International Rescue Committee response to International Development Committee’s inquiry into: ‘Humanitarian crises monitoring: impact of coronavirus

 

April 2020

 

 

 

 

 

 

 

 

 

Executive summary

  1. The International Rescue Committee (IRC) welcomes the decision of the International Development Committee to hold an inquiry into the humanitarian impact of COVID-19 and the UK and international community’s response to the crisis.
  2. COVID-19 is in the early stages of spreading – there is a window of opportunity to mount a concerted coordinated response that will ease suffering today and guard against dangerous secondary impacts tomorrow. However, data shows that this window is closing. In Bangladesh cases of COVID are doubling every 2.5 days and in Mali and Niger cases are doubling every 5-6 days. A step change in the funding and delivery of the COVID response is required to mitigate the worse primary (health) and secondary (social, economic, political and security) impacts.
  3. Protracted economic, political and security crises have rendered many countries ill-equipped to respond to the disease. Health systems have been weakened and populations living in these areas are already vulnerable due to underlying health conditions, limited access to healthcare and existing dependence on assistance to survive.
  4. Displaced populations are particularly vulnerable to rapid virus transmission due to the overcrowded nature of camps and urban areas where refugees often live, and lack of sanitation services. Refugees are often also excluded from national preparedness and response plans.
  5. Women and girls will be disproportionately affected: levels of gender-based violence will rise and barriers to accessing services will increase with curfews and movement restrictions.
  6. Ending an outbreak in fragile contexts requires a coordinated response that draws on the experience of frontline NGOs with experience of epidemic response and knowledge and trust of communities, to reach the most vulnerable.

Section 1: The International Rescue Committee (IRC) and its response to COVID-19

  1. The IRC works in conflict-affected and fragile countries around the world to deliver life-saving assistance to people affected by war and disaster, and remains working with communities to assist with rebuilding through the post-crisis phase. Our presence in some 40 countries in education, health, protection, environmental health, women’s protection and empowerment, and economic recovery programming provides us with an expert understanding of humanitarian and development challenges in contexts of conflict and fragility.
  2. With coronavirus spreading globally, and now confirmed in crisis-affected countries with IRC operations, like Syria, Yemen, Afghanistan, South Sudan, Iraq, Burkina Faso and Venezuela, the IRC is ramping up its response to the outbreak with a focus on crisis zones with especially weak health systems.
  3. The IRC is providing life-saving programs in countries threatened by the disease. We are working across three key areas: to mitigate and respond to the spread of coronavirus within vulnerable communities; protect IRC staff; and ensure the continuation of our life-saving programming as much as possible across more than 40 countries worldwide.

 

 

Section 2: emergence, incidence and spread of coronavirus virus infections and the Covid-19 disease in developing countries

  1. Cases are growing across the global south, but available data likely represents an under estimation of all cases due to weaker detection, disease surveillance, and testing. For example, on 10th April the first case was registered in Yemen, yet with porous borders and cases registered in neighbouring countries prior to April it is highly likely the virus was already present. As we have seen in Europe, it is only a matter of time after introduction of cases that widespread transmission occurs, unless massive population level prevention measures are put into place early.
  2. Almost all (52 out of 54 African countries) now have confirmed cases of coronavirus. All African countries on the IRC’s 2020[1] Watchlist of countries at greatest risk of humanitarian crisis have seen cases.
  3. Whilst the first cases have been observed, the level of crisis in places such as Europe, Asia and the US have not yet reached the world’s poorest countries. This offers the UK and international community a window of opportunity to prevent the worst impacts of the outbreak in crisis and conflict settings. This opportunity must be seized without delay and ensure the global response is appropriately funded and supported through coordinated global diplomatic engagement to address existing and new barriers to the COVID humanitarian response.

Section 3: Direct and indirect impacts of the outbreak on crisis and conflict settings

  1. Protracted economic, political and security crises have rendered many countries ill-equipped to respond to the disease. COVID-19 continues to spread globally and has reached countries with weak health systems which are less prepared to combat the disease. Vulnerable populations and those living in crisis will be hit the hardest by this outbreak. Once the virus arrives amongst these communities, we fear a high number of excess deaths due to the inability of the weak systems to respond to those who become ill. However, the secondary impacts of the COVID-19 crisis are likely to be even more deadly and long term. Impacts on conflict dynamics, on political stability, on already weak economies will be more significant, more destabilizing, and more widespread than in wealthier countries with more resilient governance, financial systems and social safety nets.

Populations living with pre-existing conditions

  1. In many of the countries that we work in, including South Sudan, Yemen, and Syria, there are high levels of malnutrition and people living with underlying health conditions. In northwest Syria, for example, three in ten displaced children under the age of five are stunted, a sign of malnutrition[2]. The UN notes that countries with high levels of food insecurity, such as Yemen and Syria, are particularly vulnerable to the virus.
  2. Displaced populations and those living in crises are also often impacted by co-morbidities including communicable and non-communicable diseases that compromise immune systems and make then susceptible to the virus. For example, before the arrival of COVID-19, in South Sudan 44% of the population were at risk from other diseases and 75% of all child deaths were due to preventable diseases[3].

Inadequate healthcare systems

  1. In fragile and conflict affected countries, health systems have been weakened. The IRC anticipates that the scale, speed, and severity of the outbreak will be even greater in these contexts, especially where active conflict and weak health systems meet..
  2. Conflict, and the lack of accountability for violations of international humanitarian law, has contributed massively to the destruction of health systems. Across northern Syria there were 85 attacks on health facilities in the last year and health facilities in Yemen have been targeted 120 times by warring parties since 2015.
  3. The international community’s support for conflict-affected and fragile countries experiencing an outbreak will need to come not only in funding and supplies, but also in diplomatic engagement with governments and nonstate actors to enact ceasefires in active conflict zones and pressure them to halt attacks on health facilities and other infrastructure critical to the response. So far, the signs are worrying. Humanitarian organizations are racing to supply clinics in conflict zones with personal protective equipment – masks, gowns and gloves – despite the all too real risk of these facilities being bombed or shelled; there have already been 56 attacks on health care so far in 2020. While the UN Secretary General has called for ceasefires globally to facilitate the COVID-19 response, the UN Security Council has failed to unite around this call to action. Moreover, the Council deadlock has precluded any coordinated action related to the pandemic – leaving the General Assembly to fill the void with a non-binding resolution.
  4. These difficulties are compounded by a lack of basic equipment such as beds, oxygen, ventilators and personal protective equipment. In the entirety of South Sudan, whose population is 11.7 million, there are only 24 ICU beds and just four ventilators. In northeast Syria, where around 5 million people are currently residing, there are 28 ICU beds and 11 ventilators.
  5. Where healthcare facilities do exist, displaced people and those living in crisis and conflict settings struggle to access them. Two-thirds of the Yemeni population cannot access healthcare. In South Sudan, there are just 0.15 doctors per 10,000 of the population.[4] For refugee camp residents, access to health services is often limited to primary level care with inadequate capacity for isolation and intensive care of COVID-19 patients. In Al Hol camp in Northeast Syria, close to 70,000 residents are reliant on NGO services and just three field hospitals, with the UN no longer able to provide medical supplies from across the border due to the removal of the Yaroubia crossing from the latest UNSC resolution. This comes at a time when NGOs are facing significant challenges bringing staff and supplies into NE Syria from Kurdish controlled Iraq.
  6. Closure of primary medical services and facilities and interventions in an effort to focus on COVID-19 during the outbreak is of particular concern. Ensuring programme continuity will be critical to mitigate secondary health impacts on vulnerable populations. In IRC’s experience, excess mortality and morbidity from decreased availability and use of essential services during outbreaks is as significant as mortality and morbidity directly caused by an outbreak. For example, during the Ebola outbreak in eastern DRC from 2018 – 2020 more people died of measles (6,000) than of Ebola (2,240)[5]. Reports are already indicating a rise in excess deaths in Wuhan amongst those with serious illnesses who were unable to access healthcare during the peak of the crisis[6]. It is also important that maternal and child health interventions are maintained.
  7. In these settings, access to sanitation is often difficult, which can make it difficult to ensure basic preventative measures such as handwashing. Half of Yemenis lack direct access to safe water, sanitation and hygiene and in the Moria refugee camp in Greece, over 1,300 people share one water tap and over 200 share a latrine. Expanding access to basic sanitation and handwashing will be essential to facilitate the types of hygiene interventions that have proven effective in reducing the spread of COVID-19.

High-density of displacement camps puts residents at risk

  1. High population density means camps for displaced populations, including refugees and IDPs, are particularly vulnerable to rapid virus transmission: Moria camp in Greece has an estimated density of 5-7m2 per person; Cox’s Bazar an estimated 25m2 per person; and 27m2 in Al-Hol camp, Syria. This is slightly larger than two car-park spaces. To put the threat of transmission in perspective, the population density of Cox’s Bazar is twice that of the density of the Diamond Princess cruise-ship where the virus spread four times as fast as it did in Wuhan at the peak of the outbreak there.[7]

Women and girls disproportionately affected

  1. In times of conflict and crisis displacement gender-based violence (GBV) increases. IRC data shows that even before COVID-19, one in four women in Cox’s Bazar experienced GBV. The Ebola outbreak in West Africa 2013-2016 placed women and girls in particular, as well as boys, at greater risk of exploitation and sexual violence[8]. We expect that the added dimension of COVID-19 and lockdown measures will increase GBV, particularly intimate partner violence. Refuge, the UK’s largest domestic abuse charity, reported that calls to its helpline have risen by 25% since lockdown measures began. This is a trend likely to be replicated in conflict and crisis settings. Furthermore, restrictions on movement will impact on women’s ability to access services.
  2. At the same time, our experience of epidemic responses indicates that funding is often diverted from non-disease specific health activities including reproductive and sexual health services, harming women and girls. In Cox’s Bazar we have had to suspend elements of our programming for women and girls following the Government decision to close all “non-essential” activities.
  3. When health facilities are overwhelmed with COVID-19 patients, pregnant women and girls may not have access to respectful safe delivery and emergency obstetric care. In Sierra Leone alone, one study estimated there were an additional 3600 maternal deaths, neonatal deaths and stillbirths related to the decrease in health service utilization during the Ebola outbreak[9]. In addition, pregnant women with COVID-19 require specialized care to avoid transmission to health care workers during delivery and to their newborns after delivery.
  4. Accessing decent, formal work is particularly challenging for displaced women, as they face additional discrimination and administrative barriers linked to their displacement status. In crisis settings there is often a decline in private sector activity, high unemployment and weak public services, so women are forced to accept informal, poorly paid, dangerous working conditions, risk economic exploitation or resort to skipping meals and selling their few remaining assets.[10] The COVID-19 outbreak will magnify the crisis these women are already facing. Restrictions on movement and imports, rising prices and declining incomes will restrict their livelihoods and economic opportunities even further.  And at the same time, humanitarian programming aimed at supporting the most vulnerable to meet their basic needs, which includes life-saving cash distributions, has suffered delays and obstacles due to movement restrictions, market disruption and bank closures.

Barriers to delivery of humanitarian assistance

  1. As discussed further in section 5, the ability of organisations to prepare for and respond to COVID-19 is being undermined by access constraints owing to conflict, longstanding bureaucratic constraints and newly implemented restrictions to halt transmission of the virus. It is more vital than ever that diplomatic efforts are launched to tackle existing impediments to access, such as those experienced in the north and south of Yemen. Furthermore, any new restrictions, however well-intentioned, will be counterproductive if they disrupt the very supplies and humanitarian staff critical to the response
  2. At the same time, some government and non-state actors have begun to seize the panic and distraction created by the pandemic as an opportunity to expand their influence and control. These can take the form of obvious crackdowns on opposition groups or rival coordination mechanisms for the deliverance of aid, as is seen in Yemen. Less obvious are political measures rolled out during the outbreak that can have long-term impacts such as disenfranchisement or undermining trust in public institutions. As in any humanitarian crisis, efforts to contain a disease outbreak must remain independent and neutral

Recommendations

  1. Vulnerable populations should be included (refugees, IDPs, migrants, and other vulnerable and marginalized populations) in national COVID-19 preparedness plans to address both immediate response needs and longer-term global health security and system strengthening.
  2. The Government should provide further funding to adapt and improve conditions in displacement camps and support social distancing. For example, shelters can be upgraded so large families are no longer crammed together in one tiny container or flimsy shelter; additional toilets, water points, and hand washing stations can be built so that fewer people have to share facilities; essential hygiene and prevention activities can be undertaken.
  3. The Government should work with refugee hosting nations to identify opportunities for camp decongestion and temporary, voluntary relocation of refugees.

Case study figures[11]:

 

South Sudan

 

-         64% of the population are in need of assistance

-         The country has just 24 beds in intensive care units and four ventilators

-         More than half of South Sudan’s population face severe food insecurity

-         44% of the population live within 5km of nearest health facility

-         NGOs provide 80% of South Sudan’s health services.

-         GBV levels are already some of the highest in the world. 65% of women and girls experience violence and 80% of at-risk women and girls do not have access to services for gender-based violence.

-         Travel restrictions due to COVID-19 risk disrupting efforts to contain the locust swarms that threaten to massively worsen food insecurity in South Sudan in the coming months.

 

Syria

 

-         Ranks 188 of 195 in the Global Health Security Index, indicating a very low level of preparedness for an epidemic.

-         Only half of Syria’s hospitals and primary healthcare centres are functioning. In the northwest, 84 health facilities suspended operations due to hostilities in the past four months alone.

-         In the northeast, just one of 16 hospitals is fully functioning and there are only 28 ICU beds and 11 ventilators available in healthcare settings identified to quarantine and treat suspected cases.

-         One-third of the country remains displaced, most living in overcrowded or informal settlements. Hundreds of thousands are living in tents, unfinished buildings and reception centres in the northwest.

-         the UN Security Council’s failure to renew UN cross-border aid operations through the Yaroubiya border crossing in the northeast has significantly undermined efforts to pre-position medical supplies.

 

Yemen

 

-         Ranks 193 out of 195 countries in the Global Health Security Index and only 51% of health facilities are functional.

-         Yemen is the largest humanitarian crisis in the world; 80% of the population is already in need of humanitarian assistance.

 

-         Only two sites in the country, one in Sana’a and one in Aden, can conduct COVID-19 testing. What’s more, of the 244 people identified for self-isolation after entering the country between January and March, 40% are already unaccounted for[12].

-         There are only 3 doctors and 7 hospital beds per 10,000 people.

-         One third of children are malnourished and particularly susceptible to the virus.

-         Half of Yemenis lack direct access to safe water, sanitation and hygiene.

-         3.6 million internally displaced people live in overcrowded camps and informal settlements.

-         The virus’ arrival coincides with a potential new wave of cholera cases and the suspension of much humanitarian programming in northern Yemen in response to Ansar Allah (Houthi) authorities’ interference in deliverance of assistance.

-         GBV is likely to increase, with a 63% increase and tripling of child, early and forced marriage in the first three years of the conflict.

 

Camps for displaced populations

 

-         Population density is a huge concern. In Cox’s Bazar the density (40,000 people per Km2) is twice that of the Diamond Princess cruise ship (24,000 people per km2) where the virus spread at four time the rate it did in Wuhan.

-         Underlying health conditions, such as malnutrition and other communicable and non-communicable diseases, increase displaced populations’ vulnerability to the virus.

-         There is limited access to water and hygiene services. In Moria camp, Greece, over 1,30 people share one water tap and over 200 share a latrine.

-         In one site in Cox’s Bazar, Bangladesh could face 590,000 infections and over 2,100 deaths in a year if high transmission occurs, according to new research from Johns Hopkins[13].

-         The legal status and gender of displaced populations may impact their ability or willingness to access health services.

-         Displaced populations – particularly refugees and migrants – face the risks of exclusion from national preparedness and response plans (e.g. national disease surveillance, health information efforts, and access to health services).

 

 

Section 4: the UK’s response, bilaterally and with the international community, to the spread of coronavirus to developing countries.

  1. COVID-19 is in the early stages of spreading – there is a window of opportunity to mount a concerted coordinated response that will ease suffering today and guard against dangerous secondary impacts tomorrow.
  2. Without a step change in the speed, scale and nature of the COVID-19 response, the virus will soon overstretch existing humanitarian responses around the world, which 168 million people already rely on to survive[14].
  3. We welcome DFID’s use of the Rapid Response Facility (RRF) to provide quick funding for NGOs during the COVID-19 crisis. However, there remains uncertainty about how much money will be apportioned through this method. DFID should also urgently consider how it will support a global, longer-term, multi-sector response to COVID-19 beyond the initial 6-month period offered by the RRF.
  4. Ending an outbreak in fragile contexts requires a coordinated response that draws on the experience of frontline NGOs to reach the most vulnerable. NGOs have trust of communities and bring practiced methods of coordination, needs assessment, communication and logistics – thus bringing speed and scale. However, too little of the current money pledged by the UK and the UN global appeal is assigned to NGOs. Our experience responding to Ebola showed that funneling money through the UN slowed it reaching the frontline.
  5. In no circumstances must funding be diverted from ongoing humanitarian responses. Across the world, humanitarian responses are already underfunded by 40% on average. Furthermore, funds that are diverted risks allowing other health needs to cause excess deaths and neglecting the sexual and reproductive health of women and girls. During the Ebola outbreak in eastern DRC from 2018 – 2020 more people died of measles (6,000) than of Ebola (2,240)[15].
  6. The G20 announced a Finance Ministers’ Action plan that included suspension of debt payments for the poorest countries and a $200bn support package from the World Bank Group and Regional Development Banks. However, the World Bank is not accustomed to responding to emergency humanitarian situations as the slow processes and direct financing of governments can delay funding reaching the front-line responders to a crisis. Although the Ministers’ declaration referenced the particular risks faced by refugees and displaced people, we are concerned that some of the most vulnerable populations may not be reached by this budgetary support.
  7. We would have liked the G20 plan to go further to mitigate the anticipated risks in fragile contexts with weaker economies. Furthermore, the action plan does not specifically define multi-lateral and bilateral assistance for Africa or fragile and conflict affected states. ODI research shows the costs for the region will be at least $100 billion.[16]

Recommendations

  1. The activation of the Rapid Response Facility is welcome, but it should not be the final step the UK Government takes to support the world’s poorest countries deal with the outbreak.  The Government should continue to provide new, fast, sustainable, and flexible financing to COVID-19 frontline responders to quickly reach those who are most vulnerable. At least 30% of the immediate Global Humanitarian Response Plan financing should be directed to frontline NGOs, already positioned to scale up COVID responses.
  2. In parallel, DFID should urgently consider how it will support a global, longer-term, multi-sector response to COVID-19, beyond the initial 6-month period offered by the RRF.
  3. Any new funding must be additional to any aid that has already been pledged or will be pledged in the future to support vital programming in countries such as Yemen and Syria.
  4. The UK Government should shift towards financing that is long-term and flexible to allow frontline responders to adapt their responses as needs change on the ground and implement strategic and effective programming to address the pandemic’s longer-term impacts.
  5. Mental health and gender considerations should be integrated into the response from the outset. Without sufficient attention to these needs, people living in humanitarian settings, particularly women and children, will feel the effects of the COVID-19 crisis far beyond the physical health impacts.
  6. The COVID-19 response requires an international coordinating mechanism to direct resources where they are most needed, promote a harmonized response and coordinate production and distribution of critical COVID-19 supplies. UN Security Council resolution 2177 to address Ebola outbreaks in West Africa provides a model, but barring UNSC action, this coordination could be under the auspices of the G-20.

 

Section 5: the impact of the outbreak on DFID’s operations and humanitarian programming

  1. Restrictions being put in place by governments are impacting the IRC’s ability to reach those in need with lifesaving aid and will result in higher levels of need and unnecessary death.
  2. Travel restrictions are impacting on the ability to transport humanitarian aid and equipment such as PPE and ventilators.
  3. Movement restrictions make it difficult to carry out existing services, and in many cases non-essential services, in places such as Cox’s Bazar, have been suspended. In a few cases, we have secured exceptions. Our health teams in Jordan and Syria have exceptions and are still able to provide services and we are trying to reduce the amount of people coming to our facilities by going to them, for example, delivering medications to clients rather than having them come to us to fill in a prescription.
  4. Border closures will prevent vulnerable populations from accessing lifesaving needs in neighboring countries. For example, as Colombia recently closed its border with Venezuela, many Venezuelans who cross the border on a daily basis for food, work and health care are now stranded without access to basic lifesaving needs.
  5. We are also facing problems with a lack of liquidity in Iraq - banks are closed or operating at reduced hours so our access to dollars is significantly diminished. This impacts our work in Iraq and Syria as our ability to pay salaries, suppliers and do cash programming is at risk in both countries

Recommendations

  1. The UK Government should push to remove constraints to humanitarian action and service delivery – both conflict driven and bureaucratic. New travel and movement restrictions related to COVID-19 must include humanitarian exceptions to ensure flow of humanitarian goods and personnel to those in need.
  2. DFID should provide maximum flexibility and agility in the administration of its existing life-saving humanitarian programmes. This support should extend to include full coverage of necessary additional costs, budget flexibility, and streamlined grant and contract administration, including simplified reporting requirements and lighter-touch reviews and quick approvals of necessary modifications.

Section 6: lessons identified and learned from previous experience with infectious diseases

  1. The IRC has extensive experience responding to the Ebola virus. The following points are the lessons we have learned from our response.
  2. Politics must be removed, and community trust built. During the peak of the Ebola outbreak, communities and people were largely kept in the dark with minimal access to information about the disease, prevention, or treatment. Coupled with existing mistrust of the government and institutions—including the United Nations - misinformation was rampant and allowed the disease to spread further. Unfortunately, we have already seen similar failures in COVID-19 responses, with governments sharing mixed messages which undermine public trust. An effective response requires credible sources including public health experts to serve as spokespeople providing evidence-based messages and clear guidance. A one-size fits all approach does not work with a worldwide pandemic as people access information in many ways. For example, within fragile and conflict settings and low-income communities, authorities need to share information using accessible platforms and take into consideration local customs and culture. This reinforces the need to funnel funding to trusted NGOs and local delivery partners who have experience working in these contexts and already have the trust of the local communities.
  3. Women and girls will be disproportionately affected. Women are expected to take on greater caretaking roles during health crises – generally they take on three times as much of the caregiving burden than men[17]. This exposes women further to the virus. At the same time, gender-based violence has been seen to rise in conflict and crisis and services designed to support those who experience GBV are likely to be disrupted, along with other sexual and reproductive health services. This will lead to negative outcomes for women, men, girls and boys.
  4. Multilateral coordination is vitally important to ensure funding is diverted to where it is needed most. Failed cooperation in the DRC meant more lives lost to Ebola. We need governments, multilateral organizations like the United Nations, researchers, the private sector, and NGOs to pull together for a collective and rapid response to the growing global crisis.
  5. Health crises show the importance of investing in preparedness. The Ebola outbreak took over a year to contain in large part due to a weak health system. In the current crisis, high income countries and philanthropies must act quickly to help prevent the spread in low-income countries where health systems are far weaker and vulnerable populations like refugees will be hit the hardest. Testing should be quickly expanded and accessible to everybody who needs one no matter where they live.

Recommendations

  1. The UK and the international community Develop an inclusive and integrated response, built on lessons learned, to support the specific needs of the most vulnerable groups.
  2. The UK and international donors Invest in health systems of vulnerable countries to strengthen their capacity to prevent, detect and respond to diseases. Fragile and conflict-affected states will require support for enhancement of detection capabilities, maintenance of pandemic preparedness capacity after this crisis ends, training of local health workers, and health information dissemination campaigns.

 

For more information, contact Oliver Phelan, Advocacy Officer, IRC-UK: oliver.phelan@rescue.org

 

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[1] International Rescue Committee (2020) IRC Emergency Watchlist 2020 [https://www.rescue.org/resource/irc-emergency-watchlist-2020]

[2] https://reliefweb.int/report/syrian-arab-republic/recent-developments-northwest-syria-situation-report-no-10-12-march-2020

[3] UN (2019) South Sudan - Humanitarian needs overview 2020 [https://reliefweb.int/sites/reliefweb.int/files/resources/South%20Sudan%20-%20Humanitarian%20needs%20overview%202020.pdf]

 

[4] International Rescue Committee (2020) COVID-19 in humanitarian crises: a double emergency [https://www.rescue.org/report/covid-19-humanitarian-crises-double-emergency]

[5] https://apnews.com/29e06f31c05690b1f5af167c54123050

[6] https://www.telegraph.co.uk/news/2020/04/15/wuhan-hospitals-overwhelmed-seriously-patients-now-able-ask/

[7] ACAPS (2020) COVID-19 Rohingya response [https://www.acaps.org/sites/acaps/files/products/files/20200319_acaps_covid19_risk_report_rohingya_response.pdf]

[8] UNGA (2018). Protecting Humanity from Future Health Crises: Report of the High Level Panel on the Global Response to Health Crises; UNICEF Helpdesk, “GBV in Emergencies: Emergency Responses to Public Health Outbreaks,” September 2018

[9] Sochas, L., Channon, AA., Nam, S. (2017) Counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone

[10] Jayasinghe. 2019. Choices, chances and safety in crisis: a model for women’s economic empowerment. London: International Rescue Committee. https://www.rescue.org/sites/default/files/document/3480/choiceschancesandsafetyincrisis2019final.pdf

[11] International Rescue Committee (2020) COVID-19 in humanitarian crises: a double emergency [https://www.rescue.org/report/covid-19-humanitarian-crises-double-emergency]

[12] https://newint.org/features/2020/03/27/yemenis-must-not-be-forgotten-pandemic

[13] Truelove, S., Abraham, O., Altare, C., Azman, A., Spiegel, P. (2020) COVID-19: Projecting the impact in Rohingya refugee camps and beyond [http://hopkinshumanitarianhealth.org/assets/documents/COVID-19__Rohinya_Refugees__Beyond_-_Summary_FINAL_March_25_2020.pdf]

[14] UN OCHA (2020) Global Humanitarian Overview 2020 [https://www.unocha.org/sites/unocha/files/GHO-2020_v9.1.pdf]

[15] https://apnews.com/29e06f31c05690b1f5af167c54123050

[16] https://set.odi.org/wp-content/uploads/2020/03/100-billion-stimulus-africa-corona.pdf

[17] International Labour Organisation (2018). Care Work and Care Jobs for the Future of Decent Work. [https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/documents/publication/wcms_633135.pdf.]