Jun 19, 2021 Volume 397 Number 10292 p2309-2438, e16
Protecting refugees during the COVID-19 pandemic
his World Refugee Day, June 20, coincides with 70 years of the 1951 Refugee Convention, a multilateral treaty that shaped the standards that provide the bedrock of international protection for refugees against discrimination and violation of their human rights. The COVID-19 pandemic has weighed heavily on the 26·3 million refugees worldwide today. International guidelines and national programmes to curb transmission have not always considered the needs of refugees living in densely populated shelters without water and sanitation facilities. The economic harms of the pandemic disproportionately affect the poorest people, applications for asylum and resettlement were disrupted by lockdowns, and refugees have been blamed for spreading SARS-CoV-2. It is timely to consider whether the spirit of the Refugee Convention is being upheld and whether refugees are getting the protection to which they are entitled.
Vaccination is the central pillar of global recovery from the COVID-19 pandemic, but most refugees face a double burden of vaccine inequity. First, 86% of refugees live in low-income and middle-income countries (LMICs), which are heavily reliant on COVAX, an initiative set up to ensure equitable access to COVID-19 vaccines and built on principles of solidarity. But as a World Report in this issue explains, weaknesses in design and selfish political motivations have led to the failure of this vision. As of June 14, only 87 million doses have been shipped to 131 countries through COVAX, far below targets. Second, many LMICs that have received vaccines are not prioritising refugees. For example, in Bangladesh, where 2·5% of the population is fully vaccinated, not a single dose has been administered in Cox’s Bazar. In the world’s largest refugee camp, non-pharmaceutical measures remain the sole tool to prevent major outbreaks.
A report by the ECDC shows how even in high-income countries with advanced immunisation programmes that include (and in some cases prioritise) refugees, barriers to care and vaccination still exist. Uptake of vaccination is low, and the report presents evidence that vaccine acceptance in European migrant populations is undermined by communication challenges, discrimination and stigma, fear of deportation, and a loss of trust in authorities. These issues partly explain why refugees and asylum seekers more generally have suboptimal access to primary health-care services in the region. Language barriers contribute to a deficit of accurate information, and social marginalisation has allowed misinformation to spread, fuelling vaccine hesitancy. Engaging with refugee communities to understand their concerns and studying barriers to vaccination will be essential for protecting all.
Indeed, there is no shortage of research needs in studies of refugees, migration, and health. To this end, building on the recommendations of the UCL–Lancet Commission on Migration and Health, the Lancet Migration European Regional Hub launches on June 22, to fill a major gap in pan-European migration and health research initiatives. It will address research needs, foster collaboration, and bring evidence-based approaches to public discourse and policy around migration and health.
But addressing these issues is not simply a matter of acquiring more and better evidence. Political and moral discussions about migration and refugees are taking place too. All countries, including wealthy ones, have suffered grievously because of COVID-19. Millions of people have died, health systems have been overwhelmed, and economies have been shattered. A wish to turn inward at such a moment is understandable. Even US Vice-President Kamala Harris warned would-be Guatemalan migrants not to come to the USA earlier this month. How can a broken nation look beyond its own citizens? And how do we square this dilemma with the need to protect refugees?
The clearest argument is that refugees and migrants make huge contributions to society. Most international migrants who are refugees live in urban areas, where their work on the front-lines of health care and hospitality is central to pandemic response and recovery. But just as important, is health’s potential to be a unifying force. In the UK, the Government is reducing the foreign aid budget from 0·7% to 0·5% of gross national income. This decision has prompted not just criticism from humanitarian agencies and opposition parties, but also a recent rebellion from senior members of its own party. What unites them is a basic agreement that policy should not condemn individuals to death or illness. Viewed this way, health becomes an instrument to cut across political divides. In an age when the world faces competing and reinforcing challenges, of climate change, conflict, pandemics, mass forced migration, and polarised political responses, such an instrument could be invaluable.