The reproductive health of refugees: lessons beyond ICPD

Colette Harris and Ines Smyth

The vulnerability of populations affected by conflict or environmental disasters was stressed at the International Conference on Population and Development (ICPD) held in Cairo in 1994. In particular, the high mortality and morbidity rates among refugees were emphasised. The ICPD and its Programme of Action have enabled a degree of consensus to be reached on the importance of reproductive health and rights, including those of refugees and internally displaced people. Post-Cairo, some of the language and concerns of the ICPD Programme of Action are being brought into the initiatives of international agencies, including UN agencies and international NGOs. Reproductive health policies and programmes have started to be implemented in refugee communities, and service-delivery has begun to be systematised. However, if the mistakes and abuses of past family-planning programmes are to be avoided, we need to integrate some critical insights from feminists working in the fields of health and anthropology. However, there are structural constraints within relief organisations and operations which need to be overcome if they are to benefit from such insights.

Refugees are, by definition, survivors, who use their personal and material resources to escape danger, persecution, and fear. They are also very vulnerable to threats to their physical well-being and identity, as well as to threats to their survival as a group (based on ethnic, religious, or other grounds). Their vulnerability needs to be understood in the context of the increase in global economic, social, and environmental insecurity over recent decades (Baud and Smyth 1997). The key elements of this 'new world disorder' are armed conflict, military actions, and the disappearance of old State structures, all of which have profound implications for biological reproduction (Pearson 1997,12).

Data concerning the numbers of refugees in the world are notoriously unreliable. What is certain is that their numbers are on the increase. In the last few years, there has been an escalation in the numbers of those displaced by conflicts and by major natural disasters, as well as those forced to move by deliberate government policies. The International Federation of Red Cross and Red Crescent Societies (1995) reports that in 1985 there were 22 million refugees and internally displaced people, and that by 1995 their number had increased to 37 million. In 1998 alone, well over a million people in Central America, Bangladesh, Central Asia, and parts of Africa lost their homes in floods. Large numbers of refugees from Kosovo and East Timor have moved to neighbouring countries under extremely difficult conditions. It is impossible to assess how many of these people will be able to rebuild their homes and communities in the near future, and how many will continue to rely on relief agencies for help. Very long-term refugee camps now exist in a number of countries. There are also large numbers of people who have been displaced, but remain within the borders of their country of origin – at least 24 million, according to one estimate (Wulf 1994). Internally displaced people often flee their homes for the same reasons, and in the same circumstances, as those who have crossed national boundaries. However, the distinction in terminology means that they receive little recognition and help at international level, and thus, at times, may be substantially worse off than refugees who have left their country of origin.

The care of these refugee populations presents considerable challenges arising from the circumstances of extreme poverty, destitution, and insecurity in which most have to live, and the large numbers involved. They exist in a political vacuum, outside the 'normal' life of any country, stripped of political rights, and alienated from viable economic opportunities and from access to social provisioning. For large numbers of refugees, virtually the only services available – including health care – are those supplied by aid organisations. This applies not only to the first stages of emergency evacuation, but also to the succeeding stages which may continue, as has been noted above, for a very long time. Displacement is often considered a temporary situation, and the long-term solution is supposed to be repatriation to the place of origin or as near to it as possible. While a 'voluntary, safe return to their own countries' (Keen 1992) may well be the best solution to the refugees' problems, it is not always possible. Refugees represent a new type of population, rather than a temporary condition.

Refugees' health needs

The psychological and physical conditions in which refugees live may mean that they have greater need for health care and good nourishment than other citizens – either of the country of origin, or the host country. At present, the provision of health care for refugees is a long way from being adequate, and this is especially true with regard to reproductive health services. Women and children comprise a large proportion of the refugee and displaced population, at least in some contexts, and are sections of the populations with the largest health care needs.

Owing to the fact that interest in the reproductive health and rights of refugees is relatively recent, and the difficulties of carrying out studies at field level in certain situations, there is comparatively little research and information on the reproductive health status and needs of refugee women and men. It is often stated that at least 75 per cent of the world's refugee and displaced people are women and girls (Bandarage 1997), and that of these, 20 per cent are of reproductive age and 25 per cent are expectant mothers (Davidson 1995). The reproductive-health risks to which they are exposed are well known, but accurate information on the consequences is lacking. However, an impression can be gained from indirect statistical data. For example, maternal mortality in...