International Committee of the Red Cross (ICRC)
Evidence to the House of Commons International Development Committee inquiry:
Humanitarian Crises Monitoring: Impact of Coronavirus
Summary
The International Committee of the Red Cross (ICRC) operates in over 80 fragile and conflict-affected states which, like all countries, are vulnerable to the COVID-19 pandemic. The ICRC is one of the largest humanitarian organisations in the world, often unique in our access to the most 'hard to reach' places. We deliver protection and assistance for victims of armed conflict and other situations of violence, engage with authorities and parties to conflicts to enable access and to ensure compliance with the principles of neutral, independent, impartial humanitarian aid and international humanitarian law (IHL), i.e. the law of armed conflict.
The breadth of evidence we could supply is sadly verging on limitless, so in order to ensure focus and contextualization, we have chosen here to refer to Syria (to a larger degree) and West and Central Africa[1] (to a lesser degree). Both host affected populations that are particularly vulnerable to COVID-19, given the protracted nature of their conflicts, which have resulted in both large-scale displacement and severely weakened civilian infrastructure.[2] What we can also see from these two regions – as in others – is that their ability to mitigate the spread and impact of COVID-19 would be far greater had international humanitarian law (IHL) been observed by parties to the conflicts.
It is important to note that many developing countries are yet to experience the full impact of COVID-19, though it has begun to cross the borders into some of the most vulnerable contexts in which we work. At the time of writing, COVID-19 is confirmed in the contexts under discussion, and the crisis is believed to be in its early stages.
The impact of COVID-19 on vulnerable populations
Displaced Populations
It is important to note at the outset that COVID-19 is yet to make it to sites inhabited by large numbers of displaced people. The relentless nature of this pathogen, however, means that we are anticipating its arrival and humanitarian planning is (and should) work to mitigate its impact in the face of extremely challenging circumstances. Both contexts referred to here have, and continue to experience, large-scale displacement.
Syria, after nine years of violence, had its worst single wave of displacement in late 2019, in which one million people were forcibly displaced in the north west of the country. Many of them are in camps, many are living with relatives in cramped conditions and many are simply out in the open. Following violence in Baghouz in the autumn of 2019, in north east Syria 100,000 people were displaced into camps.
Similarly, in West and Central Africa, according to the UNHCR there are an estimated 5.6 million internally displaced people. The numbers in camps are extremely difficult to provide accurately, but they are cramped and the conditions reflect the intention for short-term humanitarian relief, rather than the months, years and generations that many displaced people have spent living in these places. The particular vulnerabilities we have identified that are faced by IDPs are outlined below:
- IDPs in camps and other collective sites, but also those living in informal settlements and slums in densely-populated urban areas, are particularly exposed to a coronavirus outbreak and more susceptible to die in case of complications if they get infected – due to overcrowding, poor nutritional and health status, low sanitation, lack of hygiene measures, barriers to access healthcare, etc.
- IDPs will be disproportionately impacted by the economic repercussions of lockdown measures, given their already precarious circumstances and heavy dependency on external support from host communities and humanitarian actors.
- IDPs are at risk of being stigmatized and subjected to violent acts due to contact with foreign aid workers or if coming from areas with high rates of infection.
- Authorities may use the COVID-19 emergency as an opportunity to add/create restrictions against IDPs, especially those already facing stigma e.g. due to their ethnic, religious or political affiliation(s).
Due to movement restrictions, ongoing plans for IDPs’ voluntary return or resettlement may be put on hold, without supporting their temporary local integration, further prolonging their displacement. At the same time, in countries still relatively spared by the pandemic, camp closure may be sped up, raising the risk of forced or premature returns, should authorities fail to provide alternative solutions.
Movement restrictions may undermine people’s ability to flee violence and find refuge in another place within their country or to seek asylum in other countries, particularly when it comes to blanket border closure and push-backs.
Healthcare
‘Critical care capacity’ has become a phrase that has entered the mainstream discourse as scenes from developed countries’ healthcare systems depict an overwhelmed infrastructure, forcing dedicated healthcare professionals to make decisions nobody could be comfortable with. When healthcare in Europe sees such challenges, there is grim anticipation of its impact in countries in which years of conflict and violence have seen healthcare facilities destroyed.
Syria, again, provides a grim illustration of this point. Since the outset of the conflict in 2011, 51% of its healthcare facilities have been destroyed or are only partially functioning, many of which were in urbanised areas with large populations. Healthcare facilities are protected by international humanitarian law.
LSE’s recent paper on Syria’s Response and Healthcare Facility[3] highlighted that the maximum number of COVID-19 cases that could be adequately treated in Syria is currently 6,500. This is based on the number of available Intensive Care Unit beds with ventilators across Syria, which they estimate to be 325, and the calculation is based on international COVID-19 research that an approximate 5% of the total COVID-19 cases would require critical care.
The paper states: “Once the number of cases passes this estimated threshold of 6,500, also known as the maximum capacity threshold, the healthcare system is likely to collapse, with rationing decisions needing to be made, and the overall mortality rate likely to increase by at least an additional 5 percentage points among infected people. The COVID-19 maximum capacity threshold also varies considerably between different provinces in Syria, with capacity per province ranging from 1920 (Damascus) to 0 (Deir ez-Zor).”
The regional inequality applies also to testing, a recommended suppression tactic from the World Health Organisation. In Idlib, there is no laboratory capacity and as such, no testing available. Given that Idlib does not fall under any national control, there is no recourse for this lack of facilities.
IDPs in particular suffer from many vulnerabilities, living in poor conditions in camps. Many have lived in such conditions for long enough that they are vulnerable to the more severe symptoms of COVID-19. In Al Hol Camp in Syria, not technically an IDP camp but one inhabited mainly by the wives and children of Islamic State Group (ISg) fighters, we run a field hospital jointly with the Syrian Arab Red Crescent and the Norwegian Red Cross. This is, as with all Red Cross and Red Crescent hospitals, intended to provide humanitarian relief and access to basic healthcare needs. Al Hol was built for 10,000 inhabitants and currently has 66,000 – social distancing is impossible. It hosts many vulnerable individuals and has seen high infant mortality rates. The ICRC wants to make very clear that the Al Hol Camp hospital cannot be an isolation or treatment centre as we do not have the appropriate infrastructure, the technical capacity to handle severe cases that need assisted respiration/ventilation in an ICU. Due to operational restrictions, ICRC medical staff are only available in the hospital for less than eight hours per day. Those in Al Hol are especially vulnerable to the aforementioned risk of stigmatisation given their associations with ISg despite the age and vulnerability of many. An outbreak of COVID-19 in the camp would only likely exacerbate these issues.
If we can summarise our recommendations drawn on the examples above, and indeed from many of the contexts in which we work, it is with a focus on prevention.
Syria is not the only context in which healthcare facilities have been so severely impacted by years of conflict. Indeed only 51% of health facilities function adequately in Yemen, and only 40% in South Sudan. Coupled with the extreme vulnerability to disease in camps, and humanitarian medical facilities being unable to respond to those needing intensive care or intubation, a virus as contagious as COVID-19 could spread explosively. Screening is vital, and we are – for example – training guards in Al Hol to screen for fever and coughs, installing additional handwashing points, putting up fences to prevent overcrowding and strengthening infection control measures, particularly in the Al Hol field hospital.
The importance of respect for the law in responding to the Covid-19 pandemic
In the collective response to COVID-19 in conflict zones, it is vital that key provisions of international humanitarian law (IHL) are respected in order to respond adequately to the needs of communities, health professionals and authorities during these unprecedented times. Any public health response to the crisis needs to go hand in hand with respect for the law, particularly in situations of armed conflict where there are additional layers of vulnerability. As such it is essential to understand that the pandemic, and the actions taken around it, do not displace existing international law which continues to apply alongside the pandemic providing the protections needed by vulnerable populations.
For example, it is imperative that humanitarian organisations, like the ICRC, retain access to populations amidst any COVID-19 restrictions on movement. The ability for neutral, independent and impartial humanitarian actors, like the ICRC, to access populations with unmet needs within situations of armed conflict is not only essential to mitigating the impact of COVID-19 in situations of armed conflict, it is also clearly spelt out by international humanitarian law – whether there is a pandemic or not. The ICRC is present in some of the hardest-to-reach places in the world, and while COVID-19 may take longer to reach such places than elsewhere, when it does, it could have a rapid escalation given the vulnerabilities caused by conflict and violence. And whilst there may be a case for technical asks of humanitarian organisations in order to stop the spread of the virus, these must be done in good faith and not with a view to restricting access.
It is not only in whether a belligerent allows in humanitarian assistance and protection to a population under their control, but also in wider state action that could limit the ability of humanitarian organisations like the ICRC in assisting vulnerable populations. The current COVID-19 crisis requires the mobilisation of significant humanitarian resources that are often lacking in countries affected by armed conflicts. Sanctions and other restrictive measures currently in place can impede impartial humanitarian action in these areas, to the detriment of the most vulnerable. Such measures that hinder impartial humanitarian organisations, such as the ICRC, from being able to carry out their exclusively humanitarian activities in a principled manner are incompatible with the letter and spirit of IHL. As such it is vital that such measures allow for humanitarian action whether that is the transport of essential medical equipment or personal protective equipment (PPE) for ICRC staff.
Water supply facilities are of critical importance at all times, however even more so during the current crisis. Any disruption to their functioning means civilians would no longer be able to implement the basic prevention measures, such as frequent hand-washing, which can lead to further spread of the virus. IHL expressly prohibits attacking, destroying, removing, or rendering useless objects indispensable to the survival of the civilian population. Moreover, in the conduct of military operations, constant care must be taken to spare civilian objects, including water supply network and installations. Further, the harm to the civilian population of any damage to the availability of water is greatly increased when the public reliance on washing hands is so vital. This is just one example of the considerations that warring parties need to be aware of when conducting hostilities against the backdrop of the pandemic.
The impact of COVID-19 on humanitarian resources
The world is facing an unprecedented health and humanitarian crisis, with increasing human suffering, and crippling economies. This is even more apparent in fragile and conflict-affected states where the coping capacity of already vulnerable populations means we need to act fast, and now. The ICRC is stepping up its response to meet immediate needs and contribute to building individual, community and state resilience to the pandemic. The ICRC launched a revised emergency appeal, in coordination with partners in the Red Cross Red Crescent Movement, on 26 March to help the world’s most vulnerable communities halt the spread of COVID-19. Our appeal illustrates the integration of COVID-19 activities in our operations worldwide.[4]
We are grateful to the UK Government for the commitment it has shown for our response in pledging £17 million in unearmarked, flexible funding to ICRC’s preliminary appeal (approximately 8% of our COVID-19 related appeal total). However, we have the ability to absorb and spend more in areas facing high risk.
We look forward to future collaboration with donors, where appropriate, as they make decisions and design future strategies to deal with this global crisis. Adherence to Grand Bargain principles in humanitarian finance remains more important than ever in the COVID-19 response. Flexible, unearmarked funding is key to the delivery of neutral, impartial and independent operations, particularly in forgotten or underfunded contexts. We also ask our donors to adhere to the principles of Good Humanitarian Donorship (GHD)[5], ensuring transparency and that any conditions attached to financial contributions are meaningful, context specific and in no way do harm to the integrity of the fundamental principles and operational delivery of humanitarian support. Reasonable and context specific reporting requirements will be essential, to ensure resources are allocated according to need and can deliver sustainable humanitarian impact.
The medium and long-term consequences of COVID-19, for populations affected by conflict and violence, are likely to exacerbate existing acute and chronic vulnerabilities. We expect people’s ability to cope will reduce and needs will increase further. As such, the cost of delivering humanitarian assistance will increase and additional funding will be needed, both for the immediate and longer term response. The secondary and tertiary impacts of the COVID-19 crisis should not be overlooked and frontloading investment now, to those with sustained access and the ability to operate, will contribute to strengthening resilience in the medium to longer term.
We are concerned that as developed countries understandably deal with the economic and social ramifications of COVID-19 at home, they may contemplate scaling down their efforts overseas. We hope that this will not be the case. As our President, Peter Maurer, has said: “Viruses know no borders; this is a global problem that will only be solved by global action.”[6] We aspire to work closer with DFID and Other Government Departments to develop a collective understanding of the economic impacts of COVID-19 on ODA funding and, consequently, the longer term impact on ICRC’s ability to continue to deliver life-saving support in our niche areas of capability, at scale.
In Syria, as in many other countries, it is not only healthcare which has been impacted by years of war, it is also civilian infrastructure. As an example, water plants – key civilian infrastructure protected by IHL as described above – have been destroyed in a number of contexts in which the ICRC work. To illustrate the point, the ICRC, unrelated to COVID was providing significant water programming support in Syria. This included the provision of approximately 1,200 tons of Aluminium Sulphate for main Water Treatment Plants in Al Sweida, Hama, Hassakeh, Deir Ezzor benefitting some 3,000,000 people daily. This is needed in addition to COVID-19 preparedness, ICRC is planning new and specific and responses in Syria to COVID-19. This includes support to the Syrian Arab Red Crescent (SARC) Infection Prevention and Control response; the protective equipment of volunteers, vehicles adaptations, chemicals and financing for 1000 volunteers.
Word limits prevent us from providing further examples of the many areas of activity in which we have had to rapidly devise additional programming, but initial examples can be found in our appeal documents. However, we hope this illustrates the scale of the challenge facing humanitarian organisations and the need for agility and rapid response. This is particularly applicable to regions with ongoing conflicts and situations of violence, which require the presence of neutral and impartial humanitarian actors.
The longer-term impact of COVID-19
While we are used to dealing with crises, it is certainly not in any of our professional memories that we dealt with a crisis that reached every corner of the world. We join the unanimous chorus that is responding to something unprecedented.
To echo those in the World Health Organisation, COVID-19 is an enemy of humanity. We can only predict with bleak certainty that this enemy of humanity will exploit those who have experienced a prolonged attack on their own humanity through frequent, persistent violations of international humanitarian law.
Syria, which has been referred to as an example throughout this evidence, is one of many countries in which IHL violations have destroyed healthcare and civilian infrastructure and displaced millions. For each hospital destroyed and displaced persons’ camp overcrowded, there is an opportunity for COVID-19 to perpetuate, which could have been avoided.
As not only humanitarian actors, but part of a global community, COVID-19 can only be defeated through a significant humanitarian response now, but also a new and stronger respect for and understanding of IHL. Whilst civilian populations across the world remain so vulnerable to the very worst facets of this disease, it will continue in its borderless nature to impact the rest of the world.
We remain grateful for the ongoing support of DfID, and indeed wider HMG, in both our response to conflicts and situations of violence and now to the dual vulnerabilities presented where violence and disease meet. When we have seen the virus reach its peak in our operational contexts, we hope that adherence to international humanitarian law will be a central part of the approach to reducing the vulnerabilities of those who are likely to be hit the hardest.