Refugee housing in India reaches healthcare crisis pointBMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o351 (Published 15 February 2022) Cite this as: BMJ 2022;376:o351
- Geetanjali Krishna, freelance journalist,
- Sally Howard, freelance journalist
Outside Jaisalmer in Rajasthan’s Thar desert, a red sari flutters above yellow sand, hung from a mound of stone. It indicates that someone is using the makeshift toilet with half walls. Outside it, stagnant water is pooling. Beyond it the narrow alleys with shanties on either side are home to Pakistani Hindus, mostly from the nomadic Bhil tribe, who have lived here for over 12 years.
Meanwhile, at a camp in the neighbouring state of Haryana, Rohingya refugees struggle to get back on track after a fire burnt down 32 of 35 shanties—huts built with the cheapest available materials, such as highly flammable bamboo, cardboard, and plastic.
Such a crisis is echoed in refugee camps around the world. Overcrowding, a lack of medical infrastructure, and poor water, sanitation, and hygiene conditions in these settlements now pose more of a public health danger than ever before (video 1).
“Host governments who choose to house refugees in camps are by nature signalling that these communities are temporary residents,” says Bill Frelick, director of Human Right Watch’s Refugee and Migrant Rights Division. He adds that such communities will naturally find it harder to access national services—such as healthcare, supplies of water, sewage, and electricity, as well as shelter—that adhere to host nations’ minimum housing standards, if implemented. And despite the focus on temporariness among many host nations, the average refugee camp is inhabited for 22 years.1
Impossibility of social distancing
“Most of the common health problems faced [by refugees] are due to lack of infrastructure,” says Fateh Singh Sodha, a doctor who runs a private clinic in Jodhpur and is himself a Pakistani Hindu migrant.
In Jodhpur’s Anganwa camp, Pakistani Hindu refugees face a lack of water, sanitation, and hygiene infrastructure. “Open defecation over the years has contaminated the soil and water, resulting in gastrointestinal diseases,” says Sodha. “Waste water stagnating outside makeshift bathing areas enables malaria and dengue-bearing mosquitoes to proliferate, and with eight to 10 household members sharing a small space, if one person should contract an infectious disease there is a higher chance of other household members falling sick.”
At the Chandeni camp in Haryana, dwellings are constructed with bamboo, grass matting, and plastic sheets, and there’s no water supply or sewage system: residents have built their own makeshift pit toilets. In the 12 year old settlement of Pakistani Hindu refugees in Jaisalmer, residents can’t easily access clean water and have to walk long distances to fetch it. In the absence of drains or any sort of sewage system, waste water tends to accumulate everywhere, giving rise to stagnant water and vectorborne diseases.
Jan Bahadur, a 34 year old schoolteacher who fled his home in Pakistan’s Punjab province in 2014, reckons that his camp has about 200 households in cramped homes of one or two rooms. “I estimate each household has at least eight members,” he says. In a pandemic, “social distancing is impossible.”
Rohingya settlements, not just in Haryana but also in Jammu, Kashmir, and Telangana, are equally overcrowded, says Sabber Kyaw Min, who founded the Rohingya Human Rights Initiative in India in 2017. For example, the Chandeni Rohingya camp in Haryana has 157 people (41 households) living on roughly an acre of land. Houses are one or two rooms each, measuring barely 15 feet by 30 feet. One resident, Alishaan, says, “In the last two years, we have found that it has been impossible for people with covid, or covid-like symptoms, to isolate.”
During the pandemic many refugee camps, including Anganwa, Chandeni, and Sadiq Nagar, were sealed off from outsider host communities, but overcrowding was a critical roadblock to implementing some recommended public health measures. Frelick says, “Covid showed us that we need to process asylum claims and urgently decongest these [refugee camp] centres.”
It’s a similar picture even in major camps in the global north supported by non-governmental organisations (NGOs). Laure Joachim, medical activity manager for refugees at Médecins Sans Frontières (MSF) in Lesbos, Greece, says that overcrowding in the Moria 2.0 camp (one of Europe’s largest) is a concern. Basic, container made dwellings are unheated and poorly ventilated, and new arrivals often have to be housed in large tents of several families without privacy, where disease transmission is a risk.
“Urine infections are also common, as families do not feel safe visiting latrines at night,” says Joachim.
Poverty of shelter
Tom Corsellis, executive director of Shelter Centre, a knowledge sharing NGO working with MSF and others to improve infrastructure in refugee camps, says that improving refugee camp shelter is “a more complex input” than improving access to medical care or education. “There are gaps in technical knowledge, and there are material and price constraints and local constraints, such as how what you might be building fits into national planning regulations,” he says.
An estimated 87.9% of refugees and internally displaced people living in camps rely on biomass fuel, making them vulnerable to indoor air pollutants that cause pneumonia and other acute respiratory infections.2 At Cambridge University, UK, research conducted by Corsellis and others found that refugee dwellings needed seven or more changes of air an hour to be properly ventilated, compared with the urban dwelling norm of three changes. The Cambridge study found that interstitial condensation (which causes mould and damp) added to respiratory risks in refugee dwellings. A study from the NGO Care International and Oxford Brookes University found a link between poor quality of refugee shelters and negative health outcomes.3
“You have to remember that the dwellings we live in are machines developed over hundreds of years to prevent us from getting sick,” says Corsellis. “When you return to rudimentary shelter—without sanitation or cleanable surfaces—it’s no surprise that there is a health risk.”
No surprise, either, that camps are often breeding grounds for disease vectors and viruses. Sodha says, “When camp residents go to the city to work in factories, construction sites, and local homes, they carry these diseases without even realising it.”
Covid lockdowns in refugee host nations have shown that little is understood about thermal comfort, ventilation, and fire control in temporary refugee dwellings, says Johan Karlsson, managing director of Better Shelter, a Swedish social enterprise that develops and provides innovative housing solutions for displaced people.
Karlsson has partnered with the Sustainable Environment and Ecological Development Society (SEEDS), an India based NGO that has pioneered the use of Structure, a modular shelter designed by Better Shelter as a stripped-back version of its Relief Housing Unit. Developed with the UN Refugee Agency (UNHCR) and the Ikea Foundation, it has been used to provide covid healthcare facilities in countries worldwide including Brazil, Colombia, Jordan, and Niger. The Structure model allows a simple imported frame to be insulated with locally sourced materials such as wattle and daub, bamboo, or tarpaulin to reduce costs and allow a dwelling to be more suitable to the environment, while being adaptable and still habitable several years down the line.
UNHCR stipulates that no refugee camp should house more than 20 000 people and that shelters should have a minimum 3.5 m2 per person, if cooking and toilet facilities are outside.4 SEEDS has changed its refugee camp building density from 5 m2 to 9 m2 per person in light of what covid has taught it about infection control, such as distancing and ventilation. “These changes are necessary because of covid,” says the NGO’s cofounder, Manu Gupta—“but they will have other positive effects for infectious disease.”
The dwellings SEEDS has installed in Kerala for residents affected by the monsoon need no electricity, use breathable local bamboo, timber, and wattle, and have a lockable door and a solar powered lamp. This helps reduce security related health risks such as urinary tract infections and snake bites, while improved ventilation reduces population acute respiratory infections. The Structure model has four ventilation inlets and four window inlets enabling an air exchange of more than 35 m3 per hour per person, as well as a thermal resistance panel and mosquito nets on all openings to prevent mosquitoes and insects from entering.5
Corsellis believes that country rooted solutions such as SEEDS’s shelter work are the most effective humanitarian response in a context where global heating and conflict are predicted to generate large cross country refugee flows, as well as internal displacement, in coming decades.6 “And you have to remember that most refugee dwellings in the world are built by refugees themselves rather than outside actors,” he says.
David Coley, who runs the Better Housing for Refugees research group at Bath University, UK, says that the next decade needs to see “a revolution in the quality of refugee shelter, as we did in the ’80s with addressing famine and the ’90s with providing basic healthcare to vulnerable populations. Hopefully, what covid has taught us about refugee shelter will be the impetus we need.”
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: this project was funded by the European Journalism Centre through the Global Health Security Call. This programme is supported by the Bill & Melinda Gates Foundation.
Provenance and peer review: Commissioned, not externally peer reviewed.