Social distancing is a key step toward slowing the spread of COVID-19, but for many refugees and displaced people, it’s impossible to practice this and other preventative measures. We asked SIS professor Tazreena Sajjad to discuss how refugees around the world are especially vulnerable to the novel coronavirus pandemic.
Q: There are thousands of refugees living in camps around the world. What are the living conditions usually like in these camps?
According to the UNHCR, by the end of 2018, there were 70.8 million individuals forcibly displaced worldwide as a result of persecution, conflict, violence, or human rights violations. Of them, 25.9 million people fit the definition of a “refugee” as offered by the 1951 Refugee Convention. Many of these refugees live in what are largely defined as “camps”—temporary facilities that were created to provide emergency assistance and shelter in host countries and along borders until the situation on the ground was safe enough for them to go home. In reality, in many contexts, camps have become permanent shelters for generations of refugees, since many of the conflicts in the international system are protracted in nature, and the possibility of sustainable return is compromised by complex social, political, economic, and environmental conditions in the refugees’ countries of origin.
There are two persistent misconceptions that shape our understanding of the lived experiences of refugees. First, while there are some variations in terms of numbers, existing research overwhelmingly shows that the majority of the world’s refugees do not actually live in camps. In fact, according to the 2018 World Refugee report, only about 40 percent of the world’s refugees live in camps, which means 60 percent of refugees actually live in often densely packed urban areas and informal settlements. Some settlements resemble cities while others could look like shanty towns or slums; others could fit the mold of what most people imagine camps to look like—densely packed areas with plastic tents as in the case of Calais, France or the ones that have sprung up along the US-Mexico border. Succinctly, this means the majority of the world’s refugees live in close quarters with the world’s urban poor, amidst low-income communities and others who may be forcibly displaced by factors like environmental disasters, large-scale development projects, and/or stateless populations. Given the length of many conflicts and the fact that different ethnic, racial, and religious groups may be on the move from the same country or from multiple countries toward an immediate host state, many camps are diverse communities, which allow unique dynamics of collaboration, cooperation, and tensions to emerge that vary from context to context.
All of these realities mean that the living conditions in refugee camps are quite diverse. For instance, some of the oldest ‘temporary shelters’ are the 58 Palestinian registered refugee camps, located in Jordan, the West Bank, Gaza, Syria, and Lebanon. Many of these camps resemble overcrowded urban-like centers with visibly crumbling and insufficient infrastructure, poor sewage systems and visible conditions of poverty. In the 12 Palestinian camps in Lebanon, conditions are abysmal with the absence of basic infrastructures such as roads or sanitation. In moments of political crisis, people can go for months with limited or no access to electricity. The Palestinian camps inside Gaza have similar issues as the camps in Lebanon, with their residents struggling with the challenges of chronic health and psychological distress, limited access to medical supplies, and high levels of food insecurity that have produced conditions of malnutrition among children.
In contrast, the now well-known Za’atari refugee camp in Jordan, which has become home to about 80,000 Syrians, has transformed from a UNHCR tent establishment to what is now Jordan’s fourth largest city. There is a lot of international and national focus on the Za’atari camp, allowing for several economic, health, and education facilities to be available for the camp’s refugee community. This, however, should does not mean all Syrian refugees are thriving in the Za’atari camp; there continue to be ongoing challenges for the camp’s refugee community, including security concerns, inadequate access to education for all children, and high incidences of child labor and forced and early marriages.
Living conditions in refugee camps have similar challenges—population density, lack of access to proper and adequate nutrition, employment opportunities, varying restrictions in mobility, lack of adequate educational opportunities and health and medical facilities, and ongoing issues of insecurity facing its residents. The living conditions for the elderly, people with disabilities, unaccompanied children, and members of the LGBTQ+ community may be precarious in many of these contexts.
Q: Normally, can refugees access health care while living in the camps?
A broad generalization that may be made about refugees in camps is that they often struggle with complex medical problems as a result of physical injuries received during conflict and in flight that may not receive timely medical attention. In addition, overcrowding, poor housing and sanitary environments, loss of primary caregivers, and exposure to extreme temperatures render refugees extremely vulnerable to health challenges. Poor vaccination coverage or its absence, food insecurity, lack of access to clean water, and exposure to infectious diseases are also some of the common experiences in many refugee camps. Furthermore, difficult labor conditions and exposure to environmental hazards also compromise health of refugees. Other health challenges include the risk of sexual abuse and domestic violence, the need for palliative care, absence of specialized care for sexual and reproductive health, and lack of treatment in many instances for non-communicable diseases such as cancer and diabetes. However, it must be emphasized that camps vary significantly in terms of their location, the length of time for which they have existed, the length of time within which each group of refugees has arrived, the capacity and cooperation of host countries, the kind of attention they receive from the international community, and the extent to which they receive funding. Subsequently, access to health care for refugees can vary considerably.
One of the most overlooked health challenges in refugee is the overall lack of adequate attention and facilities for mental health support. Many refugees struggle with anxiety disorder, PTSD, stress, depression and other mental health challenges. Yet the sheer scale of many of the refugee camps and the enormous needs for physical health challenges mean that this particular health challenge is either overlooked or does not often get the kind of funding that would provide the context-specific support of refugee adults, children, youth, the elderly, people with disabilities, members of the LGBTQ+ community, and the specific needs of women and girls. As mentioned earlier, most of the world’s refugees do not live in official camps, and recognition of this reality opens a bigger discussion about the kinds of physical and mental health challenges that exist for refugees in urban areas and impoverished informal settlements and the extent to which they have access to either state health facilities or ones provided by the international health community. Last, but not the least, people in internally displaced persons (IDP) camps (comprising of people who may have faced the same realities as refugees but were not able to cross an international border) in contexts as varied as Venezuela, the Democratic Republic of the Congo (DRC), the Central African Republic (CAR), and Mali also have significant health challenges. Yet, because they are stranded inside the very contexts that have produced the conditions of forced displacement, including war, conflict, violence, or human rights violations, or they do not get as much international attention, they are far more unlikely to receive medical assistance, and it is much more challenging for medical and humanitarian organizations to reach them.
Q: How vulnerable are refugee populations to the spread of COVID-19 given that major host countries are mostly located in the Global South, and how prepared are these countries for this health crisis?
Countries in the Global South and, largely speaking, refugee camps across the world are not adequately prepared for COVID-19. For example, Pakistan, Uganda, Kenya, Lebanon, and Bangladesh already have existing health challenges with regard to their respective populations to varying degrees. Refugee camps in several of these contexts have also been facing crises-like situations, stemming from communicable and non-communicable diseases as well as other complex health challenges. COVID-19 has already exposed the weaknesses of the health infrastructures in established and powerful democracies such as the United States and has overwhelmed developed contexts such as Italy and Spain. For countries in the Global South, the impact of the pandemic will be catastrophic for their citizens and for the refugees they host. Countries that receive less attention, have even weaker infrastructure, and receive even less sustained humanitarian support will face more devastating consequences.
Many countries in the Global South still struggle with access to clean and safe water—a problem that is exacerbated in city centers where the urban poor live, remote contexts where the infrastructure in many contexts are not as well-established, where there is overpopulation and air and water pollution, and where adequate health infrastructure and lack of specialists already place citizens at great risk. The vast majority of the populations in each of these countries cannot telecommute nor telework since they are agricultural farmers, fisher(wo)men, garments factory workers, daily laborers, domestic workers, and all those who work in the informal economy, which may sometimes be bigger than the formal economic sector. They depend on their daily earnings to survive, struggle often with persistent food insecurity, and they cannot be placed under a long-term lockdown. In many of these contexts, citizens do not have a social safety net or a healthcare system that will adequately provide for a health emergency. Social distancing is a privilege for the vast majority of the world’s population—especially for those in the Global South and certainly for those who live in highly congested environments.
In overcrowded refugee camps, as well informal refugee settlements and urban settlements, the absence of adequate access to clean water, soap, and sanitizer, and the impossibility of social distancing—which are the critical guidelines for protection from COVID-19—increase the vulnerability of refugees. In several instances, camps are restricted areas and can be placed under lockdown by host governments, and the mobility of refugees can be further restricted, which multiplies the threat of COVID-19’s rapid spread many times over. In addition, the fact that many refugees in camps struggle with malnutrition, respiratory problems as a result of cooking and breathing woodfires, tuberculosis, war injuries, and other pre-existing conditions mean they already have compromised immune systems. The fact that they live in countries where the health infrastructure is already weak means their access to medical care remains limited. In the context of COVID-19, many face situations where there is little access to doctors and hospitals, let alone to tests, face masks, specialists, and intensive care units with ventilators. Since many refugee camps are also in poor and remote areas, the possibility of timely detection and transport of infected persons for emergency treatment may well be an impossibility. Additional challenges to refugee communities are limited access to reliable information, the spread of misinformation, the absence of adequate communication networks, language barriers, and, in some cases, mistrust of authorities.
Local and international health practitioners, scholars, and those in the field of humanitarian assistance have already started raising the alarm about the vulnerability of refugees in the camps in Bangladesh and Syria, but the issue is not limited to the Global South. There is rising concerns about the spread of COVID-19 in refugee camps in Greece and in the very new informal camps that have sprung up in Mexico, along the US-Mexico border, and France. The world is still in the early days of the COVID-19 crisis, and collaborative, cooperative, and creative responses and information-sharing among the global governance health infrastructures, national and local governments, donor countries and agencies, and local and international humanitarian actors will be critical in the effort to contain the pandemic before it wreaks havoc on the most vulnerable amongst us.
Q: Are any governments or global institutions taking measures to slow the spread of the coronavirus in refugee camps, and what should be done to help refugees during this pandemic?
For any pandemic, including COVID-19, it’s important to look at the capacity of each host country, the role and leadership of different international and national actors, and the support or neglect of the international community. It cannot be expected that large refugee host countries will be chastised for not responding adequately to the refugee communities amidst them while there is little support and infrastructure to respond to the country’s own citizens, many of whom may be poor or who live in economically precarious situations and struggle with health challenges. Neither can any government ignore the existence of refugee camps—official and informal—inside its borders, because that too will have disastrous consequences.
We are just starting to see official reporting of confirmed COVID-19 deaths from several countries in the Global South. Chances are many cases are going unreported, and certainly, the capacity for testing—as it exists in Germany, South Korea, China, New Zealand or Finland—does not exist in several of those contexts. We are also hearing more about the unfolding situation in official camps and the ones that have received the most amount of international attention, which means we are still not fully informed about the realities unfolding in many informal refugee camps, settlements, IDP camps, and informal urban settlements where COVID-19 is just beginning to emerge with fatal consequences.
In terms of preparedness, the World Health Organization (WHO) is playing a critical leadership role in terms of bringing together global health experts to share information, providing medical guidance, and working closely with national governments to prepare them for the pandemic. Organizations that work with refugees and forcibly displaced populations such as the UNHCR, the International Rescue Committee (IRC), CARE International, and the International Organization for Migration (IOM) are working with national governments and local health and humanitarian actors to provide training and disseminate COVID-19 prevention information. National governments, to varying degrees, are also stepping up by closing down their borders; working with local and international health experts to share information, strategies, and best practices; allocating resources; facilitating access to camps; enforcing lockdowns; and disseminating public service health information. The role of local volunteers and local medical efforts who are on the ground cannot be overemphasized since they are on the frontlines of the impending crisis.
There are multiple ways in which refugees can be assisted during the pandemic, but recommendations should be context specific and context responsive. Broadly speaking, international organizations such as UNHCR and local organizations working to provide refugees with adequate access to clean water, waste disposal, and soap should be provided with the emergency funding and additional assistance they need to conduct their work in an effective and timely manner. This is not the time to cut back on international development and health and humanitarian assistance. Recognizing and supporting local initiatives that have access, experience, and understanding of the challenges in a context, including women’s rights groups and organizations that are often in the frontlines of any crisis, will be critical. Local refugee leaders should be identified to conduct information workshops and trainings against COVID-19 such that camp communities can continue the critical work of information-sharing and good health practices even if outsiders cannot access the camps. COVID-19 responses need to take into consideration questions of inclusion particularly for marginalized communities including people with disabilities.
Governments cannot cut back on food and water supplies and should ensure their supply with minimal disruption. Neither can they pander to or be held hostage by xenophobic and anti-immigrant sentiments that will threaten access to emergency humanitarian assistance to vulnerable populations and frame them as the “problem”—a legitimate concern that can well be raised about the camps and informal settlements in contexts such as the US, Greece, France, and Hungary. Testing should be systematic and widespread, with adequate arrangements to allow infected individuals to be isolated from the rest of the population and receive medical attention. In contexts where refugees are denied health services, the right to work, and mobility, governments should work with international and national organizations to provide documentation so that they are not “policed” for seeking assistance or for working in and around camps as and when lockdowns ease. Refugees need access to information—and governments should ensure that they have access to the internet and cellphone networks. Local volunteers should not be criminalized if they follow established protocol and engage in providing emergency humanitarian assistance.
COVID-19 responses should consider not just the refugees in official camps, but also include a coordinated response for the vast majority of those who reside in less visible informal camps and settlements around border areas and within urban areas. Investing only in the crisis areas that are best known will result in unmitigated and catastrophic outcomes in countries and contexts that, for complex reasons, may not have caught the attention of the general public in the West and the attention of donor agencies and countries.
Last but not the least, such measures cannot and should not distinguish between a ‘de jure’ refugee and those who are stateless, forcibly displaced by ecological and/or development factors, internal migrants, and the urban poor. All of this means refugee organizations and those that work with forcibly displaced populations will need to coordinate closely with organizations that work with those who work on poverty alleviation and health issues in every context. This is a race against time, and all communities are vulnerable by virtue of being human. A global response to a pandemic should consistently keep that in mind in designing and implementing programs on assistance for health services.