Does Occupational Therapy Have a Role in Refugee Camps?

Image courtesy of The New York Times

Occupational therapy (OT) is not easy to define. Part of this is due to the inherent breadth of our practice area. Having a broad field of practice has advantages, such as allowing us to be involved in helping many populations ranging from the elderly to young children, from those with Alzheimer’s disease to someone with a broken finger. A disadvantage of such breadth, however, is that it can be difficult for us to succinctly explain to others and to ourselves what we do and why we are valuable members of a healthcare team. As an evolving field in a changing world, it is understandable that our practice parameters will change. These changes bring potential opportunities for occupational therapists (OTs). Areas of practice where OTs could make contributions include servicing individuals in refugee camps, hospital emergency rooms, primary care, and professional sports rehabilitation settings. But to be included, we will need to do a better job of convincing those on the established healthcare teams that we have something well defined, unique, and important to offer.

There are many barriers to entering new areas of practice. Focusing on the arena of international refugee aid work, the first hurdle we must tackle is asking ourselves, “What is our unique contribution? Where do we fit in? Do we want to participate as part of the mental health profession or the physical rehabilitation team, or do we want to push to be acknowledged as our own entity?” This is not clear to us or to those involved with helping refugees. Doctors without Borders, the American and International Red Cross, the United Nations High Commissioner for Refugees are some of the front line aid organizations that do not formally recognize the place of OTs on their teams.

To understand our potential roles and contributions, we need to know what a refugee camp in today’s world looks like. Refugee camps were originally intended as relatively short-term places of safety. Most post-WWII camps were closed by 1952. This is not the situation today, with the majority of the 15.4 million refugees living in limbo for more than five years. The world’s longest-running camp, Dadaab in Kenya, is now 20 years old and houses more than 420,000 people. Around the world, the number of refugees is the highest since the Rwandan genocide. Many are Syrians who have been fleeing conflict at home for three years and turning to Turkey, Jordan, and Lebanon for safety. Some estimate that these people will not be able to return home for at least 12 years, now the average time a refugee spends in a camp (McClelland, 2014).

The model of the camps has been slow to adapt to these longer-term stays. Many are the size of small cities yet they often lack organization and infrastructure. Even those that are able to provide basic needs such as food, water, and shelter still suffer from high rates of violent crime including rape and child labor exploitation (Kumar-Sen, 2013). And many people in the camps suffer from psychological and emotional problems, including high rates of suicide, which are exacerbated by the long periods of uncertainty that they live in (McClelland, 2014).

Changes are slowly happening. Some describe Kilis, in Turkey, as the closest we have come to creating a perfect refugee camp. Opened in 2012, it now houses 14,000 people. The Turkish government runs the camp with an emphasis on safety and improved living conditions, living conditions that mimic life at home as much as possible. This is clearly seen in the new food distribution model they created. The camp provides real grocery stores with real choices of food. People purchase groceries with a government-issued pre-paid debit card. The structure is cost-effective for the government and provides choice and a semblance of home for the refugees. Other organizations such as the World Food Programme intend to use this model in other camps when feasible. Crime is almost non-existent at the camp and everyone interviewed for a recent article in the New York Times proclaimed their appreciation for what the Turkish government has done for them (McClelland, 2014).

Yet, something is still missing. When asked if they are happy, these same camp respondents said no. “Besides the comforts, and the cleanliness, and the impressive facilities of the Kilis camp, there is one important thing to note: Nobody likes living there.” “It’s hard for us,” said Basheer Alito, the section leader who was so effusive in his praise for the camp and the Turks. “Inside, we’re unhappy. In my heart, it’s temporary, not permanent.” “In a noncamp setting,” Batchelor went on to say, “if people are able to keep themselves engaged, that provides a healthy outlook, helps establish local integration, keeps alive their skill sets if they repatriate.” The longer a refugee resides in a camp, the harder it can become to sustain psychological well-being.” “… refugee camps don’t provide opportunities for livelihood” Like many refugees, Rouba Bakri often finds herself at loose ends: “In a camp, no matter how large the family, boredom prevails. Aside from cooking and cleaning, there is little to do. Errands are within a five-minute walk; there is no livestock to tend or garden to hoe.” To keep busy, Bakri works as the unpaid manager of the camp’s laundry centers (McClelland, 2014).

The long-term effects of boredom and lack of meaningful occupation are often considered contributing factors to depression and anxiety. Occupational science research provides evidence that engagement in meaningful activities is a basic human need (Zemke & Clark, 1996). And the lack of meaning in one’s life does not compensate for mere safety. This is clear from the statements above and can also be seen by the fact that there are 400,000 Syrian urban refugees living without legal status in the Turkish cities. They have no rights to work and they often go hungry and without shelter. Yet most refuse to enter the safety of the refugee camps from a fear of living an “open-ended” existence.

This is where OTs have an opportunity to contribute. Sensing the need for more meaningful activity, some camps have set up workshops where refugees can learn new skills or keep up with old ones. In a pilot program at the Adiyaman refugee camp in Turkey, women weave traditional rugs. "This [work] helps us forget trauma, like losing relatives, or to stop thinking all the time about the children still in Syria. This course can offer relief.” One of the instructors there, Gamze Karayilan, sees in this activity an opportunity for self-empowerment. Another pilot workshop has just been started where men learn to sew. Just as in Kilis, those not involved in workshops have nothing to do. “Unlike urban refugees, they are not free to move outside the camp and therefore cannot find work during the cotton harvest. And so thousands sit, or stand and wait. There is, for them, little else to do” (Murray, 2013). In the Zaatari camp in Jordan, the second largest refugee camp in the world, there are over 60,000 children. American artist Samantha Robison has started art workshops for them. "So many children are bored in Zaatari. They just throw rocks because they have nothing else to do," Robison said. "There's a lot of violent tendencies and negative energy, so if you bring in art and give them a positive activity, it helps a lot… the artwork helps children take a sense of ownership in the crowded refugee camp." It may also help prevent “producing a generation plagued with illiteracy and filled with hate” (Gavlac, 2013).

Although these initiatives are providing much needed services, they are scattered and ad-hoc. OTs do have an opportunity to push for the establishment of such programs as a necessary and regular component of refugee camp life, seen as essential as providing food, shelter, and safety. We have the opportunity to be seen as vital members of the teams that provide refugee services, perhaps from a mental health standpoint or via a new understanding of OT services not yet completely realized and defined. It provides us with the challenge and the opportunity to demonstrate our skills in helping these populations not only as individuals with a desire to contribute, but as a profession with the unique qualifications to serve these populations as well as the right to serve alongside other professions. To do this, OTs will need to create well-defined, formalized, data-driven protocols that can be utilized across camps with modifications and adaptations as needed. If we listen to what those in the camps are telling us, we can provide them with interventions that will serve to increase self-empowerment, create a sense of order out of chaos, provide opportunities for participation in meaningful activities, and decrease depression and anxiety. This not only improves the lives of those in the camps, but these tools can serve them when they eventually return home. They can return with skills, dignity, and hope.

References

Gavlak, D. (2013, July 23). US artist, Syrian children beautify refugee camp. The Associated Press. Retrieved from http://news.yahoo.com/us-artist-syrian-children-beautify-refugee-camp-162534804.html

Kumar-Sen, A. (2013, November 5). Syrian war refugees find crowds, crime, contagion at camps. The Washington Times. Retrieved from http://www.washingtontimes.com/news/2013/nov/5/syrian-war-refugees-find-crowds-crime-contagion-at/?page=all

McClelland, M. (2014, February 13). How to build a perfect refugee camp. The New York Times. Retrieved from http://www.nytimes.com/2014/02/16/magazine/how-to-build-a-perfect refugeecamp.html?module=Search&mabReward=relbias%3Ar%2C{%221%22%3A%22RI%3A8%22}

Murray, D. (2013, October 24). Syrian refugee women battle boredom and bad memories by making carpets. United Nations High Commissioner for Refugees website. Retrieved from http://www.unhcr.org/52690c9d6.html

Zemke, R. & Clark, F. (1996). Occupational Science: The evolving discipline. Philadelphia, F.A.Davis.