On April 3 1990, Centers for Disease Control (CDC) scientist Dr Michael Toole gave testimony before a U.S. Senate Subcommittee hearing on 'Examining the effects of war and dislocation upon children.' Commenting on the 'poorly documented' phenomenon of internal displacement and its effects on health and mortality, Toole stated:
[A]ccess by relief workers to internally displaced populations has been
severely restricted by the political and security situation in areas where the displaced are situated. Those data that have been collected indicate that the plight of the internally displaced is very serious. For example, during 1988, several million people were displaced by the war in southern Sudan and located in various camps in the South Darfur and South Kordofan provinces of Sudan. CDC epidemiologists determined that death rates recorded in some of these camps were among the highest ever reported for civilian camp populations [...] death rates among the displaced were up to 60 times greater than those of non-displaced Sudanese. It is most likely, therefore, that more than 150,000 children died in southern Sudan during 1988 as a result of their displacement by war.2
Toole went on to cite malnutrition as the underlying cause of death in most cases, but also highlighted the communicable diseases common among displaced people that often constitute the primary cause of death, including measles, diarrhea, pneumonia, meningitis, and hepatitis. He noted in addition that severe crowding, inadequate food, shelter, water and sanitation in camps for displaced people, typically during the emergency phase, were critical factors behind the high death rates of these populations. Closing his remarks, Toole asserted, 'An institutional memory is lacking in refugee health. Standardizing lessons learned and effective approaches would be useful.'3
Over a decade and a half later, internally displaced persons (IDPs) have been more firmly placed on the agenda of international organizations, and institutional arrangements to meet the unique challenges of internal displacement have grown significantly. Research and monitoring of IDP situations throughout the world now provide us with essential information on their numbers and location. However, a 2002 report on 'Armed Conflict and Public Health' by the Centre for Research on the Epidemiology of Disasters (CRED) reviewed existing research and found that roughly 50 percent of studies reviewed were for refugee populations, 35 percent had residents as subjects, and only 15 percent were on IDPs.4
This distribution illustrates a substantial dearth of reliable information on internal displacement and health. There is a growing consensus among observers and practitioners that mortality, morbidity and malnutrition rates among IDPs remain high, relative to 'normal' national or regional rates of non-displaced people and refugees. Without a proper base of evidence, however, these accounts remain anecdotal and merit more thorough investigation using epidemiological methods for assessing population health. This paper reviews existing data on mortality and health indicators for IDP situations, identifies some of their limitations, and identifies an agenda for future research.
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The author would like to acknowledge helpful comments from Dr. Khalid Koser and Dr. Courtland Robinson
Dr. Michael Toole, testimony before the U.S. Senate Subcommittee on Children, Family, Drugs and Alcoholism, Hearing on "Examining the Effects of War and Dislocation upon Children," April 3, 1990, 20-21.
Ibid., p. 22
CRED (Debaratie Guha-Sapir and Willem van Panhuis), "Armed Conflict and Public Health: A Report on Knowledge and Knowledge Gaps," Brussels, 2002:13