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Newsletter 12-21
September 2012

Health and Sanitation for Displaced Persons

MAJ April R. Verlo, U.S. Army

Vignette

Your unit is responsible for a displaced persons camp and has been successful in ensuring access to health care and providing an abundance of food and certified clean water. You think you have provided them the resources that are essential to life, health, and livelihood. However, the camp is experiencing unusually high mortality and illness rates, and the population of the camp is dissatisfied and miserable. Where did you go wrong?

Introduction

It is not just food and clean water that will afford refugees and displaced persons the ability to sustain life, health, livelihood, and dignity. Adequate sanitation (to include excreta disposal), management of solid waste, control of waste water drainage, control of vectors, and good hygiene practices prove equally essential to the survival and well-being of the camp population. Persons affected by emergencies often suffer from malnourishment, stress, and fatigue, which, when combined with substandard sanitation, poor hygiene, and insufficient water supplies, lead to an increased vulnerability to disease. The spread of communicable diseases can be controlled and prevented through the management of environmental conditions and individual and community behaviors.

Disease Transmission

Diarrheal diseases, acute respiratory infections, measles, malaria, and malnutrition are among the most common causes of death in emergencies.1 Most diarrheal diseases are transmitted through fecal-oral means, when the feces of one person are ingested by another person. These diseases are easily spread in overcrowded, unsanitary conditions through incorrect food handling or preparation, unsafe water, or inadequate hygiene practices. Figure 9-1 illustrates fecal-oral disease transmission routes.2

Overcrowding, poor sanitation, and inadequate hygiene practices also contribute greatly to the spread of other communicable diseases, such as acute respiratory illnesses and measles. Vector-borne diseases are transmitted through rodent or insect vectors carrying pathogens between human or animal reservoirs. Malaria is a major cause of death in many parts of the world. Exposure to rodents or insects increases during an emergency, when shelter is often inadequate to protect the population. In addition to contributing to the spread of disease, painful bites can increase the stress and suffering of the population.



Graphic showing Fecal-oral disease transmission routes

Figure 9-1. Fecal-oral disease transmission routes



Military units can utilize preventive medicine assets and medical personnel to assist in conducting assessments of the hygiene, sanitation, and environmental conditions that could affect the health of the population. It is also best to consult the help of international nongovernmental organizations (NGOs), which have competency in providing for these needs during an emergency, as well as valuable local expertise.

Emergency Phase

During the emergent phase of a refugee or internally displaced persons (IDPs) situation, providing water and sanitation should be among the top priorities. Appropriate disposal of the deceased is an important sanitation-related consideration that should be planned from the start of an emergency, as a displaced population generally experiences an increased mortality rate.

Water

With limited shelter, the absence of water will quickly become detrimental to the survival of the population. The first priority is to provide clean drinking water, followed by the provision of sufficient quantities of water for sanitation purposes to protect the health of the camp. A displaced population requires sufficient quantities of water to meet drinking, cooking, personal hygiene needs, and domestic hygiene needs. The provision of increased amounts of water is more effective in protecting against fecal-oral diseases than providing cleaner water.3

Two options for water sources in an emergency are surface water or ground water. Surface water is easily accessible but may require treatment before it is of acceptable quality for use. Ground water is generally purer but is more difficult and expensive to access.



Photo showing children retrieving water

Figure 9-2. Children retrieving water from the International Committee of the Red Cross well in Liberia (http://www.icrc.org/eng/resources/documents/photo-gallery/photos_water_03-2004.htm)



Assessment of water during the emergency phase should include evaluation of whether the quantity of resources available will meet demand and if the available water is reaching the households within the camp in an equitable manner. The minimum standards for water supply and excreta disposal, according to the United Nations High Commissioner for Refugees (UNHCR) and Sphere Project, are shown in Table 9-1.4

Sanitation

Sanitation efforts must be established immediately during the first stages of an emergency displaced person situation. Planners must take into account excreta disposal, wastewater management, solid waste disposal, vector control, disposal of human remains, and hygiene promotion. Methods to contain excreta provide the greatest protection against diarrheal diseases as compared to any other preventive measure. During the onset of emergency, communal facilities, such as defecation fields, trenches, or barrel latrines, are the easiest and quickest option for large populations.



Standard

UNHCR

Sphere Project

Average quantity of water per person per day

> 20 liters

> 15 liters

Water containers per household (average five members)

1 x 20 liters, 2 x 10 liters, 2 x 5 liters

2 x 10-20 liters and enough for storage at household level

Commercial latrines

20 people per latrine

20 people per latrine

Distance from farthest dwelling to water point

< 200 meters

< 500 meters

Number of persons per water point

80-100 per tap 200-300 per hand pump or well

250 per tap 500 per hand pump 400 per well

Optimum distance from latrine to household

6-50 meters

< 50 meters

Table 9-1



Given the possibility of a protracted emergency scenario, latrine construction should begin immediately and should be in accordance with the cultures and customs of the affected population. The 2007 UNHCR Emergency Handbook recommends the following standards for sanitary facilities in emergencies and as guidelines for camp development:5



 

Preferred Option

Alternate Option

Minimum for Emergencies

Excreta disposal

1 latrine/family

1 cubicle/20 persons

1 cubicle/100 persons or defecation field

 

Storage

Transport

Final Disposal

Refuse/Garbage disposal

1 bin, 100 liters/10 families or 50 persons

1 wheel barrow/500 persons and 1 tipper/5,000 persons

1 landfill (50m2 x 1.2 meters deep)/500 persons and 1 incinerator and 1 deep pit/clinic

Table 9-2



Education

A key aspect of long-term success of a sanitation and hygiene program includes community participation aimed at instituting behavior changes encouraging healthy life choices. Enabling the population to adhere to sanitation recommendations requires them to possess, at a minimum, hygiene kits, soap, and water storage containers, and requires adequate water supplies to conduct them. They must be empowered with information regarding safe food-handling procedures, hand washing, the use of safe water, and vectors. This information should accommodate the population's customs and traditions and be targeted toward appropriate audiences.

Stable Phase

Plans to improve a camp should begin at the onset of the displacement. Most situations that produce a refugee population have consequences that last for years, leaving the populations displaced for extended periods of time. It is essential to the health of the population that conditions within the camp be improved as quickly as possible. Protection, resources, and other factors must be considered when providing a sustainable, sanitary habitat for the population. It is also important to integrate cultural norms into the design and layout of any plan to maximize utilization and compliance.

A technical expert should design any water supply system to ensure it will be an effective, sustainable, and cost-efficient plan that will meet the needs of the population. Water systems that require little ongoing maintenance are preferable, as they will remain operational for longer periods, and are easier for a population to sustain if support organizations have to reduce manpower. Some additional considerations include:

  • Water supply rates should match the usage by the population.
  • Adequate drainage to redirect water away from the distribution points will reduce the amount of stagnant water and improve area sanitation.
  • UNCHR advocates at least 10 liters of storage per person per day at the household level. This allows for a family to continue a sanitary practice if an event preventing the production or collection of water occurs.

Maintaining the integrity of the water quality is important to allow for its continued use for sanitary purposes. Storage containers that provide the best water quality protections are narrow necked and have a lid. This style can prevent contamination through environmental means or during use, such as dirty hands reaching into the container.

Facility Considerations

Providing mature sanitation facilities and adequate resources is essential to prevent fecal-oral disease transmission in an enduring camp. General excreta sanitation guidelines that will promote acceptance by the population are:

  • Maximum of 20 people per communal latrine, segregated by gender. Eventually, the goal should be to provide each family with a separate facility.
  • Male and female latrines and showers should be constructed with roofs and lockable doors, separated by sufficient distance, and placed in a well-lighted area close to dwellings to deter access by the opposite gender.
  • Facilities need to be built from good quality materials (nonporous is ideal) that can be easily cleaned to encourage use.
  • Design considerations need to account for the soil capacity and type to afford adequate drainage but not risk ground water pollution.
  • Special considerations should be made for populations with special needs for the elderly and young children, such as smaller diameter latrine holes and easier accessibility.
  • Provision of personal cleansing materials should consider cultural norms. If water is required, an additional 3 liters per day per person should be forecasted.

Waste Management Considerations

In addition to excreta disposal, sanitation considerations include provisions for solid waste disposal, waste water control, vector control, and hygiene promotion. UNHCR considerations for solid waste management are:

  • Dump pits should provide 20 m3 per 500 persons.
  • Pits should be located more than 100 meters from households and more than 30 meters from water sources to avoid potential contamination.
  • Solid waste should be covered with 15 centimeters of soil each week and covered with 50 centimeters of soil and marked when closed.
  • Pits should be fenced to prevent access by children and animals.
  • Medical waste requires special handling due to the potential public health risks. Consult medical personnel to plan for risk mitigation and proper disposal.

Drainage

Waste water from water sources, cooking, shower and laundry facilities, and surface runoff from rainwater or natural sources must be properly drained to prevent the buildup of stagnant water and exposure to health risks. Camp construction should account for soil conditions, water table depths, topography, and the type of waste to be drained to mitigate the development of conditions adverse to health and well-being.

Displaced person camps provide ideal conditions for the spread of disease associated with poor sanitation through contact with flies, mosquitoes, lice, and rodents. The following measures will work to reduce disease transmission and contribute to eradication of disease vectors:

  • Install screens on latrine doors, windows, and ventilation pipes as well as in the doors and windows of food preparation areas. Install covers on latrine holes.
  • Locate latrines as far as possible from food preparation and storage areas.
  • Provide chemically treated mosquito nets to the camp population.
  • Design drainage areas with an appropriate slope to minimize water stagnation.
  • Consult qualified vector control personnel for the application of appropriate chemicals.

Education

Health promotion aims at preventing disease and increasing physical, mental, and social well-being. Health education provides awareness of the links between sanitation, poor hygiene, and disease. Done correctly, it can motivate a population to adopt new behaviors that will benefit their health following the resolution of the emergency. A population requires sufficient amounts of clean water, sanitation facilities, and appropriate information on hygienic practices in order for a sanitation program to be successful. Hygiene education should be reinforced through multiple channels (school, health care workers, and community services) and emphasize the following key principles:

  • The use of safe water and protection of water from contamination during collection and storage.
  • Proper disposal of solid and liquid wastes.
  • Elimination of mosquito breeding areas and rodent harborage.
  • Emphasis on safe food preparation and storage (fruit and vegetable washing, proper cooking temperatures, etc.).
  • Proper excreta disposal for babies and elderly use of sanitation facilities.
  • Personal hygiene and hand washing.


Photo showing displaced persons conducting personal and household hygiene

Figure 9-3. Displaced persons conducting personal and household hygiene at an improvised facility in Timor-Leste. (Photo from UNHCR: http://www.unhcr.org/44b3b4474.html)



Conclusion

Camps holding displaced persons or refugees demand high levels of personal, domestic, and communal hygiene to mitigate the increased risk of communicable disease transmission. The military might be asked to aid in camp establishment or management in conjunction with local resources. While our experiences establishing military operating bases will be extremely valuable, it is also important to understand some of the differences in needs, standards, and resources available to support a displaced population.

Additional information is available through the following sources:

  • UNHCR Emergency Handbook.
  • Sphere Handbook (Sphere 2011).
  • Excreta Disposal in Emergencies: A Field Manual (IFRC, OXFAM, UNHCR, UNICEF, WEDC, 2007).
  • Emergency Water Sources (WEDC, 1997).


Endnotes

1. The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies, Public Health Guide for Emergencies (Geneva, Switzerland: 2008), 375.

2. Ibid., 379.

3. Ibid., 395.

4. UNHCR, A Guidance for UNHCR Field Operations on Water and Sanitation Services (Geneva, Switzerland: 2008), 5

5. UNHCR, A Guidance for UNHCR Field Operations on Water and Sanitation Services (Geneva, Switzerland: 2008), 12.


 

 
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