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
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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 fieldtested 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
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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 PostConflict 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.
Gro Harlem Brundtland
Invited Guest Editor
Acta Psychiatrica Scandinavica
References:
1.
2.
3.
4.
5.
Petevi M, Forced Displacement: Refugee Trauma, Protection and Assistance. In
International Responses to Traumatic Stress, Danieli Y, Rodney N, and Weisaeth L, (Eds).
United Nations Publication, Baywood Publishing Company, New York 1996.
Jong, JP de, Scholte WF, Koeter MWJ, Hart AAM. The prevalence of mental health
problems in Rwandan and Burundese refugee camps. Acta Psychiatr Scand 2000: XXXX
WHO. WHO/UNHCR Mental Health of Refugees. WHO, Geneva 1999.
WHO. Declaration of Cooperation in Mental Health of Refugees and Internally Displaced
Populations in Conflict and Post-Conflict Situations, Ed. Petevi M, WHO, Pre-final draft,
Geneva 1999.
Petevi M, Revel J.P., Jacobs, G.A. WHO tool for the Rapid Assessment of Mental Health
Needs of Refugees and Displaced Populations and Resources, in Conflict and Post-Conflict
Situations. Pre-final draft. WHO, Geneva 1999.
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