Planning: It’s Key to Saving Refugees’ Lives : Health: Without organization and coordination of services provided to camps in a given country, all the generosity in the world will not help.

When Michael J. Toole was coordinating health care in Somalia’s refugee camps in 1981, a mysterious illness erupted that struck the children especially hard.

The main symptom was pain and weakness in joints so terrible the youngsters could barely walk and, often, could not stand. Most of them also had bleeding gums.

In one camp, some fathers told the doctors they had cured their children by taking them out into the bush and feeding them camel’s milk. But the doctors didn’t know for some time what was so special about the milk of the camel.

Finally, after consulting by phone with specialists at the U.S. Centers for Disease Control in Atlanta and after sending X-rays of some of the sick children, the doctors in Somalia got their answer. They were shocked. None of them had ever seen a case before. It was practically unheard of in Africa, although once it was the scourge of European navies and crowded cities.

It was scurvy.

Today, Toole, a CDC epidemiologist and one of the world’s few specialists in the management of health in refugee camps, notes that it takes only minute quantities of Vitamin C to prevent scurvy. But these children were getting none at all, even though Africa is virtually a Vitamin C factory, with naturally growing fruits and vegetables. “We gave them megadoses of Vitamin C,” he recalls, “and it was like Lazarus rising from the dead. They just got up cured.”

Subsequent investigation showed that food going to the refugee camps where the outbreaks occurred was mainly corn, dried beans and oil, perhaps a little dried milk--foods with little or no Vitamin C. The investigators also learned that camel’s milk is extraordinarily rich in Vitamin C, quite unlike the milk of other vegetarian mammals in the area, goats, for example, or sheep.

Since then, there have been other major outbreaks of scurvy in refugee camps around the world, but now they are quickly recognized and dealt with.

Toole uses that story to illustrate what he sees as a major problem in caring for about 15 million refugees worldwide.

Without meticulous planning, nutrition assessments, an overview of all the camps in a given country and careful monitoring of death rates, Toole said, all the generosity in the world will not help.

Lack of planning, he insists, is one reason that death rates remain high in refugee camps. He points out that the world’s outpouring of charity in the form of food, funds or volunteer health workers is often largely ineffective when there is no coordination, assessment and centralized monitoring.

This is not to say that people should stop giving--these refugees are destitute, totally dependent on outside help for their very survival--but those who administer the programs must be properly trained and briefed.

Toole, who grew up in Melbourne, Australia, graduated from Monash University Medical School in Melbourne in 1971. He interned in Perth and, almost by accident, did his residency in a hospital in Thailand. (He fell in love with Thailand while vacationing there. He simply walked into the hospital and asked for a job.)

In 1976, he studied tropical medicine in London and went back to Thailand just in time for the influx of refugees from Laos fleeing the North Vietnamese after the Americans left Vietnam.

In subsequent years, Toole has worked with Laotian hill tribe refugees, Ethiopian and Somali refugees and refugees at camps in Mozambique, Togo, Nigeria, Malawi, Zambia, Burma and India.

Now, as part of a CDC team that serves as an international crisis-response group, Toole is spreading the message: “We are involved in what is almost a crusade to increase the recognition of the uniqueness of what we call the health risks to refugees.”

The CDC team is warning that however well-meaning relief efforts have been, they can only end in further disaster unless accompanied by immunizations, oral rehydration salts (for the ubiquitous diarrhea) and someone overseeing all the camps.

Toole cites another example: A nurse was engaged in a supplemental feeding program for children under age 5 in a camp in Ethiopia. Despite her efforts, the death rate among the children continued to rise. What she did not know was that the families were receiving virtually no rations at all. The “supplement” the children were getting was all they were getting.

“It wasn’t her fault at all,” Toole said. “There was no one there with an overview. No institutional memory.”

Toole was in Washington recently to participate in a seminar at the State Department on the international refugee problem. He has also testified before the House Select Committee on Hunger, urging better education and organization for the participants in refugee care. For instance, he said, during the great Ethiopian famine of 1984-85, about 300,000 Ethiopians flooded into Sudan, which was also suffering a drought.

They were put in crowded camps with very little water. The camps were located in inaccessible places--the NIMBY, or “not in my back yard” syndrome, works worldwide. About 10% died in a year, about five times as many deaths as normally would occur.

The reason they died “is very simple,” Toole said. There was no implementation of basic public-health programs, “despite the willingness of the world, despite the publicity, despite the terrible plight of these people.”

Youngsters were not vaccinated against measles, a major killer in the Third World; malnutrition rates soared because not enough food got through. There was no adequate water, no adequate sanitation, no protection against diarrhea.

Volunteer doctors and nurses would go, but “they go unguided by any sort of written policies or guidelines. They simply do what they would have done in Minnesota or Australia or France or whatever. And a lot of mistakes are made by well-meaning people.”

Rep. Tony P. Hall (D-Ohio), who chairs the House Select Committee on Hunger, recently urged an increase in the U.S. contribution to refugee assistance, which, he said, dropped 22%, from $206 million in 1984 to $169 million in 1990, even though the number of refugees has increased from 9 million in 1984 to 15 million today.

Partly at the urging of Toole and his colleagues, and with their participation, the United Nations High Commissioner on Refugees has published guidelines for those responsible for health in refugee camps, the first of which is to vaccinate the children against measles. “Measles,” Toole said, “will almost totally wipe out the positive benefits of enough food.”

But there are good examples too. Over the last few years, about 1 million refugees from Mozambique, on the southeast coast of Africa, fled to neighboring Malawi to escape warfare.

The government of Malawi took charge and told the international relief agencies they would have to perform in a unified and coordinated manner instead of each agency going its own way. Also, Toole said, Malawi is poor but not destitute, as other nearby countries are. The agencies from France, Britain and the United States, under orders from the government, collected good information, such as death rates, disease incidence and nutritional needs, and designed their programs according to the data. Perhaps most important, once the refugees crossed the border, they were relatively safe.

There is another famine in northern Ethiopia this year, and Toole sees another international refugee emergency in the making. Last month, the main port of entry for the food supply was captured by the Eritrean rebels, who are the insurgents attempting to overthrow the existing Ethiopian regime. Between 4 million and 5 million people are threatened again by the famine and the unrest. “The way the world is,” Toole said, “there will be more refugees.”

And in Ethiopia, where it is 10 months to the next harvest, Toole said, “I’m not sure we can get enough food in for more than about a third of the people who will need it.” But, he said, “this time the children will be vaccinated against measles”--so what food there is will save lives.