Background

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  Refugee (based on the 1951 Convention’s Article One): an individual, who, because of actual and present fear of hostility and treatment, as a result of his/her ethnic group, religious belief, nationality, association with a specific social group, or views in politics, finds him/herself outside his/her country of origin or nationality, and, as such, fails to or is reluctant to avail of the said country’s protection.

  
  
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  Internally displaced individual: a person with no other course but to flee the home or city they reside in to avert the impact of armed conflicts and generalized conditions of violence, human rights violations, or disasters that are either man-made or natural. By definition, internally displaced individuals have not stepped beyond internationally recognized borders of their state.

  
  
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  There are an unprecedented 65.6 million individuals all over the world today who have been forced out of their homes.

  
  
  
  
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    This includes almost 22.5 million refugees, of whom more than 50% are younger than 18 years ; they are especially vulnerable to exploitation.

    
    
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    Adolescents are more likely to be victimized by armed conflict and without support than younger children, particularly with respect to child labor, sexual violence/exploitation, and forced combatant status. They are often denied basic education and experience sexual violence and exploitation. ^{, ,}

    
    
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    Many youth suffer posttraumatic stress disorder (PTSD), depression, and anxiety.

  
  
  
  
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  Case study: Syrian Civil War

  
  
  
  
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    Majority of citizens displaced.

    
    
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    About 75% of Syrian refugees are women and children.

    
    
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    According to the United Nations (UN), around 70,000 pregnant women run the risk of giving birth in unsafe conditions if further assistance is not extended to them.

    
    
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    Some 80% (8.4 million) are Syrian child refugees or internally displaced persons (IDPs).

    
    
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    Majority refugees/IDPs are under 18 years old, 40% under 12 years old.

    
    
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    Some estimate that between 2011 and 2017, over 18,000 children were killed.

    
    
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    Refugee/IDP children are at higher risk than adults of physical and mental trauma, and lack of safe shelter, clean water, and food.

    
    
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    Poor nutrition and health care present major threats.

    
    
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    Routine immunization unavailable to 33% of children under 5 years old; resulted in resurgence of measles and meningitis.

    
    
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    Polio had been eradicated from Syria in 1995, but returned; indeed, up to 80,000 children in Syria are thought to be carriers.

    
    
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    Access to education decreased; more than 4000 assaults on schools recorded.

    
    
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    Half of school-age children not enrolled in school in the 2014–2015 school year.

  
  

Table 11.1 shows acute emergency situations and the subsequent postemergency phase.

• 1.
  

  Restricted access to health care

  
  
  
  
  • a.
    

    Up to 200,000 pediatric deaths have been attributed to lack of access to medical care in Syria.

    
    
  • b.
    

    Although many welcoming countries offer in principle some medical screening upon arrival, impact is often minimal because of poor quality or delay ( Table 11.2 ).

    
    
    
    

    Table 11.2

    
    

    Factors Related to Restricted Access to Effective Healthcare Acces

    
    

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    

    	Internally Displaced Persons	Refugees
    1.	Loss of healthcare personnel; in Syria, for example, about 160 doctors were killed and many more jailed, which resulted in about 80,000 doctors moving to other counties	Poor quality of screening programs
    2.	Destruction of healthcare facilities	Legal restrictions impeding access
    3.	Destruction of transportation routes	Host nation-imposed waiting periods before granting access to care
    4.	Shortage of drugs and other pharmaceutics	Undocumented status of many refugees and uncertainties about entitlements for failed asylum seekers.
    5.	Insecurity and lack of protective factors for healthcare personnel	Insufficient funds from the United Nations High Commissioner for Refugees and nongovernment organizations

     
    
    

  
  
  
  
• 2.
  

  Outbreak of vaccine-preventable diseases and tuberculosis

  
  
  
  
  • a.
    

    War and natural disasters increase risk for certain diseases and infection caused by degradation of infrastructure and immunization programs.

    
    
  • b.
    

    In Syria, vaccination rates decreased from 91% to 45% between 2010 and 2013 in some places.

    
    
  • c.
    

    Some 58% of 1.8 million children born in Syria are not vaccinated.

    
    
  • d.
    

    Immunization campaign efficacy is often impaired because of risks to volunteers in war zones.

  
  
  
  
• 3.
  

  Restricted access to education

  
  
  
  
  • a.
    

    Entire generations of refugee children from countries like Syria, Afghanistan, Palestine, and South Sudan have had to leave their homes and schools.

    
    
  • b.
    

    Recent UN High Commissioner for Refugees (UNHCR) data estimate that worldwide, 50% of primary school-age refugee children are out of school and 75% of adolescent refugees at the secondary education level are out of school. Refugee children and adolescents are five times more likely to be out of school than their nonrefugee peers.

    
    
  • c.
    

    One and a half million school-aged Syrian refugee children live in Turkey, Jordan, and Lebanon, but approximately half of them do not have access to formal education.

    
    
  • d.
    

    In 2014–2015, half of Syrian children (about three-quarters in the worst-affected areas) did not go to school, one of the lowest school attendance rates globally.

    
    
  • e.
    

    Education in refugee and IDP camps is not given priority because of competing immediate demands, such as for food, clean water, safe shelter, control of communicable diseases, and security.

  
  
  
  
• 4.
  

  Malnutrition and lack of clean water

  
  
  
  
  • a.
    

    Food and nutrition insecurity accelerate in armed conflict areas.

    
    
  • b.
    

    About 112 million malnourished children live in areas affected by armed conflict, accounting for two-thirds of all malnourished children in poor countries.

    
    
  • c.
    

    Poor nutrition is not only caused by lack of food; it is also related to poor hygiene, contaminated water, and lack of health education.

    
    
  • d.
    

    Malnutrition is particularly injurious from birth to 2 years, contributing to irreversible mental and physical harm.

    
    
  • e.
    

    The World Food Program (WFP) reports that around 2000 of the displaced Syrian children in Lebanon are experiencing extreme intense poor health, which may lead to death without rapid interventions.

    
    
  • f.
    

    Another 8000 Syrian children in Lebanon are experiencing less extreme hunger.

    
    
  • g.
    

    The WFP likewise expresses that around 4% of exiled Syrian children in Jordan less than 5 years old need treatment for severe diseases.

    
    
  • h.
    

    Hunger is also an issue for internally displaced populations within Syria. Poor access to food and healthcare services and lack of potable water leads to diarrheal diseases, general poor health, and even death.

  
  
  
  
• 5.
  

  Child labor

  
  
  
  
  • a.
    

    Forcibly displaced and refugee children are particularly vulnerable to child labor.

    
    
  • b.
    

    In conflicts and disasters, parents may lose their jobs, and schools may be damaged. In such situations, children often begin working.

    
    
  • c.
    

    In other scenarios, children may end up separated from their parents in conflict areas and need to support themselves. However, working children may sacrifice their health, safety, and education to help their families or sustain their living expenses.

    
    
  • d.
    

    In Syria’s case, specific figures on the number of children in the Syrian labor market do not exist; a UN Children’s Fund (UNICEF) report released in March 2017 estimates that around 1.7 million children are out of school. Large numbers of them are believed to have been forced to work in an expanding catastrophe that the UN says is only getting worse.

    
    
  • e.
    

    Whether in Syria or in neighboring countries, children are forced to work in conditions that are mentally, physically, and socially dangerous.

    
    
  • f.
    

    Save the Children and UNICEF outlined that inside Syria, children are contributing to the family income in more than 75% of reviewed families.

    
    
  • g.
    

    In Jordan, almost all displaced Syrian children are presently the joint or sole family providers in families studied.

    
    
  • h.
    

    In Lebanon, children as young as 6 years of age are purportedly working.

    
    
  • i.
    

    A spiraling number of children are regularly used in unsafe working conditions, being exposed to pesticides and poisonous chemicals, and working for extended periods of time with little pay, in dangerous and undesirable conditions.

  
  
  
  
• 6.
  

  Mental health issues

  
  
  
  
  • a.
    

    Children are dependent on external sources for their protection and care and have their own individual developmental and psychological requirements.

    
    
  • b.
    

    Refugee/IDP children are at substantial risk of experiencing emotional and psychological problems.

    
    
  • c.
    

    Starting from their native countries, many refugees/IDP children have been exposed to significant trauma.

    
    
  • d.
    

    Many children have been forced to flee their homes to escape war and have been confronted with violence, torture, and loss of close family and friends.

    
    
  • e.
    

    The journey of refugees to a settlement place can be a source of further stress. It may take several weeks to months and expose the refugees to several life-threatening situations.

    
    
  • f.
    

    Refugee children at these times may be exposed to separation from parents, either by accident or as a strategy to guarantee their safety.

    
    
  • g.
    

    Arriving at the final destination and starting a new life can be a source of additional difficulty, as many have to prove their asylum claims and also try to integrate in a new society.

    
    
  • h.
    

    Syrian displaced/refugee children are likewise in danger of a scope of issues related to their psychological well-being because of their horrendous experiences.

    
    
  • i.
    

    These children have experienced a high degree of trauma: 79% had encountered a demise in the family; 60% had seen somebody beaten, shot, or physically abused; and 30% had themselves been kicked, shot at, or physically hurt.

    
    
  • j.
    

    Some 45% showed side effects of PTSD—10 times the usual rate in children—and 44% were suffering from depression as a side effect.

    
    
  • k.
    

    Soykoek and his team studied a representative sample of 96 Syrian children (0–14 years) from a reception camp and detected PTSD in 11 (26%) of 42 children aged 0 to 6 years using the Posttraumatic Stress Disorder Semi-Structured Interview (PTSDSSI) and in 18 (33%) of 54 children aged 7 to 14 years using Kinder-DIPS.

  
  

Approach to the Challenges Confronting Internally Displaced Persons/Refugee Children

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  Approach to IDP/refugee children includes dealing with acute emergency situations and the subsequent postemergency phase. It is wise here to recall the 10 priorities set by Médecins Sans Frontières (MSF) for approaching refugee health in the emergency phase ( Box 11.1 ).

  
  
  
  

  Box 11.1

  
  

  The Médecins Sans Frontières 10 priorities

  
  

  
  

  
  

  
  
  • 1.
    

    Initial assessment

    
    
  • 2.
    

    Measles immunization

    
    
  • 3.
    

    Water and sanitation

    
    
  • 4.
    

    Food and nutrition

    
    
  • 5.
    

    Shelter and site planning

    
    
  • 6.
    

    Health care in the emergency phase

    
    
  • 7.
    

    Control of communicable diseases and epidemics

    
    
  • 8.
    

    Public health surveillance

    
    
  • 9.
    

    Human resources and training

    
    
  • 10.
    

    Coordination

  
  

  
  

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  Although the MSF priorities were established in 1997, after 20 years most of the parameters are still valid and need to be followed; if we need to change anything, it would probably be the second priority, which is related to measles immunization.

  
  
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  Measles was noticed to affect many refugee camps and resulted in many preventable deaths in the 1990s and before; however, the situation nowadays is much worse, with a range of diseases preventable by immunization threatening the health and lives of refugee children, such as poliomyelitis, tuberculosis, and meningitis, in addition to measles.

In response to disasters, several national and international players will act:

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  The Office for the Coordination of Humanitarian Affairs (OCHA) in collaboration with the Inter-Agency Standing Committee (IASC) is the arm of the UN responsible for bringing together national and international humanitarian providers to ensure a coherent response to emergencies.

  
  
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  The other actors are the International Committee of the Red Cross (ICRC), leading international nongovernmental organizations (NGOs) working through volunteers, donors, and local committees.

  
  
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  In the early phase of disasters, there will be a flood of refugees/displaced people seeking security and safety.

  
  
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  There must be rapid action by the international community to make it possible to deal with these floods of refugees into regions that are sometimes difficult to reach, and where food, water, shelter, sanitary equipment, and so on must be urgently transported.

  
  
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  There are basic requirements that determine the well-being of refugees/displaced people in the early phase of disaster; these are safe shelter, clean water, food, and health care. All these requirements are covered by the UNHCR, which coordinates assistance to refugees, in close cooperation with other UN agencies, the local government, and different specialized NGOs.