The Cost of Poor Camp Design on Refugee Health
‘The Cost of Poor Camp Design on Refugee Health’ is a project which takes inspiration from a previous BRE project, ‘The Cost of poor housing on the NHS’, and investigates the relationship between the health of refugee populations, and the conditions of the camp in which they live. Focusing specifically on medical data collected in Moria refugee camp on the island of Lesbos, Greece, the aim of the project is to identify the most costly health complications in refugees presenting to NGO doctors, and to explore the prevalence of these complications amongst disaggregated groupings across different camp contexts.
BRE Trust initiated this project in collaboration with Bath University. The Healthy Housing for the Displaced (HHftD) team at Bath are a research unit focused on improving the living conditions in refugee camps by designing low cost and easy to construct housing that will moderate extremes of temperature and ensure the privacy, comfort and dignity of residents. BRE Trust, through the development of the QSAND sustainability tool, have been focused on shelter and settlement solutions in post-disaster contexts, and are developing additional technical guidance around shelter resilience and sustainability. After initial conversations with the HHftD team, it was decided that a student from Bath could join the BRE Trust team as part of a placement to build on some of these themes.
Anna Gatti, an Architecture student at Bath, joined the team with an interest in the effects of different shelter types on the health of inhabitants. Having spent time volunteering in the Moria refugee camp in Greece, Anna was particularly interested in the impacts of poor quality shelter on the health of refugees, and was able to utilise her contacts in Moria to gain access to the anonymised medical data of 18,719 refugee consultations (25,862 diagnoses) from the primary medical center in the camp. From this, the concept of health and housing tool for application in refugee settings was developed.
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The result is displayed in the form of an excel tool in which medical data is inputted, and the statistical significance of the distributions of illnesses is outputted. It looks at the age, sex, and location distributions of each illness, and compares it to what one would expect to see in a ‘normal’ healthy population. This tool can be used for any medical data set, for any camp and in any environment. It shows which medical conditions are affecting the population more than they should, and whether different shelter types have a different impact on health outcomes. Anna also developed another tool which analyses the medicines most frequently prescribed and assesses their costs (taken as NHS costs), allowing one to view which ailments are costing the medical NGOs the most to treat. Combining these two tools allows one to see the largest costs to refugee health alongside the largest costs to medical NGOs, therefore providing a cost-analysis which can help funding and aid packages target specific issues. This will not only increase aid efficiency, but also allow a deeper understanding into how certain aspects of camp design and management increase or decrease the health of refugees, and how these contributing aspects may change over time, location, and environment.
The Moria Context
In order to assess the impact and opportunities of these tools, medical data from the Greek camp of Moria was inputted. From this data, covering a nine-month period and considering all illnesses, it is clear that women are disproportionately affected by ailments, representing 44% of diagnosed conditions although they only account for 25% of the population. Even when considering the fact that women tend to consult more frequently than men, one would still only expect 34% of diagnoses to be to women. It is also clear that those living in tents, rather than in Iso Boxes (sturdier shelters similar to shipping containers), are more likely to need medical treatment – 61% of the population in Moria live in tents, but they account for 81% of diagnoses. These trends are more extreme when assessing individual ailments. Children requiring medical aid to combat infections are over two times more than would be expected (43% rather than 20% of diagnoses), and women are far more likely to have a respiratory issue in Moria, accounting for 48% rather than the expected 28% of diagnoses.
However, perhaps the most telling statistic is that of accommodation type. In addition to tents preforming worse that Iso Boxes overall, there is in fact no single type of illness in which tents preform better. This is a huge indicator for where more research is needed, as additional information concerning the various conditions surrounding tents and Iso Boxes would allow one to see whether this increased health is due to better water, sanitation, and hygiene (WASH) facilities, additional security, promotion of good hygiene standards, or something integral to life in an Iso Box. It is also interesting to note that there are recorded cases, predominantly in very warm climates, where Iso Boxes have performed significantly worse than tents at protecting refugees from ailments. With the use of this tool, and the continued collection of the inputted data, it would be possible to see how these various trends change of time, location, and population. This would allow funding to be better directed at the onset of a crisis, as the effectiveness of different shelters and the likely severity of ailment types would be more predictable in advance. This could contribute towards a huge increase in resource efficiency as the sector begins to understand where various resources and equipment are most likely to be needed.
Disaggregated Health Data from Moria
This shows that there are more women presenting with endocrine system issues than we would expect, whereas the largest disparity seen for men is for urological problems. Overall however, women are seen to be more affected by illness in Moria than men.
The data from Moria reveals that minors are most disproportionally affected by infection, and adults by ENT (ear, nose and throat) conditions. Children under the age of 18 also appear to be more affected by illnesses overall than adults.
The data indicates that those living in tents are more susceptible to illness than in other shelter types, which is an important finding for resource distribution. However, as all the results follow such a similar pattern, it suggests there may be an underlying contributor which has not been taken into account. Here the lack of data, and the impact this has, is clearly illustrated.
A particular issue that was discovered in the process of this research was the difficulty in accessing good quality data on both health and shelter outcomes in refugee settings. It is well-documented that humanitarian data collection is often not as rigorous as in academic settings (nor does it need to be) but what benefits would one expect to see if better data was available? In order to assess this, Anna developed an example of a rigorous data chain that mirrors academic practice (and the rewards reaped from this method of research) and compared this to what she found in the humanitarian sector. From this it has been made clear that if good data chains exist, there is not only the potential for huge economic and social benefits, but that sharing data effectively allows the research to be fed back into the information chain to advance and inform further research.
The future of these projects lies in their potential to show the true value of collecting and sharing data between Cluster groups. The more times these tools are used (even with incomplete data sets), the more the benefits of good data analysis can be seen through increased resource efficiency and improved camp health. The goal is that this will be enough to encourage the Cluster groups to share their raw data and findings with one another and make it available to academics and practitioners who want to investigate further. To this end, we hope that the research undertaken here can help to demonstrate how effective data collection and sharing can allow future humanitarian actors to more effectively collaboration both across clusters and across sectors, for example with academic researchers or industry in procurement practices.
Health and Housing – Learning from COVID-19
This research was undertaken at the beginning of 2020, at the very start of the global COVID-19 pandemic. As this global event has reshaped so much of our lives, we must now view the issues laid out in Moria as at the core of humanitarian action moving forward. Health and Housing are inextricably linked, and addressing the impact that shelter and housing can have on human health is a fundamental challenge for shelter and settlement actors in the future.