Coronavirus lockdowns force the world's poorest into deadly trade-offs between their health and livelihoods
This article is republished from The Conversation under a Creative Commons license. Read the original article here.
Abu Bakr’s family had packed up their improvised tents in Sindh, south-east Pakistan, by mid-October 2019. Three months earlier, they had lost their houses and fields due to uncharacteristically heavy monsoon rains. Now they were returning to their village near the settlement of Mirpur Sakro to rebuild their homes. But any hope that the family could return to normality might turn out to be short-lived.
The family lives off what it grows, selling any excess produce and the occasional buffalo at the market to obtain cash for supplies or healthcare. Except that by mid-March, many of Sindh’s markets were closed because of COVID-19.
I met Abu Bakr during my ongoing research into the risks and vulnerabilities of displaced populations to zoonoses – diseases transmittable between animals and humans. In Pakistan, internally displaced populations such as Abu Bakr’s family often depend on movement to keep safe during the monsoon, for livestock grazing and the occasional seasonal work.
As they share their living, cooking and washing spaces with their livestock, zoonoses are a real concern. Even if it’s rare for these diseases such as COVID-19 to move from animals to humans, endemic zoonotic and other infectious diseases are common among displaced populations. If people are displaced from their homes, they may become more vulnerable because of their changing environment, the limited availability of services such as healthcare, and the inadequate supply of food or its poor preparation.
Displaced people are also more at risk of COVID-19, since prevention measures such as physical distancing are less effective in crowded relief camps where large households live in small shelters. Regular hand washing is often impossible without a sufficient supply of clean water.
The lockdowns are disproportionally affecting the world’s poor and displaced populations in other places too. In Karachi, Afghan refugees have been unable to access work due to movement restrictions imposed by a curfew. The effect on their livelihood is increasingly becoming a risk to their health.
In Jordan, host to one of the world’s largest refugee populations, the government closed its borders early in the pandemic. It also imposed strict curfews, restricting access to refugee camps from outside visitors, which affected how much aid was available to its inhabitants.
Some humanitarian agencies shut down non-essential programmes as a result of the pandemic. For example, nutritional programmes targeted at refugees and displaced people – essential to people’s immune response – were affected.
Syrian refugees in the Zaatari refugee camp in Jordan are struggling to meet basic needs as they can no longer leave the camp to work. Their poor nutrition will inadvertently increase their vulnerability to disease. It doesn’t help that livestock are often not allowed in formal relief camps, since they could contribute to people’s livelihoods and food, improving nutrition.
In late March, the UN launched a US$2 billion (£0.9 billion) COVID-19 humanitarian response plan urging donors not to neglect funding to ongoing emergencies – including refugee and displacement crises. It stressed that providing basic healthcare and preventing overlapping health conditions are essential in limiting the severity of disease.
But health programmes are already being affected by the crisis. In April, the WHO’s Strategic Advisory Group of Experts on Immunisation advised countries to suspend mass vaccination campaigns. Early reports suggest that polio cases in Sindh have increased, a situation bound to worsen due to the lack of vaccinations. This could have far-reaching and long-term negative effects in the region.
Other efforts to control disease will be affected by COVID-19 too, as healthcare systems get overwhelmed, limiting access to health clinics and the supply of medicines. In Jordan, humanitarian health support provided through urban health clinics to the refugees, most of them Syrian, living outside the camps, has been suspended.
Abu Bakr’s family suffers from seasonal malaria outbreaks – important when one remembers that reduced access to anti-malarial health services and mosquito nets in west Africa during the Ebola outbreak caused more deaths than the virus itself.
Look to the long term
Indiscriminately implementing standard prevention measures against COVID-19 or other zoonotic disease in countries with limited resources, complex emergencies or high levels of displacement has life-threatening consequences. Government policies and humanitarian responses need to address immediate health needs, as well as long-term livelihoods and food supply.
It’s long been an ambition of humanitarian and development agencies to include migrants, refugees and displaced people in the delivery and design of aid operations. Today’s restrictions on international and local movement reiterate the importance of shifting responsibility of humanitarian responses to local groups. In Sindh, local leaders are already actively increasing COVID-19 awareness among communities.
Soon Abu Bakr will have to decide how to safely protect his family and their livestock from the monsoon floods as well as COVID-19. Trade-offs between health risks and livelihoods need to be carefully negotiated. One way to do this would be to use data on levels of poverty and coping mechanisms to contribute to models of how diseases spread. Wherever possible, researchers developing such models and responses to zoonotic diseases should get displaced populations to participate as much as possible. The weakest populations need to be supported to protect the global health of all of us.
This post was published earlier on 12 May 2020 under the same title on the Centre for the Study of Global Human Movement blog: https://centreghum.com/2020/05/12/covid-19-in-displaced-populations
While walking through the mud among the improvised tented shelters of an informal camp housing Syrian refugees in Jordan, I was approached by a desperate mother and her young disabled son. Amina showed me a hand-written prescription of the medication she needed but had been unable to obtain, after losing access to medical assistance. As the war in Syria drags on, humanitarian actors have shifted from emergency response towards longer term development aid, affecting the assistance available to people living outside formal refugee camps.
The recent measures, that have been implemented to reduce the impact of the unfolding COVID-19 pandemic have further restricted the availability of aid. Lockdowns and movement restrictions have severely disrupted the supply of medical and food items available to refugees in- and outside camps. ‘Worldwide COVID-19 policy and health responses have so far mainly relied on uncontextualized ‘science-based’ risk assessments, which risk exacerbating local socio-economic and health inequalities.
Interconnected and compound hazards
COVID-19 is a zoonotic disease, with its pathogen – in this case a virus – originating in animals. While over 60 percent of diseases infectious to humans are believed to be of animal origin, few evolve from an interspecies (animal to human) to intraspecies (human to human) pathogen such as the novel coronavirus. There are many known zoonoses, like Bovine Tuberculosis and Brucellosis, although most are ‘endemic’: constantly circulating through animal populations and causing significant economic and health losses among people dependent on livestock for their livelihoods and nutrition.
Zoonoses show us the interconnectedness of organisms. In response to the artificial barrier which historically existed between sectors, the ‘One Health’ approach was developed to combine human, animal and environmental health research and responses. While this approach has been effective in integrating cross-sector responses by addressing issues such as wildlife trafficking, environmental degradation and food supply, the societal impacts of the recent pandemic have demonstrated the need to further improve interdisciplinary approaches to address zoonotic health risks.
The risk of disease infection and transmission depends on complex interactions of not only biological but also environmental, socio-economic and political factors, which may exacerbate or mitigate one another. In the UK, the elderly and people with underlying health conditions are generally considered most vulnerable to COVID-19; however, in countries with limited resources that face complex emergencies, high levels of unemployment and poverty, and a limited availability and capacity of healthcare, many more people are at risk. The pandemic is certainly not the ‘great equalizer’ as Madonna mused early on. Interpersonal relations within households and communities further determine risk of infection. While COVID-19 seems to affect men more severely, in many low-income settings women are traditionally in charge of caring for sick household members, putting them at increased risk for disease infection.
There is growing evidence that persistent socio-economic and health inequalities related to political and economic processes adversely affect the disease risks of resource-poor communities. COVID-19 has rendered this inequality visible even in the UK, where COVID-19 related deaths were twice as high in the poorest areas such as Newham in London. While prevention and treatment are key in mitigating infectious disease outcomes (Hammer et al, 2018), resource-poor countries often lack the resources for comprehensive health systems, thereby exacerbating socio-economic vulnerabilities.
While lockdowns have grounded global and national movements to a halt, curfews are a measure of luxury, worsening social inequality, especially in countries where many people are dependent on daily wages and labor migration. For example, the sudden imposition of curfew, then lockdown, followed by the suspension of train and bus services has led to the loss of livelihoods, massive internal migration and even death in India. In Pakistan, pastoralists are no longer able to move their herds to seasonal water and food sources, risking the loss of thousands of livestock in the Thar desert, as well as their main source of nutrition and income. Imposing blanket movement restrictions can thereby risk exacerbating people’s ill health.
Increased vulnerability of displaced
Meanwhile, displacement itself can be considered a risk to population health. Displaced populations are among the most vulnerable people to disease, as they tend to be poorer, stigmatized, stressed and subject to structural violence (Singer et al, 2017). Displaced populations may inhabit unregulated areas in informal settings, lacking official status and coping mechanisms. Many internally displaced and refugees depend on humanitarian assistance, which is now heavily affected by the restrictions put in place due to the COVID-19 outbreak. The lack of resilience among displaced communities due to the loss of assets and fragmented social infrastructure influences available coping mechanisms to deal with ill health and disease.
The pandemic is expected to increase the mortality rate of other diseases across regions as healthcare systems get overwhelmed and health professionals fall ill. Resources to develop vaccines and treatment, ventilators and protective gear will be less available in low-income settings, especially to non-indigenous populations. Standard responses to COVID-19 such as physical distancing and improved hygiene are difficult to implement in areas where people live closely together and share sanitation facilities. Refugees and internal displaced populations often lack access to basic healthcare, especially when living outside formal relief camps. COVID-19 therefore not only has significant health impacts, but also both the disease and the responses to it risk increasing poverty and displacement. The shift to remote operations by humanitarian agencies further increases the risk of highlighting any pre-existing inequalities, by those with least access to humanitarian assistance now potentially losing out altogether.
To prevent zoonotic disease transmission, livestock is often prevented from accessing formal relief and refugee camps, even though losing this important source of nutrition may negatively impact people’s immunity and overall health status. In response, refugees may choose to live in informal tented settlements as they consider official camps unsafe or unsuitable to their livelihood. Livestock owners living outside formal camps often have limited access to humanitarian assistance. Informal tented settlements, which have grown organically without planning, often have limited water and sanitation facilities, the lack of hygiene posing further risks to the residents’ health.
COVID-19 will have a significant impact on refugee and other displaced populations worldwide beyond health. If policies and responses are not carefully contextualized, these risk increasing people’s vulnerabilities, not only to disease but to (further) displacement. Socio-economic and health inequalities need to be addressed to prevent negative coping mechanisms to zoonoses such as environmental degradation and conflict, which may in turn cause more displacement and health risks.
The range of trajectories in COVID-19 outbreaks across countries and communities show us the importance of studying socio-economic and political decisions and interactions. More research is needed to determine how policies impact displaced people’s decisions, and the effect on their vulnerability to disease. Responses need to primarily be based on local people’s knowledge, experiences and traditional community responses to infectious diseases.
As COVID-19 spreads through this interconnected world, we must also improve interconnectivity of sectoral responses, ensuring an interdisciplinary approach to public health. Addressing underlying causes of health inequality is just one of the issues which needs to be resolved, to ensure Amina can get the medication her son needs.
 Not her real name.
 Narrod et al (2012). A One Health Framework for Estimating the Economic Costs of Zoonotic Diseases on Society. 9 (2) 150-162.
 Hammer, C. et al (2018). Risk factors and risk factor cascades for communicable disease outbreaks in complex humanitarian emergencies: a qualitative systematic review. BMJ Global Health 3(4).
 Singer, M. et al (2017). Syndemics and the biosocial conception of health. Lancet 4;389 941-950.