Preparing refugees and internally displaced people for pandemic

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Geoffrey P. Johnston
Workers of Yemen’s Southern Transitional Council prepare to drain sewage water from camp flooded by rainwater for Yemenis displaced by conflict from Taez, Ibb and Hodeida, and currently residing in the Khor Maksar district of the second city of Aden. Squalid camps for internally displaced people are ideal breeding grounds for disease, with little chance for proper sanitation or social distancing. (Saleh Al-Obeidi/Getty Images)
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After enduring years of war, civil strife and a genocide perpetrated by the Islamic State against Christians and Yazidis, those who have suffered the most in Iraq are now facing another looming threat to their existence — a global pandemic.

International humanitarian organizations on the ground in Iraq are racing to prevent outbreaks of the highly contagious coronavirus in camps and settlements where hundreds of thousands of vulnerable displaced civilians reside.

According to the United Nations High Commission on Refugees, many Iraqi civilians remain displaced after years of conflict. “Iraq is experiencing ongoing displacement, with around 300,000 internally displaced persons in formal camp locations, and more than 150,000 in informal settlements and collective centres throughout the country,” the UNHCR’s online operational portal detailing the IDP situation notes.

In addition, an online UNHCR Iraq Factsheet posted on Feb. 10, 2020, notes that “around 99,000 Syrian refugees reside in 10 camps throughout the Kurdistan Region of Iraq.”

Baroness of Winterbourne

What is the general health of the IDPs in Iraq?

“The health of the IDPs is actually pretty good considering the environment they live in,” Emma Nicholson, Baroness of Winterbourne and a member of the House of Lords, said. She is also the founder and chair of the AMAR Foundation, a British charity working in areas of conflict to help rebuild the lives of civilians.

“The main problems for our doctors, before the threat of COVID-19, of course, were respiratory diseases and cardio-vascular complaints, plus lots of nasty accidents like burns, with children getting too close to the stove and so on,” Nicholson told the Whig-Standard in an email.

“Of course, when the majority first arrived after escaping ISIS, there was a lot of sickness,” she said of the IDPs who fled the genocidal campaign waged by the Islamic State. “Waterborne diseases, dehydration, malnutrition, were all big problems, but almost six years on, everything has settled down. We have a comprehensive vaccination program, which starts with the babies, and this obviously has all but eradicated all the usual suspects, such as cholera and typhus.”

The most vulnerable

“IDPs and refugees are among the most vulnerable groups for a spread of diseases including COVID-19,” Shirin Ali, assistant head of mission for Médecins Sans Frontières (MSF) in Iraq, told the Whig-Standard in an email.

“IDPs in Iraq have been suffering for years from dwelling in precarious, often cramped formal and informal camps settings. In the camps where MSF provides medical care, families have scarce access to adequate hygiene facilities.”

According to the U.S. Centers for Disease Control and Prevention website, “older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19.” Many of the displaced Iraqis suffer from underlying medical conditions, such as hypertension, diabetes and heart disease, Ali said.

“In the communities we work with, there are people who are particularly vulnerable to this virus, such as the elderly and those with existing health conditions,” Ali added. “Such patients are in continuous need to receive their medications on a regular basis or risk life-threatening consequences.”

Risk of infection

“Like refugees and forcibly displaced populations elsewhere, Iraqi refugees and IDPs are at risk of contracting COVID-19 due to various factors,” Gisèle Nyembwe, a communication associate for the UNHCR in Canada, said. For example, overcrowding in camps and settlements makes “social distancing and the ability to isolate cases difficult.”

In addition, Nyembwe stated in an email that “the lack of adequate basic services, including health care, sanitation and water,” put refugees and IDPs at greater risk of contracting the virus. Echoing the MSF official, Nyembwe said many of the displaced suffer from underlying health conditions that put them at high risk of serious illness, including “malnutrition, chronic health conditions in adults such as diabetes, high blood pressure (and) common childhood diseases.”

Nicholson agrees that Iraqi IDPs “most definitely are high-risk.” And she noted that “people are still living in tents, albeit it that they now mostly have solid walls of breeze block to support them.”

“Traditionally, the Yazidis have very large families, so it is common for there to be 10 or 12 people living in very close proximity,” she continued. “There is running water and toilets, but as you can imagine, facilities are basic, to say the least. You have 15,000 people living cheek by jowl. If COVID-19 gets in, we would be extremely fearful.”

Race to prevent outbreaks

According to UNHCR’s Nyembwe, “there are no known cases among refugees or IDPs in Iraq.” She revealed that “individuals who may have had COVID-19 in refugee and IDP camps in Iraq were tested, with negative test results.”

“However, UNHCR and its partners are in a race against time to prevent and prepare for an outbreak in camps or settlements, as the virus is already affecting many countries with large refugee and IDP populations,” Nyembwe added.

Specifically, what are the hygiene challenges faced by Iraqi refugees and IDPs who are living in camps or informal settings?

“Safe access to quality water in sufficient quantities,” Nyembwe replied. “For example, when the water quality is degraded, personal hygiene suffers and there is incidence of parasitic, fungal and other infectious diseases.”

“In the camps we work in, people have to cope with scarce sanitation facilities and clean water supplies around them,” MSF’s Ali said. “Also the congested living conditions make it hard for them to keep distance. It is critical that adequate WASH (water, sanitation and hygiene) facilities and hygiene supplies are provided to these populations.”

“The problem is the very basic nature of the toilet and washing facilities,” Nicholson added. “Things have gotten better and most people now only have to share a ‘loo’ with their immediate family, but they are still not ideal.

“This is why AMAR doctors and nurses are constantly delivering health and hygiene messages to the residents. Our women health volunteers are out each day, speaking to families, explaining how the virus spreads and what prevention measures to take. So far, touch wood, it seems to be working. People are really obeying all the rules.”

Nicholson offered high praise for AMAR’s staff on the ground in Iraq. “They are obviously doing all they can to make sure we do not have an outbreak,” she said.

The UNHCR and its partner organizations also conduct educational hygiene workshops for IDPs and refugees, which include proper handwashing.

In addition, the UN refugee agency is providing IDP and refugee families, mostly in camps, with cash assistance to help them buy hygiene items. The cash disbursement first began on April 15 in the Basirma refugee camp in Erbil Governorate. And UNHCR is rolling out the program in other refugee and IDP camps.

UNHCR will soon also distribute sanitary kits to women and girls of menstrual age in refugee and IDP camps.

Personal protective equipment

Is there sufficient personal protective equipment in refugee/IDP settings?

“There is sufficient PPE available in the region, but we have to buy it,” Nicholson replied. “Obviously this was not included in our budgets for this year, so that’s why we launched the appeal to ensure we have sufficient funds to keep everyone safe. Our doctors see up to 300 patients a day at each of our two clinics near Dohuk, so that’s a lot of PPE!”

According to Nyembwe, “UNHCR has donated personal protective equipment to health authorities in the Kurdistan Region of Iraq, including to the Dohuk Department of Health, in order to support the government to establish health screening and other measures at the border in order to support continued access to the territory of Iraq for asylum-seekers fleeing persecution.”

Mental health

Is AMAR seeing mental health problems among IDPs, especially among Christian and Yazidi survivors of the genocide perpetrated by the Islamic State?

“Yes,” Nicholson replied. “We have specially trained doctors and nurses to deal with the serious mental health problems the IDPs suffer from.”

In 2016, AMAR launched a special program, referred to as Escaping Darkness, “to help the many hundreds of Yazidi women and girls — some as young as nine — who escaped from ISIS captivity after being held as sex slaves,” she continued.

“As you can imagine, many of them suffered horrifically — raped, beaten, tortured. We were asked by the Dohuk Health Directorate to help as they were being overwhelmed by the number of cases — they only had four psychiatrists for the whole region.”

Sinjar district was ground zero for the genocide perpetrated against the Yazidi people. The jihadists slaughtered men, boys and mature women, while forcing girls and young women into sexual slavery.

“MSF works in Sinjar district where, among other more community-oriented activities, we are supporting Sinuni general hospital, providing free health care for the local mixed population of Yazidi and Arabs,” Ali said.

Ali noted that MSF “could observe a significant mental health new trend during March compared to February, with an increase of suicidal thoughts or even attempts and many more depression symptoms.” MSF is “not sure of the exact reason” for this trend, she said. “But we think it’s related to the curfew or fear of being ill.”

Humanitarian response

MSF is helping to bolster the Iraqi health system. For example, MSF has assisted health authorities set up isolation and treatment facilities for suspected COVID-19 cases in Mosul.

“MSF has also been supporting local health facilities in Erbil and in the capital Baghdad, by providing technical support, logistic support and training for their staff on infection prevention and control (IPC),” Ali said. Meanwhile, MSF continues to keep “most of its regular medical projects” open across Iraq.

“MSF teams have implemented triage measures for any suspected COVID-19 cases inside our projects in the IDP camps in Kirkuk and other project locations around Iraq,” Ali continued. “MSF is also trying to set up preparations for a potential outbreak inside the camps. But again further access to hygiene facilities and facilities for isolation are needed.”

Nyembwe said UNHCR is helping the Directorate of Health in Duhok and Erbil in northern Iraq by providing training to medical staff on disease detection and treatment of suspected COVID-19 cases. The UN agency is also setting up isolation areas within camps to be used as quarantine wards in case public hospitals are overwhelmed by the pandemic.

In addition, UNHCR is conducting health awareness programs that focus on preventing the transmission of the virus in refugee and IDP camps, registration centres and in some urban areas.

Preparing refugees and internally displaced people for pandemic