Thursday, April 2, 2015

Alcohol and Refugee Populations

How displaced peoples are harmed and helped by alcohol.

Although it is impossible to know with certainty, 50 million is the current U.N. estimate of the number of human beings around the world categorized as refugees or displaced persons due to war and other violence. These "conflict-affected populations" suffer in a thousand different ways, but widely overlooked is the frightening prevalence of alcohol and other drug use disorders in these groups. The humanitarian health sector’s understandable focus on “immediate life-saving activities” means that longer-term chronic and behavioral issues remain unexamined.

What are the risks of ignoring alcohol use disorders in these populations? Bayard Roberts and Nadine Ezard, in an editorial for the journal Addiction, suggest that they are formidable. For conflict-affected groups, the “risk environment” includes loss of home and livelihood, exposure to war trauma, PTSD, anxiety, violence, and depression. In such environments, alcohol and other drugs are capable of producing a familiar and depressing litany of results are enumerated in setting after setting: Disruptions to household economies, alcohol-related suicides, violence against women, increased HIV and other blood-born viruses, unsafe sex practices, and increased mental health problems.

Nadine Ezard, co-author of the editorial in Addiction, was also lead author of a 2011 paper, “Six rapid assessments of alcohol and other substance use in populations displaced by conflict,” published in the journal Conflict and Health. Ezard and colleagues conducted extensive interviews on substance use and abuse in a range of populations displaced by conflict in Kenya, Liberia, Uganda, Iran, Pakistan, and Thailand. The work resulted in the development of a field guide for rapid assessment of alcohol and other substance use used by the United Nations High Commissioner for Refugees and the World Health Organization (WHO).

The aim of the study was to describe current substance use patterns in the study populations, and to identify possible interventions. As Ezard et al. write, “A number of effective interventions exist for problem substance use, but little attempt has been made to adapt these interventions to populations displaced by conflict.”

The six assessments took place between 2006 and 2008. Populations included refugees both in and out of camps, residents of nearby communities, returning populations, in both urban and rural settings.


The main study group was located in Kakuma Refugee Camp and nearby Kakuma town, each with about 100,000 people. The camp was established in 1992 to house Sudanese refugees, but at the time of assessment there were refugees in the camp from nine countries. Alcohol production and use was common, while cocaine and heroin were relatively rare. Food rations provided a workable source for fermentation products. Local women produced a cereal-based brew, busaa, and a stronger distilled version, changa’a. These were important sources of income in the area. The distilled product was illegal and associated with family disruption, violence, and gender abuse. One woman told researchers: “I brew because I want my children to survive. When my customers buy my brew and buy my body, even if I die, my children will inherit my brewing business.”


In 2003, a 14-year civil war ended after 250,000 casualties and near-total destruction of infrastructure. Nearly a million refugees and displaced persons, supported largely by non-government organization, have been there ever since. Alcohol and marijuana were cheap, easily available, and widely consumed. Distilled cane juice liquor and palm wine were popular. “Beer is drunk like water,” said one respondent, “assuming that people can afford it.” Cannabis is popular with young people, who use it, according to one youthful observer, “to stop the bad dreams.” Benzodiazepines were also in play, with sex workers reporting that diazepam was frequently used in the bars as a date rape drug.  Cocaine was also available, particularly when smoked with marijuana in a mix called a “dugee.” No respondents indicated any drug injection. There were no specific alcohol or drug treatment services available in the region.


At the time of the assessment, more than 2 million people, displaced due to protracted civil conflicts, were scattered across an archipelago of more than 100 displaced persons camps. Alcohol was readily available, acknowledged to be a serious problem, and health care was limited. The usual results of alcohol abuse were in evidence in the disruption of community cohesion that “left families short of food and children hungry.” Both male and female respondents “drew causal links between dispossession and alcohol use. Dispossession promoted alienation, idleness and loss of traditional gender roles among men…. As a result, cultural norms were changing, as one woman explained: ‘now there are no rules for drinking alcohol.’” As one youth said, “how can I respect these older men when I see them becoming drunk and falling down in the dirt.” Yet once again, alcohol brewing was a crucial source of income for many women in poverty.


For the past 20 years, Iran has been host to Afghan refuges, an undocumented million of which live outside the camps. The prevailing drug problem in this population is widespread opiate use, rather than alcohol. According to the study, “Refugees are permitted access to basic education and health care on the same basis as Iranian citizens. Service utilization by Afghans is thought to be low due to a combination of barriers such as poverty, lack of awareness, and perceived discrimination,” as well as fear of the authorities. “Newer opiates were becoming more popular, such as heroin, Iranian ‘crack’ and crystal (highly concentrated forms of heroin), and there was some transition to injection. Nevertheless, respondents perceived opiate as less prevalent among the Afghan refugee population than the host population.” Respondents also reported a number of benefits to opiate use: “pain relief, pleasure and socialization.”


In 2007, Pakistan contained an estimated 3 million Afghans, half of them living in so-called “refugee villages” along the border. In this region, the main substance use classes included opium, plus hashish for men, and benzodiazepines, commonly, for women.  There were not specialist drug abuse services available in the villages. “Although each refugee village context was distinct, substance use patterns were characterized as a continuation or exaggeration of pre-displacement use modified under the influence of patterns of availability and village livelihood options…. For example, in urban, but not rural areas substances were sometimes injected, reflecting the substance use patterns of the host population.” Alcohol use was uncommon and confined to home-brew made from sugarcane or grapes and predominantly used by young people. In fact, “one third of the women interviewed said that they knew someone who had a serious problem with hashish and gave accounts of domestic violence associated with its use. Respondents believed that limited skills, education and employment opportunities promoted substance use.”


Refugees from civil war in Myanmar have been in Thailand now for decades. Out of the millions of undocumented migrants, the study group concentrated on 150,000 refugees living in nine camps along the border.  Access to health care was considered good, and in this case there were residential substance abuse treatment programs available in the camps. Alcohol was the primary public health concern. Home-brewed distilled rice liquor was the primary source. Less prominent drugs included meth and caffeine were available, as were diazepam, cough syrup, opiates, and marijuana.  The results were predictable: “dependence, high risk sexual behavior, family disruption, and gender-based violence.” Young people had three choices, according to one young man: “They can leave the camp and look for work, they can lead a traditional life which means they will have lots of babies, or they can drink alcohol.”

Despite all this, the authors sensibly urge that public health workers should not ignore “the perception in some communities that substance use may have important social functions…. The combined effect of substance use problems may inhibit community capacity to recover from conflict, yet some types of substance use may be important for social cohesion in some settings.”

The authors believe that conflict-affect populations require, as a minimum, “screening and brief intervention for high risk alcohol use” as well as “identification and treatment of severe mental illness (as both a cause and consequence of substance use).” In addition, “primary health services should be capable of managing withdrawal and other acute problems.”

What else needs to be done?

—Brief community-based interventions, which have proven cost-effective in higher income settings.

—Gender-sensitive interventions.

—More epidemiological research on alcohol risks and comorbidity with mental health disorders including depression and anxiety.

—Evaluation of feasibility and cost-effectiveness of interventions, including the use of experimental designs.

“This requires a public health approach,” Ezard and Roberts write, “for example, ensuring that work on non-communicable diseases addresses underlying risk factors as well as treatment; exploring community-based responses; supporting better coordination between different sectors such as health and protection or mental health and psychosocial support with communicable disease control activities…. And ensuring that the needs of conflict-affected civilians are recognized in global alcohol control activities.”

There is, however, one clear-cut approach to drug abuse problems in such communities that the authors most definitely do not recommend, and it is the most time-honored modality of all: “Despite their popularity among many service providers and community groups, general public information campaigns and school-based education for primary prevention programs have been shown to be ineffective to reduce alcohol-related harm.”

What would be the benefits of tackling alcohol disorders in these beleaguered, violence-prone communities? Roberts and Ezard argue for several:

—Improved mental and physical health.

—Reduced risk of disease, injuries, and accidents.

—Reduced harm and violence to others.

—Improved family relations and social networks.

—Improved economic productivity.

—Reduced health care costs.

The editorial concludes that “without greater engagement, alcohol use disorder and its consequences among conflict-affected civilians will remain neglected and the multiple benefits of tackling it will continue to be ignored.”

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