British Red Cross Submission - Humanitarian Crises Monitoring: Impact of Coronavirus

April 2020

1. Executive Summary

In this submission, British Red Cross aims to capture a number of direct impacts and threats emerging as a result of the COVID-19 pandemic. The submission will focus on how the pandemic both exacerbates and is exacerbated by existing vulnerabilities. It does so by looking at the contexts where British Red Cross supports Red Cross and Red Crescent National Societies. These include West and Central Africa (WCA), Bangladesh and Greece[1] where humanitarian crises, conflict, resource limitations and poor infrastructure limit the ability to respond effectively. It concludes with recommendations for how the humanitarian community can better prepare for and respond to the consequences of COVID-19. Key issues discussed include:

• The vulnerability of migrants, refugees, and displaced people in these contexts to the direct impacts of the virus;
• The underlying vulnerabilities of conflict settings and how they impact on the ability to respond to the COVID-19 crisis;
• The specific impacts of COVID-19 on communities affected by chronic hunger and the immediate impacts of the pandemic on food security and nutrition;
• The increased risk of Sexual and Gender-Based Violence as a result of the response to the virus; and
• The impacts of COVID-19 on the international humanitarian response and the key role of local actors as responders on the ground.

2. Introduction

1. British Red Cross is a neutral auxiliary to the UK Government in the humanitarian field. British Red Cross provides life-saving humanitarian assistance and expert advisory support on core humanitarian themes, at home and abroad and works closely with government departments, including the Department for International Development (DFID). 
2. British Red Cross is part of the world’s largest, independent humanitarian network, the International Red Cross and Red Crescent Movement (the Movement). Commitment to the Fundamental Principles of humanity, impartiality, neutrality, independence, voluntary service, unity, and universality are core to our approach. In collaboration with our Movement partners, the International Committee of the Red Cross (ICRC) and the International Federation of Red Cross and Red Crescent Societies (IFRC), with its 193 National Societies, British Red Cross works to meet the needs of people affected by humanitarian crisis.

3. Reason for submitting evidence

3. Focus on the most vulnerable - While the full extent of the coronavirus pandemic and its aftermath is not yet clear, the outbreak will exacerbate existing vulnerabilities worldwide, disproportionally affecting countries facing humanitarian crisis.
4. Insights from local responders on the ground - As a member of the world’s largest humanitarian network, British Red Cross is supporting our National Society partners to respond to the emerging needs on the ground through their vast community-based volunteer networks. This submission focusses on countries where British Red Cross was able to rapidly gather information through the National Societies and is not intended to be an exhaustive analysis of vulnerable groups necessitating immediate assistance nor was it developed based on the most at risk globally. This submission has been developed using evidence collected from colleagues working at a regional level in WCA, Bangladesh and Greece which was repurposed for this submission, as well as British Red Cross technical and policy advisors. This places British Red Cross in a unique position to provide insight into some of the most pressing issues of this inquiry related to the primary impacts of COVID-19.

4. Emergence, incidence, and spread of the Covid-19 disease in developing countries

5. Controlling the spread and impact of COVID-19 in humanitarian contexts is likely to be more difficult in communities affected by conflict and crisis, and among migrants, refugees and displaced communities and people living in poverty. This is due to a number of factors:
6. Limitations of accessing water, sanitation, and hygiene facilities and social distancing and quarantine measures when living in large households, precarious housing arrangements and overcrowded camps and detention centres and in communities where facilities have been destroyed by conflict and disaster. By 2030, it is estimated that two-thirds of the world’s poor will live in fragile conflict affected countries.[2] Many migrants, IDPs and refugees, as well as those affected by conflict and disaster live hand-to-mouth without access to adequate social protection mechanisms, many will be unable to stay home as they rely on daily wages to feed their families. For instance:

6.1. Many of the over 70 million people who have been forcibly displaced who are currently living in over-crowded camps such as those in Bangladesh, Greece, Jordan and Kenya. A large-scale outbreak is highly likely in the refugee camps in Cox’s Bazar in Bangladesh, even under a low transmission scenario, according to a John Hopkins Centre study projecting the impacts of COVID-19.[3]

6.2. Populations living in poor conditions in the WCA region, where even seemingly simple hygiene strategies of washing hands will prove difficult. As of 17 April, there are over 18,000 confirmed cases of COVID-19 across the African continent, with numbers increasing rapidly.[4]

7. Practical challenges facing already poor and weak infrastructure, including health systems. For example:

7.1 Challenges with access to resources such as ventilators and intensive care facilities, a lack of trained personnel, personal protective equipment [PPE] and disinfectant, and inadequate training on use of PPE. In the whole Central African Republic, there are only three ventilators available.[5] Furthermore, contact tracing to identify a COVID-19 infected person’s interactions will be difficult as it relies on health-seeking behaviour, community surveillance and on effective testing, much of which is missing or weak in many contexts. The ease of transmission, the vast geographies and densely populated areas will also compound the challenges of contact tracing.

7.2 In refugee camps in Cox’s Bazar, limited testing capacity and consequent possible delays in securing results, may also impact the effectiveness of the response. Even if equipment was available, a challenge will be securing skilled medical staff.

8. Fragile governance may hinder effective disaster response planning and public health management to control the spread of the virus and respond to the secondary impacts in conflict and disaster affected countries.

5. Direct Impacts of the Outbreak and Specific Risks and Threats

Migrant, Displaced, and Refugee Communities

9. People on the move face a range of humanitarian challenges, including lack or limited access to health and other essential services, lack of access to information on rights, risks and opportunities, border closures and other protection risks. These vulnerabilities both exacerbate and are exacerbated by the direct impacts of and the additional risks and threats posed by COVID-19.

Higher Mortality Rates

10. Higher mortality rates due to the virus is a primary concern for refugees, IDPs, and migrants.

10.1 The 855,000 refugees who are currently residing in 34 makeshift camps in Cox’s Bazar are highly vulnerable to COVID-19 and their potential mortality and morbidity risk is likely to surpass global averages.[6] The key contributing factors include: unhygienic conditions of the camps, limited access to water, underlying poor health status of the population, limited access to health care, use of communal hygiene facilities, pre-existing prevalence of Acute Respiratory Infection (ARI) as other respiratory diseases which transmit much like COVID-19. There have already been 174,128 reported cases of Acute Respiratory Infection (ARI) since January 2020.

10.2 Similarly, migrants and displaced persons may be at increased risk from the current outbreak of COVID-19 due to high prevalence of existing healthcare vulnerabilities. As IOM notes, in the WCA region migration status is a significant determinant of health vulnerabilities, due to “high levels of internal and cross-border migration, with a high prevalence of communicable diseases, a weak public health-care system and policy frameworks, weak or non-existent cross-border cooperation and collaboration mechanisms on migration and health, and a lack of data on mobility and health.”[7] Mobile populations may also have limited social support networks to provide care if they fall sick.

Lack of access to basic services – including healthcare

11. Migrants experience significant barriers to accessing basic services,[8] especially healthcare. These include: legal; eligibility restrictions; high service costs; lack of understanding and information about rights and entitlements (both among migrant communities and service providers); language; socio-cultural; protection risks; fear of arrest or deportation; organisation and quality of services; and lack of coordination between care providers.
12. When access to healthcare is available, it is generally limited to primary healthcare. Intensive care, which is needed when patients develop acute respiratory infections, tends to be scarce to non-existent, particularly in camp settings.[9] In Cox’s Bazar, currently none of the hospitals have Intensive Care Unit facilities or medical equipment to support critical patients with breathing difficulties. This is a major concern, as it will inhibit the ability to provide needed care quickly for serious or complicated cases.
13. In WCA, we know that migrants will be among those least able to get the support they need if they display symptoms of the virus due to existing barriers to healthcare. In addition, as borders close, mobility will be reduced, meaning that migrants may become trapped in areas with no access to basic services or support or unable to return to countries of origin if they wish to do so.
14. Similarly, in Greece, access to secondary and tertiary health care facilities for migrants in Reception and Identification Centres (RIC) and detention centres is challenging due to movement restrictions in force. New movement restrictions have been introduced as part of the COVID-19 emergency procedures which limits movement from RICs.

Lack of access to information

15. Access to reliable, up-to-date information about COVID-19, preventative measures, and access to health services is one of the most powerful tools that can be deployed in the response.
16. In WCA, the current situation is not conducive to this as migrants are often unable to access clear, credible and trusted information, including about their rights and entitlements to basic services. This can be due to various challenges, including complex policy frameworks, lack of trust in authorities providing information, misinformation, social isolation, lack of translation of communication materials, or lack of information tailored to specific cultures and customs. 
17. Given the long-standing restrictions placed on telecommunications and internet access in the camps in Cox’s Bazar, information is only reaching a small portion of the community, while misinformation often spreads quickly. Information sources in refugee camps in Cox’s Bazar are predominantly informal networks on WhatsApp and social media forums.[10] There is no awareness of how the virus should be tested for. There is also a lack of clarity on how to identify infection and whether there is a vaccine and the population is largely mistrustful of health service provision.

Disruption of humanitarian programming and exclusion from response planning

18. COVID-19 may disrupt already stretched humanitarian programming, which migrants and refugees rely on for support, including livelihoods, cash, food, and water and other essentials. In addition, some referral systems may become non-functional or significantly weakened, as may coordination among humanitarian actors.
19. In addition, migrants and refugees may not be included in national strategies and response planning and may be difficult to reach as they move. To protect not only these communities, but societies at a large it is critical – and established good practice – for migrants, refugees and IDPs to be included in national response planning to the virus.

Populations affected by conflict

20. The impacts of COVID-19 will be particularly serious in conflict settings due to attacks on healthcare, weakened health systems, lack of humanitarian access, and displacement.

20.1 There were over 1,000 attacks on health care recorded in 2019.[11] This represents an increasing trend which has decimated health systems in conflict zones such as Syria, Yemen and Afghanistan, due to the destruction of health infrastructure and the killing or wounding of staff. These stretched capacities will face tremendous challenges in attempting to continue to offer war wounded and other lifesaving services in addition to the increased demand for specialised, segregated services for COVID-19 patients.

20.2 Lack of humanitarian access - where outbreaks take place in areas of active conflict, humanitarian actors may struggle to get access to affected populations. In 2019, the World Health Organization (WHO) and INGOs struggled to contain an Ebola outbreak in the eastern Democratic Republic of the Congo (DRC), due to violence. COVID-19 is expected to have similar impacts. Populations in and around conflict areas may be prevented from leaving by certain groups and violence, which will also make it perilous for humanitarian actors to deliver assistance.

20.3 Displacement due to conflict will continue to exacerbate vulnerabilities in populations and reduce access to healthcare services. In Burkina Faso, conflict has heightened significantly, with a reported 650% increase in civilian deaths since 2018.[12] It is now considered the world’s fastest-growing displacement crisis, with nearly 60,000 people displaced in March 2020 alone, bringing the total displaced in the last 16 months to 840,000.[13] There are already 515 confirmed cases of COVID-19 in Burkina Faso.

21. In some conflict zones there have been attempts at establishing ceasefires in the light of COVID-19, with mixed results. However, it is to be expected that in contexts where a global health emergency intersects with protracted conflict and political instability, the primary and secondary impacts of the outbreak could trigger new conflicts or exacerbate existing ones.[14]

Food Security

22. COVID-19 will significantly impact populations who are undernourished, such as the over 20% of the population on the African continent – the highest undernourished percentage on the planet.[15] While existing evidence suggests that the elderly and those whose health is already compromised are at higher risk of becoming ill and dying as a result of the virus, this is also likely to include malnourished people.[16] For many children, school feeding programmes accounts for nearly 50% of their daily calories and with schools shutting down, this critical lifeline of food is no longer available. As a result of the pandemic, there has also been a general reduction in access to fresh food and high nutritional values, which are essential to boost the immune system.

23. In addition, market disruption, immediate loss of livelihoods and lack of access to social safety nets as a result of quarantines, bans, and restrictions on movement may have further dramatic impacts on food and nutrition security.

Sexual and Gender-Based Violence (SGBV)

24. The COVID-19 outbreak, and the public health responses such as social distancing, school closure, and increased levels of unemployment have led to increased incidence of domestic violence, sexual exploitation and abuse.[17] In China there was a three-fold increase in domestic violence reports to the police.[18] These responses also create significant challenges for victims/survivors in accessing the support and protection they need; this is particularly concerning for children. DFID’s What Works to Prevent Violence Against Women programme has produced a strong body of evidence to demonstrate that conflict and disaster increases exposure to sexual and gender-based violence, including intimate partner violence, with women, children, disabled persons and sexual minorities disproportionality affected.[19] A COVID-19 outbreak in communities already affected by ongoing conflict or protracted crisis will create a double burden, with gender-inequality exposing women and girls to a triple burden.
25. Prior to COVID-19, the situation in the refugee camps in Cox’s Bazar already raised significant protection concerns. An outbreak in the camps is likely to increase the already significant protection risks for all vulnerable social groups. For example, domestic violence, SGBV, child protection, early/forced marriage, and trafficking risks will all likely increase as a result of heightened anxiety, frustration, isolation, and enforced proximity to abusers.

6. The UK’s response to the spread of coronavirus to developing countries

26. British Red Cross welcomes the UK government’s generous package to help bolster vulnerable health care systems in developing countries and reduce mass-infections, including £50 million in support of the Red Cross and Red Crescent. British Red Cross’s technical offer complements collaboration with DFID on cash-based programming, community engagement and accountability, working with refugees and migrants, prevention of SGBV, and strengthening National Societies.
27. It is now clear that the role of national and local actors in the COVID-19 response will be key, as the rapid evolution and spread of the virus globally has reduced availability of international personnel. DFID’s contribution is key to ensuring that British Red Cross is able to access and support vulnerable people and communities effectively and mobilise National Societies as auxiliaries to their states.
28. However, as learned from the Ebola response,[20] more needs to be done to support these small, community-based organisations and community volunteers, addressing the challenges faced by local actors. This support should include: ensuring local actors are placed front and centre of decision making on response plans and funding, ensuring flexible long-term funding, funding for core costs, support to supply chains, provision of technical and operational support which responds to the needs identified by them and funding technical support to ensure local staff and volunteer safeguarding. 

7. Recommendations

29. Recommendation 1: scale up humanitarian support to countries that will need additional financial, technical, or operational resources to prevent further infections and assist health systems so they have the capacity to cope with new requirements. This includes investment in water, sanitation and hygiene services, prioritisation of health promotion activities and increased protection and support for service users, staff, and volunteers. Multi-purpose cash can facilitate access to basic services, including health, education, and water and digital payments have lower transmission risks.[21] This can also be facilitated by building on existing networks, programmes, and expertise and exploring the potential for community organisations already working in partnership to support with disease surveillance and mapping activities.
30. Recommendation 2: Maintain and adapt existing programming to ensure that lifesaving humanitarian assistance can be maintained and mainstreamed with COVID-19 response activities. Issues such as food security, conflict, SGBV, and vulnerabilities faced by migrants and refugees are likely to worsen during the pandemic.
31. Recommendation 3: Put local actors front and centre of decision-making and ensure they have the resources they need. National and local actors require immediate access to flexible funding which includes support to core running costs and institutional capacity development, this must include adequate resources to safeguard and protect their staff and volunteers. Supply chains for the provision of essential items must also be protected and maintained. A range of local stakeholders should be engaged and supported to address both the primary and secondary impacts, including women-led organisations which provide invaluable support in accessing marginalised women and girls and provide survivor support to victims of domestic violence.
32. Recommendation 4: Communities most in need and who are hardest to reach should receive inclusive humanitarian assistance and access basic services. For instance, this should include, but not be limited to, targeted support to prevent and address SGBV, in particular ensuring the availability and funding of specialised support services to respond to a likely increase in demand. National and local response plans should also include migrants, refugees, and IDPs to address obstacles to accessing healthcare and ensure that risk communication and prevention messaging reaches them.
33. Recommendation 5: Ensure that communities are engaged. People experiencing crisis, especially the most marginalised, should be engaged in an on-going dialogue in which their voices are heard, responded to, and acted upon. Community engagement and accountability is vital, to build trust in the response and interventions, provide reliable information about the pandemic, and better understand individuals own strategies in different communities – so that these can be incorporated as a key pillar of responses. Risk communication and community engagement needs to be accessible and adapted to reach marginalised populations.

8