Introducing Nerdy Guest Dr. Paula Tavrow, who joins us to talk to us about what’s happening with COVID-19 in refugee camps. Dr. Tavrow is an adjunct professor of Community Health Sciences at UCLA’s Fielding School of Public Health. She has been working on African public health issues since 1984.
A: I can speak to what’s happening in refugee camps in Africa. If you are a Darfuri refugee living in camps in Tanzania, Chad, or Cameroon, COVID-19 is a very scary prospect. The information you have received about COVID-19 has been limited or plain wrong; camp conditions make even basic hygiene and isolation of sick people a challenge; and health services are inadequate. Camp leaders are worried that COVID-19 outbreaks will be devastating, but if they manage to avoid an outbreak by cutting off the outside world, they could die of hunger instead.
Seventeen years ago, after rebel groups attacked the Sudanese government, a campaign of ethnic cleansing of Darfuris began. With the covert support of the government, Janjaweed militia composed of Sudanese Arabs began a campaign of terror—massacring thousands and setting whole villages ablaze.
According to the UN refugee agency, UNHCR, two million Sudanese have been displaced inside Sudan, and 650,000 now live in refugee camps in neighboring countries. Some children have lived their entire lives in the camps. Refugees survive on meager food rations, with little access to water, soap, and other essentials. UNHCR, the main source of supplies for camps, has been decreasing food rations over the past few years–which has heightened the need for refugees to eke out a livelihood in the surrounding area. Refugees are uncertain if they will ever be able to return home or will be permanently re-settled elsewhere. Their constant worry is that the host government will decide to close the camp and forcibly repatriate them.
Then came COVID-19. Gabriel Stauring is the founder of iACT, a nonprofit which for more than a decade has been involved in advocacy and service provision to African refugees. In mid-March, he sent a survey to refugee leaders to find out what information they received about the disease and how they could cope with an outbreak. Their responses were sobering.
First, the information refugees were getting from aid organizations working in the camps was limited and often muddled. They were told to wash their hands, but many misinterpreted the information as a generic hygiene message that they should be washing their hands with soap after using the latrine or before eating. How the disease was transmitted was not made clear. They were told that they should not congregate, yet the major way they received any important information was through mass meetings. They understood that there was to be no more hand-shaking, hugging, or kissing. The refugees also quickly replaced their standard forms of greeting with the no-contact placement of their right hand on their heart.
Second, the conditions of camp life make it very difficult to follow the most basic prevention recommendations. While water was available in camps in Tanzania, refugees in Chad and Cameroon generally had to travel for up to ten miles to bring water back to the camp because of low supply. Some refugees had access to a donkey or horse to carry water, but others had to bring water back in containers balanced on their heads. Many people do not have soap. Most donor agencies who provide supplies had stopped giving out soap in the camps a year or two ago. Refugees could purchase soap in local markets, but this meant they had less money for other essentials, like food, clothes, and medicines. During the initial panic about COVID-19, the World Food Program temporarily stopped providing monthly food rations, which were already far below the global recommendation of 2,100 calories per person per day, in some camps because it was concerned about people gathering at the drop-off locations. Camps are quite dependent on this food source. Fortunately, the organization resumed food distribution the next month.
Camp health infrastructure is another enormous problem. While health facilities run by the well-regarded Médecins Sans Frontières (MSF) in Tanzania were praised, in Chad and Cameroon the refugees were expected to use local health clinics, which were often poorly outfitted and could not handle the current basic needs of the refugees. Some camps with 50,000 to 70,000 people have only one doctor, a handful of nurses and midwives, and no laboratory facilities. Camp health centers are not equipped to test and treat people for COVID-19. As one refugee leader noted, “The health structures here are provisional and not worthy of the name.” Refugees were told that if they get sick with COVID-19 they should go to the hospital, but hospitals are far from the camps and road conditions are abysmal.
Meanwhile, because refugees live in very close quarters, isolating sick people is extremely difficult. One major university in the U.S. had recommended “pooling” together healthy and sick family members in different households. In other words, when multiple families living near each other have both healthy and sick family members, the university suggested that all the sick family members live in one household while healthy family members live in another. Healthy family members taking care of the group of sick people would be expected to follow COVID-19 guidelines.
However, this strategy could actually have major negative consequences. It might lead sick people to be entirely abandoned since healthy family members would be advised to go to another household, and might be afraid to return to tend to the sick. Even worse, pre-symptomatic people might leave a “sick” household and move to a “healthy” household, where they could then infect everyone there. Lastly, pooling households leaves some people (particularly girls and young women) more vulnerable to assault from male neighbors and cousins.
Currently, there is an effort to outfit refugees with masks and to ramp up soap distribution. In the face of this crisis, iACT has been forced to pause activities related to education, sports, and human rights. Their focus now is exclusively on public health. Some epidemiologists have wondered if refugee camps’ relative isolation could be their best defense against the coronavirus. If NGOs were able to curtail all outside visits to camps and monitor closely the current populations, they might be able to keep the disease out. But refugees need to interact with people in their host country in order to earn money for certain necessities. As one refugee respondent in Cameroon lamented, “Faced with this potential crisis, the community is very afraid. Many say that if COVID-19 arrives in Gado, the refugees will die like animals because there are no health structures and inadequate personnel to take care of all or them. Others believe that if we isolate the camp, it will be hunger that will kill the refugees.”
The Darfuri refugees’ situation was already precarious before the advent of COVID-19. The specter of disease has created additional anxiety and hardship.