Targeting COVID-19 interventions towards migrants in humanitarian settings

Millions of refugees and migrants reside in countries devastated by protracted conflicts with weakened health systems, and in countries where they are forced to live in substandard conditions in camps and compounds, and high-density slum settings.¹ Although many such settings have yet to feel the full impact of coronavirus disease 2019 (COVID-19), the pandemic is now having an unprecedented impact on mobility, in terms of border and migration management, as well as on the health, social, and economic situation of migrant populations globally. An urgent coordinated effort is now needed to align these populations with national and global COVID-19 responses.

Migrants—including the internally displaced, asylum seekers and refugees, undocumented migrants, and low-waged labour migrants—can be neglected and marginalised, live in precarious conditions, and face barriers to accessing public health and social services in the countries in which they reside. These factors considerably complicate the control of the COVID-19 pandemic. This is exemplified by the situation facing low-waged labour migrants in the Middle East working in the construction sector, where living quarters are completely sealed off after cases of COVID-19 are detected. Movement in and out of compounds is being prohibited, with workers left living in suboptimal and overcrowded conditions with limited access to health care, and substantial knock-on effects from foregone salaries for both themselves and their families back home.² Elsewhere, there have been reports of tens of thousands of labour migrants being expelled overnight back to their country of origin with no clear arrangements or provision of basic needs, such as food or shelter. In other countries, the mass movement of now unemployed labour migrants, who are evacuating cities to return home to rural communities, highlights that labour migrants—the biggest global migrant group—have not been well considered since public health measures have been introduced.³ Despite a strong public health rationale to extend COVID-19 strategies to everyone to prevent ongoing transmission, governments might prioritise their own citizens, with migrants facing devastating consequences.

In an attempt to provide targeted advice to governments and agencies dealing with large populations of migrants, the Inter-Agency Standing Committee (IASC) has released interim technical guidance on strategies to support outbreak readiness and response among migrants in high-risk camp and slum settings.⁴ Living conditions in these contexts are highly conducive to outbreaks of communicable diseases. Migrants in these settings are susceptible to COVID-19 because of the health risks associated with overcrowding, poor sanitation, exposure to the elements due to substandard shelter, and prevailing malnutrition and ill health in some cases. The guidance calls on countries to ensure that migrants are not scapegoated, stigmatised, or otherwise targeted with specific or discriminatory measures. Additionally, the recommendations highlight key interventions that will have a positive effect, including maximising site planning for improved distancing among residents and crowd management, and practical interventions to promote infection prevention and control standards.

An important component will be strong risk communication and community engagement, such as timely and accurate information in appropriate forms and accessible languages, and community involvement in the design of readiness and response plans. Lessons learned from past outbreaks in these contexts highlight that meaningful community engagement is a key element in ensuring that public health strategies are effective, including rapid uptake of vaccinations once available. Urgently strengthening surveillance systems to detect initial cases early can greatly reduce the propensity for COVID-19 to spread, and appropriate case management can reduce mortality among people infected with the virus. The declaration of temporary amnesties (eg, overturning restrictions on access to mainstream health systems) will also be crucial and is occurring in some countries. In Cox's Bazar, Bangladesh, which is home to 1 million Rohingya refugees, the Government of Bangladesh's national plan to respond to COVID-19 makes specific provision for Rohingya refugees,⁵ with preparedness efforts underway, including rapid production of cloth masks for frontline workers. Furthermore, food distribution agencies are implementing new ways of distributing food that minimise close person-to-person contact and volunteers are mobilising to spread hygiene and prevention messages.⁵ In Kenya, which hosts 500 000 refugees from Somalia and South Sudan, the UN High Commissioner for Refugees is using text messaging to encourage migrants to report COVID-19 symptoms. Social distancing and other such measures are unlikely to be feasible in these settings. Instead of lockdowns and movement restrictions, emphasis should be placed on improving surveillance and testing; implementing feasible infection control measures, such as cohorting of cases; and ensuring prompt access to health care. These measures will be vitally important as the pandemic advances into these regions of the world because it seems probable that the virus' impact could well be severe on people living in low-income countries, specifically migrants and those affected by humanitarian crises.⁶ In these contexts there could be high transmissibility due to large household sizes, intense social mixing between older and younger age groups, and high infection-to-case ratios and progression to severe disease due to the virus' interaction with highly prevalent comorbidities (eg, non-communicable diseases, undernutrition, tuberculosis and HIV).⁶ Maintaining the continuity of other important health programmes will also be crucial. Humanitarian stakeholders are rightly seizing opportunities now to maximise the simplification of care and treatment of diseases including tuberculosis and HIV, and delivery of vaccination programmes, to ensure that the global health gains made in recent years are not lost.

The fragile health systems in many of these countries see major challenges in addressing the case load and it is conceivable that governments hosting many refugees and migrants could face difficult decisions around the allocation of scarce resources, how to deal with migrants within their borders, and the strategies and approaches needed to incorporate them effectively into their COVID-19 response. Therefore, action is now required to advocate for migrants globally and to guarantee their protection. 40 years of responding to the HIV epidemic has clearly taught us the benefits of a rights-based approach to ensuring an effective and proportionate response to outbreaks.⁷ Advocating for equal prevention and treatment opportunities should be highlighted as a central pillar in reducing global transmission of COVID-19.⁸ These migrant populations need support now, alongside early access to tests, drugs, and vaccines once available.