91av

For the thousands fleeing war in Afghanistan, the problems they face seem overwhelming. But it’s all too familiar to Michael Toole. A refugee health expert, Toole has worked in every major humanitarian emergency of the past 25 years, including Somalia, Cambodia and Rwanda. Through the US Centers for Disease Control, Médecins Sans Frontières and others, he has contributed more than anyone to our understanding of how disease and malnutrition affect refugee populations. He is now working on HIV prevention in poor countries at the Burnet Institute in Melbourne. Rachel Nowak asks him about life on the front line, and the lessons for those involved in the current crisis.

What is in store for the Afghan refugees?

Those trapped inside the country are going to face very, very difficult times. There has been a drought, there are food shortages, the infrastructure of the country has collapsed and there are no services. For those who are able to get into Pakistan, I presume the international community will support the Pakistan government.

What diseases will the refugees face?

We have an enormous body of knowledge about the health problems of refugees. In low-income countries they tend to be nutritional deficiencies, diarrhoeal diseases, acute infections such as meningitis, measles in an unimmunised population-and very few Afghans have been vaccinated against measles. Malaria tends to be a major problem where people have no immunity and inadequate shelter.

There has been an outbreak of Crimean-Congo haemorrhagic fever on the border with Pakistan. Is that going to be a problem?

I think people often get distracted by the more exotic-sounding diseases. Measles doesn’t sound very exciting. But prior to the 1980s, it was the number one killer in refugee camps. During an epidemic it could account for up to two-thirds of all deaths, as it did at our camp in Sudan. Now the more responsible NGOs have adopted measles immunisation as a number one priority so that everyone is protected from that very preventable disease.

What’s the first thing you do in an emergency?

Assess the situation, look at what the public health priorities are and what resources are absent, and establish how many people there are.

And then?

You have a team that is doing a number of things simultaneously. You look at the water situation. The minimum amount of water needed for drinking, cooking and washing is 15 litres per person per day. You need to look at sanitation. You can’t build a load of latrines overnight so you may just designate a field for women and a field for men and make sure the field for women is very, very secure. You need to look at the location of the camp. For example, in the wet season will the roads be accessible? You talk to people and gather information about the diseases they have or have had. The World Health Organization will have some information on the main public health problems in Afghanistan, but you’d also need to talk to doctors, nurses, traditional healers and village leaders among the refugees.

What are you looking for?

Acute under-nutrition-that’s recent weight loss, particularly in children under five. If that is a problem, then you immediately put nutrition as one of your priorities. Some of that food could be bought locally. If you bring in a lot of free food, it could be bad for the local economy. You have to think very carefully about the impact on the local people as well as the refugees. You need to cater for at least 2100 calories per person per day for a developing country where you have a lot of kids and not as many adults. Afghanistan is going into winter, and for every degree less than 20 °C you need to add another 21 calories. You’ve got to provide micronutrients. We have had a lot of problems in the past with massive epidemics of scurvy.

What caused the scurvy epidemic in Somalia in the 1980s?

There were about a million refugees from Ethiopia and Somalia in 1980. The source of vitamin C in the traditional Somali diet is camel’s milk. People were put into very large camps, they didn’t have their camels, and they were put on a diet that contained no vitamin C. We started to get reports of an illness that doctors couldn’t diagnose or treat. Eight, nine and ten-year-olds were coming in with very sore joints, knees, ankles, hips. Some of them had bleeding gums, some had fever. Eventually, we took a couple of them down to Mogadishu and a French radiologist took some X-rays and hey presto, it was classic scurvy, an artificially created epidemic.

What else do you have to prepare for?

Cholera and dysentery. Both cause very high death rates. Bacterial dysentery spreads very quickly, much quicker even than cholera. You have to treat it with an antibiotic, whereas cholera you don’t. So logistically, a dysentery outbreak is more difficult because you have to identify every case and provide them with five days of drugs. With cholera you just have to rehydrate sufferers, not that that is always easy.

Which is more important, to treat people or stop transmission of the disease?

That’s the whole debate in public health. I think most of the experienced NGOs would value prevention over clinical facilities. You have to set up some clinical facilities but you shouldn’t be flying in field hospitals.

When refugees are fleeing a conflict, are injuries more of a problem than disease?

Afghanistan and Cambodia have the highest number of landmines in the world, and as people flee they are likely to step on them. The International Committee of the Red Cross already has two very good hospitals on the Afghan border. They will be well set up to manage injuries.

Is depression a problem in refugee camps?

There are enormous psychosocial problems. Mental health in an emergency setting is an evolving field. Many people have taken the Western model of addressing post-traumatic stress disorder through individual counselling. Others feel that is not appropriate, and that you need to take a community-based approach where you sit down with people and recognise the anxieties and the fear and discuss culturally appropriate ways for the community to address them.

Are the camps violent places?

There is an increase in domestic violence because community structures break down. There is an increase in sexual violence. If people are displaced away from a village setting into a huge camp, there tends to be a change in sexual behaviour. Adolescents start having sex earlier than they would have. Men may have more opportunities to have sex outside of marriage. There are more tensions. The role of men tends to change more than the role of women. Women basically continue to do what they always did: look after their kids, look after their home, fetch water, fetch wood. Only it is more difficult than usual. Men are left without a role. They can’t go to work, they can’t go to the fields. So there is a lot of frustration and maybe alcohol and substance abuse. Don’t forget Afghanistan is in a major opium-producing area.

You no longer work in refugee camps. Why?

In the mid-1990s there was an epidemic of emergencies. I found myself in Somalia, Bosnia and Rwanda all in one year and felt that exposure to that degree of misery was starting to affect my world-view negatively.

Did you burn out?

I don’t know, you would have to ask my friends, but I found myself appalled. The last place I went to was Goma, where a million refugees crossed a bridge in a week from Rwanda to Zaire. There was a cholera outbreak and there was misery on a massive scale. I think some of the younger relief workers thought it was always like this-they seemed to cope-but the older ones just sank into despair with the pressure.

What is the worst mistake that you made?

Maybe in not speaking out as forcefully as I should. For example, in Goma during the first week of the refugee outflow, all the refugees were getting water from a lake that was also being used for other purposes, and it quickly became contaminated. The American army wanted to bring in a very high-tech plant that would treat the water, but it was going to take several weeks to set up. What I should have done was insist immediately on a low-tech solution-maybe hiring a thousand people to throw chlorine in every bucket of water. We probably could not have prevented the cholera outbreak, but we could have postponed that explosive spread until we were ready to cope with it.

Why didn’t you?

When you are confronted with an emergency of such magnitude, it is very difficult to find the time or space to reflect on what is the best thing to do. The atmosphere is so charged, you are living on adrenaline, trying to find somewhere to sleep, there are endlessly long coordination meetings, there are forty different agencies, and twenty different public health problems. To come up with the most rational decision is very difficult. That is why we need to learn from those mistakes.

And what was your proudest moment?

Leaking my report on the situation in the former Yugoslavia to The New York Times and pointing out how it differed from the official report by the National Security Council. The people who had been asked to come up with humanitarian options for the US government were more or less unanimous that the major problem was violence. People were being killed, they weren’t dying of starvation or measles. To protect those civilians, the US had to take the lead in resolving the conflict at a time when Europe was being very indecisive. But the US government was still hurting from the failure in Somalia and so the official report said there were a lot of humanitarian actions that could be taken-provide food, for instance. When The New York Times story appeared, President Clinton immediately responded by sending his Secretary of State to Europe to try and mobilise a coalition to act more dynamically to stop the violence. But that failed, so in a way it might have been one of the better things I did, but it didn’t work.

Your home country, Australia, recently barred a cargo ship with hundreds of mainly Afghan asylum seekers from its shores. How has that affected its reputation in humanitarian medicine?

Adversely, quite adversely. Most of the asylum seekers were fleeing very oppressive governments. To keep saying that Australia is one of the most generous countries is quite false. It ignores the fact that Iran has been hosting two million Afghan refugees for twenty years.