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Amid Coronavirus Spread, Host Countries Ignore Refugee Health at Their Own Peril

Refugees are particularly vulnerable to a pandemic—which is why their needs must be taken into account.

Palestinian children play with face masks
Palestinian children play with face masks at the Shati refugee camp in Gaza City on March 25, amid the coronavirus pandemic. MOHAMMED ABED/AFP via Getty Images

As the world braces against COVID-19, governments, health systems, and international organizations are grappling with the ways in which the pandemic will disproportionately harm the most vulnerable members of society. Of those vulnerable groups, refugees are uniquely at risk of experiencing severe illness and death. Yet many countries’ pandemic plans—including countries hosting large numbers of refugees, migrants, and displaced persons—do not explicitly account for the complex needs of this population during such a health crisis.

In recent years, conflict, forced migration, climate change, and political instability have led to a surge in the number of refugees worldwide. In 2019, there were 20.4 million refugees under the mandate of the United Nations High Commissioner for Refugees (UNHCR), up from nearly 17.2 million in 2016. Globally, some 70.8 million people are forcibly displaced.

Already, 199 countries and territories have reported confirmed cases of the coronavirus. This number includes four of the countries with the largest refugee populations: Germany, Sudan, Pakistan, and Turkey. And it includes dozens more countries that host tens of thousands of refugees. In response to the pandemic, UNHCR has appealed for $33 million to improve conditions at refugee camps and settlements by, among other things, expanding primary and secondary health services, establishing surveillance networks, and countering the spread of misinformation among refugee communities.

These efforts alone will not be enough. More than 80 percent of the world’s refugees reside in low- and middle-income countries—many of which already report larger numbers of HIV/AIDS cases, lower rates of immunization, and higher rates of malnutrition than their higher-income counterparts. These are conditions that weaken people’s immune systems, rendering them susceptible to a range of other infections. As a result, many refugees remain especially vulnerable to emerging threats like the coronavirus.

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The destruction of health facilities, unstable supply chains, and health care worker shortages further prevent refugees from accessing much-needed diagnostic testing and medical care. And two of the most effective precautionary measures against the coronavirus—social distancing and hand-washing—are extremely difficult to implement in camps and settlements, where space, shelter, soap, and clean water are often in short supply. These living conditions often catalyze disease transmission, threatening the well-being of refugees living in settlements as well as those residing in host communities. This holds especially true when there is high traffic between the two settings and when the host community already struggles with substandard health care. Low immunization coverage and limited health service access among refugees and host communities in Kenya and Ivory Coast, for instance, have resulted in outbreaks of such vaccine-preventable diseases as measles among both groups.

Recognizing the unique threat that this pandemic poses, UNHCR, the International Organization for Migration (IOM), the World Health Organization, and the International Federation of Red Cross and Red Crescent Societies recently released interim guidance outlining COVID-19 readiness and response considerations for refugee camps and camp-like settings. On March 17, UNHCR and IOM also announced a temporary suspension of refugee resettlement travel. Though travel restrictions have already been implemented in many parts of the world, flattening the curve among refugees will require additional solutions in both the near and distant terms.

Immediate steps should include expanding testing services in countries with large refugee populations and setting up screening facilities at camps and settlements. Health care workers and volunteers must also be mobilized and trained to support testing efforts in humanitarian settings, trace contacts, and identify and isolate people who may have been exposed to the virus in these settings. Provincial- and district-level public health authorities and their partners should undertake robust community engagement and communication efforts to ensure that refugees are aware of the potential risks of coronavirus, receive information about how to protect themselves, and retain access to needed social services. For their part, international organizations, nongovernmental organizations, manufacturers, and ministries of health and finance should consider strategies for repurposing or leveraging existing global health procurement mechanisms to ensure that health workers caring for refugees can access affordable supplies of gloves, masks, essential medicines, and other assets needed to treat large influxes of sick patients.

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Public-private partnerships between host country governments and key private-sector and civil society stakeholders could prove instrumental in ensuring that these solutions can be feasibly implemented. Given the wide-ranging impacts of COVID-19 on economies and health systems at both regional and global levels, country governments should also leverage partnerships with humanitarian organizations and other nations. Such multilateral approaches can help ensure that refugee health needs are sufficiently addressed regionally as well as nationally.

Admittedly, coordinating this kind of multi-sectoral response during a crisis demands significant funding and political will. To that end, António Guterres, secretary-general of the United Nations, recently issued a humanitarian appeal for $2 billion to combat the ongoing pandemic and its impacts on refugees and displaced persons. Though even wealthy countries are struggling to test and care for sick patients with COVID-19, supporting humanitarian efforts to protect refugee health should still remain a top priority for decision-makers. Given the magnitude of this outbreak, the ways in which it has torn the social fabric of communities, and the enormous damage it has already inflicted upon the global economy, it is clear that no country can afford to leave its most vulnerable behind. The costs of allowing the disease to continue spreading are simply too great.

Short-term measures will help countries avert inequitable losses of health and life among vulnerable refugees during this pandemic. But preparing for future emergencies will require longer-term solutions, too. Countries should incorporate refugee needs into the routine steps they take to protect themselves—for example, by revising pandemic plans to include language on refugees, practicing these plans using routine exercises, building and training health workforces to meet the complex health needs of refugee populations, and establishing new lines of funding for addressing refugee needs during public health emergencies. This approach could improve strategies for vaccinating refugees, purchasing and administering needed medicines, and ensuring continued access to essential primary care, reproductive, and mental health services during a pandemic.

There are several reasons why many countries have not already addressed refugee needs in routine pandemic planning. In some cases, countries have explicitly stated that they are unable or unwilling to provide refugees with the same rights and access to health services as citizens, citing perceived threats to state sovereignty. But in many others, accounting for refugee needs in pandemic planning presents decision-makers with major technical challenges. For example, legal and administrative barriers often prevent refugees from accessing health services in some host countries. In conflict settings, national governments may not retain full political control over certain regions, which could create health coverage gaps among residents who fall outside their jurisdiction. In addition, conflict often results in medical brain drain—an exodus of the public health and health care workers who would otherwise form the backbone of a strong pandemic response. And the sheer size and mobility of refugee populations in some settings makes it difficult for health officials in host countries to track people at risk of infection and ensure that sufficient medical supplies are readily available. Past outbreaks—from Ebola in the Democratic Republic of the Congo and measles in Kenya, to cholera in Haiti and every year’s bout of seasonal influenza—have shown that these challenges, unsurprisingly, limit health service access and exacerbate the impacts of disease in refugee settings.

Though such challenges are inevitable, there are still strong legal, moral, and humanitarian imperatives to protect refugees. Pandemic plans that are inclusive of refugee needs align with the United Nations’ Universal Declaration of Human Rights, which affirms every person’s right to health. Similarly, the Geneva Conventions protect access to health care during armed conflict. The U.N.’s 1951 Refugee Convention and its 1967 Protocol forbid ratifying nations from forcibly returning refugees to home countries where they may face threats to their lives. Refugee advocates have argued that this principle, known as non-refoulement, holds true even amid the coronavirus outbreak. Refugees should not be rejected based on real or perceived fears of coronavirus transmission, especially since viruses do not respect national borders. When countries fail to protect refugees from infectious disease threats, all of society shoulders the ensuing risk.

Some political leaders have attempted to assign blame for the outbreak to refugees and migrants. Matteo Salvini, the right-wing leader of Italy’s Lega Nord party, wrongly declared that African migrants were responsible for introducing coronavirus to Italy. Hungary’s prime minister, Viktor Orbán, also alleged a false link between the virus and illegal immigration. And just days ago, the Trump administration announced that it would halt the processing of undocumented migrants and asylum-seekers at the U.S.-Mexico border, citing concerns about the spread of COVID-19 in the United States. Such unjustified claims only stigmatize refugees most at risk of illness and death—making it increasingly difficult for them to access and receive care during large-scale crises.

The geopolitical backdrop of coronavirus makes refugee health protection an even more urgent public health priority. Even repatriated or resettled refugees struggle to seek and receive care in their new homes due to social stigmatization and language barriers. Nationalism, isolationism, and xenophobia—forces that further marginalize refugees and make health care harder to access—are antithetical to effective pandemic response. If refugees are afraid or unable to seek medical care, it will be impossible to halt the spread of coronavirus.

Global crises demand global cooperation. When countries embrace multilateralism, undertake planning efforts that include marginalized groups, and uphold international norms around equitable access to health care, they create a safety net for those who need it most and insure them against disproportionate harm. The coronavirus has laid bare an ominous truth: that the world will never be truly prepared for future pandemics until we equip our global health architecture to meet the needs of our most vulnerable.

Sanjana Ravi is a senior research associate at the Johns Hopkins Center for Health Security. Her research examines the health system impacts of public health emergencies. Twitter: @sanjravi89