By: Dorien Braam
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.
Dorien Braam is a PhD Candidate at St John’s College Cambridge funded by the Gates Cambridge Trust, and Director of Praxis Labs, a global research collective focusing on displacement, protection, labour migration and health. Her PhD research looks at the risks of zoonotic disease transmission among displaced populations, for which she conducted fieldwork in Sindh, Pakistan and Mafraq, Jordan.
 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.