A brief analysis of

1) in 2) Tibetan 3) Sri Lankan Refugees in India 4) Sri Lankan IDPs

Centre for Research on the Epidemiology of Disasters (CRED)

Complex Emergency Database (CE‐DAT)

March 7th, 2008 Brussels, Belgium

Further information: [email protected] +32‐2‐764.34.47 1

1) Bhutanese Refugees in Nepal

Population 106,690 refugees as of 30/06/2007

Public Generally, health and nutrition indicators suggest that the health and nutrition status of Health Bhutanese refugees is satisfactory. The indicators show a situation that is better than Profile that of the average Nepali citizen and that the services available in the refugee camps exceed the national standards.

Mortality Rates are significantly below emergency thresholds, even better than what one would expect in a stable setting.

Wasting (acute malnutrition) values are below emergency thresholds.

Global Actute Malnutrition Rates of Bhutanese Refugees in Nepal 18 16 14 12 10 WH<80% 8 WHZ <‐2SD 6 4 2 0

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Stunting is relatively low compared to Nepali resident population, but high by international standards. This is an potential indication that a high proportion of young children are having recurrent episodes of infectious diseases and/or repeated bouts of under‐nutrition, especially micronutrient deficiencies.

Global and Severe Chronic Malnutrition (stunting) in Bhutanese Refugees in Nepal 35 30 25

20 HAZ<‐2SD 15 HAZ<‐3SD 10 5 0 1999 2000 2001 2002 2003

Anemia significant with 43.3% (january 2007) in children and 13.6 in women Night blindness in 2% of children and 10% of mothers High frequency of TB among refugees is similar to other reports.

Literacy rate among Bhutanese refugees is estimated at 65%

Refugees in camps are completely dependent on WFP for food.

Though things seem to have calmed down, there was much violence in early 2007

Young refugees happy to relocate, while older refugees want repatriation to . Relocation would mean a loss of the right to repatriation.

Due to intimidations and a lack of security inside the camps, a number of refugees have left the camps and do not have access to UNHCR protection, food rations and health services.

Recent fire in Goldhap refugee camps has increased the vulnerability of thousands of refugees (95% of camp was burned down & 7 to 9,000 refugees homeless).

Risk of a large number (80,000) of Bhutanese of Nepali origin finding refuge in Nepal due to indigenous Bhutanese having allegedly started unleashing atrocities against Nepali‐speaking Bhutanese. Gaps and Census was carried out in 2006 but data not available to international humanitarian recommen community. Hence Lack of data on basic demographics of the refugees dations Lack of recent data on mortality & malnutrition in camps

Quality nutrition surveys with support from qualified staff need to be carried out on a regular basis. These should assess under‐nutrition, stunting and micronutrient deficiencies.

There is a need to push for the use of standardized survey methodologies (e.g. SMART) to ensure comparability of survey results across time and refugee populations. 3

Lack of data on Bhutanese who have recently left the camps due to security and who do not have access to UNHCR protection and food rations. It is estimated that 30% of refugees are staying out of the camps either temporarily or permanently. Necessary to survey refugees who have left the camps and provide assistance based on this needs assessment. Nutrition Information in Crisis Situations, May 2007, report Number XIII Sources Refugee health in Nepal, joint UNHCR‐WHO evaluation of health and health programmes in Bhutanese refugee camps in Nepal, April 2005

Report Of UNHCR/ WFP Joint Assessment Mission Assistance To Bhutanese Refugees In Nepal (29 May – 9 June 2006)

Needs assessment of reproductive health among refugee women, Centre for Research on the Epidemiology of Disasters, 1998

High success rate of TB treatment among Bhutanese refugees in Nepal. International Journal of Tuberculosis and Lung Disease 11(1):54‐58, 2007

CDC. Surveillance of the Health Status of Bhutanese Refugees – Nepal, 1992. Morbidity and Mortality Weekly Report (MMWR), 1993;42:14—7.

Marfin, Anthony et al. Infectious Disease surveillance During Emergency Relief to Bhutanese Refugees in Nepal. Journal of the American Medical Association, Vol. 272(5), 3 August 1994, pp 377‐381

Woodruff, Bradlet et al. Anemia, iron status and vitamin A deficiency among adolescent refugees in Kenya and Nepal. Public Health Nutrition. 9(1),26‐34, 2006

CDC. Nutritional Assessment of Adolescent Refugees – Nepal, 1999. Morbidity and Mortality Weekly Report (MMWR), 2000;49(38):864‐7.

ReliefWeb; Nepal: UNHCR needs funds for camp razed by fire. March 7, 2008; http://www.reliefweb.int/rw/RWB.NSF/db900SID/ASAZ‐7CHJRM?OpenDocument

Refugees International. Nepal: Time for Bhutanese Refugees to choose their future paths. 17 October 2007

Drukpa atrocities on Nepali‐speakers. eKantipur.com http://www.kantipuronline.com/kolnews.php?&nid=138180

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2) Tibetan Refugees in India

Population While reliable numbers are hard to come by, Tripathy et al. (2006), report a 1998 Tibetan demography survey that enumerates 85,147 refugees. Full information on Tibetan demographics is available in Bhatia et al. (2005). Public In 1996, Bhatia et al. (2002) characterized Tibetan refugees as representing a society “in Health transition from the profile typical of developing countries to that more typical of Profile developed countries.” Today, “Tibetans in India resemble populations from developed countries who are described as urban, having a sedentary way of life (Tripathy et al. 2006).”

High levels of obesity (11.7%) and overweight (27.9%) refugees are observed. Very few refugees were found to be underweight (4.8%)(Tripathy et al. 2006).

Infant mortality was reported as 20.7/1000 live births in 1996 (Bhatia et al. 2002), down from 162/1000 live births in 1990 (Sowa et al. 1991). More recent figures are not available and crude death rates are unreliable due to the political nature of total refugee population numbers (Bhatia et al. 2002).

The main causes of death in 1996 were reported to be cancers (14%), pulmonary tuberculosis (13.7%, 35% characterized as drug resistant), old age (9.7%), and accidental causes (9.2%; primarily “vehicular accidents, altercations, and drowning”). In Northeastern India refugee camps cirrhosis of the liver (likely due to alcohol consumption) and malaria were important causes of death (Ibid). Sowa et al. (1991) report that 40% of child deaths in 1990 were characterized as being a result of malnutrition potentially explaining their elevated numbers.

Bhatia et al. (Ibid) report child vaccination levels of 47% for tetanus (BCG), 39% for polio (full DPT series), and 31% for measles containing vaccine (MCV) in 1996. These levels are quite low, but over a decade old and may have improved due to vaccination campaigns funded by international donors in the 1990s (Sowa et al. 1991).

Tibetan refugees demonstrate high levels of Tuberculosis (TB) prevalence. Values for TB prevalence are estimated at 1200/100 000 in a 2002 study, 835/100 000 in a survey of 90% of the adult population over the period 1994‐1996 (Tripathy et al. 2006). TB cases are reported to have arisen at a rate of 300 new cases per year in 1990 (Sowa et al. 1991). Tibetan refugees to the United States and Canada throughout the 1990s showed high levels (98% and 97% respectively) of exposure to TB upon arrival (Nelson et al. 2005). TB rates may have improved since the time of last survey due to expansion of a WHO anti‐TB campaign in India known as the DOTS program (Ibid.). HIV/AIDS has not been reported as a problem in refugee camps to date (Nelson et al. 2005, Tripathy et al. 2006).

Hypertension among Tibetan refugees residing in India is also quite high, although it is not immediately evident whether this poses a health concern for environmental reasons related to Tibetans nature as a high altitudes dwelling people (Tripathy et al. 2006).

Gaps and Data gaps on TB and child vaccination levels since 1996 and a general lack of information recommen on the cardiovascular health of Tibetan refugees makes it difficult to assess possible risks dations to health.

A study of current TB and child vaccination levels would be advisable, with potential proposals for appropriate interventions to follow. It may also be advisable to continue

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monitoring the populations cardiovascular health given high levels of obesity and hypertension. Bhatia S, Dranyi T and D Rowley (2002). A social and demographic study of Tibet refugees Sources in India. Social Science & Medicine 54: 411‐422.

Nelson LJ, Naik Y, Tsering K and JP Cegielski (2005). Population‐based risk factors for tuberculosis and adverse outcomes among Tibetan refugees in India, 1994‐1996. Int J Tuberc Lung Dis 9(9): 1018‐1026.

Sowa K, Nishikura T and K Maruki (1991). A report of two visitis to the Tibetan refugee camp in Dharamsala, North India. Accessed March 5th, 2008

Tripathy V, Statapathy KS and R Gupta (2006). Nutritional status and hypertension among Tibetan Adults in India.Human Ecology Special Issue 14: 77‐82.

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3) Sri Lanka Refugees in India

Population Estimation 1. Indian Ministry of Home Affairs reports that there are 50,750 refugees in 103 camps in Tamil Nadu (and one camp in Orissa) (IMHA, 2006) 2. 17,064 live outside of camps (IMHA, 2006) 3. UNHCR has similar camp estimate: 50,730 refugees (UNHCR, 2005) 4. Camps are of varying sizes across 23 out of 29 districts in Tamil Nadu (Acharya, 2007) Public 1. The full scope of the public health problem is unknown as data is lacking and this Health group is under the protection of the Government of India (GoI) who has restricted Profile the access of UNHCR and international agencies to the population. 2. Despite this, some interventions and qualitative assessments have been carried out very sporadically by agencies. The Organisation for Eelam Refugees Rehabilitation (OfERR), a local NGO, received funding from ECHO to carry out nutritional interventions and basic health support in the short‐term. 3. The GoI provides monthly stipends, electricity, rice, water and health and educational facilities although several agencies have commented that there are not enough goods provided for survival (Refugees International 2004; Saha, 2007). 4. OfERR (2006) carried out nutritional surveys since 2002, but these were not obtainable in this short time period. Summary information is available, but clarification is needed on data quality, methods and further results (for example, the reported age categories are not standardized). Surveys were used to target interventions for at‐risk groups (defined as pregnant women, lactating mothers, children from 0 to 18): • 87% of children aged 5‐14 were “undernourished” (most probably meaning, underweight/weight for age) and were given supplementary nutrition • Anemia prevalence is “extremely high” (prevalence not stated) due to repeated hookworm infestation, unsanitary conditions and undernourishment • Supplementary rations given to 18,350 vulnerable refugees and 23,850 most vulnerable refugees received micro‐nutrient supplements • Low birth weight (LBW) prevalence is low compared to Tamil Nadu. LBW was reduced from 13.6% in July 2002 to 1.3% in Feb. 2006 which is much lower than the rate in Tamil Nadu in 2001 (15.79%) (SPC, 2007) • Infant mortality rate (IMR) is low compared to Tamil Nadu. IMR was 17.09 per 1,000 live births in 2005 which is lower than the IMR in 2004 (22/1,000 live births) and the rate in Tamil Nadu (41/1,000 live births) (Statistical Handbook, 2006) • Maternal mortality rate (MMR) is higher than that of Tamil Nadu. MMR was 2.14 per 1,000 live births in 2005 which is higher than the MMR for Tamil Nadu (1.1/1,000 live births) (Health and Welfare Department, 2006) 5. Rapid health assessment in 2003 found malnutrition to be similar to neighbouring communities (Bazroy et al, 2005). Of the 125 refugee children under 5 years of age in a camp in Kizhuputtupati, Villupuram district found that: • 92% had complete immunization, 7.2% had partial immunization, 0.8% had no immunization • 2.4% had severe acute malnutrition (SAM), 10.4% had global acute malnutrition (GAM) • Rates were very similar to a neighbouring community (SAM – 1.5%, GAM – 8.1%, complete immunization ‐ 97.8%) 6. A food security assessment funded by ECHO (2005) found: • GoI aid packages meet only 26% of the costs of the food basket supplying sufficient calories to an average family 7

• Average monthly amount spent on food meets only 58% of the minimum amount needed for adequate nutrition • 40% of families have an income that is inadequate for meeting the minimum food requirements The ECHO mission found that water provision was not always secure and poor housing, sanitation and toilet facilities result in recurrent infectious and chronic disease Gaps and 1. There is a clear lack of essential public health data and food security data on Sri recommen Lankan refugees in Tamil Nadu and further investigation by a credible international dations organization or NGO is warranted. 2. Given that 103 refugee camps of varying sizes are spread throughout Tamil Nadu, it is difficult to make concrete recommendations for the population as a whole. 3. The extremely high prevalence of underweight children (ages 5‐14) reported by OfERR is an unusual statistic that deserves further investigation. On the positive side, the IMR, MMR, low birth weight figures reported by OfERR are close or even lower than those of Tamil Nadu. 4. Nutrition is a problem in many parts of India. A GAM ≥10 was reported in the Kizhuputtupati camp, which typically indicates a serious nutrition situation in humanitarian emergencies. However, this GAM was similar to that of the neighbouring community and lower than the Tamil Nadu rate (22.2%) (DHS, 2007). In light of UNHCR’s lack of access to the refugees, the varying accounts of the GoI’s provisions for the refugees are of concern. Bazroy J, Panda P, Purty AJ, Philip B. Refugee children in India: a comparative study. HK J Sources Paediatr 2005;10:101‐108.

ECHO (2005), The Evaluation of ECHO’s Actions in Sri Lanka and in the Tamil Refugee Camps in Tamil Nadu, India.

Government of Tamil Nadu Department of Economics and Statistics (2006), Statistical Handbook.

Health and Family Welfare Department (2006), Policy Note ‐ 2005 – 2006 Demand No.18 Chapter – 6 FAMILY WELFARE PROGRAMME.

India: DHS, 2005/2006, (2007), Chapter 10: Nutrition and anemia. http://www.measuredhs.com/pubs/pdf/FRIND3/10Chapter10.pdf

OfERR (2006), Enhancing the Nutritional Status of the Refugees.

Refugees International (2004), Sri Lankan Refugees in India: Hesitant to Return.

Saha K.C. (2004), Learning from Empowerment of Sri Lankan Refugees in India. Forced Migration Review 20.

State Planning Committee (2007) Tenth Plan Five Year Plan. 2002‐2007. http://www.tn.gov.in/spc/tenthplan/

UNHCR (2006). UNHCR Statistical Yearbook, Geneva.

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4) Sri Lanka IDPs

Population Population estimate: 460,000 IDPs

It is difficult to determine the exact numbers of internally displaced people in Sri Lanka today due to the overlap between those displaced by the conflict and the 2004 tsunami, and between those displaced by the conflict before and since 2006. According to estimates, however, around 460,000 people remained displaced in Sri Lanka in August 2007 as a result of conflict and violence, including over 181,000 people, or 49,000 families, displaced by the fighting since April 2006. Over 312,000 people were still registered as displaced due to conflict and violence in April 2006. By the end of December 2006, this figure appeared to have risen to 520,000 people, out of Sri Lanka’s total population of 20 million. The renewed fighting had in the year to April 2007 displaced an additional estimated 301,000 people from their homes. An estimated 101,000 of these newly displaced people have returned to their areas of origin as of September 2007, within government‐ and UNHCR‐supported return programmes in Trincomalee and Batticaloa districts, including over 3,000 who are staying in transit camps until a durable solution is found for them. Some IDPs have also returned spontaneously to their areas of origin. In August 2007, the International Organization for Migration in Sri Lanka reported that almost 11,000 families displaced by the 2004 tsunami remained in transitional sites. This number did not include those displaced from the LTTE‐controlled areas of Kilinochchi and Mullaitivu, where figures were not available, or tsunami‐displaced people living with host families. A group not included in these IDP statistics is “night IDPs” who stay at their homes during the day, but spend the night in jungle areas or away from their homes due to fear of violence from armed groups. The phenomenon of night IDPs has been increasingly observed since 2006.

Figure 1: Location of new IDPs (displaced after Jan 2006) 9

Public 1. Malnutrition rates rising Health Nutritional data from IDPs in Jaffna district in 2007 (north of the country) suggested Profile increased levels of malnutrition (GAM 19.9%, SAM 4.9%). In general however, malnutrition rates tend to be rather high in Sri Lanka. 2. Lack of access to education At the height of the conflict between the army and the LTTE in the east during 2006‐ 2007, more than a quarter of a million children experienced partial or complete disruption of their education. In Batticaloa district alone, the education of at least 135,000 students was affected. Many schools were closed as they were used as shelters for IDPs. 3. Recruitment of child soldiers into rebel factions By the end of July 2007, UNICEF had listed 1,518 outstanding cases of LTTE under‐age recruitment, including 401 children currently under the age of 18 years, with 60 per cent of the recruits being male, and 40 per cent female. 4. Mental health issues The conflict situation has caused widespread mental health problems among IDPs and hosts. In December 2006, the World Health Organization noted that an estimated two per cent of the population could be in need of mental health services, and warned of an increase in the number of suicides, even though Sri Lanka already has one of the highest suicide rates in the world.

Gaps and • There is a significant shortage of IDP data in Sri Lanka. More data collection is crucial in recommen order to better assess the needs. Security issues however could hamper this. dations • For a country that suffers no significant food shortages and provides extensive, free maternal and child health services, it is rather paradoxical that malnutrition affects nearly one‐third of children and one quarter of women. This unusual malnutrition pattern in Sri Lanka is not fully understood, hence the need for a causal analysis.

Sources Sources: IDMC, UNICEF, WFP, IRIN

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