Large population displacements are always associated with a high rate of mortality due to infectious diseases. Measles immunization, the provision of clean water and sanitation and the effective management of malaria, diarrhoea and pneumonia cases are the main measures for preventing excess mortality at the initial phase of a refugee influx. During the postemergency phase, public health activities also target specific issues such as tuberculosis and reproductive health.

Since 1992, 117 000 Somali refugees have settled in three refugee camps located in drought-stricken, northeastern Kenya. By the end of 1993, the high rates of mortality and malnutrition that had prevailed among refugees on arrival at the camps were brought down to acceptable levels. In November, 1996, we conducted an epidemiological investigation in one of these camps at Hagadera, and extracted quantitative data from the routine epidemiological surveillance system, which was set up according to international standards.1CDC.Famine-affected, refugee, and displaced populations: recommendations for public health issues.MMWR CDC Surveill Summ. 1992; 41: 1-76Google Scholar Focus-group discussions were held to assess the health perception of the refugees.2Dawson S Manderson L Tallo V The Focus Group Manual. TDR/SER/MSR/92.1. WHO, Geneva1992Google ScholarThe refugees identified three key features of the inadequate food supply as causes of ill-health in the camp. First, the quantity of food: “the main problem is lack of food, and drugs cannot replace food”. Second, the quality of the diet: “children are always given the same… which is not a balanced diet”. Third, the inedible cereal distributed since August, 1995: “there is no treatment for the diarrhoea which you get from UN's food”. Acceptance of this cereal was low. Many refugees sold part of their ration to buy rice, at the expense of their calorie intake.Between August, 1995, and December, 1996, the official World Food Programme daily food ration was gradually decreased from 2100 to 1700 kcal per person. This reduction corresponded to an increase in the number of severely malnourished children from the camp who were admitted to hospital each month (2·8 per 1000 in August, 1995, 17·9 per 1000 in August, 1996, and 32·7 per 1000 in January, 1997) *Figure of daily food ration and monthly admission rate for severe malnutrition in children, September, 1994, to November, 1996, available from the authors or The Lancet, on request. and an increase in acute malnutrition (12·1% (95% CI 9·1–15·9) in August, 1995, 18·2% (14·7–22·2) in August, 1996, and 28·0% (24·0–32·0) in January, 1997). Scurvy is a constant problem in the camp; during one outbreak between July and October, 1996, 508 cases were reported.Malnutrition levels are now back to those seen during the emergency phase when refugees arrived at the camp. Despite international commitments to provide adequate relief rations,3Toole MJ Nieburg P Waldman RJ et al.Adequacy of refugee relief rations.Lancet. 1989; ii: 268Abstract Scopus (2) Google Scholar today's refugees are paying the price for low food reserves and unclear policy.4Editorial.“Food for all”: slogan or worthy goal?.Lancet. 1996; 348: 1109Summary Full Text Full Text PDF PubMed Google Scholar But hunger will not force the refugees to return home, because return is “not an issue of food, but of stable government. If there was a president… we would walk even tonight, back to Kismayo”.In the absence of a political solution, we believe that there are only two ethical alternatives. Preferably, more autonomy should be granted to the refugees and aid should be targeted towards restoring their livelihoods. Such a change would probably involve dividing the camps into smaller, integrated groups within an economically more resourceful environment.5Van Damme W Do refugees belong in camps? Experiences from Goma and Guinea.Lancet. 1995; 346: 360-362Crossref PubMed Scopus (58) Google Scholar Alternatively, an adequate food supply, both in quantity and quality, should be guaranteed by the international community. *Figure of daily food ration and monthly admission rate for severe malnutrition in children, September, 1994, to November, 1996, available from the authors or The Lancet, on request. Since 1992, 117 000 Somali refugees have settled in three refugee camps located in drought-stricken, northeastern Kenya. By the end of 1993, the high rates of mortality and malnutrition that had prevailed among refugees on arrival at the camps were brought down to acceptable levels. In November, 1996, we conducted an epidemiological investigation in one of these camps at Hagadera, and extracted quantitative data from the routine epidemiological surveillance system, which was set up according to international standards.1CDC.Famine-affected, refugee, and displaced populations: recommendations for public health issues.MMWR CDC Surveill Summ. 1992; 41: 1-76Google Scholar Focus-group discussions were held to assess the health perception of the refugees.2Dawson S Manderson L Tallo V The Focus Group Manual. TDR/SER/MSR/92.1. WHO, Geneva1992Google Scholar The refugees identified three key features of the inadequate food supply as causes of ill-health in the camp. First, the quantity of food: “the main problem is lack of food, and drugs cannot replace food”. Second, the quality of the diet: “children are always given the same… which is not a balanced diet”. Third, the inedible cereal distributed since August, 1995: “there is no treatment for the diarrhoea which you get from UN's food”. Acceptance of this cereal was low. Many refugees sold part of their ration to buy rice, at the expense of their calorie intake. Between August, 1995, and December, 1996, the official World Food Programme daily food ration was gradually decreased from 2100 to 1700 kcal per person. This reduction corresponded to an increase in the number of severely malnourished children from the camp who were admitted to hospital each month (2·8 per 1000 in August, 1995, 17·9 per 1000 in August, 1996, and 32·7 per 1000 in January, 1997) *Figure of daily food ration and monthly admission rate for severe malnutrition in children, September, 1994, to November, 1996, available from the authors or The Lancet, on request. and an increase in acute malnutrition (12·1% (95% CI 9·1–15·9) in August, 1995, 18·2% (14·7–22·2) in August, 1996, and 28·0% (24·0–32·0) in January, 1997). Scurvy is a constant problem in the camp; during one outbreak between July and October, 1996, 508 cases were reported. Malnutrition levels are now back to those seen during the emergency phase when refugees arrived at the camp. Despite international commitments to provide adequate relief rations,3Toole MJ Nieburg P Waldman RJ et al.Adequacy of refugee relief rations.Lancet. 1989; ii: 268Abstract Scopus (2) Google Scholar today's refugees are paying the price for low food reserves and unclear policy.4Editorial.“Food for all”: slogan or worthy goal?.Lancet. 1996; 348: 1109Summary Full Text Full Text PDF PubMed Google Scholar But hunger will not force the refugees to return home, because return is “not an issue of food, but of stable government. If there was a president… we would walk even tonight, back to Kismayo”. In the absence of a political solution, we believe that there are only two ethical alternatives. Preferably, more autonomy should be granted to the refugees and aid should be targeted towards restoring their livelihoods. Such a change would probably involve dividing the camps into smaller, integrated groups within an economically more resourceful environment.5Van Damme W Do refugees belong in camps? Experiences from Goma and Guinea.Lancet. 1995; 346: 360-362Crossref PubMed Scopus (58) Google Scholar Alternatively, an adequate food supply, both in quantity and quality, should be guaranteed by the international community. *Figure of daily food ration and monthly admission rate for severe malnutrition in children, September, 1994, to November, 1996, available from the authors or The Lancet, on request.