Health situation

At the tim e o f the research, the camps in Karagwe district could be characterised as being in the post-em ergency phase. The crude mortality rate in Chabalisa II did not generally exceed the normal rate for developing countries o f 0.5/10,000/day (Hakewill, 1991). Health profiles w ere similar to those o f the local Tanzanian population with malaria and respiratory infections most frequently diagnosed followed by skin diseases and diarrhoea. It is understandable that th e incidence o f diarrhoea increased in tim es o f water shortage (October-November) and during the rainy season w hen firewood was scarce and people used to cook for m ore than one day (January-M arch). Scabies was more prevalent among the refugees than in the Tanzanian community probably due to irregular distribution o f soap and sharing o f clothes and bedding. Ram pant scabies was

also noted am ong refugees in Zaire when soap w as not distributed (Reed & Habicht, 1998).

Chapter 8 Discussion 1 5 9

Cough, nausea, fever and high blood pressure w ere the most commonly reported signs and symptoms o f health problems among older Rwandan refugees. Respiratory infections and cough may have been relatively highly prevalent due to poor housing and clothing in combination w ith the climate (strong, dusty winds in summer and cold humid conditions in winter). According to health staff, fever symptoms were mainly malaria-related and the camp was indeed situated in a swampy valley w here mosquitoes were present. A blood pressure above 140/90 mm H g ‘ was diagnosed in 19% o f the refugees which was higher than the 10% reported am ong older Rwandan hospital patients and 12% among older rural Kenyans1 2, but similar to the 20% found am ong rural Balinese2 (Mets, 1993; W asw a et al, 1988; Syryani et al; 1988). A higher figure o f 25% w as found among Tanzanian hospital patients (Matuja & Ndosi, 1994).

Chewing, mobility and visual problems were the m ost frequent complaints o f sensory and disabling nature. As mentioned before, chewing difficulties (47%) and nausea (13% ) were probably partly caused by frustrations with th e diet, although mastication problem s were also found to be highly prevalent (41% ) am ong Ethiopian elderly where “injera” , a soft sour bread is the staple food (Dejene, 1995). Among Saharawi refugees who mainly eat rice, cous-cous and bread, chewing problems were not reported among adults o f all ages (Branca, 1998). Health problems in other developing country elderly populations also centred around senses, chewing problems and reduced mobility (Manton, 1987; Wilson, 1991; Fernando & Seneviratna, 1993; D ejene, 1995).

Most signs and symptoms w ere more prevalent in women and in older age gro u p s and these groups also significantly more often perceived their health as poor. Similar findings have been reported elsewhere (Bassey et al, 1989a; Fernando & Seneviratna, 1993; Dejene, 1995). It is unclear why w om en’s health status was poorer than that o f men. It has been hypothesised that women suffer more from chronic conditions that are nonfatal. There is evidence that both men and women report fairly accurately, so it can be assumed

1 WHO defines normotension as systolic blood pressure <140 and diastolic <90 mm Hg (WHO, 1996). 2 Above 160/90 mm Hg.

that reported symptoms and physical complaints truly reflect health and functional problems (Merrill et al, 1997). This m ay indicate gender differences in physical and mental strain during the course o f life. Particularly in rural developing country populations, girls may receive less care and medical attention than boys and are likely to experience many pregnancies in poor conditions. This cohort o f w om en gave birth to an average o f nine children3 which presumably had a health impact.

Reporting poor health probably em bodies more than the presence o f medical conditions and physical problems. As mentioned, it was noticed that the Rwandan refugees seemed to incorporate socio-economic conditions in the interpretation o f their health status. Thus in addition to the significantly greater occurrence o f health problem s among female and older refugees, their disadvantaged socio-econom ic situation may have contributed to a relatively poor perceived health.

Men significantly more often smoked and consumed alcohol, although there were no heavy smokers in the sample. These w ere presumably indicators o f health rather than o f socio-economic status since high levels o f smoking and drinking w ere related to a high BMI. Drinking beer and smoking w as com mon among older Rw andan hospital patients, however inhalation was only practised by few. Although alcohol consum ption was fairly high, there was no correlation with presence o f cirrhosis (M ets, 1993).

The relatively small number o f people that presented signs o f micronutrient deficiencies, gastro-intestinal disorders and tuberculosis, must be attributed to the different ways o f supplementing the diet, the presence o f fortified foods in the ration and the relatively high water quality and sanitation standard in the camp. H ow ever clinical assessment o f vitamin deficiencies is not very reliable as it is non-specific, poorly sensitive and prone to observer error. Therefore sub-clinical deficiencies may very well have been present and perhaps also contributed to the generally poor self-rated health and vague complaints such as headache and weakness. 1

C h a p te r 8 D iscu ssio n 160

1 This compares with a national average of six calculated over the period 1988-1993 (World Bank, 1995). Older rural female Rwandan hospital patients had had an average of nine children (Mets, 1993).

Frequent occurrence o f anxiety and depression symptoms in the last year w ere reported by 22% o f the sample. Among rural Balinese elderly 18% w ere found to suffer from anxiety and 14% o f depression, which was judged to be relatively high for a stable situation. The elderly believed their symptoms w ere amongst others caused by tension within families and loneliness (Syryani et al, 1988). In a study in rural Botswana, 9.2% o f the elderly w ere diagnosed as depressed (Clausen & Sandberg, 1994). It is acknow­ ledged that assessment techniques were not exactly the same and refugees would not easily have disclosed personal experiences, assuming the questions were valid. However agricultural w ork and gardening has always been their main and favourite occupation, and engaging in such activities, for which there were more possibilities in and around Chabalisa II com pared to the average refugee camp, may have been an effective coping mechanism for the functionally able.

On the other hand, older people in the camp complained about boredom since they were less active than they desired. M oreover it w as said that in Rw anda younger people used to spend more tim e listening to elders. This may just be a perception but may also be related to the loss o f friends and relatives, the increased need to generate income and the long time spent fetching firewood and water. Less attention from younger people in times o f greater boredom and distress may have resulted in a com mon feeling o f loneliness and loss o f respect, particularly among the oldest old and functionally impaired.

The level o f custom ary activity among older refugees was quite high: almost 72% was gardening regularly and 71% and 42% w ere engaged in light and heavy household activities respectively. This may be partly attributed to the fact that this was a self- selected group o f relatively fit older people, although it is generally seen in developing countries that older people who live at home remain active into very old age. A consider­ able number o f older Rwandans had been working until o r close to hospitalisation, and an average o f five hours per day were spent working in the fields (M ets, 1993). Like­ wise, the Malawian and Indian elderly show ed high activity patterns (Chilima, 1998; Manandhar, 1999) and a Balinese survey reported that 53% o f the elderly worked as usual and 42 % w orked less com pared with younger years (Syryani et al, 1988).