Overlooked Migrants Of The COVID-19 Pandemic: Displaced Populations
African Platform for Migration and Inclusion in Health (APMIH) is one of the emerging authorities for information and resources about the health of vulnerable migrant communities on the African continent. In response to the ongoing pandemic of COVID-19, APMIH is publishing a 4-part blog series: ‘Overlooked Migrants of the COVID-19 Pandemic’.
Published: 2nd June 2020
As COVID-19 gains ground in numerous African countries, health systems are critically under-resourced, with existing infectious disease outbreaks ongoing amidst displacement within and across country borders. The African continent hosts at least 26%(1) of the global refugee population; in addition, more than 17 million internally displaced persons (IDP) have been forcibly displaced within country borders due to state repression, conflict, climate change, and natural disasters.
COVID-19 places displaced populations at particularly high risk. Those living in refugee and IDP camps and settlements face serious health and safety risks. Reduced UN agency staff presence in some camps, as well as the abrupt suspension of resettlement programs, has limited the availability of support mechanisms for displaced populations. Additionally, a funding shortfall for crucial food aid programs caused by the pandemic threatens to plunge displaced populations into food insecurity. Ensuring protection for these communities is, therefore, an urgent imperative.
COVID-19 is an acute respiratory infection with a global average R0 of 3.28 that is known to spread via respiratory droplets; these remain stable as aerosols for several hours and on surfaces for several days. Its transmission can pose an elevated risk for displaced populations. Already within displaced populations, acute respiratory infections are among the major causes of mortality and morbidity. The stability of the virus in the air and on surfaces could mean that persons having to flee - consider roughly 25 people every minute are forced to flee due to violence from armed groups - could contract the virus as they escape, either by touching a contaminated surface or by running through an area contaminated by aerosolized virus. These persons could then become ill and/or infect about 3 other people throughout their journeys. Displaced persons already residing in camps, settlements, or detention facilities are at increased likelihood to be infected by or transmit COVID-19 due to their time in transit or present living conditions – malnutrition, dehydration, comorbidities, overcrowding, water, sanitation, and hygiene (WASH) limitations.
Epidemiologically, these elements impacting disease transmission could result in variability in COVID-19 disease prevalence, risk, and incidence between displaced populations, in particular refugees and asylum seekers, and non-displaced communities. This could create challenges for countries trying to capture a full epidemiological picture of COVID-19 transmission to determine the effectiveness of public health responses and strategies.
Many African countries are implementing measures - border closures, lockdowns, curfews, physical distancing, and WASH practices - to stymie the transmission of COVID-19 in communities long enough to test, trace, and isolate cases as well as determine resourcing for health services. But, for displaced persons, fleeing conflict, climate change, persecution, or violence overrides adherence to closures or lockdown policies; their physical location presents a greater threat to their immediate safety than COVID-19. Therefore, should COVID-19 circulate in displaced communities, it is likely that many cases will be lost to follow-up. Furthermore, present uncertainties will force infected persons to unknowingly spread COVID-19 within and across countries. In addition, the common living conditions of these sub-groups are overcrowded spaces with limited WASH capacity. These factors would make adhering to WASH guidance and physical distancing difficult.
For both displaced - and non-displaced - populations, the COVID-19 pandemic threatens health systems already overburdened by resource gaps, ongoing conflict, or existing disease outbreaks that pre-date the onset of the pandemic. Prior to the current health crisis, healthcare access for displaced populations has been funded and managed either through the state (in some cases through public-private partnerships) or through NGOs and humanitarian aid.
However, refugees and asylum seekers are often not included in the health system. Some countries implement regular health check-ups in refugee centers and/or offer healthcare coverage for people in difficult situations. Others rely mostly on humanitarian aid and other partners to provide healthcare.
As a result of the measures taken by countries to prevent the transmission of COVID-19, displaced populations face additional challenges in accessing healthcare. In Central and West Africa, several countries hosting displaced populations often have insufficient resources to combat COVID-19 and/or are ill-equipped to do so with available resources. In some countries, ongoing conflicts have pushed some health centers to close. As a result, displaced populations and the local population must rely on fewer, larger facilities. These other centers, already experiencing an increased demand for care, must now support a growing catchment population with fewer options to manage caseloads.
Some NGOs are preparing stocks of supplies or training on infection prevention and control measures; these responses are not sufficient to meet the needs of the displaced population. In some countries, the lockdowns and curfews, combined with international and national transport bans, impede health or aid worker access to displaced populations in remote camps or settlements. This could drive displaced populations to seek care outside of the camp. This could present two problems. First, they risk imprisonment in the attempt to seek care due to restriction of movement outside the camp. Second, if they are able to leave the camp, they face an out-of-pocket cost that is unaffordable--either the refugees and asylum seekers may not be given money by aid organizations as a form of assistance or their cost is higher than the local population if their country of residence does not include them in national health insurance schemes. Employment as a solution to pay out-of-pocket costs is extremely difficult, given challenges migrant workers continually face.
In cases where lockdown procedures are extremely strict, access to many services deemed non-essential or unrelated to COVID19 prevention or screening is limited - such as mental health services. This, coupled with supply shortages and reductions in health access, could create a dangerous shortage in essential medications that displaced populations need to mitigate communicable or noncommunicable diseases. These shortages are exacerbated by transport bans that prevent provision of necessary supplies. Only recently, some countries reopened health services unrelated to the COVID19 infection, such as reproductive and sexual health services.
APMIH advocates for the inclusion of displaced populations in local, national and regional responses to COVID-19 alongside civil society actors, academics, and multilateral agencies such as the UN Refugee Agency (UNHCR), UN Migration Agency (IOM) and the World Health Organization (WHO).
Current crucial, multilateral financial support is unsustainable; African countries must look internally for additional funding for COVID-19 responses. Examples of sourcing funds could be temporary donations of salaries from high-level officials, as done in Ghana, or a suspension of benefits for ministers and deputies, as was done in Namibia. Trust in authorities leading pandemic responses is critical, even more so when dealing with disenfranchised groups; health officials must collaborate with local entities with established relationships with displaced communities in named camps, settlements, and detention facilities to reach these marginalized populations.
These local entities must be given access to provide enhanced hygiene and health support. “Test, Trace, Isolate” remains a central tenet of infectious disease management; the many millions of displaced persons on the continent must benefit from such an intervention. African countries must strive to remain holistic in their health services, addressing COVID-19 related care and prevention as well as other health issues.
Border closures remain a key consideration. Closing known, porous land borders between African countries is unlikely to be effective in stopping all crossings; yet, enforcing ineffective border closures threatens the health and wellbeing of refugees and asylum seekers by making it more difficult and perilous for them to cross to safety. This also negatively impacts COVID-19 disease surveillance and response. Individuals seeking safety should, therefore, not be prevented from crossing borders. COVID-19 testing, health checks and preventative measures must be implemented at porous land borders across the continent. Bordering countries should collaborate to report, test, and treat COVID-19 at designated health outposts close to borders. This will boost COVID-19 surveillance and allocate resources to all personnel assigned to the border while upholding the human rights of refugees and asylum seekers crossing it.
The right to health of displaced populations must be upheld by providing unrestricted access to available public services - including healthcare and health-promoting social services, such as housing and asylum processing. Deportations of refugees and asylum seekers do not promote health and wellbeing and hinder efforts to control disease transmission. This must be halted during the pandemic. Mental health provision must be a part of any public health response, given the existing trauma and stress associated with displaced populations’ prior migratory experiences. Upholding the right to mental health will be increasingly critical during the pandemic; poor mental health is likely to be exacerbated by the economic, social, and political disruptions. These trends will be compounded by the abrupt reduction in food assistance, health support, and resettlement programs of multilateral initiatives based within camps and settlements. For this reason, it is crucial that such initiatives receive continued investment - or, in some cases, are reinstated - through emergency funding from high-income UN member states and other major donors. Multilateral agencies should continue to explore partnerships with local authorities and locally based NGOs to find cost-effective and sustainable solutions, given that they play a key role in identifying the most pressing needs of displaced populations.
Local health authorities should work with sanitation companies to lead on increasing hand-washing and disinfection facilities in detention centres, as well as in camps and settlements. Water availability in multiple camps and settlements across the continent strive to meet the 20 litres per day goal but often fall far below the recommended scale-up of 35 liters per person. This likely precludes any effective response to the pandemic.
Finally, APMIH stands against the discriminatory targeting of displaced populations, whether through xenophobia, sexism, homophobia, or transphobia. Policymakers and program designers at all levels must take action to counter these narratives; displaced populations should not be used as scapegoats. Practical solutions can include utilizing social media platforms, such as WhatsApp, Twitter, and Facebook, to debunk false information, holding media entities to account, and enlisting the support of artists and creatives. Anti-discrimination must also be core to all public health responses to COVID-19. We must ensure that no individual is left behind during the pandemic. We cannot allow vulnerable communities with unmet needs to be pushed even further into the margins.
(1) According to the UNHCR, there are over 7 million refugees and asylum seekers in Sub-Saharan Africa. These figures do not include the almost 600,000 additional refugees and asylum-seekers currently present in North Africa.
Laëtitia KM Diatezua - Knowledge Repository and Policy Researcher; Sherihane Bensemmane - Research & Repository Manager; and Christy Adeola Braham - Founder
APMIH thanks Mr. Christoffer Gowesky, M.A. for his support in the creation of this piece.
**APMIH would like to support individuals from migrant communities in Africa who have been impacted by the COVID-19 pandemic. We invite you to anonymously share your experiences with us in English or in French**