The following is a guest post by Kwan Kew Lai, M.D., DMD, FACP
On March 11, 2020, Director-General of the World Health Organization Dr. Tedros Adhanom Ghebreyesus recognized the spread of the new coronavirus, SARS-CoV-2 as a pandemic. By that time, it had traveled to 114 countries, infecting more than 120,000 people worldwide with more than 4,000 deaths. It may be a matter of time before it arrives at one of the crowded refugee camps.
This coronavirus has shown that even the most advanced countries with state-of-the-art healthcare systems have been caught unprepared and are struggling to get the prevention, control measures and care in order. If and when it arrives at the crowded refugee camps dotted throughout the world, would they be ready for a possible COVID-19 outbreak? Given the often widely traveled workers from non-governmental organizations and numerous volunteers from all over the world, it is not inconceivable that the coronavirus would find its way into the camps.
As of 2018, the United Nation High Commissioner for Refugees recorded that 70.8 million individuals have been forcibly displaced worldwide because of persecution, conflict, violence, or human rights violations; 42 million internally displaced and 26 million refugees.
Communicable disease control in refugee camps poses a challenge. During an acute emergency, water availability, sanitation, and crowded living conditions in camp settings present a favorable environment for epidemics of infectious diseases. Preparedness to recognize and manage an outbreak of communicable disease is essential.
As a humanitarian response volunteer, I have been to the Rohingya refugee camps in Cox’s Bazaar, Bangladesh, housing over a million refugees after their “ethnic cleansing” and August 2017 forced exodus by the Myanmar military. The poor living conditions typically seen in refugee settings: such as reduced access to health care, low standards of clean water, sanitation and hygiene, malnutrition, and high population density, often associated with infectious disease outbreaks, still prevail.
At the end of 2017, three months after the waves of refugees crossed the border to Bangladesh, a diphtheria outbreak beset the camps with 440 cases reported during the first month and till now sporadic cases of diphtheria still occur. The camps at Cox’s Bazaar with the existent non-governmental organizations have had experience in dealing with the disease outbreak at a time when sanitary conditions in the camps were in their infancy and they had admirably coped with it in very short notice.
On the other hand, the Greek islands are bursting with thousands of refugees in crowded camps that were supposed to house much fewer number of refugees. I also volunteered at Moria Camp on the Greek island of Lesvos where 20,000 refugees are housed in a camp designated for 2,000, the conditions are even more dire with anti-migrant riots and setting of fires in the camps leaving refugees with little food and medical care as attacks on medical volunteers have caused several non-governmental organizations to leave temporarily. The morale of the refugees is at an all-time low. Similarly, thousands of Syrian refugees camping in neighboring countries of Turkey, Lebanon, and Jordan, are all vulnerable to a potential threat of infectious diseases.
Recently, the first case of COVID-19 on Lesvos brought fears of a potential outbreak in the camp to the forefront. Refugees in Moria camp often travel to Mytilene, the city on the Lesvos Island to shop, invariably they would be interacting with the locals. Bangladesh has 24 cases of COVID-19 as of March 21, 2020.
The coronavirus which started in Wuhan, Hebei Province of the People’s Republic of China at the end of last year quickly spread within China despite the best efforts of identification, isolation with lockdowns and curfews and prevention methods. It soon spread within China and beyond.
Would the refugee camps become the new Wuhan in this novel coronavirus outbreak?
At Cox’s Bazaar, recognizing the potential threat of the new coronavirus, UNHCR has started to work with the Ministry of Health of Bangladesh to set up “a multi-sector preparedness and response plan”. The first line of defense is disease outbreak detection, isolation, and contact tracing. Hundreds of health workers in the camp area are receiving training in infection and control of COVID-19. The Rohingya community is urged to heighten personal and food hygiene measures. Designated isolation facilities have also been set up and WHO has provided basic personal protection equipment to the district hospital. It has also distributed non-contact thermometers to Cox’s Bazar airport as health officials had started screening all passengers.
Women and children comprised most of the inhabitants of almost all refugee camps. Although there is no data on the vulnerability of pregnant women to SARS-CoV-2 virus and children seem to fare better than elderly people especially those with underlying conditions experiencing higher mortality. It remains unknown how malnourished children in refugee camps would fare in this coronavirus infection.
It may be an opportune time for UNHCR to have all refugee camps to be prepared for a possible coronavirus onslaught. The challenges are, almost all the refugee camps already have many unfulfilled basic needs even before more consistent and concrete preparation for an outbreak can be envisioned. In the short term, the refugees themselves may not see this as their priority.
Despite these challenges, UNHCR, along with the on-the-ground-partners, should take steps to prepare for a potential coronavirus outbreak at the refugee camps. At a minimum, all camps must have an active disease surveillance by trained health workers using accepted case definition and making diagnostic tests and results readily available. Early detection of cases will allow timely initiation of control measures and activation of outbreak operational plans to control the spread. For that to happen, many people will have to be trained for surveillance and the coronavirus tests have to be made available. Where morale for the crowded Greek island refugee camps was devastatingly low, it might be difficult to convince leaders of the various sectors of the camps to recruit trainees for disease surveillance.
Community mobilization may be key to successful prevention and control of epidemics. The members of the refugee camps should be educated and made aware of a potential coronavirus outbreak and enhance personal hygiene. In the case of the refugees on the Greek islands, it would be extremely difficult to enforce given the crowded conditions and difficult access to water sanitation facilities and healthcare. Not until the crowded conditions and ready access to sanitation are addressed, it may be a challenge to convince the refugee community that they need to get together to confront the possibility of an outbreak.
The need to expand health facilities and/or create an isolation ward may arise suddenly in outbreak situations. In the planning stages for the possibility of a coronavirus infection, contingency plans should address this eventuality. Key personnel may include collaboration with site planer, water and sanitation engineers and local partners to decide where an isolation ward could be situated and do all necessary preparation work.
During an epidemic, essential supplies will be needed urgently while transportation may be disrupted. In addition to making sure there are health facilities and health services for an outbreak, the stockpiling of supplies of medicines and materials is essential. For coronavirus, personal protective equipment will be crucial along with access to soaps and alcohol-based hand sanitizers. In the developed world, these things are already in short supplies, competing with such players by the refugee camps may prove difficult. Already there are non-governmental organizations that have made their mission to help stock up such materials for Cox’s Bazaar, refugee camps in Syria, Lebanon, and Gaza.
SARS-CoV-2 has proven to be capable of widespread community spread. Once introduced into a crowded refugee camp, such spreading of a rising tide of COVID-19 infection will be difficult to stem without preparedness and contingency plans. The nongovernment organizations I know are actively helping the refugees to get ready are MedGlobal and SAMS — the Syrian American Medical Society. I’m sure there are others. But containing transmissions, and their impacts across the world and among the most vulnerable populations on earth will require national and international investments everywhere infectious diseases spread.
Kwan Kew Lai, MD, DMD, FACP is a Harvard Medical School faculty physician and the author of Lest We Forget; A Doctor’s Experience with Life and Death during the Ebola Outbreak and the upcoming Into the African Bush out of Academia: A Doctor’s Memoir.
Photo credit: Charles FitzGibbon