Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ EPIDEMIOLOGY OF HEALTH PROBLEMS AMONG INTERNALLY DISPLACED PERSONS (IDPS)' CAMPS Salwa S. Abdul-Wahid Al-Kinani 1,4 Nabeel Fadhil Hathaf 2 Jnan Mohamed Salih3 1 Community Medicine, Diyala Medical College, University of Diyala, Iraq. 2 Community Medicine, Diyala Directorate of Health, Ministry of Health, Iraq. 3 Family Medicine, Diyala Medical College, University of Diyala, Iraq. 4Corresponding author: sshabdulwahid@yahoo.co.uk ABSTRACT Internally displaced persons (IDPs) are people who have been forced to flee or to leave their homes in order to avoid the effects of armed conflict, violence, violations of human rights, natural or human-made disasters. To highlights the internal displacement waves, and IDPs situation in Diyala Province, and to describe some of the key health issues for displaced populations, and to assess other effects associated with internal displacement. Retrospective study conducted for the period 1st Sep 2015 to 1st March 2016, in Diyala Province. Review of records and registries of IDPS from Diyala Directorate of Health (DoH), Public health department, emergency committee and follow-up of internally displaced persons. Direct Interviews with officers responsible for IDPs in Diyala DoH was also conducted. Diyala faced three main waves of internal displacement, the first one was before 2006, the second wave was after 2006, while the third wave which is the greater one followed Al-mousel occupation at 10th June 2014. During the last wave Diyala province has been affected dramatically since the beginning of that crisis which lead to displacement of 190,000 persons from Al-Udhiem, Jalula, Saadia sub-districts, and many villages of Al-moqdadia and Al-mansoria Districts. IDPs following the last crisis distributed into three main camps were number of IDPs (22,000) representing 11.6% of all IDPs. The remains of IDPs were distributed through urban and rural areas of the province. Rapid increase in the number of internally displaced persons have influenced a negative impact on the preventive and curative health services, in addition to increasing needs for medical materials, equipment, supplies and available human resources due to the fact that the IDPs are Living critical and risky situation. Diyala province affected dramatically from violence, conflict and internal displacement, which lead to a lot of challenges related to public health, and represented by spread of Communicable Diseases. Key words: Internally displaced persons (IDPs), Health problems, Diyala. Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ INTRODUCTION Internally displaced persons (IDPs) are people or groups of people who have been forced to flee or to leave their homes or place of habitual residence in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters (Depoortere et al., 2004). IDPs have not crossed an internationally recognized State border. They stay under the protection of their government, even if that government is the reason for their displacement (Thomas and Thomas, 2004) . As a result, these people are among the most vulnerable in the world3. By the end of 2014, a record- breaking 38 million people had become displaced within their own country as a result of violence (Toole and Waldman 1990) . A massive 11 million of them were newly reported during 2014, equal to 30,000 people a day (Toole and Waldman, 1993). UNHCR cared for around 26 million of the world's IDP population in 2014 (UNHCR, 2014b). The majority of the increase in new displacement during that year was the result of protracted crises in Democratic Republic of the Congo, Iraq, Nigeria, South Sudan and Syria. In total, these five countries accounted for 60 per cent of new displacement worldwide (UNHCR, 2014b). War and civil strife have been largely responsible for this epidemic of mass migration that has affected almost every region of the world, including Europe. Violence in Darfur, Sudan, has rendered more than one million people internally displaced (Emergency and IDPs Followup Committee in Diyala, 2015). In Iraq up to 2.1 million people were displaced and unable to achieve durable solutions. This includes up to 1.1 million people displaced since the sectarian violence of 2006, and at least one million IDPs displaced from previous waves of displacement. The actual process of moving and displacement can lead to health related difficulties, or risk of abuse of their basic rights particularly for vulnerable groups such as children, women and the elderly. The risks associated with displacement due to lack of basic survival necessities required to sustain ‘good’ basic health such as food, shelter, safe water, sanitation and lack of access to emergency health care in times of need (Thomas and Thomas, 2004;United Nations Human Rights Office of the High Commissionaire, 2017). Many populations will have pre-existing vulnerable groups due to poverty, poor housing, violence, ethnicity, religion; those are more susceptible to the effects of conflict or an otherwise adverse event and therefore more likely to become displaced internally or internationally (Depoortere et al., 2004 ; UNHCR, 2014a). Displaced persons suffer significantly higher rates of mortality than the general population. They also remain at high risk of physical attack, sexual assault and Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 080 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ abduction, and frequently are deprived of adequate shelter, food and health services (United Nations Secretary General Kofi Annan 2000;Roberts et al., 2009) . This paper highlights the internal displacement situation and waves in Diyala Province, and to describe some of the key health issues for displaced populations, and to investigate other effect of internal displacement. SUBJECTS AND METHODS Retrospective study conducted for the period 1st Sep 2015 to 1st March 2016, in Diyala Province. Review of records and registries of IDPS from Diyala DoH, Public health department, emergency committee and follow-up of internally displaced persons, registries and statistics of IDPs camps in Baquba and Khanakin districts. Interviews with officers responsible for IDPs in Diyala DoH. Diyala is an Iraqi Province, located (60) Km northeast to Baghdad the Capital of Iraq. Bordered to the east by Iran, Sulymania and Kirkuk Provinces to the North, Salahdin Governorate to the West, Baghdad and Wasit Governorates to the South and Southwest. Population 1,600,000, area 18000 Km2. Diyala included (7) Districts, Baquba, Al-kalis, Al-moqdadia, Beladruze, Al-mansoria and Khanakin. Baquba is the center, most densely populated represented 33% of total Province' population. There are (10) hospitals, (7) Primary health districts, (53) main Primary health care centers, (42) health centers and one border health center in Al-muntharia. All these health facilities presented medical, health and preventive services in this governorate. RESULTS Figure 1. Internal displacement waves in Diyala from the period 2006 to 2014 Reference: Diyala Governorate Profile/February 2010; & registries of Emergency and follow-up Committee of internally displaced persons. 1-Number of IDPs before 2006. 2-Number of IDPs after 2006, by Iraqi Ministry of Displacement and Migration. 3-Number of IDPs after 2006, assessed by International Organization for Migration. (IOM) not the total number of IDPs in the governorate. Phase II Monitoring/December 2005. June/2014. thNumber of IDPs after 10 -4 0 50000 100000 150000 200000 12345 IDPs waves No IDPs Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ Table 1. Distribution of IDPs camps in Diyala after June 2014 % of IDPs from total Diyala pop. No of IDPs Camps 11.4 2500 Baquba' camp (Muasker saad) 88.6 19500 Khanakin camps (Alyawa and Al-wind camps) 11.6 * 1.5** 22000 Total IDPs in the camps 12.7*** 190000 Total IDPs in & out the amps *% of IDPs from all IDPs (in the camps and out of the camps). **% of IDPs in the camps from the total population of the Province. ***% of IDPs in & out the camps from total population of the Province. Table 2. Socio-demographic characteristic of IDPs in the camps % from total IDPs in the camps Socio- demographic characteristics of IDPs 49.0 50.5 Gender Males Females 17.7 < 5 children 3.7 >60 years 1.6 People with Special needs 4.8 Patients with chronic diseases 10.0 IDPs move to other governorates Table 3. Distribution of diseases and health problems among IDPs in Khanakin' camps during last three months of 2014 Number of cases <5 years % of Total Number of cases for all ages % of Total Disease 3087 (38.30 ) 8078 (38.70) Respiratory system diseases 2407 (46.80) 5144 (24.60) Disease of GIT 188 (6.30) 2973 (14.20) Diseases of UTI 373 (27.60) 1352 (6.50) Skin diseases (scabies) 22 (19.50) 113 (0.40) Cutaneous leishmaniasis 49 (12.00) 396 (1.90) Anemia 32 (23.20) 138 (0.60) Burns 41(6%) 2531(12.1) Other * 6374 (30.50) 20877 (100) Total *Eye, Orthopedics dis., Dental problems, minor surgical conditions, Fever and other. Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ Table 4. Distribution of diseases among IDPs (inside and outside camps) according to age/ 2015 >5 years Male Females Total No (%) No (%) No (%) < 5 years Male Females No (%) No (%) Diseases 97 (45.1) 70 (34.3) 304 (42.9) 63 (42.6) 74 (51.7) Upper RTI 21 (9.8) 21(10.3) 67 (9.4) 16 (10.8) 9 (6.3) Lower RTI 20 (9.3) 23(11.3) 73 (10.3) 16 (10.8) 14 (9.8) Diarrheal diseases 7 (3.3) 7 (3.4) 27 (3.8) 6 (4.1) 7 (4.9) Skin diseases 69 (32.0) 83(40.7) 227 (32.0) 36 (24.3) 39 (27.2) Cutaneus leishmaniasis 0 (0.0) 0 (0.0) 11 (1.5) 11 (7.4) 0 (0.0) Visceral leishmaniasis (100) 215 (100) 204 (100) 709 148 (100) 143 (100) Total DISCUSSION The humanitarian communities are increasingly aware of the crisis of internal displacement which affects over 24 million people worldwide, while responsibility for the protection of IDPs rests with national government and local authorities. It is important for the international community to see how best it can contribute to protect IDPs (Internal Displacement Monitoring Centre 2016). Iraq has witnessed over the past years, especially after the bombing of religious shrines in Samarra during February 2006, and the subsequent armed acts, and terrorism, in many provinces which led to waves of internal displacement (UNHCR, 2014b). Diyala province witnessed three main waves of internal displacement, (Figure 1). The first one was before February/2006, number of IDPs were 54699 persons. The second wave was after February 2006, at that time about 136891 persons were internally displaced. The third and highest wave was after Muosel occupation in 10th of June/2014. Diyala has been affected dramatically since the beginning of that crisis. Violence, conflict and internal displacement included many districts, sub-districts and villages such as Al-Udhiem, Jalula, Saadia. Large number Al-moqdadia' and Al-mansoria' villages. That was led to the displacement of about 190,000 persons across the province or leave it to other provinces in search for security (Table 1 and 2). Displacement movement has made many IDPs homeless, or they live in places lacks to the basic components and services for living, while some of them exist in buildings' skeletons, tents or caravan in best conditions. In such places IDPs faced worst influences of environment, climate, in-security, and loss of human needs and basic services. Displacement may occur within an individual’s own country (internal displacement), or lead to flight across national borders to neighboring or other Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ countries (as asylum seekers). The process of displacement will inevitably lead to an added health and social burden on the receiving region or country (Roberts et al. , 2009). The existence of significant challenges in providing food aid to IDPs due to their large number and their presence in separated places. A variety of events and factors can make individuals and populations susceptible to health risks. Scarcity of water or in- availability of safe water, problem of sanitation and hygiene, which itself is considered a real challenge to the strength of infra- structure and municipality services in the province (Depoortere et al. , 2004; UNHCR, 2014b). Rapid increase in the number of internally displaced persons have influenced a negative impact on the preventive and curative health services, in addition to increasing needs for medical materials, equipment, supplies and available human resources due to the fact that the IDPs are Living critical and risky situation. Displacement and migration play an important role in the spread and transmission of acute cases of some communicable diseases from one geographical area to another, as well as the changing pattern of infectious disease in the communities. This concern becomes significant when these crises are accompanied by large population movements of internally displaced persons and refugees (due to the presence of the carrier of the disease and the lack of or low routine vaccinations. Also, the population displacement associated with the spread of some diseases, like respiratory diseases, diarrheal diseases, scabies, visceral and cutaneous leishmaniasis (Table 3 and 4). Human activity plays an important role in bringing about a continuous change of the balance between vector, reservoir, agent and host. The movement of internal displacement and migration contribute to the variables of such balance (Amowitz et al., 2002 ; Gushulak and MacPherson, 2006 ; Betancourt and Williams, 2008 ; Spiegel et al., 2010 ; Siriwardhana and Stewart, 2013 ; Akinsulure-Smith, 2014 ; Shin et al., 2016). Despite the harsh circumstances facing IDPs in Diyala and their exposure to health and environmental Living situation favorable for the spread of many diseases and epidemics, but the spread of infectious diseases was in proportions is possible to be controlled, through the rabid response of Diyala Directorate of Health and its Director General, all relevant departments, medical and health staff and appropriate health and emergency plans for IDPs to present preventive and curative health care (UNHCR, 2014b). The crisis of displacement also showed significant burdens on the availability of services in the host community in general, particularly on health services. Quantification of the health care needs of these groups is therefore required so Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ that sometimes scarce resources can best be targeted to meet the challenging needs of these diverse groups (Depoortere et al. , 2004 ; Gushulak and MacPherson, 2006). The education is a priority for the resident population and for IDPs; also it is an essential component for the treatment of psychological trauma. Failure to resolve the challenges of education increases the risk and the effects of social and behavioral tensions and increased distractions. On the other hand poverty and un- employment of in the new destination or even their areas of origin increase the suffering of IDPs and added a negative impact on that society (Depoortere et al., 2004). Changes in population densities following displacement will influence the original community, which has been deteriorating in regard to needed service, environmental and municipal infrastructure as a result of armed violence (Akinsulure-Smith, 2014 ; Shin et al., 2016). Measles, malaria, diarrhoea and acute respiratory infections all contribute to an excess Crude mortality rate (CMR) amongst displaced populations, especially in under-developed countries. For example a study of 25,000 Kurds in refugee camps in north-western Iran had a CMR nine times higher than the CMR of Iraq (Siriwardhana and Stewart, 2013). The question as to the demands displaced populations place on health care resources and health care providers in their destination countries or regions remains the subject of great debate. People adversely affected by the displacement process and those with existing conditions will be the most vulnerable to health difficulties immediately upon arrival in their destination place (Babille et al., 1994). Initial needs that require addressing for the entire displaced population will relate to basic housing, food, water and sanitation (Akinsulure-Smith, 2012).However, for many displaced people, movement merely means a shift from one poor and vulnerable situation into similar further vulnerable circumstances. Recommendations This study was done with some limitation due to difficulties in reaching all data regarding IDPs from practical and authority's point of view. In spite of that, it had provided an epidemiological evidence for internal displacement. There must be a consistent, clear and well thought out plans for IDPs to deal with how to address the displacement crisis and minimize the negative effects over time. The priorities for them are, providing protection and security, and to deal with what can be generated by this crisis to society as a whole. Securing the provision of safe water and food by increasing coordination between the relevant authorities on the ground. Water supply, sanitation with emphasis on personal hygiene. Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ Careful monitoring of the impact of the crisis on the local economy. Strengthen municipal services and environmental services. Promote education for the affected categories of IDPs. Implement and coordinate assistance of international agencies to displaced populations are urgently needed. IDPs crisis requires that researchers, policymakers, and clinicians comprehend the magnitude of the psychological consequences of forced displacement and the factors that moderate them. Acknowledgment I would like to express my gratefulness and thanks to Dr. Wissam Saadon, manager of Communicable diseases/ Diyala DoH, and to Dr. Ali Naser and Mr. Talib in the Emergency and IDPs Follow-up Committee/ Diyala DoH, for support, continuous assistance and cooperation to finalize this study. REFERENCES Akinsulure-Smith, A. M. 2012. Responding to the trauma of sexual violence in asylum seekers: A clinical case study. Clinical Case Studies, 11: 285-298. Akinsulure-Smith, A. M. 2014. Displaced African female survivors of conflict- related sexual violence: Challenges for mental health providers. Violence against women, 20: 677-694. Amowitz, L. L., Reis, C., Lyons, K. H., Vann, B., Mansaray, B., Akinsulure- Smith, A. M., Taylor, L. & Iacopino, V. 2002. Prevalence of war-related sexual violence and other human rights abuses among internally displaced persons in Sierra Leone. Jama, 287: 513-521. Babille, M., Colombani, P. D., Guerra, R., Zagaria, N. & Zanetti, C. 1994. Post‐ Emergency Epidemiological Surveillance in Iraqi‐Kurdish Refugee Camps in Iran. Disasters, 18: 58-75. Betancourt, T. S. & Williams, T. 2008. Building an evidence base on mental health interventions for children affected by armed conflict. Intervention (Amstelveen, Netherlands), 6: 39. Depoortere, E., Checchi, F., Broillet, F., Gerstl, S., Minetti, A., Gayraud, O., Briet, V., Pahl, J., Defourny, I. & Tatay, M. 2004. Violence and mortality in West Darfur, Sudan (2003–04): epidemiological evidence from four surveys. The Lancet, 364: 1315-1320. Emergency and IDPs Followup Committee in Diyala 2015. IDPs crisis in Diyala after 10th June,2014. Diyala Health Directorate conference 2015. Diyala- Baqubah: Diyala Health Directorate, Iraq. Gushulak, B. D. & MacPherson, D. W. 2006. The basic principles of migration health: population mobility and gaps in disease prevalence. Emerging themes in epidemiology, 3: 3. Internal Displacement Monitoring Centre 2016. Internal Displacement Monitoring Centre (IDMC) Report. 2016. http://www.internal- displacement.org/. Palais des Nations Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 088 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ Roberts, B., Ocaka, K. F., Browne, J., Oyok, T. & Sondorp, E. 2009. Factors associated with the health status of internally displaced persons in northern Uganda. Journal of Epidemiology & Community Health, 63: 227-232. Shin, H.-Y., Lee, H. & Park, S. M. 2016. Mental Health and Its Associated Factors Among North Korean Defectors Living in South Korea: A Case-Control Study. Asia Pacific Journal of Public Health, 28: 592-600. Siriwardhana, C. & Stewart, R. 2013. Forced migration and mental health: prolonged internal displacement, return migration and resilience. International health, 5: 19-23. Spiegel, P. B., Checchi, F., Colombo, S. & Paik, E. 2010. Health-care needs of people affected by conflict: future trends and changing frameworks. The Lancet, 375: 341-345. Thomas, S. L. & Thomas, S. D. 2004. Displacement and health. British medical bulletin, 69: 115-127. Toole, M. & Waldman , R. 1990. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 263: 3296-302. Toole, M. J. & Waldman, R. J. 1993. Refugees and displaced persons: war, hunger, and public health. Jama, 270: 600-605. UNHCR 2014a. Global Overview 2014: People internally displaced by conflict and violence–Iraq, IDMC, Annual Report, IRQ,5374748030. UNHCR. 2014b. UNHCR global report 2014(Internally displaced People) [Online]. UNHCR Available: http://www.unhcr.org/internally-displaced- people.html [Accessed January 2017]. United Nations Human Rights Office of the High Commissionaire. 2017. Questions and Answers about IDPs [Online]. United Nations Human Rights Office of the High Commissionaire Available: https://www.ohchr.org/EN/Issues/IDPersons/Pages/Issues.aspx [Accessed January 2017]. United Nations Secretary General Kofi Annan 2000. Address to the fifty-first session of the Executive Committee of the High Commissioner for Refugees,2 october 2000. Palais des Nations. داخليا في المخيماتانتشار المشاكل الصحية بين األشخاص النازحين 3جنان محمد صالح 2نبيل فاضل 4 ،1سلوى شلش عبد الواحد الكناني فرع طب المجتمع، كلية الطب، جامعة ديالى، العراق. 2 طب المجتمع، دائرة صحة ديالى، وزارة الصحة، العراق. 0 فرع طب العائلة، كلية الطب، جمعة ديالى، العراق. 2 2 sshabdulwahid@yahoo.co.ukالمسؤول عن النشر: المستخلص النزاع آثار لتجنب منازلهم مغادرة أو الفرار على أجبروا أشخاص هم داخليا المشردون األشخاص ت اجري .اإلنسان صنع الكوارث من أو الطبيعية الكوارث أو اإلنسان حقوق انتهاكات أو العنف أو المسلح Diyala Journal of Agriculture Science, 10(Special issue): 280-289, 2018 Al-Kinani et al. 082 Scientific Conf., College of Vet. Med. Diyala Univ., 2018 st1 http://www.agriculmag.uodiyala.edu.iq/ ديالى، محافظة في النازحين ووضع الداخلي، النزوح موجات على الضوء تسليط هذه الدراسة بهدف .الداخلي تشردبال المرتبطة األخرى اآلثار وتقييم النازحين، للسكان الرئيسة الصحية القضايا بعض ووصف مارس لغاية االول من 0222 سبتمبراالول من من للفترة في محافظة ديالى نفذت هذه الدراسة االسترجاعية العامة، قسم الصحة ،(DoH) ديالى دائرة صحة من IDPS سجالت استندت الدراسة على مراجعة. 0222 عن نالمسؤولي مع المباشرة المقابالت أجريتو ،في دائرة الصحة ا داخلي النازحين ومتابعة الطوارئ ولجنة نم رئيسة موجات واجهت ثالث اظهرت النتائج ان محافظة ديالى .ديالى في داخليا النازحين األشخاص الموجة جاءت حين في ،0222 عام بعد الثانية الموجة وكانت ،0222 عام قبل كانت األولى الداخلي، النزوح النزوح تأثرت من األخيرة الموجة خالل. 0222 يونيو 22 في الموصل احتالل بعد األكبر وهي الثالثة من واسعة منطقة من ( شخص222,222) نزوح إلى أدت التي األزمة تلك بداية منذ كبير بشكلالمحافظة نکا. ةوريوالمنص المقدادية قرى من والعديد السعدية،و جلوالء،و العظيم، أحياء من رئيس بشكل المحافظة ونيمثل وهم( 00,222) وعددهم ئيسيةر تمخيما ثالثة في نعيوزلما رةألخيا مةزألا بعقاأ في ونحزلناا أثرت وقد. بالمقاطعة والريفية الحضرية المناطق خالل من النازحين توزيع تم. نحيزلناا نم 22.2% العالجية،و الوقائية الصحية الخدمات في سلبيا تأثيرا داخليا المشردين األشخاص عدد في السريعة الزيادة ازحونالن ويعيش المتاحة، البشرية والموارد واللوازم والمعدات الطبية للمواد االحتياجات زيادة فضال عن راعوالص العنف من كبير تاثرت بشكل ديالى الدراسة بان محافظة استنتجت .خطيرة و حرجة حالة في مرا األ انتشار في وممثلة العامة، بالصحة المتعلقة التحديات من الكثير إلى أدى مما الداخلي، والنزوح .السارية .ديالى ،المشاكل الصحية ،االشخاص النازحين داخليا المفتاحية:الكلمات