Deprioritised in the health response: fragility of refugees in the Middle East and North Africa region during the COVID-19 pandemic
Jasmin Lilian Diab and Dana Nabulsi, American University of Beirut, Lebanon
The Middle East and North Africa (MENA) region has experienced a massive influx of refugees and internally displaced persons over the last decade with Jordan and Lebanon currently home to the highest number of refugees per capita worldwide. In Jordan there are 657,000 UNHCR-registered Syrian refugees and in Lebanon there are 1.7 million refugees including 1.5 million from Syria – with unregistered migrants putting that number somewhere between 1.5 and 2 million refugees. A number of refugees live in heavily populated camps or impoverished regions with poorer health, water, sanitation and hygiene facilities making preventive measures in these areas and throughout these camps, such as regular access to water and basic sanitation and hygiene, social distancing and self-quarantine, very challenging to implement. As a result, the situation for refugees amid COVID-19 is exceptionally challenging in Jordan and Lebanon in terms of access to health services and opportunities to obtain legal work permits amid large-scale unemployment exacerbated by the pandemic. In conflict-ridden areas, where health systems are already fragile and medical resources are scarce, refugees lack adequate access to both detection mechanisms and necessary medical attention, rendering it almost impossible to assess the prevalence of the pandemic and track its spread. It is evident at this stage in the spread of the COVID-19 pandemic that it has rendered humanitarian and conflict-affected areas especially vulnerable and finding ways to integrate migrants and refugees, regardless of their formal/legal standing, in national development and rescue plans for tackling the virus is essential toward preventing the pandemic from spreading in refugee camps.
In early March 2020, the Lebanese Ministry for Social Affairs unveiled a preventive plan in coordination with representatives from nongovernmental organisations (NGOs) and international organisations to prevent the spread of the virus in areas hosting refugees. The plan encompasses hygiene awareness campaigns targeted at refugees as well as the provision of disinfection equipment across camps and informal settlements. The United Nations High Commissioner for Refugees (UNHCR) is leading the pandemic response among refugee communities through its partner NGOs. This response includes community engagement and awareness, and support for the healthcare system and coverage of COVID-related expenses among refugees. The UNHCR, currently responsible for Syrian refugees in the country, and the United Nations Relief and Works Agency (UNRWA), currently responsible for Palestinian refugee community, have both said they will only cover the cost of testing and treatment of refugees if the refugee has first contacted the hotline and followed its instructions – but resources such as phones and overall communication in camps remains limited.
In Jordan, the instituted lockdown disrupted existing aid distribution systems with restricted mobility. However, the government, in coordination with UNHCR, has put measures in place to ensure sustained access to national health services for refugees, including referrals of suspected cases to designated quarantine locations and the provision of requisite treatment. Temperature screening has been implemented at the entrance of two major refugee camps, electricity provision has been enhanced and the supermarkets are running extended hours to facilitate social distancing. In-kind aid distributions are offered through the Jordanian Hashemite Charity Organization with a significant portion of these distributions targeting refugees particularly. Nonetheless, the majority of refugees do not rely solely on aid and employment is essential for their livelihoods, a requisite that has been severely restricted.
Organisations are redirecting their funds to COVID emergency response from existing programmes which, without additional funding, will create long-term consequences. International organisations have hyperextended themselves to collectively mobilise and assist some of the most fragile states in the region by strengthening their capacity and response to the crisis. To this aim, the World Bank announced a 26.9 USD million grant to support Yemen’s efforts to contain the outbreak, most of which will finance the procurement of medical equipment, the rehabilitation of health facilities, as well as training for additional emergency medical staff. Furthermore, ongoing discussions are assessing the manners through which cash transfers can be made to Syrian refugees in camps. Lastly, the European Union has approved close to 240 million EUR to cement resilience in neighbouring states hosting Syrian refugees while they struggle to contain the COVID-19 pandemic.
In spite of these tireless efforts, several obstacles to their success remain from both health and political economy perspectives. Although to this day no ‘major’ outbreaks have been reported across any of the refugee camps throughout the region, the lack of or limited testing capacity in areas with high concentrations of refugee communities continues to raise concerns about the possibility of hidden COVID-19 cases. This risk is compounded by the limited capacity of health systems in the region which has ultimately led to refugees being ‘deprioritised’ in the health response. Furthermore, limited refugee healthcare access has continued to deteriorate during the pandemic as discriminatory measures of lockdown and curfews have increasingly restricted their mobility, including their ability to access healthcare. Unregistered refugees face additional restrictions and obstacles in this regard as they stand not to benefit from return support when this is put in place and UNHCR may not be able monitor their movement as per its mandated responsibilities, which may result in renewed forms of displacement amid the escalating pandemic. At this stage of the spread more than ever, it is pivotal that national health systems factor in the testing and treatment of refugees.
The COVID-19 outbreak has worked to cement additional and severe strains upon refugees’ economic security – assuming they had any economic security prior to this crisis. Most refugees, and women more specifically, work in the informal sector. As the UNHCR report, ‘Woman Alone: The Fight for Survival by Syria’s Refugee Women’ highlights, these women rely heavily on jobs where they earn their income on a daily or hourly basis. However, restrictions on mobility, closures of small businesses, labour opportunities shifting to more manual work, and scaremongering when it comes to the virus infiltrating the refugee community in the region has prevented, and continues to prevent, refugees from working at all. This has raised essential concerns as to their ability to sustain themselves economically and provide for their basic needs. Human Rights Watch has insisted that prolonged confinement measures risk exacerbating poverty among refugees and, in turn, is ‘threatening everyone’s health’. This poses significant challenges in countries such as Lebanon where the World Bank estimates that approximately one third of refugees already lived in extreme poverty prior to the outbreak.
In tandem to health and economic impacts, the COVID-19 outbreak has also had severe implications upon the relocation processes of the refugee community as part of their asylum-seeking processes. With UNHCR and IOM announcing the resumption of resettlement travel for refugees only recently in a joint statement, border closures and travel restrictions have heavily affected and delayed the right to asylum as all resettlement procedures have been on hold for months. This has forced hundreds of thousands of individuals to return to situations where they fear persecution or torture in violation of the non-refoulement principle of the 1951 Refugee Convention.
In a region where currently some 50 million people are undernourished, governments will need to safeguard a swift response to slow down the increase in food insecurity which has already begun in the region because of the escalating economic consequences of COVID-19. This risk will be intensified if disruptions in global food supplies due to the pandemic lead to food shortages and instigate price hikes in MENA countries which are highly dependent on food imports. Such is the case in Lebanon where its dwindling currency currently intersects with the pandemic.
Despite a non-universal approach over the best way forward and out of this pandemic, most states gradually moving out of lockdown are implementing strict physical distancing rules as they try to avoid lasting economic damage. However, with no known treatment or vaccine available, experts warn that an extensive lifting of controls could spark a second (and perhaps deadlier) wave of a pandemic that has so far sickened more than five million people and caused more than 330,000 related deaths as of June 2020. Indeed, the World Health Organization has repeatedly urged countries to be cautious about easing coronavirus-related restrictions, warning that a premature lifting could lead to an uncontrolled resurgence in transmission and an amplified second wave of cases. In recent weeks, as debates about exit strategies intensified globally, experts around the world have published relevant guidance, with many referencing the past to offer recommendations on the path ahead.
The Center for Infectious Disease Research and Policy predicts ‘the worst-case scenario’ as a larger second wave before the end of 2020, followed by one or more smaller waves next year. This is based on trends recorded during the influenza pandemic of 1918-1919 that killed an estimated 50 million people, as well as the 2009-2010 H1N1 pandemic. Moving forward, it is important that we consider refugees and the effect of restrictions and lockdown on their livelihoods as well as their health in any guidelines and plans for the next phase of the pandemic. At this stage of the conflict it is pivotal to establish a balance between controlling the spread of the virus whilst also mitigating the intersectional risks it poses on refugees. The integration of migrants and refugees, regardless of their formal/legal standing, in national development and rescue plans remains the only viable solution for containment at this stage in a region that already grapples with post-hoc policies to combat unforeseen conflicts on all levels.
Jasmin Lilian Diab and Dana Nabulsi
Jasmin Lilian Diab, ABD currently serves as a Research Associate at the Global Health Institute at the American University of Beirut, where she works on the Political Economy of Health in Conflict under the Institute's Refugee Health Program. She also serves as the MENA Regional Focal Point on Migration to the United Nations Major Group for Children and Youth. She is completing a PhD in International Relations and Diplomacy at the CEDS, INSEEC U. with an emphasis on migration and security.
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