Sudan and South Sudan are in crisis. Between the two sub-Saharan African nations, 2.2 million nationals are displaced from their homes; a number which does not include refugees from neighboring countries. “The profound impact of displacement penetrates every aspect of a community. Every age group, gender, socio-economic status, religion,” said Erin Downey, Sc.D., MPH and former analyst to the Bureau of Population, Refugees and Migration, speaking about the humanitarian crisis in Sudan. Downey develops strategies to address humanitarian issues in refugee populations from the perspective of public health. She has found that access to critical health care infrastructures becomes compromised during crises. Downey teaches hospital disaster emergency planning and speaks before humanitarian health care leaders from around the world. Her colleagues are other professionals who seek solutions for the medical and mental health challenges that face countries such as Sudan in times of crisis. In the interests of full disclosure, Downey is the author’s cousin.
In crisis situations, access to regular health care is critical. Even in developed countries during peaceful times, health care resources can be challenged. Populations age, mental illness resources are strained and chronic diseases require ongoing and consistent care. In times of internal conflict, however, pressures on critical infrastructures like health care and mental health systems reveal that adequate resources do not exist to meet the needs of affected populations. Lack of access to regular vaccinations is endemic to refugee populations, increasing the risk of the spread of communicable diseases. Where vaccination is inconsistent and population migration is dynamic, a lack of access to medical care can result in outbreaks of disease that are otherwise preventable and treatable. In Syria, polio is making a reappearance, and in Sudan and South Sudan, cholera is making a comeback.
Systems that can meet the ordinary needs of their populations in good times usually fail in times of crisis. “Needs simply exceed resources,” Downey said. Access to medicine disappears. Violence multiplies the demand for medical trauma staff, medicines and supplies. Facilities are not adequately staffed because staffs become undependable when they are concerned with their own family’s safety. Hospital workers and aid workers are both subject to the threats that cause the surrounding unrest.
“Desperate populations act desperately, and migrating populations are often desperate populations,” Downey noted. The trends that humanitarian health care workers see emerging from today’s displaced populations are cause for concern, according to Downey.
Among other things, Downey is concerned about the long-term medical and mental health costs associated with refugee populations in times of crisis, like the ones that currently exist in Sudan and Syria. “When large groups with differing world views flood into a population with a stable identity, the landscape and identity of that existing culture is forever altered,” she explained. “The disruption of this loss of structure for both groups of people amplifies the challenges on the social systems,” she said.
According to Downey, the biggest factor, aside from immediate safety concerns, that causes people to pick up roots and move is the search for basic human needs like food, water and shelter. America saw this phenomenon after Hurricane Katrina. As affected Louisianans fled for their lives, they entered nearby communities whose resources were taxed in the effort to absorb the afflicted.
As an analyst versed with the global refugee situation, Downey became familiar with the attitudes that nations bring to humanitarian efforts. She noted that in the international community, Turkey stood up and assumed a leadership role in global humanitarian efforts. Not long after doing so, the Syrian crisis brought refugees to Turkey’s doorstep. The country had to divert its resources and humanitarian will to absorb the displaced population that arrived on its own border with the influx of refugees from Syria.
In the case of Sudan, however, there were no extra resources to help alleviate the pressures put upon the system by the migrating population. In fact, Sudan’s mental health system was broken before the conflict began. In 2009, a World Health Organization publication reported that for every 100,000 people in Sudan, there was only 0.92 trained mental health professionals. Adding the trauma of a migrating population to that mix is a recipe for trouble.
The report further stated that the range of drugs used to treat mental illness available was limited. Additionally, the cost for such drugs is prohibitive for most patients. In a country where the average daily wage is $1, psychotropic drugs cost 27 percent of a patient’s daily wage while antidepressants cost 18 percent and anti-psychotic medications cost 41 percent.
In addition to the lack of access to medication in Sudan, there is an undeveloped relationship between the formal medical system and mental health care providers. Only the state of Gazira has a pilot program that is designed to incorporate mental health into the wider health care system. The lack of centralized control over mental health systems accounts for negligible and entirely unreliable reporting mechanisms. The metrics that do exist, however, indicate that of the mental illness diagnoses made, 47 percent are of schizophrenia.
Medical and mental health issues challenge both the nations whose citizens are affected by displacement as well as the humanitarian organizations that are involved in creating and supporting critical health care structures to service them. Downey is part of the World Association for Disaster Emergency Medicine (WADEM). She and her colleagues recognize that health care is in danger in crisis areas, and they are trying to find solutions to secure medical facilities and care workers from violence so that they are able to continue providing care.
“In extreme situations you’ve got the bombing of hospitals,” Downey said. “This puts patients and health care workers at risk. Compromising the access to health care exacerbates an already pressured system,” she said. “In these crisis situations, critical community infrastructure is at risk of collapsing. Those in crisis always need more medical help, and now medical facilities themselves and the staffs who work in them are being targeted.”
The solution, says Downey, falls in the laps of the governments themselves. Outside workers, foreign aid and international military support can only go so far. For long-term sustainable solutions, governments have to be vested in creating safe and secure climates for their own citizens. Meanwhile, global medical humanitarian leaders are trying to develop strategies to keep critical infrastructures and health care workers secure in areas of great conflict. As the crises in Sudan and Syria demonstrate, the challenges that face medical and mental health systems only increase during times of crisis.
By Kaley Perkins