COVID-19, Refugees, and War Zones
An update on COVID19 in refugee camps, informal settlements and dense urban slums.
Phil Botha. 2019.
Ongoing conflicts continue to produce refugees into a system (or lack thereof) that is already over capacity. It is well known that conflict, political instability, resource limitations, poor governance, weak health systems and public health infrastructures, and poor air and water quality make responding to disease outbreaks extremely difficult. Of 169 countries reporting cases of COVID-19, 79 are refugee-hosting countries with reported cases of local transmission at the end of March. Here is a brief update based upon recent documents and experience from previous epidemics.
In North West Syria, population 4 million, there are a total of 153 ventilators and 148 beds in ICUs, while nearly a million recently displaced people are living in overcrowded areas. In North East Syria, with approximately 2 million inhabitants there are fewer than 30 ICU beds, only ten adult ventilators and just one paediatric ventilator
In Gaza, there are 70 ICU beds and 62 ventilators for 2 million people. It is also one of the most densely populated areas in the world, with a high proportion of the population living in refugee camps with limited access to water and other basic services.
In Yemen, where only half of the hospitals are still fully functional, there are 700 ICU beds, including 60 for children, and 500 ventilators.
Reporting from north-west Syria, the head of Idlib’s health directorate, Dr Munzer al-Khalil, said: “In one year, we lost around 76 health facilities. Donors have cut their funds and medical staff have been killed, arrested or displaced. The health sector in Idlib cannot cope with the inevitable outbreak and we fear 100,000 people could die unless we get supplies immediately. Our ventilators are always 100% occupied and we don’t have one single bed ready for a corona virus case today. Camps are the perfect breeding ground for the virus and [we are] 400% over capacity, with 10 or more people sharing one tent.”
We have seen that social distancing is very challenging in crowded cities like NYC, with devastating consequence. Imagine the speed of transmission in packed refugee camps and food distribution sites.
However, as an April 8th 2020 Nature Medicine publication attests, based upon previous epidemics and pandemics (Ebola, SARS, MERS, H1N1, and influenza) the death from indirect effects (interruption of life-saving treatment for TB, DM, CVD, HIV, diversion of resources, medical supply disruptions, death & illness in providers, absenteeism) exceeds the death from the disease. During 2014–16 Ebola epidemic in West Africa, reduced Rx for TB, HIV & malaria caused 10,600 deaths while the total Ebola deaths in same countries caused 11,300 deaths.
Survival Rules:
Observe the ceasefire
Maintain essential services
Protect healthcare workers, with PPE, testing and economic protection from impacts of quarantine and self-isolation
Promote access to infection prevention measures
Build/maintain transparency, trust and community partnerships with authorities who are responsible for the camps
Avoid stigmatizing policies
Countries housing refugees are technically responsible for the wellbeing of those refugees, but many are prioritizing their own citizens (for example, in early March, Greek authorities on the Island of Lesbos were unable to provide food and medical attention to refugees being held there). Restrictions on humanitarian aid to vulnerable areas, such as Israeli restrictions on Gaza, must be lifted.
Finally, stigmatizing and harsh migration enforcement with disregard for displaced pop-ulations undermines the first-line public health defences, i.e. the willingness for individuals to report symptoms and seek care. Pandemics do not discriminate and access to care should not either. Protecting our most vulnerable populations is not only a moral imperative but an urgent public health requirement: the health of one is the health of all.
These notes are compiled from the talk by Tim Takaro, MD, MPH to the IPPNW Canada Active Member Meeting on 8 April 2020, reprinted with his permission.