In late March 1991, following military and civil strife in Iraq, approximately 400,000 ethnic Kurds and other Iraqi minority groups sought refuge in rugged mountains on the border of Iraq and Turkey (Figure 1); an additional estimated 1.3 million Iraqi refugees fled to Iran. In contrast to groups affected in other recent refugee emergencies, a large proportion of this displaced population comprised educated urban dwellers. This report describes the major public health consequences of this population displacement and international relief efforts directed toward these problems.

Beginning in early April, the international community mounted a massive relief effort to prevent excess mortality among displaced civilians on the Turkey-Iraq border. Relief assistance was provided by the military forces of different countries, private voluntary organizations (PVOs), national and international Red Cross and Red Crescent societies, United Nations (U.N.) agencies, the Turkish government, and a Disaster Assistance and Response Team from the Office of U.S. Foreign Disaster Assistance, including CDC staff, which provided technical advice and liaison between civilian and military agencies. A similar relief operation led by the U.N. was launched in Iran. Mortality and Morbidity Surveillance

A simple, standardized mortality and morbidity surveillance system was established in the six main border camps by PVOs (Medecins Sans Frontieres (MSF)/France and MSF/Holland) and by U.S. Army Special Forces (USASF). In some camps, mortality surveillance was limited because there were no designated burial sites. In at least three camps (Cukurca, Isikveren, and Uzumlu), mortality reporting commenced as early as April 11; in a fourth large camp (Yekmal), reporting began April 26. Crude mortality rates (CMR) in the first three camps ranged from 4.0 to 10.4 per 10,000 population per day during April 4-18 (MSF and USASF, unpublished data). The highest rate was reported in Cukurca and is equivalent to an annual CMR of 380 per 1000, more than 45 times the expected CMR reported for Iraq (1). By the week of May 3-9, death rates in all four camps had declined to less than 2 per 10,000 per day. More than 60% of deaths occurred in children aged less than 5 years, who comprised approximately 18% of the population. The most commonly reported causes of death were diarrhea, acute respiratory infections, and trauma.

During the first 2 weeks of April, more than 60% of all clinic outpatient visits in the main border camps were for diarrhea; by early May, this proportion decreased to approximately 20%. Population surveys conducted early in April indicated that as many as 70% of all refugees had diarrhea on the days of the survey (MSF and USASF, unpublished data). Because Vibrio cholerae O1, El Tor, Ogawa, was isolated from the stools of some patients with severe diarrhea in two camps (Cukurca and Uzumlu), guidelines for cholera control were implemented in these camps. Other causes of morbidity included acute respiratory infections, malnutrition, and trauma. A total of 34 cases of measles were reported, all in Yekmal camp. Relief Measures

For all camps, major priorities were the equitable distribution of adequate and culturally acceptable food rations; the provision of adequate shelter, clean water, and sanitation facilities; measles vaccination for children aged less than 5 years; diarrheal disease control, including appropriate case management with oral rehydration salts; and surveillance for diseases and injuries of public health importance. Because surveys conducted in April indicated that acute malnutrition was not a major health problem, there was limited implementation of selective feeding programs.

Military forces made a unique contribution to this refugee relief effort. Upon arrival in the camps during the second week of April, USASF rapidly organized an orderly food and tent distribution system, coordinated with PVOs to improve water and sanitation facilities, and provided prevention-oriented, community-based health care. The military logistics system enabled the rapid and efficient delivery of essential relief supplies to these remote camps. British military medical teams established an effective system of medical way stations for the repatriation program; and Canadian, French, and Dutch military teams helped restore health facilities in the Iraqi towns to which the majority of refugees have returned. Overall Mortality and Acute Malnutrition

During the voluntary repatriation of refugees to northern Iraq, which occurred during May, a population census was conducted in one Zakhu transit camp (N=17,863) to estimate mortality during the period of displacement (March 29- May 24). In addition, anthropometry was used to assess current nutritional status in a systematic sample of children aged less than 5 years (n=816). During this 2-month period, the overall CMR was 169 per 10,000; 63% of all deaths occurred among children aged less than 5 years. Seventy-four percent of deaths were associated with diarrhea, dehydration, or malnutrition. Death rates peaked during April 13-26 (mean daily CMR=5.7 per 10,000), and then declined to a mean daily CMR of 2.2 per 10,000 during April 27- May 10. This trend was consistent with routine surveillance data collected in the border camps. Based on these data from the transit camp, of approximately 400,000 Iraqi refugees, an estimated minimum 6700 persons died while camped on the Turkey-Iraq border. According to published mortality rates for Iraq, however, approximately 500 of these persons would have died during this period under routine conditions in their normal places of residence (1).

The nutritional status assessment of children indicated the prevalence of acute malnutrition (defined as weight-for-height less than -2 standard deviation units from the CDC's National Center for Health Statistics/World Health Organization reference median) was 4.1% (95% confidence interval (CI)=2.8%-5.4%). However, among children aged 12-23 months, the prevalence of acute malnutrition was substantially higher (13.5%; 95% CI=8.0%-19.0%) than in each of the other age groups in the sample (p less than 0.01; chi-square goodness of fit).

In early May, following the creation of ``safe havens'' by allied military forces, the displaced persons and refugees in the border camps began to return to their homes in northern Iraq, either directly or via transit camps. As of June 6, approximately 10,000 refugees remained in the border camps. Reported by: Epicentre and Medecins Sans Frontieres, Paris, France. Artsen Zonder Grenzen/Medecins Sans Frontieres Holland, Amsterdam, The Netherlands. International Rescue Committee, New York. Bur for Refugee Programs, US Dept of State, Washington, DC. US Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy. Combined Task Force Provide Comfort Surgeon's Office, Incirlik, Turkey. US Army Special Operations Command, Fort Bragg, North Carolina. International Health Program Office; Div of Nutrition, National Center for Chronic Disease Prevention and Health Promotion; Global EIS Program, Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note:

The sudden migration of Kurds and other Iraqi minorities was associated with substantial mortality; however, death rates declined rapidly as soon as relief efforts focused on providing basic needs (i.e., food, shelter, and clean water). Death rates among these refugees during the first month of their displacement were approximately one half those reported among Ethiopian refugees in Sudan in January 1985 and Cambodian refugees in Thailand in October 1979--two recent large-scale refugee movements (2). However, the general health status of the northern Iraqis before their displacement was probably substantially better than that of the latter two refugee populations.

As in previous refugee emergencies, diarrheal illness was a major cause of death among the northern Iraqis. In addition, recurrent or persistent diarrheal illness may have been responsible for increased malnutrition among children aged 12-23 months (3). This finding underscores the need for relief workers to be trained in the case management of diarrheal diseases, including both the treatment of dehydration and continued feeding. The widespread use of baby bottles and infant formulas may have contributed to the high incidence of diarrhea in toddlers; this practice has been officially discouraged under existing U.N. policies (4).

The low incidence of measles may have reflected the reportedly high rates of measles immunization coverage in Iraq before January 1991 (1). However, because reliable measles immunization coverage rates specific to the northern areas of Iraq were not available to relief workers, a mass vaccination campaign was implemented for children aged less than 5 years to prevent a potentially lethal outbreak of measles in the border camps.

Although programs that addressed the most critical public health problems of the displaced persons and refugees were eventually implemented, delays occurred initially in the absence of an international coordinating focus. The U.N. system for coordinating disaster preparedness and relief permits a consistent and politically neutral response. For this international response, the cooperation between military and civilian relief agencies was noteworthy and unprecedented.

References

1. United Nations Children's Fund. State of the world's children, 1990. New York: Oxford University Press, 1990.

2. Toole MJ, Waldman RJ. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 1990;263:3296-302.

3. Parker RL, Rinehart W, Piotrow PT, Doucette L. Oral rehydration for childhood diarrhea. Popul Rep L 1985;12:41-2.

4. Berry-Koch A, Katona-Apte J. UNHCR and WFP issue guidelines on use of milk powder. New York: United Nations Administrative Committee on Coordination, Subcommittee on Nutrition, 1990. (SCN News; no. 6).

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