International Committee of the Red Cross (ICRC)

Evidence to the House of Commons International Development Committee inquiry:

Coronavirus in developing countries: secondary impacts

Background

1. The ICRC is an impartial, neutral and independent organisation whose exclusively humanitarian mission is to protect the lives and dignity of the victims of armed conflict and other situations of violence and to provide them with assistance. The ICRC also endeavors to prevent suffering by promoting and strengthening international humanitarian law (IHL) and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the Geneva Conventions and the International Red Cross and Red Crescent Movement. It directs and coordinates the international activities conducted by the Movement in armed conflicts and other situations of violence.

2. The purpose of this submission is to outline the key secondary impacts identified by the ICRC, and to provide our recommendations for mitigating policy and examples of assistance aimed to provide relief for the wider impacts of COVID-19 in conflict-affected regions.

Introduction

3. The pandemic cannot be thought about in public health terms alone. The full scale and veracity of the COVID-19 pandemic means that the secondary impacts are broad and complex.  Like the pandemic itself, those impacts have not yet reached their peak.  This is especially true in the conflict and violence-affected states in which the ICRC is operational. Here violence interacts with transnational impacts, and global inter-dependencies are exposed.

4. In early 2020, little was known of the novel coronavirus, policies for working around such a crisis were noticeably lacking across a number of sectors and many of us were simply reacting to a new, existential threat. This was especially true of those of us in the humanitarian sector, working in heavily populated camps, with vulnerable individuals and within healthcare infrastructures that were simply not resourced to cope with a COVID-19 outbreak.

5. Now, we are living in a world that is – to varying degrees – adapting to the existence of COVID-19. While many, if not most, countries will struggle to suppress the virus entirely, the objective now remains a humanitarian one. That is, that those with COVID-19 and of course the myriad of other conditions and injuries that require access to healthcare are able to do so. As such, it now appears that we are in a cycle of restrictions introduced to ensure that people who need medical care are afforded this most human of dignities. These restrictions, however, do not come without the cost of additional humanitarian needs and while the first wave has peaked in many places, the secondary impacts of the crisis are yet to fully manifest.

Disruptive and wide-reaching social impact

6. Lockdowns have been a shared experience across the world, to varying degrees, bringing concerns about isolation and abuse. Stigmatisation is another issue, both of groups and individuals. Humanitarian and development actors have intensified discussions on the links between humanitarian action and social protection systems in light of the pandemic. Social safety nets – such as (un)conditional cash transfers, pensions, food and in-kind transfers, fee waivers, and public works – have been central to both government and non-government responses to COVID-19. This has reinvigorated ongoing efforts to better link small-scale community safety nets with broader and more institutionalised social protection systems (where they exist). The International Labour Organisation (ILO) has highlighted social protection as a particularly strategic form of response to this pandemic, given the secondary impacts of the measures to prevent and stem infections. The ICRC has identified the following key social consequences of COVID-19 in our operational contexts.

a)      Exclusion or neglect of specific groups in the population from the COVID-19 response, particularly people living in areas controlled by non-State armed groups, people deprived of their liberty, people with disabilities, women and girls as well as sexual and gender minorities who have unequal access to health care, information, and decision-making processes or who face threats to their safety and lives; migrants and IDPs, including those living in camps and overcrowded spaces.

b)      Resort to harmful coping mechanisms (e.g. self-medication, damaging alternative income generation), particularly among households with lower incomes and insecure or informal employment; children dealing with prolonged school closures; sexual and gender-based violence survivors who may experience a disruption in care and support.

c)       Exposure to violence and “coercive confinement”, particularly among people arrested for defying containment measures due to economic hardship; children and women living in abusive home environments; and health personnel in areas where pandemic control measures are not understood or accepted and/or where armed conflict and violence are daily realities.

d)      Family separation, inadequate management of the dead, and their impacts on the bereavement process: in many contexts, the number of deaths resulting from COVID-19 may overwhelm local capacity and create a difficult dilemma between ensuring the safety of all those involved in the management of the dead and addressing the needs and rights of families who have lost their loved ones, often without having been able to accompany them in their last moments. Getting the balance right between staff safety and family needs is not only a humanitarian imperative, it is also critical in the context of a pandemic which tests the very fabric of society.

e)      Healthcare workers are also at risk of stigmatisation given their exposure to COVID-19, and could face abuse and attacks from frightened groups or individuals. People may also to be too fearful to access healthcare through concerns about exposure to the virus, thus allowing medical conditions and injuries to go untreated.

Recommendations

7. Our policy recommendations for mitigating the social impact of COVID-19 are as follows:

i)                     Talk and listen to communities: prioritise engagement with communities, particularly women, to better understand the medical, protection, economic and other impacts of the crisis on the different groups, and to establish channels for the effective transmission of information to the groups they represent.

ii)                   Empower local actors who know their communities best: leverage the knowledge and expertise of local actors and organisations operating close to affected populations to identify existing services, and positive coping strategies, as well as practical or political barriers that would need to be addressed to effectively mitigate the pandemic’s secondary impacts of the pandemic in light of the specific context.

iii)                 Communicate clearly and consistently: Prioritise transparent and clear, timely and accessible communication about the rationale, scope and duration of public health measures, including in relation to the management of the dead, and about how communities can access support. This is critical to ensure adherence to public health measures, protect health staff and health structures from violence, as well as to stem misinformation and avoid further exclusion and erosion of citizen-State trust

Examples of where the ICRC has sought to diminish these impacts are as follows:

8. In May 2020, the ICRC developed specific protocols for Restoring Family Links (RFL) services in refugee camps in Jordan, installed WIFI hotspots in migration camps in Libya, and passed self-protection COVID-19-related messages through the network of the missing programme in Nigeria.

9. In Georgia, in addition to donating protective equipment, disinfecting materials, hygiene items, infrared thermometers and/or posters to curb COVID-19 transmission to places of detention, the ICRC is facilitating phone/video calls to detainees’ family members who are unable to visit them due to COVID-19-related movement restrictions. While not the same as face-to-face contact, this contact helps ensure a semblance of normalcy in their lives.

10. In Yemen, during a food distribution at the most active Southern frontline (Al Dhale), targeting 18,000 IDPs, the ICRC also facilitated prevention and risk education sessions. These sessions were through community leaders and volunteers with the objective of minimising the rapid spread of COVID-19 in the southern governorates of Yemen.

11. In Eastern Ukraine, COVID-19 has made living in the Donbas conflict zone more difficult as crossing the entry-exit checkpoints (EECPs) require the installation of a special application to track potential disease transmission. For the elderly and others who may not have smartphones and who are placed under observation when attempting to cross the EECPs, the ICRC is supporting them with food deliveries and hygiene kits.

12. In Kenya, work is ongoing in 43 prisons to enhance their quarantine areas and discussions were held with the Kenyan Prison Service to set up regional isolation sections in selected prisons. Touchless thermometers and phones (to maintain family links) were also distributed.

13. In Libya, following various meetings with the country’s COVID-19 Supreme Committee, the ICRC was able to schedule trainings with death care providers (e.g. body washers, morgue attendants, ambulance drivers, and cemetery workers) on the safe handling of dead bodies related to the virus.

Increased Political Disruption and Destabilisation

14. COVID-19 has the potential for a ‘perfect storm’ leading to instability and polarisation. Authorities can become overwhelmed with the pandemic and struggle to provide security and maintain law and order. The Ebola response showed that using excessive force to implement public health measures does not work (“healthcare at gunpoint”) and can foment mistrust in state institutions and humanitarian actors alike. Non-State armed groups can also utilise the pandemic to recruit new members, leading to further insecurity and instability nationally and regionally. Particular groups (e.g. families of foreign fighters) may be further stigmatised for having spread COVID-19.  

15. There is also increased likelihood of a further erosion of trust between the citizen and State. A number of factors can contribute to this, including:  the unchecked resort to (open-ended) “states of emergency” and the resulting potential for abuse and discrimination; excessive use of force to enforce draconian measures imposed only ostensibly for reasons of public health; the lack of transparency and clear communication about the pandemic and related government decisions; the actual or potential misuse of personal information and geolocation data. In essence, these factors contribute to a breakdown of belief in the ‘social contract’ and can create an environment in which misinformation thrives given an increasing vacuum in perceived authority.

Recommendations

16. The ICRC recommends the following courses of actions to maintain stability, particularly as pertains to COVID-19 and conflict-affected contexts:

i)                     Use minimum force: Law enforcement officials, including military forces carrying out law enforcement operations, must respect law and standards and, in carrying out their duties, as far as possible, apply non-violent means[1]. 

ii)                   Ensure any exceptional measures[2] are proportionate, necessary, time-bound: Measures undertaken under a state of emergency in derogation of international human rights obligations must be proportionate, necessary and non-discriminatory and must not involve the violation of States’ other international obligations. Restrictions on individual human rights must have a legal basis and must be justifiable by an internationally recognised public interest, like public health, national security or public order.

iii)                 Ensure any exceptional measures do not contravene obligations under IHL to allow neutral humanitarian actors access to those spaces in need of humanitarian assistance.

iv)                 Communicate clearly and consistently: Prioritise transparent and clear, timely and accessible communication about the rationale, scope and duration of public health measures, including in relation to the management of the dead, and about how communities can access support. This is critical to ensure adherence to public health measures, protect health staff and health structures from violence, as well as to stem misinformation and avoid further exclusion and erosion of citizen-State trust.

Harmful Economic Impact

17. We are yet to reach the nadir of the global economic downturn brought about by COVID-19, and with the second wave arrived but potentially yet to reach its peak, many countries face cyclical lockdowns, disruption between supply and demand, and deep recessions[3]. Many of the contexts in which the ICRC work, quite obviously, were already suffering from fragile economies and significant proportions of their populations in insecure work. The ubiquitous nature of this impact means we cannot only focus on the microeconomic impact on those individuals and populations who are (now even more) economically vulnerable. Instead it must be viewed also through a macroeconomic prism, given the global economic downturn and its potentially devastating impact on donors’ ability and obligation to assist those most in need.

18. Low-income countries, with compromised economies that are either in conflict and/or in a food security crisis, are those at highest risk of a further collapse of state and household economies. The ICRC’s Economic Security Division (EcoSec) has created the COVID-19 Economic Vulnerability Index (CEVI), helping to reveal multidimensional vulnerabilities and risks. The Index suggests that pre-existing structural failures and limited economic independence are at the base of countries economic vulnerability to COVID-19[4].
     
19. The ICRC have identified three key economic risks emerging from COVID-19 in vulnerable contexts:

a)      Job losses and poverty: workers in the informal economy, small and medium enterprises, the self-employed, and daily wage earners are hit the hardest by containment measures and the overall economic downturn (which the IMF predicts will be deeper than first anticipated (cumulative global loss of $12 trillion 2020-21)). Income losses are expected to exceed $220 billion in developing countries, and nearly half of all jobs in Africa could be lost, according to ILO estimates. COVID-19 also poses a great threat to countries lacking robust social safety nets. In 2018, less than 20% of people living in low-income countries had access to social protection of any kind, as reported by the World Bank.

b)      Gaps in remittances: job losses among migrant workers in high income countries will have a knock-on effect on remittances. Migrant workers account for almost 30% of labour in some of the most affected sectors in OECD countries and are particularly vulnerable to job losses due to the pandemic. 

c)       Food insecurity and malnutrition: countries that rely heavily on imported food to meet demand— including many in NAME and sub-Saharan Africa—face disproportionate risk from supply chain failures. Uncertainty about food availability can spark a wave of export restrictions, creating a shortage on the global market. Such reactions can alter the balance between food supply and demand, resulting in price spikes and increased price volatility.

Recommendations

20. In respect of mitigating policy, the ICRC recommends that it is ensured that COVID-19 response measures are economically viable and socially inclusive: public health decisions relating to the fight against COVID-19 need to be based not only on epidemiological data, but also on an analysis of the economic and social repercussions of movement restrictions or other COVID-19-related public health measures in the short, medium, and long-term. This analysis needs to be context-specific (even area-specific) and take into account the situation of vulnerable groups, including persons deprived of their liberty, separated families, the bereaved, IDPs, migrants, notably those in irregular situations.

21. As examples, the ICRC has spent much of 2020 incorporating management of this devastating economic impact of COVID-19 into humanitarian programmes. Livelihood, food, and cash support to help people shoulder the economic impact of both conflict and COVID-19 has been provided across our contexts. Numerous Delegations have been scaling-up these activities. Examples include:

a)      In Colombia, the ICRC is providing livelihood support for vulnerable individuals whose employment contracts have been terminated, or whose small businesses are severely affected or have shut down. This involves increasing its salary support for local businesses to avoid employee dismissals or forced unpaid holidays.

b)      In the Philippines, the ICRC is complementing the government’s initiative to ensure food security across the country by targeting vulnerable groups affected by the pandemic as well as the conflict in Mindanao. While cash transfers give flexibility to targeted people in terms of spending, areas where markets are not functional or are difficult to access especially in very remote places, an in-kind assistance for food and agricultural input is provided. Both cash transfers (90% of support) and food and essential items distribution are planned to reach out to those that are more vulnerable despite the government’s support.

Secondary Health Issues

22. There is an inevitable risk of deterioration of the general health of the population due to lack of capacity of health systems to handle non-COVID-19 related illnesses. As an example, due to COVID-19, routine childhood immunisation services have been severely hit in at least 68 countries; measles campaigns have been suspended in 27 countries and polio campaigns put on hold in 38 countries. As a result, according to the UN and Red Cross Red Crescent Movement, at least 80 million children under one are at risk for diseases like measles, diphtheria, and polio. 

23. Beyond the control of other infectious disease, there is a real threat as regards the social determinants of health. These include access to healthy food and clean water, as well as mental health issues arising from other secondary impacts (e.g. unsafe neighbourhoods, misinformation, tenuous housing and livelihood situations, lack of education). Mental health strains are a particular concern in populations with high levels of violence and toxic stress, the latter of which particularly impacts children in protracted conflicts such as Syria[5].  

24. The ICRC advocates for continuity of essential health services – and other public services – during the pandemic. Stemming COVID-19 infections must be done in addition to – not at the expense of – fighting other diseases. Lessons learned from past epidemics stress the importance of ensuring the continuity of essential health services throughout the emergency to avoid a higher mortality rates due to other illnesses. This includes other public services such as water, wastewater, and electricity.  

Recommendations

25. We recommend protecting health structures, staff, and supplies: measures to protect health-care facilities should not spoil the local community’s perception of the structures as protected places, and must not impede access to patients, their relatives, or health-care personnel. If measures are implemented to control access and entries, including initial security screening, then this screening and medical triage should be clearly separated. Guards should be employed only for security duties and at control points, not for triage. Health care services should be delivered according to medical needs (impartiality).

Vaccine Distribution

26. The political dynamics around the development and distribution of a COVID-19 vaccine risk further exacerbating the secondary impacts of the pandemic in humanitarian settings. While the ACT Accelerator is the main initiative pooling efforts to develop and distribute a COVID-19 vaccine, and while USD8.8 billion surpassed the ask-for USD7.4 billion at the June 2020 GAVI conference, political uncertainties remain about how ensuring “equitable access” will function like in practice. There is a concern that any protectionist tendencies in the early stages of the crisis may be harbingers of future political dynamics which will not be conducive to an equitable roll-out of the vaccine, including in low resource countries where public health measures to prevent and curb infections are harder to implement.

27. The ICRC strongly supports equitable global access to any vaccine developed to combat COVID-19. As a neutral humanitarian actor, the ICRC will however not formally support or join initiatives around the development of a vaccine, including the ACT Accelerator Initiative. The ICRC and International Federation of the Red Cross (IFRC) continue to advocate for equitable access on humanitarian grounds. Beyond that, the ICRC is likely to make a stronger contribution to equitable access to a vaccine by promoting equitable access to the hardest to reach populations through networking channels with all sides of armed conflicts and violence.
     
28. In ICRC’s estimate, 66 million people live under the state-like governance of a non-state

armed group, underlining the critical nature of the full and safe access, granted by legal mandate to the ICRC, to negotiate with any parties to a conflict and provide humanitarian support to affected populations anywhere in the world[6].

29. Indeed, IHL is applicable in the respect of provision of vaccines without discrimination. States have the obligation to take necessary steps towards preventing, treating and controlling epidemics and to ensure the provision of healthcare for everyone under their jurisdiction. Within IHL, specific provisions exist to protect detainees. There are also provisions which specifically protect the displaced, and those provisions which are applicable to populations in occupied territories.

30. The ICRC’s position on vaccine distribution stems from one simple assertion. That is that a COVID-19 vaccine must be accessible to everyone, and relevant policies be determined with this objective in mind. This will mean observing international law and international humanitarian law, and resisting the very real potential of geopolitical arguments and strategic posturing.

31. We welcome the UK Government’s broader commitment at UNGA to a principled humanitarian equitable distribution of the COVID-19 vaccine. Smallpox eradication 40 years ago shows that it is possible. Efforts including the ACT Accelerator offer hope of the end of the COVID-19 crisis, but only if access is genuinely equitable. As polio demonstrates, we cannot beat COVID anywhere unless we beat it everywhere – including in the hardest-to-reach and conflict affected places.

Recommendations

32. IHL obligations and those complemented by international human rights law, must be implemented without adverse distinction, i.e. distinction on any grounds other than health-related considerations. Health-related considerations may actually require prioritised or even differentiated treatment so as to ensure de facto equal treatment. This means prioritising vaccinations for people who may be particularly at risk, such as older people, people with co-morbidities, or health workers themselves. It also requires States to take specific positive measures for people who have particular difficulties accessing vaccination programmes, including children, older people, or people with disabilities[7].

Conclusion

33. We thank the UK Government for its ongoing support, both in respect of funding and advocating the humanitarian approach laid out above. We ask that the Government continues to support humanitarian “business continuity” to reduce the secondary impacts of COVID-19: continue to support a broad spectrum of humanitarian activities, including (a) those directly contributing to stemming COVID-19 infections and (b) those helping to build the resilience of communities (including to prevent food insecurity and loss of livelihoods), services, and systems in light of the pandemic’s broader and longer-term secondary impacts.

34. We also ask that programmatic flexibility is enabled: given the fluid and unpredictable nature of the crisis, and in the spirit of the Grand Bargain commitments, the ICRC calls on its donors to stay flexible in their support (in terms of allocation of funds and reporting requirements) to the ICRC and other Red Cross and Red Crescent Movement components, in order to allow for a robust and agile response to rapidly evolving needs.
     
35. To end, and to quote our Director General Robert Mardini when he spoke to the Committee earlier this year, “the secondary and the socio-economic consequences are as deadly as the primary consequences. … those countries where the economic situation is dire and/or contact is affected by war are the most vulnerable. … The livelihood support programmes are extremely important, as important as anything we can do to prevent [the pandemic] and to support hospitals and health centres.”

36. While there is little to “look forward to” in respect of the COVID-19 pandemic, we do however look forward to working with the Government in ensuring that vulnerable populations are as protected as possible from the secondary impacts of this global crisis.