refugee income generating projects and occupational health

Refugee Income Generating Projects -

and Occupational Health

STEPHANIE SIMMONDS

The shiftfrom purely emergency relieffor refugees in developing countries to aid within the context of development strategies is slowly gathering momentum (UN, 1983; UNHCR, 1984; Simmonds, 1984). Such a move implies that ifself-reliance is to be a realistic goal then employment for refugees is essential; a number of income-generating schemes are therefore being both proposed and developed (KO, 1983 and 1984).

Many of these schemes have implications for the health of the refugees, so this paper summarises some occupational health hazards and offers suggestions forfuture action.

INTRODUCTION

The complex political, socio-economic, environmental and health and disease issues surrounding refugees often make them a particularly "at risk" group of people. Thus whilst acknowledging that the subject of occupational health in developing countries already presents an enormous challenge, refugees and the poorest of the poor among the local population who may also be involved in refugee funded projects require special consideration if the quality of the life of the refugees or locals is not to deteriorate further. In the past health advisors have often become involved too late in the planning or evaluation of refugee health and health related services in camps. For example, following the worst in environmental (non) planning, highly-expensive, expatriate-run, high-visability emergency medical and surgical services have been implemented, to the neglect of preventive health care and other the basic principles of primary health care. As a result, the

health of refugees has often deteriorated amid serious health and disease problems (Arnow et al, 1977; Mulholland, 1985; Ryan, 1975; Tresalti et al., 1985). The main aim of this paper is to outline why occupational health should be more than a marginal issue in refugee camps; to class- lfy, with reference to health issues, some of the incoming-generating projects both proposed and established; to highlight any occupational health and disease problem they may precipitate; and to summarise the findings in the form of guidelines for future action.

WHY REFUGEE OCCUPATIONAL HEALTH?

A number of publications deal with the problems confronting occupational health and employment in developing countries (Asogwa, 1981; El Batawi, 1972; Hall, 1970; Szal, 1984; WHO, 1979). These problems range from low income and stagnating growth coupled with a general lack of employment, to the failure of occupational

DISASTERS VOLUME 12 NUMBER 2

170 Stephanie Simmonds

health and safety legislation to set standards or implement and monitor proced- ures. Furthermore, the endemicity of disease in developing countries means that much sickness, absence and loss of pro- ductivity is due to non-industrial disease, and that workers are frequently at risk of aggravating general health problems by inadequately controlled occupational hazards. Occupation-related diseases are often forgotten because of the widespread misconception that occupational health is concerned mainly with industry and industrialized countries, and because of the lack of adequate health data, for example, about agricultural workers. Workers in agriculture and in small industries form together the major part of the productive workforce in both refugee camps and also in developing countries generally. They are less well paid than other workers and are usually not organized in labour unions. Many of them are not protected by occupational health and safety legislation. Furthermore, the health services per se often pay little attention to occupational diseases.

Issues in the health sector that make refugees different from more stable communities are extensively covered in the literature and are not further reviewed here (Dick and Simmonds, 1983; Sim- monds et al., 1985 and 1985-86). When applying these findings to occupational health it can reasonably be presumed that many of the difficulties encountered when creating employment opportunities for self-reliance in refugee communities will emanate from political, economic, cultural and management factors, the heterogeneity of the refugees and the often marginal, inhospitable environment in which they are settled. Furthermore, sustained economic employment is rare and therefore it is crucial to ensure that those who are working are given every opportunity to maintain their health.

It has also been noted that:

0 Refugees often accept employment on a day to day basis at less than the going wage (Szal, 1984).

0 They are a resource which the less poor and more powerful among the host population may readily utilise. For example, in Sudan, the agricultural schemes around Wad el Dilayeur paid excessively low wages and employed mainly women and children (Chambers, 1982). The accelerated pace of social change sometimes noted in refugee communities has been particularly reflected in the changing values of female participation in employment (Christensen, 1982).

0 The provision of employment is one of the most positive factors in the pro- motion of the mental health of refugees (Simmonds, 1985).

WHAT ACTIVITIES AND WHAT POSSIBLE HEALTH PROBLEMS?

Experience to date indicates that viable refugee income-generating activities tend to fall into the following four areas:

(i) Agriculture. (ii) Small-scale industries. (iii) Major public works. (iv) Professional workers.

Within each of these categories there is not only a wide range of activities that can be considered but also two basic levels of employment, namely individual employment (including self-employment) and group employment. Both of these may operate inside or outside the camp, as refugee projects or in conjunction with local nationals. Occupational health surveillance therefore needs to address itself to these important, often forgotten issues.

Agriculture

Figure 1 outlines examples of agricultural income-generating projects in refugee


Refugee income generating projects and occupational health 171

Poultry Small Scale Livestock Silkworm Fodder Vegetable Cash Raising Dairy Farming Grazing Production Production Gardening Crops

Afghan' Afghan" Afghant Afghan' keeping Sudantt tea

Sudantt Sudantt Afghan" Tibetan'

Small L Scale Free Range Poultry Farms Poultry Raising

eg eg eg eg + bee eg eg

Tibetan' Tibetan' eg eg

Sudantt

Sources ILO, 1983

* * Simmonds, 1984 t Simmonds, 1981 t t ILO, 1984 ' Help the Aged, 1981

FIGURE 1 Agricdturul activities for income generufiori

camps. Little or no reference is made in project proposals or the literature to any occupational health problems associated with these projects, yet they are potentially responsible for a significant amount of disease, disability and even death. The use of pesticides for example is increasing, particularly as developing countries concern themselves with higher agricul- 'tural yield. The main occupational health problems associated with pesticides arise from poisoning by the toxic organo- phosphorous and carbonate compounds. Under-reporting occurs because symptoms such as diarrhoea, vomiting and skin rashes are mild and shortlived at the onset of poisoning. However, serious cases of intoxication have been reported usually as a result of spraying without adequate protection such as special clothing.

With the increasing use of agricultural tools and machinery, such as tractors and threshing machines, occupational injuries are now more numerous. Exposure to vegetable and other organic dusts is widespread, precipitating lung diseases such as byssinosis, aspergillosis and occupational asthma. Exposure to dusts of grains, rice, cocoa, coconut fibre, tea, kapok, tobacco and wood is common in countries where

these products are grown. There is evid- ence that such exposures may cause obstructive respiratory disease and asthma.

Small-scale Industries

Figure 2 gives examples of small scale industries that have been estimated to constitute a high percentage of the workforce in refugee camps and settlements. In spite of their large number and importance to the camp economy, the standard for working conditions has tended to depend on the economic and technical competence and the attitude towards the refugee workers on the part of the aid sponsoring organizations.

Listed in Table 1 are some of the potential occupational health risks associated with small income generating projects. The list is by no means comprehensive but is a guide to the surveillance of symptoms and diseases. The need for such monitoring is highlighted by the conclusions of a field study review of a number of countries (WHO, 1976) which found workers in small industries to have a greater risk of suffering from toxic effects or fully developed occupational disease than those in large industries.



TABLE 1 Occupational diseases associated with small scale income generating projects

~~~~ ~

Project Occupational Hazard

Alcohol Production

Food Processing

Vegetable Oil

Soap Manufacture

Textile Production

Carpet Weaving

Silk Production Leather Training and Shoe Making

Woodworking

Brick Production

Poor quality control causing optic atrophy and fatal intoxication. Alcoholism Infectious or parasitic diseases spread by animals or waste products of animals used in manufacture e.g. Brucellosis, Lepto- spiroses, Bovine TB, Erysipeloid, Foot and Mouth disease. Contact dermatoses and allergies of skin or respiratory system due to animal or vegetable products. Skin sensitivity or diseases from contact with oil. Aflatoxins in peanut oil processing contributing to increased prevalence of liver diseases. Chemical hazards. Burns of skin and eyes from caustic soda and sodium silicate. Allergies from colouring or perfume additives. Skin diseases from dyeing and bleaching. Anthrax spores given off by alpaca wool and camel hair. Byssinosis from dust exposure to cotton, flax and hemp. Asbestos is from asbestos spinning. Exploitation of child labour. Dermatitis from sodium bichromate dyes. Poison from lead colourings. Arthritis and neuralgia of hands. Genu Valgum in young and Scoliosis. Eye strain. Contact dermatitis. Asthmatic reactions. Anthrax from infected hides. Chronic bronchitis and cancer hazards e.g. larynx for fine dust. Skin ulceration chrome and Leucoderma. Skin and conjunctival irritation and Kertitis from contact with green wood. Asthma and nasal rhinitis from dusts. Nasal cancer and Hodgkins Disease. Soft tissue sarcomas from chlorophenols. Silicosis from high concentrations of silica dust. Lead poisoning from glazes.

Major Public Works ditches and contour trenches, erection of barbed wire fencing, construction of motor-

Since refugee settlements tend to be able roads and inspection paths and plant- located in rural areas it is possible to ation and sowing of trees (World Bank, consider a whole range of major work 1984). Other large industries described are schemes. Such projects include construc- tea estates, woollen and polyfibre mills, tion of dams, excavation of percolation and lime and mineral industries (Help the



SMALL-SCALE INDUSTRIES

NON FOOD-PROCESSING SUPPORTING INDUSTRY FOOD PROCESSING FOR AGRICULTURAL PRODUCTION 1

GENERAL FOOD CHEESE FOOD MILLS VEGETABLE OIL & DRINK PRODUCTION eg Sudan"' PRODUCTION

Tibetan"

HANDICRAFTS SOAPMAKING eg Sudan"' eg Sudan'"'

Afghan' Tibetan"'

LEATHER BRICKMAKING CARPENTRY TEXTILE SPINNING TAILORING SHOEMAKING TANNING eg Sudan"" eg Afghan' PRODUCT(0N &WEAVING eg Tibetan' eg Sudan"'

LEATHER Sudan"' Tibetan' PRODUCTS Afghan" eg Sudan"'

84 Sudan"' eg Tibetan eg Sudan'"'

Sources * ILO. 1983 " * Simmonds. 1984 * * * ILO, 1984 I Help the Aged, 1981

FIGURE 2 Small-scale industries for income generation

Aged, 1981). These schemes may be designed on a self-help basis where material and expertise are supplied and the refugees provide the labour or on the basis of food for work.

The change for refugees from traditional agricultural employment to such industry can greatly influence living and working systems. Such adaptation may for example manifest itself in major psycho- logical stress.

In establishing such public works projects it is important to be aware of the major groups of occupational diseases that frequently occur. They include the pneumoconioses and obstructive respiratory diseases caused by dusts; intoxic- ations by various pesticides, poisoning by metals, particularly lead and by solvents; occupational dermatitis, acute and chronic effects of respiratory irritant gases and vapours; and noise induced hearing loss (WHO, 1979).

In addition there are work related diseases in which work plays only a partial role in causation. For example, chronic

gastroenteritis and gastro-duodenal ulcer have been described among workers in various occupations associated with in- adequate dietary habits, irritants in the work, and work stress including altern- ative shifts (El Batawi, 1972). Arthritis and locomotor disorders are described with unduly, heavy physical work and inappro- priate posture.

Occupational accidents are also a major cause of disability due to work. The three main factors that play a role in the high incidence of occupational accidents are inadequately controlled environment, limited safety education and lack of protec- tive equipment, and higher susceptibility attributable to difficulties in adapting to mechanized work and to low standards of general health, prevalent among refugees.

Professional Workers

Mental stress is probably one of the most important occupational health hazards facing refugee health workers in camps. The often serious political and manage-



ment problems encountered in the planning and implementation of health care can place serious and prolonged pressures on health workers.

GUIDELINES FOR FUTURE ACTIONS

There is a need to develop a new understanding of occupational health in refugee communities in order to make the best use of limited resources. 1. Planning: In order to design a viable strategy, occupational health needs to be on the agenda of all plans for economic self-reliance.

--.;I?., 2. Evaluation and- monitoring: To identify occupational health problems ana Illell magnitude, surveys should aim at evaluating environmental exposures and exam- ining workers for specified diseases in a standardized manner. Continued monitoring would enable control measures to be assessed, identify specific needs of refugee camps and provide information for further planning and evaluation. For this to be effective criteria need to be defined for health examinations as well as cheap, reliable techniques for detecting and evaluating occupational hazards among income-generating projects. 3. Training: In the design of occupational training programmes emphasis should be given to areas that are of particular importance to employment in refugee camps, in addition to the specific aspects of occupational health. These include cultural factors, heterogeneity, and family struc- ture as well as employees/government attitudes. Besides the orientation of employers and employees in occupational health there is need for the specific training of health assistants in occupational hygiene, ergonomics and toxicology. It has also been found that there is a serious lack of managerial training (Szal, 1984) and apprenticeship schemes for small scale enterprises. The creation of a new camp of refugees has the potential for undertaking

management and apprenticeship development training, included in which should be occupational health. The type of training depends on specific needs and problems of the refugee camps and perhaps because of their disbursement mobile training units may be required (ILO, 1983). 4. Health services in refugee communities need to concern themselves with the pre- vention of specific health problems related to occupations. Furthermore resources should be made available on employment projects for the development of preventive health care for workers and wherever possible their families. 5. Development of research in to occupational health issues of concern to refugees and others. To achieve this, continuous contact and co-ordination at the international and national level are essential for the harmonization of methods, development of standards and co-ordination of research.

What is clear from this overview is that a great deal more can and needs to be done to achieve the objectives of d healthy workforce within refugee communities. Coordination, understanding and co- operation will help in the development of an effective occupational health service. Such a sense of responsibility for the health and safety of workers can be stimulated by education and training, and by demonstrating the social and economic value of a healthy workforce.

Acknowledgements

Thanks are particularly due to Patrick Kiernan who undertook much of the research for this paper and to Neil Anderson of the Department of Occupational Health, London School of Hygiene and Tropical Medicine.

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176 Stephaiiie Simmonds

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Stephanie Simmonds Lecturer in Community Health and Head, WHO Collaborating Centre for the Health of Refugees and other Displaced Communities Evaluation and Planning Centre for Health Care London School of Hygiene and Tropical Medicine Keppel Street, London WC1 -


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