A surge in coronavirus cases outside China has raised concerns the outbreak could be particularly devastating for vulnerable refugee and migrant populations in countries hobbled by conflict.
Over the last week, cases of the illness known as Covid-19 have escalated dramatically in Iran, and new infections linked to the cluster have emerged in more than half a dozen other countries in the region including Iraq, Afghanistan, and Lebanon.
At least 12 million refugees and internally displaced people (IDPs) live between Iraq, Syria, Lebanon, and Turkey – countries linked to Iran by either frequent travel, irregular migration routes, shared borders, or all three. Iran itself hosts nearly one million refugees, mostly from neighbouring Afghanistan, and an estimated 1.5 to two million undocumented people.
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The effects of armed conflict “fragment the public health system and the infrastructure that enables governments to actively perform surveillance of diseases”, said Dr. Mohammed Jawad, a researcher at Imperial College London who studies the impact of conflict on public health.
Dr. Adam Coutts, a public health specialist at Cambridge University who focuses on the Middle East, said refugees are especially vulnerable to the coronavirus or other diseases, due to ”high geographical mobility, instability, living in overcrowded conditions, lack of sanitation and WASH (waters, sanitation and hygiene) facilities, and lack of access to decent healthcare or vaccination programmes in host communities”.
But refugee populations are often left out of disaster and epidemic preparedness planning at the best of times. And simply reaching marginalised refugees and migrants with information is also a challenge.
Politicians in Italy and Greece have already started using the spectre of asylum seekers and migrants carrying the virus across international borders to drum up support for hardline migration policies. But public health experts believe the real risk is to refugee and migrant communities themselves, who face instability, sporadic access to healthcare, and now the growing threat of stigmatisation.
“The healthiest and wealthiest are the ones that tend to migrate,” Jawad said. “The ones left behind are poorer and sicker.”
Impact of conflict and displacement
Borders throughout the Middle East already tend to be porous, with refugees, economic migrants, and others often travelling along informal routes. Countries affected by war can have a hard time monitoring who is entering and leaving their territory, according to Jawad. But the biggest challenge to an effective coronavirus response is the region’s weak or broken public health systems.
“The best way to control coronavirus is through what we call contact tracing,” Jawad said. “That is finding out who you’ve been meeting, who you’ve been interacting with, and providing advice – sometimes advice to self-isolate, but certainly hygiene advice – to really drum that home with the relevant people.”
That may be difficult to do in parts of the Middle East. Refugees and IDPs often don’t have fixed places to live, and authorities might not know how to contact them or have the capacity to coordinate a response. Governments may not prioritise healthcare services for refugees and IDPs, especially in countries like Lebanon where many refugees live in dismal conditions and there is strong anti-refugee sentiment among national authorities.
Iran has recorded the most publicly confirmed coronavirus deaths of any country outside China, where the outbreak originated in December.
After initially denying reports of infections, Iranian health authorities have confirmed dozens of cases and multiple deaths since 19 February.
Since then, the virus has spread around the region. Authorities ranging from neighbours Afghanistan, Pakistan, and Iraq to several Gulf state countries and even Canada have all linked emerging cases to Iran.
The ratio of deaths to overall cases – about one to seven going by officially confirmed infections as of 26 February – is far higher than China’s estimated rate, which hovers at around one in 50, or two percent. This has sparked fears that Iran’s outbreak could be far wider than it is reporting.
But many public health experts say border closures and travel restrictions can actually exacerbate risks by pushing travellers underground – out of reach of disease detection, containment, and treatment measures – and racking up huge economic costs better spent on preparedness.
The situation also differs between countries. Turkey, for example, has a robust healthcare system, Coutts said, but “Iraq and Lebanon have severely weak public health systems due to conflict and political neglect, and are not able to adequately monitor what is going on and provide a robust public health response”.
In Syria, nearly a million people have fled towards the Turkish border as government forces – backed by Russian airstrikes – have advanced on the last opposition-held enclave in the country. Even without the added factor of coronavirus, the humanitarian suffering caused by the advance has overwhelmed aid efforts.
The Syrian government and Russian airstrikes have systematically targeted hospitals in Idlib, and displaced people are sleeping without shelter in the streets, in olive groves, or in overcrowded camps that often lack clean water, according to Leyla Hasso, communication and advocacy supervisor for the Hurras Network, a Syrian aid group.
“It will be a disaster if we have coronavirus in northwest [Syria],” Hasso told The New Humanitarian.
Refugees missing from coronavirus focus
If the coronavirus spreads to refugee populations in the Middle East, international indifference may also play a role in how severe the outbreak becomes.
“The health situation among refugees and IDPs from the Syria crisis has [gotten] worse over recent years due to declines in humanitarian funding and dwindling political attention from Europe, UK and US,” Coutts said.
But there has been little public discussion about how the coronavirus might impact refugees and migrants during the current outbreak, he said: “A cruise liner of tourists has got far more press, political, and policy attention than three million people being continuously bombed in Idlib.”
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Much of the World Health Organisation’s basic advice for protecting against the coronavirus comes down to staying away from people who may be infected, vigilant personal hygiene, and seeking medical attention if symptoms occur.
This prevention advice will be difficult to follow in Idlib and other parts of the Middle East, where refugees and IDPs often live in overcrowded and unhygienic camps, informal settlements, and substandard urban housing. But, according to Jawad, there are still steps that can be taken.
Aid groups, civil society organisations, and governments can target hygiene and prevention advice to these displaced communities, he said.
“If possible, carrying small hand sanitisers around with you at all times, or just simply not touching your face if your hands are unwashed,” he said. “It’s difficult… but there are small things that can be done to help mitigate the problem.”
“A cruise liner of tourists has got far more press, political, and policy attention.”
Organisations like national Red Cross and Red Crescent societies have prioritised migrant communities as part of coronavirus preparedness programmes. This week, the UN’s migration agency, IOM, launched a response plan that has a heavy focus on migration elements, including fighting stigma and risk communication.
“Messaging must be issued in languages that are adapted to the context, and treatment must take into account specific cultures and customs,” said Jacqueline Weekers, director of migration health at the IOM.
It’s also crucial to ensure people can report their symptoms and get healthcare without fear of arrest or deportation, she added.
“It’s not just the right thing to do; it’s also the smart thing to do from a public health perspective,” Weekers said.
Some politicians have used the virus threat to push for the closure of migrant detention centres in Greece, or to “armour-plate” borders. New cases in multiple European countries – and as far away as Brazil – have been traced to an outbreak in Italy.
The fear of refugees or migrants from the Middle East – or elsewhere – carrying the coronavirus to Europe along irregular migration routes doesn’t make sense from a public health standpoint, according to Jawad.
Italy and Greece have both recorded cases of coronavirus unrelated to irregular migration, and Jawad said he is more concerned about refugees and asylum seekers in those countries catching the disease from the host populations than the other way around.
“Migrants tend to have a stereotype of being bearers of diseases, but in fact they're often healthier than the population they migrate to,” Jawad said.
As the coronavirus continues to spread, public health analysts say the international community must pay greater attention to how the outbreak could hit displaced populations.
Health crises have been an integral part of the Middle East’s conflicts and the displacement crises they have caused, Jawad said. He pointed to the outbreak of polio in Syria and Iraq in 2014, and the surge in cases of the so-called Aleppo Boil – a parasitic illness spread by sand flies – and its spread to neighbouring countries after the beginning of the civil war in Syria in 2011.
“It’s one of the things we’ve seen over and over again,” Jawad said, referring to the spread of diseases and viruses among refugees and displaced communities. “I wouldn’t be too surprised if something like coronavirus also starts spreading throughout the population because it’s part and parcel of the humanitarian disaster we have to deal with, unfortunately.”
Behind the headlines: How will COVID-19 impact crisis zones? | Thursday 19 March
Aid agencies are scrambling to adapt as the COVID-19 pandemic is felt throughout the world. Join Senior Editor Ben Parker as he speaks to leading experts and practitioners from across the humanitarian sector to discuss some of the most pressing issues.