DISPLACED AND OTHER POPULATIONS
AFFECTED BY CONFLICT
endorsed at the
International Consultation on
Mental Health of Refugees and Displaced Populations
in Conflict and Post-Conflict Situations,
23-25 October 2000, Geneva
1. Conflicts subject people to frequent and gross human rights violations. New patterns of violent situations, coupled with shortcomings in the international legal regime, and lack of respect for legal standards, exclude millions of people from humanitarian protection and assistance. The most vulnerable are under greater physical and psychological pressure. These include, but are not limited to: children; unaccompanied minors; orphans; children heads of households; the physically and mentally disabled; the chronically mentally ill; elderly persons alone; survivors of organised violence, torture, sexual violence; detainees; and prisoners of war. Their special needs should be addressed. Women are increasingly the targets of harsh persecution, while paying a very heavy price due to the family, and social dislocation and the added responsibilities which result from the situation.
2. This Declaration is intended to serve as a working instrument. It provides a framework to achieve increased consensus and cooperation in operational models, including policy strategies, and programmes. It is aimed at promoting evidence-based, holistic and community-based approaches that are effective and which can be implemented rapidly.
3. Given the magnitude and the nature of the problem, the fact that the reactions of populations affected by conflict are expected reactions to extraordinarily abnormal situations, and the shortcomings of other models, community-based psychosocial approaches are recommended. They must be sensitive to gender, to culture, and to the context. They must be empowering, mobilizing and supporting the refugees and other populations affected by conflict to continue taking responsibility for their lives and strengthen social cohesion within the communities.
4. The Declaration is consistent with the existing international instruments related to humanitarian protection and assistance, to human rights, to children, to women, and vulnerable groups.
5. The World Health Organization calls upon all governments, organizations and institutions to adopt and implement the following concrete steps, in taking up the challenge to prevent and reduce mental disorders and mental health problems, to restore hope, dignity, mental and social well-being, and normality to the lives of refugees, displaced and other populations affected by conflict.
PREVENTION AND RESPONSE
It is widely recognised that conflict, human rights violations, and forced displacement have a substantial negative impact on the physical and mental health of millions of people. This is a serious public health concern, requiring priority action from the emergency onwards to address the consequences of trauma, to prevent personal and collective psychosocial disability and dependency, and to contribute towards preventing future conflicts.
It is established that the majority of forcibly displaced populations are women and children. The physical safety, health, psychosocial protection, and healthy development of children must be given priority action. Mental health policies and programmes must be well adapted to the context, be sensitive to the different needs of women, to their culture, must avoid stigmatization and re-victimization. It is recognised that women with special needs must receive due protection and support, whilst a balance must be maintained with the significant needs of other groups.
Local regional and international policies and plans should pursue immediate and long-term mental health capacity-building, based on models that respond to the needs of the greatest number of persons affected by conflict, without neglecting those with special needs. Therefore, community-based, psychosocial, phase-specific, cultural and gender-sensitive programmes must be given first priority when establishing or reconstructing mental health care systems. They should bridge in a coherent way emergency response to development. Specialised clinical interventions responding to individual needs are limited. They must be balanced, because they respond to the needs of a few, may possibly become stigmatizing, tackle problems in isolation, are expensive and non-sustainable. In addition to providing treatment mental health professionals should serve as a resource for early detection of people in need of urgent care, for capacity building, on the job support, monitoring, and coordination.
In national services, in camps and settings for displaced populations personnel of the primary health care system should be mobilized and be given basic training in mental health, including sensitivity to culture, context, and prejudice. Human resources available within communities affected by conflict, such as camp leaders, staff of national, regional, international, governmental, non-governmental and UN agencies and volunteers must be included in this training. Also, staff of other sectors such as social welfare, education, employment, police and justice, relief project managers and workers, relevant administrators, local press and mass media must receive this training. This should occur in all emergencies, as soon as the peak of the survival crisis starts yielding. Mechanisms must be established enabling these professionals to work together to improve mental health care and psychosocial activities, to develop a well coordinated sustainable, multi-disciplinary, and multi-sectoral mental health response.
In the emergency phase, a rapid assessment of initial mental health needs and available resources should be carried out in collaboration with local authorities, professionals and concerned groups to define priorities and to identify: available psychological, social, and economic resources; the severely mentally ill and other vulnerable groups; community and environmental aspects. This will help design and implement adequate programmes.
In the long-term phase consolidation, replication, and scaling-up of the most useful programmes should be pursued with the necessary adaptations to the various situations. In the reconstruction phase mental health of refugees and other populations affected by conflict must be included in continuing education of essential personnel and in the curricula of relevant secondary and in university education. This is very important for teachers, social workers, nurses and post-secondary vocational training, midwives, doctors, psychologists, psychiatrists, and other service providers. Efforts must be made to integrate external educational resources into existing local and national systems of education whenever feasible. Establishing parallel systems of education must be avoided they complement the local systems on a temporary basis.
Cooperation and partnerships between governments, international, non-governmental organisations, United Nations agencies, the communities affected by conflict and the host communities, scientists, donors, health authorities are essential for good mental health practice, cost-effective and sustainable programmes. Increased information gathering and sharing among agencies must prevent duplication of assessments and programmes. Use of the comparative advantages of agencies should be emphasised to decrease costs, competition, and delays, to limit the risk of re-traumatising the communities concerned, and to accelerate implementation of response.
Information on the rights of people, and on the meaning of the psychosocial consequences of violence, should be provided to the populations affected by conflict and to the host communities through ad hoc mass media campaigns and other activities. Access to communications with family and relatives and to family reunion must be facilitated, because these are very effective methods in promoting mental well-being, in reassuring people, especially children. Access to interpretation should be guaranteed when refugees and displaced persons are dealing with authorities, various services, or agencies.
For immediate local capacity-building the following summarises the critical activities to pursue in mental health and other social sectors by local and international bodies:
· rapid assessment of mental health needs and available resources; ( 1)
· training of trainers for health, mental health, and other workers involved in protection and assistance, who would multiply knowledge and skills; ( 2),( 3)
· in-service training, supervision, support, monitoring, and evaluation;
· workshops providing technical support in the design, planning, monitoring and evaluation of mental health projects;
· mechanisms for coordination of activities;
· awareness and information campaigns;
· creation of mobile mental health teams where appropriate;
· support appropriate existing activities among the community affected by conflict, within national services, NGOs, and UN agencies;
· protection of the local and expatriate personnel working in conflict areas, who are at risk of violence for expressing their opinions, for being neutral, and for being perceived as potential witnesses is critical. Their agencies should provide guidelines and mechanisms to protect and prevent risky behaviour. This should include prevention and care for secondary traumatization and burnout.
In situations of prolonged conflict, camp life, displacement, or repatriation, national policies and plans should be elaborated to contribute to the continuity and coherence of achievable goals in psychosocial rehabilitation and to decrease dependency. The participation of the community affected by conflict in the planning and implementation of rehabilitation programmes is essential.
SURVIVORS OF EXTREME VIOLENCE
Survivors of torture and sexual violence should be provided with physical protection and legal advice unconditionally. They should also be provided with the necessary safe physical and psychological environments that will enable them to talk about their experiences if they choose to do so. Medical, psychological, emotional, and social support should be given to survivors of extreme violence with the accepted professional ethical code of confidentiality. All interventions used in these cases should be sensitive to gender, to their cultural and political contexts. Those detained in concentration camps, prisons, and similar settings should be given first priority and full attention.
Interventions in mental health, education, employment, and socio-economic support should effectively empower all conflict-affected women to play an active role in organising their lives, in self-sufficiency, and in the reduction of dependency. Such efforts are crucial for women in the high-risk groups such as: widows; pregnant women; single mothers; girls who are heads of families; and survivors of organised violence, torture, sexual, and domestic violence. The principle of equal rights must be applied.
CHILDREN AND ADOLESCENTS
In full respect of the best interest of children and adolescents, and the Convention of the Rights of the Child, and other internationally recognised conventions and instruments, and because conflict, forced displacement, family and social disruptions are serious dangers to their psychosocial development and well-being, mental health support should be an integral part of their protection, health care and education. Female children face the risks of both children and women. Enrolment of children in military or paramilitary forces must be forbidden. Demobilised child soldiers should receive equal care as other children, although initially they might require special rehabilitation programmes.
Early family reunion, access to communication with absent family members, support of foster families, and care by peer groups should be implemented from the emergency phase through repatriation as a matter of priority. Furthermore, personnel providing mental health care, education, social welfare, recreational, cultural, sports and other activities should centre their efforts on:
· physical, mental, and social well-being of children;
· prevention of institutionalisation;
· promoting respect for human rights;
· fostering abilities to cope and resilience;
· attending to the special needs of families with children as heads of household;
· prevention of violence against and among children and adolescents;
· prevention of delinquency and other anti-social behaviour;
· prevention of substance abuse;
· prevention of sexual violence and exploitation;
· prevention of family and school drop-outs;
· prevention of harmful and exploitative labour;
· organization of cultural, creative and recreational activities;
· introduction of mental health and psychosocial activities for children in educational and other settings
· introduction of conflict resolution activities.
Low income asylum countries, which are willing to offer long term local integration or citizenship to refugees, on an individual basis or as a group, should be provided with technical, material and financial resources to facilitate their smooth integration and to prevent prejudice against national populations. Integration should be voluntary.
In the elaboration of post-conflict mental health policies and programmes, policy- makers must take into account the possible conflict of aims in promoting return, recovery, and reconstruction. Realistic transitional objectives must be developed to avoid overburdening physically and mentally exhausted and traumatised populations with unduly ambitious goals.
In so far as it affects adversely the lives of refugees and other displaced persons, their situation must not be normalised. For all refugees and displaced persons, voluntary repatriation is not only a right but is essential and must be facilitated in all possible ways. Forcible repatriation must not be carried out. Whether they remain in a war-torn country or flee to exile, most of them sustain or witness atrocities, which profoundly affect them, their families and society. Because return includes a search for national reconciliation in a changed and impoverished country, there is a risk of traumatisation, so hasty individual or group repatriation must be avoided. Repatriation operations must be well coordinated between countries of asylum and origin, UN agencies and non-governmental organizations, with special attention to vulnerable groups. Efforts must be comprehensive and equitable to prevent further damage.
Repatriation programmes should include appropriate preparation of both receiving and the refugee communities to prevent discrimination, revenge and acts of violence against each other. They should also include coordination and implementation of mental health programmes for the chronically mentally ill and the traumatised. All precautions must be taken to avoid unintentional exclusion of the most deprived and of people in vulnerable groups.
Humanitarian relief agencies, the press, mass media, the staff of academic and research institutions, health and mental health professionals, and others working in war zones and other conflict situations should adopt and follow codes of conduct and ethical standards founded on the same principles that govern professional practice in their own countries. At the same time they must be sensitive to the cultural norms of the country in which they work. Individuals who work independently should do the same. Compliance should be promoted through training and other effective means. This will prevent further damage, stigmatisation, exploitation or breaches of confidentiality, which may result from the dependency of the refugees or the communities, or because they belong to a vulnerable or to a socio-cultural or political group different from that of the researcher and service provider. The prevention of re-traumatisation is essential. Agencies must also be responsible for preventing traumatisation as well as providing support and care for their personnel. Solutions for ethical neutrality must be sought. Research must be directed towards the benefit of the affected populations. The ethical standards of the Helsinki Declaration must be followed.
Governmental and non-governmental funding sources, United Nations agencies, international organizations must ensure equity in the allocation of financial resources for mental health care and psychosocial rehabilitation of refugees, displaced and other populations affected by conflict.
The Declaration of Cooperation in Mental Health of Refugees, Displaced and Other Populations Affected by Conflict and Post-Conflict Situations, is a technical consensus building document in mental health policy, strategies and programme produced by WHO.
Mental Health Determinants and Populations
Department of Mental Health and Substance Dependence
WORLD HEALTH ORGANIZATION
Geneva, January 2001
For the current status of this document, please check
The WHO Mental Health Bulletin
Methodology of Elaboration
of the Declaration
Declaration is applicable to populations in humanitarian crisis as a result
of persecution, war, and conflict. Given the evolution of the humanitarian
relief work, peace keeping and peace enforcing operations, increasingly,
humanitarian protection and assistance is extended to besieged and non-displaced
Therefore, in order to facilitate the reading, the comprehension and use of this document please note that the following terms as used herein include or mean the following:
“HEALTH is a state of complete physical, mental and social well-being and not merely the ABSENCE of disease or infirmity.” (WHO Constitution)
1 Ref: Orig. English “Rapid Assessment of the Mental Health Needs of Refugees, Displaced and Other Populations Affected by Conflict and Post-Conflict Situations and Available Resources”, Ref:WHO/MNH/MHP/99.4 Rev.1; (back)
2 Ref: WHO/UNHCR Mental Health of Refugees, WHO, 1996; (back)
3.Ref: “WHO Mental Health of Refugees, Displaced and Other Populations Affected by Conflict ” Training the Trainers” Module ( Available in English, Russian, French languages) (back)