How humanitarian disasters affect children

How humanitarian disasters affect children

By Karen N. Olness, MD

Youngsters who become refugees or are otherwise caught up in a large-scale emergency, such as civil strife or a flood, may have physical, emotional, or developmental problems for years to come.

All over the world, humanitarian disasters, such as civil war, economic collapse, or a natural catastrophe, make refugees of children and their families. After long periods living under adverse conditions, many of these children become permanent residents of other countries, including the United States. Pediatricians caring for such children may neither hear about the suffering they endured nor suspect the problems that continue to affect them and their families, including posttraumatic stress and delays in physical and emotional development and cognition. The following case histories illustrate what happens to children struck by humanitarian disasters.

Dara's story

Dara was 9 months old when she crossed the Mekong River from Laos to Thailand on a flimsy raft after the Vietnam War. Dara's mother held the child in her arms. Dara's father and three older siblings also made the crossing, but the 3-year-old slipped off the raft and drowned. When the five remaining family members reached Thailand, they were held for a week in a crowded, unsanitary Thai jail, then sent to the large refugee camp, which held about 40,000 people. A bamboo shack was their home, and camp authorities gave them basic food supplies once a week.

Dara had severe diarrhea for several days after arriving in the refugee camp and was treated with oral rehydration in the camp clinic. When she was 1 year old, she became ill with measles complicated by pneumonia and was hospitalized in the makeshift camp hospital. Her mother had little breast milk by this time, and Dara was anorexic during the acute phase of measles. Her nutritional status had been borderline; now she became severely malnourished. As a result, she remained in the hospital where personnel tried to get her to eat. When she refused, tube feeding was begun. Nurses were unavailable at night, however, and two weeks after the tube feeding began, Dara had lost more weight and was even more malnourished than when she entered the hospital. Hospital personnel taught Dara's mother how to conduct the tube feeding, and once she took over Dara consumed sufficient calories. In another two weeks she began oral feedings and was discharged at 14 months of age for outpatient follow-up. She had not begun to walk, but slowly gained weight and height.

When Dara was 18 months old, the family relocated to the United States under the sponsorship of a church group. Dara gained weight rapidly in her new home and seemed to catch up in other ways, meeting standard motor and language milestones. She attended nursery school at age 4 and entered kindergarten at 5. She was a quiet and cooperative child in school. She learned to read and write without difficulty, but had problems with math throughout grade school and was tutored. Major learning problems first became apparent in the fifth grade, when school assignments required performing a variety of tasks.

Elizaphan's story

In 1994, Elizaphan was 5 years old and living in rural Rwanda when he and his parents, 3-year-old sister, and infant brother fled toward Goma in Zaire in the wake of widespread massacres. The family traveled on foot, pushing a bicycle to which food was tied and a wheelbarrow containing bedding and clothes. They crossed the border in a few days and were herded into a very crowded area without latrines. Elizaphan's parents soon became ill with cholera and died. His baby brother also died. Elizaphan and his sister were found wandering in the camp. Elizaphan no longer spoke, and his sister cried for her mother. Since the only information the sister could supply about herself and her brother was their names, the Red Cross reunification workers could do little to find relatives beyond posting the children's photographs and first names.

Relief workers took the two children to the camp orphanage where they huddled together. The weather was cool and rainy, and soon they both were coughing. The orphanage provided meals once a day, and nurses gave them medicines. Elizaphan ate but did not speak. Older children took much of their food. The siblings became malnourished, and both had diarrhea. After a week, they were taken with eight other children to a tent on the orphanage grounds and were told that a Rwandan woman living in the tent would care for them. She was also depressed, having lost her immediate family, but she did the best she could to nurture the 10 children. Elizaphan continued to be mute in the months that followed. After six months, he and his sister were transferred to an orphanage in Rwanda.

The outlook for Dara and Elizaphan

Dara's experience typifies that of hundreds of thousands of Southeast Asian children who became refugees in the aftermath of the Vietnam war. Those children are now resettled throughout the Western world, and the stress they experienced continues to affect them, their families, and their communities. Dara's parents underwent enormous emotional strain, making the decision to flee their home and then losing a child during the frightening trip across the Mekong. The crowded, unsanitary jail in which they were placed probably facilitated the spread of measles, cholera, and many other diseases. The period during which Dara was profoundly malnourished may have led to her learning disabilities, which became obvious only when she was well along in grade school. The malnutrition may have long-term effects as well, making it difficult for her to complete school and keep a job. Behavior problems may be associated with the learning disabilities.

Elizaphan's problems represent severe posttraumatic stress disorder, exacerbated by lack of access to formal psychotherapy or even to early intervention with tender loving care to help him cope with his profound loss. The long-term outlook for Elizaphan is poor. If culturally appropriate psychotherapy should become available, Elizaphan is likely to require many years of treatment before he improves. If he does not receive any therapy, he may remain institutionalized. His sister probably also has emotional problems. She is undoubtedly a comfort to Elizaphan, and it is important that they remain in the same center.

The scope of the problem

Situations like the ones that made refugees of Dara and Elizaphan are termed "complex humanitarian emergencies" (CHEs). In CHEs, which affect large populations, property is destroyed or lost and people are injured or killed. CHEs may be natural disasters, such as floods, typhoons, and earthquakes; technological disasters, such as chemical or radioactive accidents; or disasters related to civil conflict and economic collapse. These categories sometimes overlap. A drought preceded the war and civil strife in Somalia in 1980, for example. CHEs result in political, military, economic, and natural constraints. During the past decade the number of CHEs has increased from an average of three or four a year to 27 to 30 per year. In the US, CHEs are most likely to be natural disasters.

According to estimates, disasters during the past two decades adversely affected 800 million people, half of whom were children. During the past five years, CHEs have caused 12 to 15 million children to become refugees each year. Victims in CHEs are five times more likely to be civilians than to be in the military, and most are women, children, and the elderly. Disasters have distinct stages: The early or acute stage lasts about one month; the late or recovery phase lasts one to six months; and the rehabilitation or development phase is the period beyond six months.

What children in CHEs need

Although refugee camps should provide safe havens in the aftermath of a CHE, they often contribute to continuing physical and mental risks for the most vulnerable individuals—nursing mothers and children, especially those who have no parents to care for them. People caught in a CHE require, at a minimum, food, clothing, shelter, sanitation, and easing of their stress. Although these basic requirements are the same for children and adults, filling children's needs calls for special considerations that don't apply to adults.

Ensuring fair and effective distribution of supplies to children is a major challenge for relief workers. Although breast milk is recommended for all infants, for example, the supply of breast milk may be compromised by maternal stress and lack of water. To ensure the availability of breast milk, special efforts must be made to provide food, fluids, and stress reduction for nursing women. Relief workers who are not knowledgeable about children may not realize that those who are young require small, frequent portions of food. Giving a small child an entire day's rations in one meal, a common practice in some refugee settings, may lead to malnutrition. In addition, children are at greater risk than adults for developing clinical disorders associated with deficiencies of micronutrients, which are limited in some of the food plans used in refugee camps.

Adequate clothing presents another problem. In the chaos of a CHE, children often lose clothing or it is stolen. In the large movement of Rwandan children, for example, many of those who were on their own (because they had become separated from their parents or their parents were dead) had no clothes. It was cool and rainy, and being naked and barefoot increased these children's suffering and their risk for infectious disease and trauma.

Shelter not only protects children from the elements but also reduces the likelihood of abuse, exploitation, and the negative effects of interactions with undesirable individuals. Ideally, families should be sheltered together. During refugee movements, sleeping out in the open may be the only option. The best way for children to keep warm is to sleep next to their parents or other children in an area that is out of the wind. Using available clothing and blankets for the smallest and most malnourished of the young children should be a priority. In some situations it may be important to identify all unaccompanied children and house them together. Gender differences should be considered in arranging shelter for older children. For the child without adult care, placement in a foster family generally is preferable to an orphanage, which is less likely than a foster family to provide surrogate parents.

Sanitary toilet facilities are a necessity. Children who don't have parents or surrogates to guide them find it difficult to use defecation fields or latrines and to practice basic hygiene. Lack of defined areas for defecation and convenient access to hand washing leads to an increase in infectious diseases. Education of parents and children about how disease spreads, the proper use of toilets, and hand washing is a high priority.

Health-care providers in CHEs may not realize the importance of calculating dosages of medications for infectious diseases based on the child's weight. Malnourished children may not be able to metabolize certain medications, such as acetaminophen, and sometimes should not receive them at all.

Restoration of daily routines is beneficial to children who have experienced a disaster. Once the emergency phase of the disaster has passed, it should be possible to set up schools with regular hours, have meals and take baths at predictable times, and reinstitute accustomed recreational, religious, and musical activities. Children and adolescents can participate in daily tasks, such as gathering wood, working in gardens, making food, and helping to care for young children. Adolescents can prepare entertainment programs for younger children. Depending on the culture, these might include pantomime, puppets, storytelling, or musical programs.

Children without parents

Children in CHEs may be alone because their parents have been killed or died, or because the family has been separated in the chaos of leaving and moving quickly. These unaccompanied minors are especially vulnerable to malnutrition, infectious diseases, exploitation, and poverty, and relief workers must take a proactive approach to helping them. Facilitating immediate reunification is especially important. Workers should record details about the child and, if possible, take photos. The International Committee of the Red Cross should be notified; it is this organization's responsibility to try to find families for children who are separated from their parents. Efforts should be made to provide round-the-clock caretakers for unaccompanied minors, especially those who have no older siblings and who are preschoolers. Sometimes another refugee family or an adolescent girl can be a surrogate parent. If parents are not found, placement in a foster home is usually preferable to an orphanage.

Relief workers must safeguard the food, shelter, and clothing of unaccompanied minors. Providing routines and predictable pleasant events is especially important for these children, as is creating a sense of community. Youngsters who have lost their parents are at great risk of long-lasting symptoms from posttraumatic stress.

Caring for the children of disaster

How a child responds to a disaster varies with his or her developmental stage (Table 1). Once the acute stage of the emergency is over, consideration of more than the child's basic needs becomes a priority. Parents, community health workers, physicians, nurses, teachers, or indigenous healers should monitor children and adolescents for symptoms of psychological trauma. Rapid intervention is important when such symptoms develop. All the adults who have contact with the child who has experienced a CHE should know about the special mental health risks such a child faces and the importance of getting help at the first sign of trouble. It's also important to recognize signs of depression in parents.

Table 2 summarizes special considerations in providing health care to children who have experienced a humanitarian disaster. More information on children and humanitarian disasters is available from the sources in Table 3.

TABLE 3

Where to learn more about children and CHEs

Course

Complex Humanitarian Emergencies: Focus on children and families. A problem-based, intense one-week course. Sponsored by Rainbow Babies and Children's Hospital and Case Western Reserve University. For further information call Joan Farmer at 216-844-8550 or e-mail her at joan.farmer@uhhs.com

Suggested reading

American Academy of Pediatrics Work Group on Disasters: Psychosocial Issues for Children and Families in Disasters. Washington, DC, US Department of Health and Human Services, 1995

International Committee of the Red Cross: War and Public Health. Geneva, Switzerland, ICRC, 1997

Mandalakas A, Torjesen K, Olness K: Helping the Children: A Practical Handbook for Complex Humanitarian Emergencies. New Brunswick, NJ, Johnson & Johnson Pediatric Institute, 1999. Reach the institute at 877-565-5465 or www.jnjPediatricInstitute.com.

Medicins Sans Frontiers: Nutrition Manual. Paris, France, MSF, 1995

Uniformed Services University of the Health Sciences, Pediatrics Departments: Military Medical Humanitarian Assistance Course Manual. Bethesda, MD, USUHS, 1998

United Nations High Commissioner for Refugees: Refugee Children: Guidelines on Protection and Care. Geneva, Switzerland, UNHCR, 1994

United Nations High Commissioner for Refugees/World Health Organization: Mental Health of Refugees. Geneva, Switzerland, UNHCR/WHO, 1996

The need to know

Many child health professionals will never have the opportunity to care for a child who has been part of a humanitarian disaster. Yet knowing what these children endure and how they can best be helped to become physically and emotionally healthy is an essential part of the education of everyone who works with children.

THE AUTHOR is Professor of Pediatrics, Family Medicine, and International Health, Case Western Reserve University School of Medicine, Cleveland, OH.

 

Karen Olness. How humanitarian disasters affect children. Contemporary Pediatrics 2000;4:79.