Health Impacts of Refugees from Civil Wars in the Horn of Africa: Somali and Sudanese Refugees in Ethiopia
By Kelly Nelson
In conflict areas, preventable illnesses can be as dangerous to populations, particularly children, as violence. The Horn of Africa, the region on the eastern coast of the continent between Egypt and Kenya, has been host to multiple internal and interstate conflicts in the second half of the Twentieth Century. Accompanying these conflicts has been large movements of refugee populations. Refugees travelling between the countries of the horn increase the risk of disease epidemics and threaten to introduce or reintroduce diseases to countries where these diseases are not currently endemic. Aggravating this problem is the weak epidemiological surveillance system in place in several of these countries. This study focuses on Ethiopia and the risks of disease from Sudanese and Somali refugees, who make up 78,200 of the 83,583 refugee s in Ethiopia.[1] This paper first examines the health care system in Ethiopia, followed by an examination of the two groups of refugees and a discussion of the endemic disease from their countries. Each country case includes a discussion of the country’s armed conflicts, the capacity of their government, and the prevalent diseases in the country and the capacity of those diseases to spread. The final section discusses the political economy of health in Ethiopia that compromises the country’s ability to respond.
Ethiopia is a large, ethnically diverse state that has experienced a period of civil war and regime instability in the aftermath of a military coup that deposed Haile Selasie I, the country’s traditional monarch, in 1975. Human services are poor quality and distributed unevenly throughout the country; Ethiopia ranks 169th in the world on the Human Development Index. Life expectancy in Ethiopia is 52 due to high levels of poverty, violence, and in particular because of a weak health care system.[2] The majority of government services in Ethiopia are concentrated in the northern part of the country, where the ethnic groups that comprise Ethiopia’s traditional elites, the Tigray and Amhara, reside.[3] Two hundred twenty five of the 416 trained surveillance experts live in the Tigray, Amhara, and Addis Ababa provinces.[4] The Ethiopian People’s Revolutionary Democratic Front has held power since 1991 and directs the majority of government resources to their home region of Tigray. Other regions, such as the Somali region, are far poorer than the northern highland states. The Somali regional state in the Ogaden region of Ethiopia is home to ethnically Somali pastoralists and has been an area of conflict between the governments of both Somali and Ethiopia, who both claim the territory. Many of its inhabitants travel between the two countries. These groups can come into contact with the refugees or other infected populations within either Ethiopia or Somalia.
With assistance from the World Health Organization (WHO), the country has built several laboratories capable of testing for HIV/AIDS, but these laboratories are at risk of operational complications due to poor infrastructure, a lack of supplies, and a shortage of health care human resources in the country. Because the donor community is concerned primarily with HIV/AIDS and, to a lesser extent, malaria and tuberculosis, there is a scarcity of resources available for surveillance related to other diseases endemic in the horn of Africa. The WHO has, however, had some success in eradicating certain diseases in Ethiopia, such as polio and dracunculiasis, but these diseases have not been eliminated in neighboring countries and have been reintroduced. Ethiopia’s health infrastructure is poor, meaning that the power supply necessary for refrigeration is unreliable.[5] A study of the health system in Ethiopia found that 35 percent of health facilities lacked proper refrigeration.[6] Another study found that 73.4 percent of health facilities were storing vaccines above optimum temperatures.[7] Sanitation, also poor in Ethiopia, is critical to preventing the spread of poliovirus within communities.
Health care services are especially scarce in economically neglected regions where ethnic separatist groups operate, the southern regions of Oromo and Somali. In addition to lacking the delivery of primary and specialized care in other parts of the country, the Ethiopian health care system has a paucity of laboratories with the ability to monitor for epidemic diseases. These regions, Gambella, Benishangul, and regions border Somalia and Sudan and therefore are at risk of experiencing outbreaks of diseases that refugees from these countries introduce.
Sudan, which borders several regions of Ethiopia, threatens to reintroduce dracunculiasis into Ethiopia as well as increase the prevalence of several other diseases. The southern part of the country is culturally and ethnically distinct from the ruling north and has fought for independence since the 1983. The war with the government has devastated infrastructure and displaced a large number of people from their homes. In addition to the war against the government, there are several factions in the south that have fought each other during both before and after the ceasefire and peace accords signed between the rebels and the government. Because of this hostility, as well as historical tradition of developmental neglect toward the south, government services in the southern part of the country lag behind the country’s north. Poverty is high in the south, and chronic hunger and malnutrition, which compromise the immune system’s ability to fight disease, are widespread. [8]
The displacement from this violence has produced a number of refugees that have fled into Ethiopia. These refugee groups can harbor a number of diseases. Dracunculiasis, or “Guinea worm,” is a parasitic condition in which the host human ingests the eggs of the parasite and the organism grows inside the host’s body. The fully grown creature eventually exits the body through the skin, a painful and debilitating process that can take up to since the worms can reach sizes of up to 600 to 800 mm in length and 2 mm in diameter. While WHO programs are making progress toward eliminating in Ethiopia, the disease remains endemic in Sudan and WHO views this as an obstacle to Ethiopian eradication efforts.[9] Polio has also been found in Sudan, and outbreaks of meningococcal diseases and influenza are common. Refugee from affected regions moving into Ethiopia will spread epidemics. Two of the regions bordering Sudan, Tigray and Amhara, have better health care than most portions of the country, but the Benishangul and Gambella regions lack comparable services. There were two observed cases of polio in the Gambella region in 2008.[10] A UNICEF program supported vaccinations in regions bordering Sudan, which will help deter the further spread of polio and measles between the two countries.[11] While the Ebola virus is endemic in Sudan, outbreaks of Ebola hemorrhagic fever are localized and pass quickly due to the short incubation time and highly virulent nature of the disease. As a result, there is little risk of Ebola virus spreading beyond the initial sites of epidemics into other countries in the region.
Refugees from Somalia pose a serious threat to the health of the Ethiopian population. Somalia’s state is weak and by some criteria has collapsed entirely since the end of the Siad Barre dictatorship. Violence is rampant throughout the country as the al-Qaeda affiliated al-Shabab and numerous warlord groups attack civilians and fight against government forces. The country experienced a brief period with a functional government when the Islamic Courts Union came to power in 2006, but the Ethiopian government feared the Islamist government would inflame separatist uprisings among Ethiopian Somalis and launched a United States-backed invasion to topple the Union. Since then, Somalia’s state services have again deteriorated and the government in Mogadishu has little authority outside of the capital city. Like Sudan, malnutrition is common in Somalia, leading to a population with weakened immune systems. A study of refugee populations in the United States found that Somali refugees were among the groups with the highest prevalence of tuberculosis infections. There have been several polio outbreaks in Somalia; 2006 saw Somali refugees spread the disease to Nigeria, the Democratic Republic of Congo, and to Kenya, where it had previously been nonexistent since 1984.[12]
Screening can prevent refugees from spreading diseases to the population through quarantine and treatment but, other than in camps administered by the United Nations High Commission on Refugees (UNHCR), many developing countries lack the capacity to carry out surveillance and response. Refugees in Ethiopia are not entirely housed in these camps, meaning many fall outside of the responsibility of UNHCR. Ethiopia has a low capacity for refugee screening and disease surveillance, meaning that if diseases are introduced, the response may be insufficient. Furthermore, the government is not concerned with the welfare of populations in many of the regions bordering their unstable neighbors than in other regions of the country. Regions from which the ruling party draws political support receive the majority of government resources. Neglected areas often are home to separatist groups and the government controls these regions through a combination of military repression and electoral manipulation. The government has no incentive to provide services in these regions because the support of their populations is unnecessary to remaining in power. Kebede peasant collectives are the primary mechanism through which the government influences elections in rural regions.[13] The poor quality of health care and sanitation services in these regions, combined with a prevalence of malnutrition similar to Somalia and Sudan, means that the population is highly at risk of epidemic diseases. Because those living in the area have little contact with the health care system, diseases can easily spread unchecked, making eradication of disease more difficult once discovered. The Somali refugees are especially at risk because the Ethiopian state views ethnic Somalis as potential threats and therefore is less interested in their welfare than other Ethiopian citizens.[14] Individuals do not often travel between the regions bordering Somali and the Tigray, Amhara, and Addis Ababa regions, meaning the health of those in these areas has less of an impact on the government’s political supporters.
The WHO has assisted the government in establishing monitoring facilities for HIV/AIDS, but the agency works through the state to respond to diseases. The standard response upon discovering polio cases is a “mop-up” project that involves immunizing all children in an area surrounding an outbreak.[15] These eradication projects require a large amount of human resources and conscientious management of the logistical elements of the project, such as preservation of the cold chain for vaccines. Ethiopia is lacking in these areas, having few trained physicians serving a large population. The creation of a corps of community based health extension workers has alleviated some of the shortages, and these workers have improved surveillance for diseases such as tuberculosis when they are specifically trained in surveillance.[16] Strong coordination could create surveillance response teams that draw on these workers. More challenging is maintaining the potency of vaccines, given the difficulties with maintaining a cold chain. The local government in the Somali region, which has gained some autonomy under a more federalist Ethiopian system, severely lacks in administrative capacity[17] and therefore will also have trouble carrying out any disease eradication programs.
Without improvements to the Ethiopian health care system that improves care in the neglected regions of the country, the civil wars in neighboring countries will have an impact on Ethiopian human and economic development. The spread of previously eradicated diseases into Ethiopia will worsen health in a country already suffering from a low life expectancy and high levels of childhood mortality. Health and development are closely connected, as a strong economy requires a healthy work force. Polio is particularly detrimental, as the paralysis caused by the disease severely compromises the ability to work. Parasitic illnesses such as Guinea worm leech nutrients and cause conditions such as anemia and vitamin deficiency. Malnutrition is aggravated by disease, and the two conditions often create a cycle that can lead to stunted physical and mental development.[18] Improvements to monitoring and response capacity in the threatened regions are necessary to preventing the reintroduction of eradicated diseases and preventing increases in the prevalence of others. Ethiopian politics makes this necessary step unlikely without improved state sensitivity to the needs and interests of populations living in neglected regions of the country.
Kelly Nelson is a 2010 Master’s candidate and 2009-2010 Marc Chandler Scholar at the Center for Global Affairs. His research areas include the economic determinants of civil wars, conflict-sensitive economic development, and global health. His most recent contribution to PGI was “Emissions Arbitrage in the Natural Gas Market” with CGA colleagues Samuel Lissner and Orlee Zorbaron in the Fall 2009 issue. Kelly holds a degree in history from the University of Maryland – College Park.
[1] United Nations High Commission on Refugees, “2010 UNHCR country operations profile – Ethiopia” http://www.unhcr.org/pages/49e483986.html
[2] United Nations Development Program, “Statistical Update 2008/2009 – Country Fact Sheets – Ethiopia,” http://hdrstats.undp.org/2008/countries/country_fact_sheets/cty_fs_ETH.html
[3] Trevor Trueman, “Genocide Against the Oromo People,” in Seyoum Haneso and Mohammed Hassan, Arrested Development in Ethiopia, (Trenton: Red Sea Press, 2006) 137
[4] World Health Organization, “Ethiopia – Integrated Disease Surveillance and Response,” http://www.who.int/countries/eth/areas/surveillance/en/index.html
[5] Y. Berhane and M. Demissie, “Cold Chain Status at Immunisation Centers in Ethiopia,” East African Medical Journal, 77, no. 9 (September 2000), 477 pp 476-479
[6] D Jenkins, “A Cold Chain Friendly to People…and the Environment,” Africa Health 18, no. 6 (September 1996) 19 pp 19-20
[7] Y. Berhane and M. Demissie, 477
[8] Andrew Harding, “Is This the Hungriest Place on Earth?” BBC News April 2, 2010, http://news.bbc.co.uk/2/hi/africa/8589136.stm
[9] World Health Organization, “Drancunculiasis,” http://www.who.int/countries/eth/areas/cds/dracunculiasis/en/index1.html
[10] World Health Organization, “Ethiopia Polio Campaign in the areas bordering southern Sudan,” http://www.who.int/countries/eth/news/2008/polio_vaccination_20081016/en/index.html
[11] World Health Organization, “Ethiopia Polio Campaign in the areas bordering southern Sudan.”
[12] William Church, “CIA Blowback Weakens East Africa,” Sudan Tribune October 23, 2006.
[13] Siegfried Pausewang, Kjetil Tronvoll, and Lovise Allen, “A Process of Democratisation or Control? The Historical and Political Context,” in Siegfried Pausewang, Kjetil Tronvoll, and Lovise Allen, eds. Ethiopia Since the Derg: A Decade of Democratic Pretention and Performance (New York: Zed Books, 2002), 38.
[14] Minorities at Risk Project, “Assessment for Somalis of Ethiopia,” http://www.cidcm.umd.edu/mar/assessment.asp?groupId=53005
[15] Atul Gawande, Better: A Surgeon’s Notes on Performance, New York: Metropolitan Books, 2007. 34
[16] Daniel D. Datiko and Bernt Lindtjørn, “Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial,” PLoSOne 4, no 5 (May 2009), 5 PP e5443 1-7
[17]CHF International, “Grassroots Conflict Assessment of the Somali Region, Ethiopia,” http://www.chfhq.org/files/3707_file_Somali_Region_Assessment_8.4.06.pdf 10.
[18] Alice M. Tang, Ellen Smit, and Richard D. Semba, “Nutrition and Infection,” in Konrad E. Nelson and Carolyn Masters Williams, eds. Infectious Disease Epidemiology: Theory and Practice, Second Edition, (Sadbury, MA: Jones and Bartlett, 2007) 384