Illusive Havens Part 1

Image 1: Dadaab Refugee Complex

Source: UNHCR, 2018

Dadaab, located in Kenya, is the world’s largest refugee camp (UNHCR, 2018). It houses over 235,269 Somalian refugees in informal settlements often lined with white, UNHCR tents. During the early 90’s, the first wave of Somalian refugees fleeing civil war established the first portion of the camp. A second influx of refugees took place in 2011 when drought and famine afflicted the southern region of Somalia. Around November 2015, a worrying cholera outbreak spread throughout Kenya and eventually reached the frontlines of Dadaab (CNN, 2015). By December 2015, seven people had died and hundreds were in the hospital seeking treatment. By June of 2016, fourteen deaths and almost 1,800 cases of cholera had been reported by the UNHCR to the CDC (Golicha, Qabale, & et al., 2018). Unfortunately, the demographic most ravished by the outbreak were children ages two to four, with an incidence rate of 16.9:1000 whereas adults saw an incidence rate of 5.1:1000. Evidently, children were and still are way more susceptible to diarrheal diseases such as cholera.

Image 2: Woman being treated for cholera
Source: https://www.msf.org/kenya-cholera-outbreak-spreads-dadaab-refugee-camp

Cholera, or Vibrio cholerae, is most often spread through contaminated water or food sources and exacerbated by substandard sanitary conditions (Golicha, Qabale, & et al., 2018). Once ingested, V. cholerae colonizes the linings of the human intestines and begins secreting a chemical know as Cholera Toxin, the toxin responsible for the onset of diarrhea and vomiting in infected individuals (Sim, Christianna, 2013). Surprisingly, the treatment pathway for cholera is rather simple: replenish fluids and electrolytes with subsequent delivery of antibiotics once the patient establishes normal fluid levels. However, I don't think the simplicity of the treatment of cholera infected individuals necessarily translates when medical services are required by thousands in an environment with limited resources. This seems to be one of the largest obstacles for health workers when a cholera outbreak occurs.

Mandated by the international community, the UNHCR is supposed to provide adequate living conditions for refugees. One of those requirements is the provisioning of clean water. Although the UNHCR reports that most refugee camps provide at least 32.1 liters of water per capita, this has been inconsistent with results from case studies conducted during WASH inspections by outside institutions (UNHCR, 2018; Cronin, A.A., & et al., 2008). Cronin concluded that in 79% of east African refugee camps, individuals experienced monthly to even weekly interruptions in access to water. In addition, individuals reported that disputes at water point sources were quite common. Also, it seems to me that the UNHCR 32.1 liter/capita/day figure doesn’t incorporate time spent retrieving water and the demographic responsible for fetching water.

Figure 1: Breakdown of water provisioning in refugee camps in Kenya, Tanzania, and Uganda by UNHCR as of 2007

Source: Cronin, A.A., & et al., 2008)

Dadaab, as an informal refugee settlement with little WASH infrastructure in place provided the perfect breeding ground for a cholera outbreak (CDC, 2015). With only 50% pit latrine coverage, human waste disposal services were completely inadequate, leaving free flowing waste matter in open street sewages. In addition, the onset of the rainy season compounded with poor sanitary conditions intensified the need for latrines. All subcamps at Dadaab were affected by the outbreak but the two largest subcamps, Dagahaley and Hagadera, had the highest incidence rates. These two subcamps in particular had the worst drainage infrastructure, inadequate chlorination of drinking water, and housed the majority of food markets in Dadaab. This made it an area where a significant proportion of cholera transmission occurred.

Refugee camps are an illusive safe haven. Living standards are passable at best and the undersupply of pit latrines and clean water in conjunction to living in cramped tents makes refugees vulnerable to diarrheal diseases (Sim, Christianna, 2013). Cholera outbreaks in refugee camps take place across all corners of the world and a lack of water and sanitation conditions are the most detrimental offenders.

References:

Golicha, Qabale, & et al. (2018). Cholera outbreak in Dadaab Refugee Camp, Kenya. CDC Weekly MMWR, Vol. 67, Issue 34, 958 - 961.  

Sim, Christianna. (2013). Control and intervention of cholera outbreaks in refugee camps. Global Societies Journal Vol. 1.

Cronin, A.A., Shretha, D., Cornier, N., Abdalla, F., Ezard, N., and Aramburu, C. (2008). A review of water and sanitation provision in refugee camps in association with selected health and nutrition indicators - the need for integrated service provision. Journal of Water and Health, Vol. 6, Issue 1.

Gigova, Radian. (2015). Cholera outbreak threatens world’s largest refugee camp. CNN. https://edition. cnn.com/2015/12/19/africa/cholera-kenya-refugee-camp/index.html.

UNHCR. (2018). Dadaab Refugee Complex. http://www.unhcr.org/ke/dadaab-refugee-complex.

UNHCR. (2018). Operational Update: Dadaab, Kenya.