissioner for Refugees. The current lack of international consensus over legal definitions deprives the remainder 27 million people of the same support. The overwhelming majority of refugees are from and in low-income countries; women and children represent more than 50 per cent of the total. Heavier toll is imposed on the most vulnerable: the children including the unaccompanied minors, the orphans, the child soldiers, those detained, the children heads of household; the women and girls survivors of torture and sexual violence and the widows; the disabled, the mentally ill and retarded; also the elderly who are alone.

Some 5 million constitute a group presenting chronic mental disorders (prior to the war) and of seriously traumatised, who would require specialised mental health care had it been available. Another 5 million people suffer from psychosocial dysfunctioning affecting their own lives and their community. The remainder majority are faced with distress and suffering. It is important to remember that refugees’ reactions are normal reactions to an abnormal situations.

Present day conflicts intentionally involve civilian populations. Massive human rights violations impose serious risks on millions of people. The cognitive, emotional and socio-economic burden imposed on individuals, the family and the community are enormous. It is established that an average of more than 50 per cent of refugees present mental health problems ranging from chronic mental disorders to trauma, distress and great deal of suffering.

The number of people affected by wars has increased considerably in the last decades. No matter the causes within a limited period of time and suddenly, millions of people are forcibly displaced (1). To address the mental health needs of such large populations specific management ability and approaches are required. The task becomes even more complex as health and mental health infrastructure, if it ever existed, is destroyed. Also, health professionals are often eliminated.

Given the magnitude of the problem and the lack of resources, individual psychiatric care has a limited impact. This is also stressed in the article herein, related to mental health of Burundi and Rwandan refugees, in Tanzania (2). Community-based psychosocial care must become an integral part of emergency response and of the public health care system created in camps and national services. This will help prevent psychiatric morbidity and accelerate the improvement of the psychosocial functioning of people. Efficiency is increased when the concerned community is involved.

The impact of increased mortality and morbidity will necessitate decades of human and financial efforts. Aggravated poverty endangers survival and maintains dependency. Continued human rights violations, hinders reconstruction, reconciliation, peace and development.

Until recently, traditional emergency response was limited to food, water and shelter. Health and other priority needs are often delayed. Recognition of the mental health needs of refugees is emerging but remain poorly addressed as allocation of resources does not follow. Despite scientific evidence to the fact that conflict has a devastating impact on health and on mental health, the latter is not seen as a priority by many decision-makers.

Angola, Afghanistan, Cambodia, Somalia, Burundi, Rwanda, Sierra-Leone, Kosovo, Chechnya are a few examples of prolonged human destabilisation and psychosocial dysfunctioning caused by traumatic events. Their consequences remain in the personal and collective memory even long after peace agreements and repatriation have been accomplished. Traumatic experiences such as killings, material losses, torture and sexual violence, harsh detention and uprooting, all affect people’s behaviour for generations. Life in overcrowded camps, deprivations, uncertainty over the future, disruption of community and social support networks lead to psychosocial dysfunctioning.

Assumptions, however, to the fact that entire refugee populations become mentally disturbed and are in need of psychiatric care need to be avoided. Psychiatric morbidity and psychosocial dysfunctioning depends on the nature and time span of the conflict, on the level and the rapidity with which resilience will emerge, based on socio-cultural factors, and other environmental parameters. The rapidity of mental health support is critical.

Most theories, instruments and projects in refugee mental health care have been developed in Western countries and are often implemented without the necessary adaptations. The humanitarian impulse of many well-intended people is not always associated with the needed evaluations. Therefore, approaches successful in one region do not always correspond to the needs of other regions, their context and culture. Highly specialised clinical models and techniques address the needs of very few, while the many rarely receive adequate support. Moreover, such models are not sustainable. They increase the dependency of populations concerned as well as of services of host countries upon external support and hamper local capacity building. Responses need to become holistic and multisectoral. Equity needs to be applied in the distribution of financial resources, across the globe, for humanitarian relief and development programmes. Non-mental health professionals need more effective training, technical advice and support, in order to create a strong operational network and improve quality of work; friendly-user tools for monitoring and evaluation need to be standardised and yet keep their cultural relevance to maximise the impact of their efforts and prevent burn-out. In research, cooperation between epidemiology and anthropology will increase transcultural validity of data and responses. Better coordination between mental health players and donors will prevent duplications and waste of resources.

WHO, through its normative and field activities, and in cooperation with concerned ministries of health, with other agencies, collaborating centres, academic and research institutions is trying to remedy some of the current shortcomings. Cooperation is strengthened inter-alia, with the UNHCR and the United Nations Children’s Fund. The same applies to the International Federation of Red Cross and Red Crescent societies and to NGOs, like Médecins du Monde, Enfants Réfugiés du Monde, the Norwegian Refugee Council and others. Work with academic institutions is also being pursued for example with the Disaster Mental Health Institute, University of South Dakota, USA, the Harvard Programme in Refugee Trauma, Harvard University, USA, the faculties of Psychology of Rwanda, of Burundi and others. Internal coordination is improving responses and mainstreaming of mental health of refugees. Cooperation with the refugee community is essential in this work.

A lot remains to be done and the following are a few priority areas of WHO's work:

The WHO/UNHCR manual, Mental Health of Refugees (3), now available in ten languages, is being revised to include current needs and new scientific knowledge. Community-based mental health projects, including development of policy and action plans, are implemented in several countries and are ready for replication. Also, a WHO model training of trainers program was created and field-tested in Rwanda and Burundi; it is ready for replication in other countries in the Great Lakes region and with the necessary adaptations it could be used in other countries. Recently, the WHO Declaration of Cooperation in Mental Health of Refugees and Internally Displaced Populations in Conflict and Post-Conflict Situations (4) was developed in order to improve advocacy, international consensus in policy, programmes and cooperation. Also, the WHO tool for the Rapid Assessment of Mental Health Needs of Refugees, and Displaced Populations and Resources, in Conflict and Post-Conflict Situation (5), is pre-finalised. An instrument on Practical Indicators for Mental Health Project Monitoring and Evaluation and Standards for Professionals (in preparation) is being prepared in cooperation with the Transcultural Psychosocial Organisation, a WHO Collaborating Centre. WHO will organise an international consultation in October 2000, to present these instruments for review and adoption. Then, their translation into several local languages will lead to wide use.

In brief, there is a growing global awareness of the impact of war on the mental health of refugees. International commitment to help is increasing. Certain areas of work need to be further improved. Greater international cooperation and information exchange will remedy the chaos of crisis situations. Given the impact of war on large populations, care on individual basis is not realistic. Community-based psychosocial rehabilitation has to be privileged and integrated in the primary health care services to create sustainable responses. At the earliest possible, people with chronic mental disorders and severe trauma should be detected and treated. Non-mental health personnel, given appropriate technical support, have been efficient in responding to the psychosocial distress of refugees. It is also known that long term mental health responses to crisis can lead to the reconstruction of relevant, effective and sustainable mental health services.

It is strongly hoped that these lessons learned will be used to enable all of us to play an earliest and constructive role in alleviating the suffering of millions of people. Providing the necessary resources, restoring their dignity, giving them hope and confidence in themselves and in the international community to work towards a better future are the unavoidable preconditions for their well-being as well as for reconciliation, development and peace.


-Friskila Damaris Silitonga, SKEP, NS, MPH