Leaving no one behind in the Covid-19 Pandemic: a call for urgent global action to include migrants & refugees in the Covid-19 response

Lancet Migration1 is a global collaboration between The Lancet and researchers, implementers, and others in the field of migration and health that aims to address evidence gaps and drive policy change building on the recommendations of the UCL- Lancet Commission on Migration and Health published in December 2018. This global statement was written by the executive committee of Lancet Migration. Please visit www.migrationandhealth.org for further details.

People on the move, whether they are economic migrants or forcibly displaced persons such asylum seekers, refugees, and internally displaced persons (hereafter called migrants & refugees), should be explicitly included in the responses to the coronavirus disease 2019 pandemic. This global public health emergency brings into focus, and may exacerbate, the barriers to healthcare these populations face. Many migrant & refugee populations live in conditions where physical distancing and recommended hygiene measures are particularly challenging. The Covid-19 pandemic reveals the extent of marginalisation migrant & refugee populations face. From an enlightened self-interest perspective, the Covid-19 disease outbreak control measures will only be successful if all populations are included in the response. It is counter- productive to exclude migrant & refugee populations from the preparedness and response to the Covid-19 pandemic. The Covid-19 response globally should be guided by the following recommendations from the UCL-Lancet Commission on Migration & Health:2

• Universal and equitable access to health services and to all determinants of the highest attainable standard of health within the scope of universal health coverage needs to be provided by governments to migrant populations, regardless of age, gender, or legal status.

• It is essential to recognise inclusion of mobility as key to effective health care and health systems and to shift away from the traditional structure and delivery of health systems through geopolitical borders.

• Racism and prejudice should be confronted with a zero tolerance approach. Public leaders and elected officials have a political, social, and legal responsibility to oppose xenophobia and racism that fuels prejudice and exclusion of migrant populations.

It should be noted that many of the challenges listed below for migrant & refugee populations are similar to national populations living in similar conditions. Excluding non-nationals in preparedness and response plans will negatively affect the public health of all populations.

Challenges for migrant & refugee populations in the response to Covid-19 include:

a)  Poor access to prevention capacity for Covid-19 due to poor living conditions and therefore a limited ability to follow outbreak prevention measures. Living conditions, such as large, inter-generational households and high- density collective areas (e.g. informal settlements, refugee camps, detention/reception centres) undermine social distancing guidance; populations living in slums and also vulnerable groups such as those who are homeless also face these challenges. Limited access to safe water, sanitation and hygiene facilities further restricts the ability of some migrant & refugee populations to adhere to prevention guidance. Some of these populations may also face a higher susceptibility to Covid-19 due to pre-existing health conditions and poor nutritional status.

b)  Multiple barriers to accessing healthcare already exist, including legal status; discrimination and xenophobia; lack of migrant- & refugee-inclusive health systems and health policies; which result in poor outcomes due to delayed or no access to supportive treatment. Aspects such as inaccessible or inappropriate health communications/information; and fear and mistrust of healthcare authorities or government providers also exist as challenges. The coronavirus disease 2019 pandemic brings these barriers into sharp focus and threatens large numbers of avoidable deaths in such populations due to limited access to healthcare.

c)  Greater economic precarity due to exclusion from welfare support and compensation programmes at the national level, and limited donors and logistical barriers at the international level. This also means that some migrants & refugees may have little choice but to continue working despite public health guidance, potentially increasing their exposure to and transmission of Covid-19. In many countries, migrants make up a disproportionate amount of the health and care workforce, further exacerbating this.

d) Increased xenophobia and racism have already been witnessed in response to the pandemic. In some places this rhetoric may be intentionally politicised to scapegoat migrants & refugees for the spread of Covid-19, contrary to evidence that the risk of transmission of communicable disease from migrant population to host populations is low3.

Responses to Covid-19 should explicitly include all groups of migrants & refugees. The right to health4 and global commitments of countries to ensure that “no one is left behind” in the Sustainable Development Goals (SDGs)5 need to be upheld. The Covid-19 disease outbreak control measures can only be successful if all populations are included in the response. The following recommendations are rooted in both human rights and public health principles.

Lancet Migration calls for:

Urgent access to healthcare for all migrants & refugees throughout the response to Covid-19

R1. Immediate suspension of laws that limit migrants & refugees access to healthcare services and economic support programmes. This may be achieved through measures such as temporarily granting residency to migrants & refugees and suspending health care user fees. Internal migrants and those internally displaced need special focus during lockdowns, in order to ensure that these measures do not disproportionately disadvantage these populations, and that their previous lack of access to basic shelter, water, sanitation and hygiene, or food is not compounded.

R2. ‘Firewalls’ to be put in place between health data and immigration authorities. To encourage access to healthcare for migrant & refugee populations, it is of utmost importance that there is separation between health access and legal status as well as immigration enforcement during this pandemic.

R3. Action beyond the nation-state level to uphold human rights and global health security. The coronavirus disease 2019 pandemic cannot be defeated within borders. We urge countries to support the UNHCR’s call for US$255 million to support those living in refugee and refugee-like situations.

Inclusion of all migrant & refugee populations in prevention, preparedness for and response to Covid-19

R1. Transfer of migrants & refugees held in overcrowded reception, transit and detention facilities to safer living conditions. There should be prioritised evacuation of the most vulnerable, such as those with underlying health conditions. Since such settings are generally overcrowded with poor sanitation and hygiene measures, the spread of Covid-19 has the potential to be rapid and devastating among affected populations and those working there.

R2. Deportations should be temporarily suspended, while asylum procedures should continue according to the 1951 Refugee Convention, with no forced return (refoulement).

R3. Urgent relocation and reunification of unaccompanied minors, who are particularly vulnerable as aid and support services to migrants & refugees are negatively affected by the coronavirus disease 2019 pandemic. Relocation and reunification efforts should be pursued to ensure children receive adequate fostering and care.

R4. Expedited temporary accreditation of migrants & refugees with healthcare-related degrees and qualifications to join the health and care workforce in their resident countries. With the health and care workforce in many countries stretched as never before, the workforce shortage is well documented in many migrant and refugee-hosting countries. Fast-tracking temporary accreditation of overseas degrees can help overcome this.

Responsible, transparent and migrant-inclusive public information strategies

R1. Clear, transparent public communication is critical in pandemic response. This should include migrant populations, with a focus on linguistically and culturally appropriate information.R2. Governments should also actively counter racism, xenophobia and discrimination that fuels prejudice and exclusion of migrant & refugee populations.

R3. An evidence-based approach should be key to communications during the Covid-19 pandemic.

• 1 Lancet Migration: global collaboration to advance migration health, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30107- 0/fulltext

• 2 The UCL–Lancet Commission on Migration and Health: the health of a world on the move, Abubakar I et al., Lancet. 2018; 392: 2606-2654

• 3 The UCL–Lancet Commission on Migration and Health: the health of a world on the move, Abubakar I et al., Lancet. 2018; 392: 2606-2654 

• 4 Universal Declaration of Human Rights (https://www.un.org/en/universal-declaration-human-rights/), & 1951 Refugee Convention (https://www.unhcr.org/3b66c2aa10).5 2030 Agenda for Sustainable Development, https://sustainable development.un.org/post2015/transformingourworld