Introduction

Top Abstract Introduction Participants and methods Results Discussion References

The health of refugees and displaced people has been mainly studied in camp settings,^1-3 which has strongly influenced the way such people are treated. During the current crisis in Guinea-Bissau,⁴ there have been no camps¹; all refugees have lived with either relatives, friends, or strangers, and utilised their resources. The international emergency agencies, the World Food Programme and the International Committee for the Red Cross, however, restricted food aid to the estimated 350 000 refugees (internally displaced people). This was thought both unjust and unjustified by Guineans and local expatriates concerned with humanitarian aid. Since the policies of international and local organisations represent different understandings of the implications of the displacement of people, and since there has been little research on the consequences of non-camp settings, we examined health outcomes for both refugee and resident children.

	Participants and methods

Top Abstract Introduction Participants and methods Results Discussion References

On 7 June 1998, armed conflict started in Guinea-Bissau between rebel soldiers (military junta) and the government army, which 3 days later received the support of troops from neighbouring countries Senegal and Guinea. The arrival of the foreign troops provoked a fully fledged war and the capital, Bissau, was shelled heavily by rebel artillery.

Nearly all 300 000 inhabitants of Bissau had fled the city by mid-June. Around 50 000 of the fleeing people took refuge just 5-15 km outside Bissau in the villages on the Prabis peninsular (figure), an area that before the war had an estimated population of 6858.⁴ During the most intensive fighting, houses in Prabis had on average more than 100 inhabitants when both relatives and foreigners moved in to live with the owners. Many more people fled through Prabis (the only route for cars from Bissau), en route for the Bijagos islands or the interior by canoe. The first part of the war lasted from 7 June until the end of July, a ceasefire being agreed on 26 July. As soon as the fighting stopped, refugees from the Prabis area started returning to Bissau.

View larger version (35K): [in this window] Area surrounding Bissau, 1998: during the war major battles occurred along the road to the airport (the only road to the interior of Guinea-Bissau). Government and foreign troops had heavy artillery positions in the centre of the city, whereas rebel artillery was placed around the airport and at Cumuré, south of Nhacra. Cars could only leave towards mission station in Cumura and the village of Prabis, two areas with major concentrations of refugees in Bissau. Exit from the Prabis area was only possible by canoe to Bijagos islands or by crossing the river to Quinhamel

The first relief activity implemented by national health authorities was rice distribution from the World Food Programme's store in Bissau. After 3 weeks of conflict, we began surveying children aged 9-23 months to assess vaccination status,⁴ mid-upper arm circumference, and their family's rice consumption, food expenditures, and receipt of food aid.

We randomly selected 30 clusters, each with 14 children aged 9-23 months.⁴ (Inclusion of clusters is described in more detail on www.bmj.com .)

Of the 422 children included in our survey, 104 (25%) were residents in the Prabis area before the conflict; 130 (41%) were from the area normally covered by the Bandim health project⁵ and could be identified in the project's register.

We visited all the children again 3, 6, 9, and 12 weeks later until the last week of September. At each visit we measured mid-upper arm circumference to the nearest 2 mm.

A trained assistant conducted interviews with relatives of all deceased children to obtain a description of symptoms at death and to verify the quality of the death ascertainment.

We recorded the number of people in the household and whether they had received food aid within the past 3 weeks. Food distribution was started at the end of June. In the first round of food distribution for the refugees, the Red Cross provided 25 kg of rice, 8 litres of cooking oil, and 6 kg of corned beef per household for the first week. As there was no time to organise distribution according to the number of people in a family, an average household was assumed to comprise eight people. The 3 kg of rice per person per week was estimated on the basis of a recommended minimum consumption of 400 g of cereal per person per day. As the first distribution of rice in the Prabis area took 3 weeks, it was effectively a ration of only 133 g per person per week. In the second and third round of distribution in July and August, managed by the Bandim health project, households received food allowances according to the actual number of people in the household, and the ration of rice was gradually reduced to 133 g and 80 g, owing to the expected shortage of foodstuff for humanitarian aid. After the ceasefire on 26 July, the refugees started to return to Bissau, and food distribution was stopped in Prabis. Food distribution was continued in the project area in Bissau from the end of August, providing a daily allowance of 100 g of rice for a 3 week period. We managed to distribute only in three of the four districts in the area because the World Food Programme's food stock was depleted by the first week of September. (The statistical methods are described in more detail on www.bmj.com.)

	Results

Top Abstract Introduction Participants and methods Results Discussion References

Mid-upper arm circumference and food consumption
At the first examination we found a major difference in the prevalence of mid-upper arm circumference measurements of less than 130 mm (low arm circumference) between refugee and resident children (table).

Mortality
Over the 3 month period, the 104 resident children had a significantly higher mortality (seven deaths) than the 130 project children from Bissau (two deaths; mortality ratio 4.5, 1.1 to 30.0). Mortality was also much higher for resident and refugee children in the 6 weeks while refugees were in Prabis (eight deaths) compared with the last 6 weeks when the refugees had left (one death; 7.2, 1.3 to 133.9).

	Discussion

Top Abstract Introduction Participants and methods Results Discussion References

Consequences of displacement
In the non-camp setting during the Guinean crisis, resident children aged 9-23 months suffered more than refugee children from Bissau; this age group is the most vulnerable to malnutrition, infections, and mortality. Hence, population displacement may have consequences for a wider group of people than is usually considered. ^{2 3} A profound improvement in nutritional status and mortality occurred for both refugees and resident children once the refugees had left. The children coped better in their normal environment even though the rice consumption of refugee families decreased when they returned to Bissau.

Movement of refugees
Child mortality was much lower once refugee families had returned to their homes. Food distributions also affected refugees' travelling patternsfor example, many people remained in the Prabis area to receive the expected food aid, and we were effectively delaying their return by continuing to distribute in this area. In mid-August we transferred food distribution to Bissau to prevent people from continuing to live under unhealthy conditions. However, the World Food Programme, the main agency distributing food aid to Guinea-Bissau during the present crisis, continued to distribute in the interior of the country. Furthermore, United Nations safety regulations did not permit UN employees to stay in Bissau, making it more convenient to continue the operation in the interior of the country. In the project area in Bissau, all refugees who had gone to Prabis had returned by the end of August, whereas many of those who had gone to areas where the World Food Programme continued distribution had yet to return by October.