Access to water & health impact

Understanding the Context: Refugee Population, Access to Water and Health Impact

      As the refugee population is a global phenomenon, the paper discusses the matter based on the reports of the highest internationally recognized authority: United Nations High Commissioner for Refugees (UNCHR) (Refugees, n.d.), combining data published by Médecins Sans Frontières - Doctors Without Borders for a critical exhibition of refugee reality in the field. MSF is an international humanitarian non-governmental organization operating under the values of independent, neutral, and impartial medical aid in assisting victims of natural or human-made disasters and victims of armed conflict since 1971 ('Médecins Sans Frontières (MSF) International', n.d.)

      UNCHR population of concern includes refugees, asylum-seekers, internally displaced persons (IDPs), returned refugees, returned IDPs and stateless persons who do not possess the nationality of any State. "Refugee" is the name for millions of people worldwide who have been forced to leave their homes or places of habitual residence due to armed conflict, situations of generalized violence, violations of human rights, or man-made disasters. Natural disasters and climate change mean environmental refugees and less water for everyone too.

People get terrified when they hear that refugees are coming because of the message we get from the media: refugee word today implies terrorism, violence, and crime. We must realize we are talking about individuals and families with children who are hungry and need protection. Based on the available data ('UNHCR - Figures at a Glance', n.d.), in 2014 and 2015, the proportion of children under 18 among refugees remained at 51 percent. Working age (18-59) and older (60 plus) populations were 45 and 4 percent respectively. In 2016, 49 percent of refugees were women (Kasamani, 2017).

      This paper also analyses how international policies and social inequalities related to water access affects refugees' health care and healthcare systems (Anderson et al., 2009a). It is a human right to provide refugees with medical and psychological care, lifesaving nutrition and access to safe drinking water (De Alburqueque, 2012, 2014; McKenzie, 2013). Although refugees have a global socio-economic impact regulated under international law (Kälin & American Society of International Law, 2010), most do not receive the necessary health care. Policies for refugees at the international level are fragmented. They live in regions where the healthcare system has collapsed, or it is too dangerous for independent aid agencies to operate. The health impact of lack of water manifests in the need for physical resources to deal with common diseases like dehydration and diarrhea which is especially problematic in vulnerable populations like women, children, and seniors (MSF CANADA, 2016)

Access to Water in Refugee Situations

Failed states produce political, economic and environmental refugees. Refugee camps offer a “temporary” solution for water security. They are initially established as a short-term response in times of crisis, to provide shelter, safety and food until refugees can either return to their homelands, be integrated into host countries, or receive the benefits of third-party resettlement (McKenzie, 2013). However, the reality is that less than one percent of all refugees are resettled, resulting in camp stays that average 18 years. The whole picture of the situation shows that refugee camps are overcrowded, and disease outbreaks and nutritional crises have little adequate response to their health needs (MSF CANADA, 2016)

Water is the life-sustaining resource (Organization & UNICEF, 2017). Refugees' survival, health and dignity depend on water availability in a refugee camp (McKenzie, 2013). Following the UNHCR Technical Support Section Division of Operational Support Water, this paper considers five cross-cuts vital sectors to water access: health, food and nutrition, sanitation, camp planning and shelter, and education. 

The amount of water establishes how medical services are organized, managed and provided, including cold chains in hospitals, and different types of therapy (see Appendix 1). Quantity is the most crucial hygiene aspect at personal, domestic and community levels ('unhcr_water_brochure.pdf', n.d.) Quality is essential, especially for children. Diarrhea, often the product of the consumption of poor-quality water, is one of the leading causes of infant morbidity. Regarding food and nutrition, water is one of the primary nutrients the human body needs daily (Cronk, Slaymaker, & Bartram, 2015; Nicole, 2015). Malnutrition has been a major concern in refugee situations, contributing to almost 60% of deaths of those under five. Sanitation control is essential to break the disease transmission cycle. Infection control activities include drainage, hand washing and environmental management of groundwater pollution. Water is a governing factor for camp planning and shelter selection ('Access to Water in Refugee Situations. Survival, health and Dignity for Refugees', 2016; Roberts L et al., 2001). Water points promote community ownership. Providing water facilities in safe areas prevents gender-based violence and makes special provisions for groups with special needs. Finally, education is an empowering tool to maintain water and hygiene awareness. Children fetching water impacts schooling. 

NeedsQuality (litters/person/day)Adapt to context based on
Survival: water intake (drinking and food)2.5 - 3Climate and individual physiology
Hygiene practices2 -6Social and cultural norms
Basic Cooking3 - 6Food type and social and cultural norms
Total basic water7.5 - 15 
Appendix 1. The Sphere Project, minimum hygiene items pack consists of water containers (buckets), bathing and laundry soaps, and menstrual hygiene materials.

UNHCR works to expand emergency water supplies to meet the required standards rapidly. However, finding suitable sources of water in arid areas has proved difficult. Lester R. Brown (2009) illustrates that the world's freshwater supplies are shrinking, and the world's farmers are getting a shrinking share of this shrinking supply. So while water tensions among countries are more likely to make new headlines, the jousting for water between cities and farms within nations preoccupies local political leaders. It represents another challenge because most refugees are hosted in urban areas, and most tools for providing and monitoring water supply activities have been developed for camp-based or rural settlement settings (Kälin & American Society of International Law, 2010)

      As land and water become scarce, competition for these vital resources intensifies within societies, particularly between the wealthy and those who are sick and dispossessed. Besides existing rights agreements among countries, some receive only a minuscule share of water. The growing scale of emergencies also poses other challenges in meeting the required water provision standards, particularly where a rapid increase of refugees overwhelms existing water supply systems. 

   In meeting these challenges, UNHCR deployed Water, Sanitation and Hygiene (WASH) staff to support responses to emergencies (Nicole, 2015) and signed two rapid emergency response agreements with Oxfam (Luff & Clarke, 2006) and the International Rescue Committee (IRC), which have proven experience and expertise in water supply emergency preparedness and response. According to UNHCR Technical Support, Section Division of Operational Support and the UN-Water Annual Report (United Nations, n.d.), refugees' survival, health and dignity are based on sufficient water supply for basic needs and the following water requirements. Water quality is regularly monitored for potable and palatable appearance, taste, odour and fecal contamination. In a secure physical environment, water facilities are located centrally with a minimum waiting time. Furthermore, there is a continuous maintenance of the water supply system and adequate water storage at the family and community level in case of interruptions, environmental concerns or hazards, avoiding water wastage. 

The Human Right of Water: International Policies and Legislation

      While protecting borders and access to territory falls within states’ rights and responsibilities, refugees’ rights are under the umbrella of international regulations. In 1945, after World War II, the international community created the UNHCR to protect and find durable solutions for refugees. Refugees’ rights to life, liberty and security were further codified in the 1951 Refugee Convention (‘The 1951 convention relating to the status of refugees and its 1967 protocol’, 2011). For those unable to flee or trapped in conflict, the UN’s Guiding Principles of Displacement complement their rights under the International Humanitarian Law (IHL) and the Fourth Geneva Convention (1949). States party to conflicts are obliged to care for and protect populations within their borders and/or to facilitate humanitarian agencies to do so. Refugee status granted complementary forms of protection under the 1967 Protocol and the 1969 OAU Convention Governing the Specific Aspects of Refugee Problems in Africa. Since 2007, the refugee population also includes people in a refugee-like situation, like Asylum-seekers and Returned refugees.

      The Universal Declaration of Human Rights (1948), Article 14, states that anyone suffering persecution “has the right to seek and to enjoy in other countries asylum from persecution.” States signatories of the declaration are obliged to assist refugees and to allow them to exercise their fundamental rights, including freedom of movement. Neighbouring states of conflicts are compelled to care for and protect populations within their borders and to facilitate humanitarian agencies to do so (De Alburqueque, 2012, 2014). In July 2010, the UN ratified access to clean water and sanitation as Human Right. In 2017, working towards Sustainable Development Goal 6 on sustainable water and sanitation for all, UNHCR advocated for national governments and development actors to include refugees, stateless people and IDPs in national water supply development plans (‘UN Water United Nations World Water Development Report 2017.pdf’, n.d.; World Water Assessment Programme & UNESCO, 2017)

Critical Policy Analysis of Water Issues, Policy Progress and Policy Gaps.

      To better understand the causes of the problem, we should ask what happens to the rights of people that move. UNHCR is responsible for ensuring that refugees have the right to seek asylum and receive assistance – water, food, shelter, medical care – and protection from violence. In addition, on 19 September 2016, UN Member States adopted the ‘New York Declaration for Refugees and Migrants’, committing to develop a Comprehensive Refugee Response Framework (CRRF) for emergencies and protracted situations of forced displacement. That was a recognition that situation-specific comprehensive approaches are required to find durable solutions, together with engaging governments, humanitarian and development actors, and refugees. 

   This paper highlights three policy gaps lying in. First, the rationales used for implementing these policies fall under the umbrella of “securitization.” Thereby border control is prioritized over the right of people seeking protection. Such policies and practices also evade international law and widely-held customary norms. Second is the “externalization of borders” (MSF CANADA, 2016). Several wealthier nations shift responsibilities onto developing countries, using development aid and political incentives to encourage them to manage the arrival of refugees. Third, problematic or incoherent policies and practices, including physical barriers, detention and interdiction measures. Many countries are increasingly using systematic or quasi-systematic detention as a core migration management tool to restrict the influx of refugees. These actions contravene the Universal Declaration of Human Rights, which entitles all people to have the right to freedom from arbitrary arrest and detention. Moreover, international aid agencies are regularly denied access to detention centres, which blocks transparency and free assistance or assessment.

 MSF reports that states party to the Refugee Convention routinely flout it. A growing number of nations renege on their legal obligations to share the costs of Refugee camps, and UN humanitarian agencies that attempt to respond to crises experience severe funding shortfalls. In areas where few countries are party to the Refugee Convention, there is a lack of a legal framework to protect refugees, asylum seekers and stateless people. Such government responses also demonstrate the need for responsibility-sharing for the costs of hosting refugee populations.

Developing policy responses, building political support and measuring the impact

          Many refugees are in extremely vulnerable health and psychological conditions due to the dangers caused by their migration journeys and policies exacerbating those hardships. What do we need from nurses, other health professionals, governments and the public to address the challenges? We need compassion, basic respect for humanity and a civil society that seeks to support all of its citizens (Foster, 2011). 

      The final solution to the global refugee crisis comes through policies. Governments worldwide have to uphold their responsibilities and respect International Humanitarian Law and Refugee Law they agreed to uphold. States must recognize our shared humanity, share global responsibility and address the wars and deprivation that force people to flee. Furthermore, they need to cover the costs of refugee camps, open up borders and teach and maintain reasonable standards. The global displacement crisis is our time's political challenge and will continue. Governments and citizens share the responsibility to efficiently respond to the effects of this trend – refugees, advancing deserts, and rising seas - that will take resources, collaboration and sustained commitment (Lester, 2009)

This paper claims to humanitarian motivation from the particular theoretical perspective of social justice (Anderson et al., 2009). It calls for a coherent and human response to the current global refugee crisis. Ethical practices at all levels of international policy and healthcare systems will make a difference in the refugees' situation. Global citizens have a crucial role in addressing the empathy and policy gaps concerning the inconsistent treatment of refugees. A global solidarity movement must demand a better political system that addresses, not increases, humanity's vulnerabilities and suffering. 

Measuring the impact is challenging but necessary. The availability and quality of demographic data and health status within and among nations varies between countries and population groups but tends to be highest in countries where UNHCR has an operational role and undertakes registration and primary data collection. Disaggregated data presents an important limitation in measuring the impact and comparative analysis between locations and populations over time (Coburn, David, 2010). Public health measures regarding sanitation, clean water, and improvements in medical procedures are the crucial determinants of health in refugee camps (Cronk et al., 2015). The social health measures include clean water, adequate nutrition, employment, housing, and education. Most health measures, to some degree, reflect infant mortality, although there is an overlap among measures, and they are not independent estimates of health. Life expectancy and longevity can also be considered. Nevertheless, any public sanitary measure requires political action before they become a reality. 


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           This paper critically examines the health impact of access to water on the refugee population through a policy lens to understand the problem versus the reality, and how we can make a difference.