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Medical Assistance to Self-settled Refugees Guinea, 1990-96 Wim Van Damme Studies in Health Services Organisation & Policy, 11, 1998 Studies in Health Services Organisation & Policy, 11, 1998 Series editors: W. Van Lerberghe, G. Kegels, V. De Brouwere ©ITGPress, Nationalestraat 155, B2000 Antwerp, Belgium. E-mail : [email protected] Wim Van Damme Medical Assistance to Self-settled Refugees Guinea, 1990-96 D/1998/0450/4 ISBN 90-76070-09-11-3 ISSN 1370-6462 This study was supported by a research grant from the Fund for Scientific Research, Flanders, Belgium (FWO-S 2/5-KV-E95), and from the European Union (IC18-CT96-0113). Preface My position In 1989, I came to live and work in N’Zérékoré, in the Forest Region of Guinea, as a member of Médecins Sans Frontières (MSF). My remit was to assist the Guinean Ministry of Health (MOH) to develop its public health care system. Work had barely begun when the first refugees from Liberia started to arrive. Together with my counterpart, MOH’s regional medical inspector for the Forest Region, we took on as added responsibilities the medical aspects of the Programme d’Assistance aux Réfugiés Libériens et Si- erra-Léonais (PARLS). This sequence of events influenced our perception of the refugees and PARLS. It was an added problem, a new factor, disrupting the setting-up of the still fragile Guinean health system. We thought PARLS should not be allowed to negatively influence the ongoing development of the Guinean health system; rather we tried to organise PARLS in such a way that it would strengthen the national health system. I was thus a ‘development worker’ as opposed to the ‘relief workers’, who came to Guinea ‘to assist the refugees’. From the very start, the difference in logic between development and relief was clear, and this will be a central theme throughout this study. I stayed in Guinea till mid-1992. Since then I have followed up on the evolution of PARLS during yearly field missions to Guinea till mid-1996. During these follow-up visits, I had no more operational responsibilities in Guinea. I came as a ‘researcher’ for some, as a ‘visitor’ for others. It was amazing to discover to what extent this change in position changed the ob- servations I made, and how this had an impact on my perception of the problems and merits of PARLS. Certain realities only became visible during these follow-up missions. Other problems, which were among my major preoccupations when I was working in Guinea, became less of a problem. On data and decision making This study covers the period from January 1990, when the first refugees ar- rived and PARLS was started, till August 1996, when I paid my last field visit. Information from before 1990 is used to clarify the context and health system in which PARLS was set up. The description and analysis of PARLS is mainly based on my personal experience, on analysis of written reports, and on discussions with different actors of PARLS. Studies in HSO&P, 11, 1998 1 Most quantitative data are from routine reports by the health services.* These are fraught with flaws and inaccuracies. Some data may appear im- probable, or contradict other data. This is particularly so for data on the number of refugees and on the utilisation of health services. Surveys con- ducted by PARLS are also not free from flaws. Survey methods and inclu- sion criteria changed over time, and yielded data that are not strictly com- parable. I discuss respective merits and possible biases, and compare them with other quantitative or qualitative information. Sometimes I had to rely on well-informed guesstimates rather than on hard data. On other occa- sions, no quantitative data were available to substantiate qualitative obser- vations. The possibilities and limitations of the use of routine data is a re- current theme in this study. The actual decision making process in PARLS was based on such im- precise and doubtful data – but they were the only ones available to the field workers at the moment they had to make their decisions. That data were available does not imply that the field actors knew all the information that could be generated from these data. Many insights appeared while ex- amining data years after they were collected.The next central theme of this study is to address the rationality of decision making in dealing with the refugee problem. With the benefit of hindsight, I will try to identify whether decisions were ‘good’ (‘Did it have the best results possible?’) and/or ‘ra- tional’ (‘Was the best possible decision made, given the information avail- able, and the prevailing time constraints?’). Obviously, hindsight provides us with a better – if still inadequate – basis for judging whether what had been decided was the ‘best’ and/or most ‘rational’ option. Assisting self-settled refugees and the search for appropriate methods Assisting large numbers of self-settled refugees has, to my knowledge, never been documented before. The strategies and methods thus had to be in- vented and adjusted on the spot. The two reference frames (‘types of logic’) of primary health care (PHC) as part of overall development, and of emer- gency medical assistance (EMA), or emergency relief, were constantly pres- ent. The ‘development actors’ started from the former, but recognised that assistance to refugees had to incorporate relief elements. The ‘relief actors’ started from the latter, but recognised that this had to find an adequate in- * Only the data on major obstetric interventions in Guéckédou and on measles were collected specifically for this study. 2 Studies in HSO&P, 11, 1998 terface with the Guinean health system. This continuous search for the best strategies and methods within PARLS – a constant balancing act between ‘assisting the refugees’ and ‘developing and safeguarding the Guinean health care system’ – is a third central theme. The discussion became more fruitful after two or three years, when even the most fervent relief workers came to recognise that the refugees would stay in Guinea for a very long time, and that approaches used by PARLS should be compatible with this reality. At the same time, all those primarily concerned with development came to recognise that refugees have specific needs: even after years they remain ‘strangers’ with weaker social networks. Limitations I try to cover different fields and aspects that appear relevant to the overall picture. This implies, of course, that not everything can be discussed in depth. In the words of Livi-Bacci:1 “I had to enlarge my plan of attack to in- clude several problems and topics […]. I have been haunted by the constant fear of losing the depth of this study for the breadth of its extension. This is, however, a calculated and consciously accepted risk. The temptation to take shelter within safe disciplinary boundaries is great; but problems remain complex and in order to solve them it is not sufficient that they be individually identified and isolated. Now and then it is worth making an attempt at reconstruction.” Although I use in this study some elements of anthropology, sociology and economics to understand the situation of the refugees in the Forest Re- gion, I still primarily look at PARLS, and not at the refugees, and this through the eyes of a public health manager, rather than through those of an economist, sociologist, anthropologist or political scientist. This is a pragmatic choice, and it does not distract from the need to better under- stand refugees as human beings, and not as mere numbers in a body count. Wim Van Damme Antwerp, August 1998 Studies in HSO&P, 11, 1998 3 4 Studies in HSO&P, 11, 1998 Introduction Although some 100,000 people are estimated to have died due to the famine, these deaths were caused not by lack of food but by ‘health crises’. These health crises consisted in localized outbreaks of disease, particularly measles and the diarrhoeas, which were precipitated by population movements and by lack of sanitation and clean water. It is commonly argued that diseases become more prevalent during famines because people are undernourished and so weak and more susceptible to disease. I am arguing that this is false, at least in the case of Darfur. One important factor in this was the decline in both the quantity and the quality of water. A second was the large-scale movement of people. Large concentra- tions of people accelerated the rates of transmission of infectious diseases. The new situation was equivalent to a sudden change from a dispersed or rural-type environment to a concentrated or urban-type environment. This also put pressure on water supplies and sanitation facilities in the host communities: the public health environment became degraded, for hosts and migrants alike.2 Alex de Waal The location of the refugees may range from spontaneous settlement over a wide area, through organized rural settlement, to concentration in a very limited area. Circumstances can make this last possibility un- avoidable, but the establishment of refugee camps must be only a last resort. A solution that maintains and fosters the self-reliance of the refugees is always preferable. […] Whatever the circumstances, the overriding aim must be to avoid artificial, high density, refugee camps.3 UNHCR Handbook for Emergencies Refugee emergencies are frequent, and the most dramatic Somalias, Gomas and Sudans get wide media coverage. Nowadays, concentration of refugees in camps is often considered an inherent feature of mass migration. The terms ‘refugees’ and ‘camps’ are intimately linked, both in collective con- sciousness and in practice. Most aid workers and relief administrators will acknowledge that refugee camps are a bad thing, while stating that, unfor- tunately, they cannot be avoided; “there simply is no alternative”.

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