key: cord-0816932-oqkl2jj1
authors: Matlin, Stephen A; Orcutt, Miriam; Bojorquez, Ietza; Caman, Ozge Karadag; Severoni, Santino; Spiegel, Paul; Veizis, Apostolos; Saso, Luciano
title: COVID-19 and migrant and refugee health: A pointer to system competence in future pandemic preparedness
date: 2021-05-29
journal: EClinicalMedicine
DOI: 10.1016/j.eclinm.2021.100904
sha: 9d3f357ea71dbfb7ab8c326f80669bed75ddc01c
doc_id: 816932
cord_uid: oqkl2jj1

nan

The COVID-19 pandemic has stress-tested all sectors and spheres of human activity, exposing countless weaknesses and fault linesmany of which were already known but ignored. The often-neglected health of migrants and refugees is one such area. While the world is still trying to recover and to 'build forward better' post-pandemic, there is both an opportunity and an imperative to address migrant and refugee health as an essential component of health systems and public health response [1] . Missing this opportunity will not simply perpetuate the inequities and injustices that many migrants and refugees have long experienced À it will also make it much more likely that efforts to strengthen global health security and pandemic preparedness will continue to be inadequate, leaving the world at greater risk of severe health, economic and social impacts when the next pandemic strikes.

The health services available to and accessed by migrants and refugees depends on where they are, how they are categorized by the authorities having jurisdiction over them, how they interact with and perceive the health system and care personnel. Most countries do not provide documented migrants with the same level of entitlement to health services as their citizens receive [2] and the general health situation of migrants and refugees is often poor À even where legally entitled to health services. In practice, migrants and refugees often experience under-provision of health care and exclusion from health systems, discrimination, and communication challenges. The consequences of diverse levels of provision have been illustrated in numerous settings during the COVID-19 pandemic. There have been efforts to improve the situations for refugees and camps and to set up vaccination strategies [3] , and examples of good practice in community-based healthcare for migrants and refugees have been identified [4] . Nevertheless, migrants and refugees have often been relatively underserved in the delivery of health messages, disadvantaged in their ability to take the measures recommended to protect themselves and others from infection, and excluded, ignored or low in the list of priorities for testing, treatment and vaccination programmes. Preliminary data published from the ApartTogether Survey [5] conducted by the World Health Organization (WHO) demonstrated selfreported major reasons for not accessing testing or health care in case of (suspected) COVID-19 infection as including: lack of financial means, fear of deportation, lack of availability of health-care providers and uncertain entitlement to health care.

A World Health Summit M8 Alliance Expert Meeting on the impact of COVID-19 on migrant and refugee health [6] in January 2021 heard country case studies providing evidence on diverse migration contexts from Greece, Mexico, Turkey and the USA. Overall political responses during the pandemic have been highly variable, including government use of COVID-19 controls as a tool to restrict entry of migrants and refugees (e.g. Mexico, USA), attempts to control migrant movements across countries (e.g. Greece, Mexico) and challenges of camp-based (e.g. Greece) or urban settings (e.g. Turkey) for migrants and refugees. While international solidarity has been proclaimed and endorsed by all UN Member States, responses have often excluded migrant groups (especially those of irregular or undocumented status), reflecting short-term, emergency measures, focused on bio-security in response to COVID-19, rather than sustainable protection responses.

In the health field, common characteristics suggest that, even when migrants and refugees had been accorded legal entitlement to some health services, there were major disjunctions between health policies and their implementation, and large gaps in, or absence of any official government data on how COVID-19 has been affecting migrants and refugees. However, data from other sources [7] point to wide-ranging impacts on broader social determinants of health, including significant economic impacts, problems in employment, education, shelter, nutrition, and non-communicable diseases, increase in discrimination, and mental health problems. Information gaps on the health status of migrants and refugees has been highlighted by COVID-19. The sparce data available suggests a wide range, with examples of low COVID-19 case and mortality rates in some camps [8] and reception centres, while in other cases, COVID-19 rates have been much higher than in the general population [9] and indicative of a need to de-congest camps, and improve living conditions. Monitoring certain health indicators should be central to any country's health system: the blindness to health data on migrants and refugees reflects a fundamental weakness and injustice.

The case for addressing the health of migrants and refugees can be made on different grounds, including as a humanitarian response to the basic needs of people, many of whom are vulnerable and require protection; as a legal response to rights set in international instruments and national commitments affirming equality, human rights and protections of the law; as evidence that the commitment made by UN Member States, in endorsing the Sustainable Development Goals of Agenda 2030, to 'leave no-one behind' was not empty words; and as a form of utilitarianism or enlightened self-interest. COVID-19 has starkly demonstrated the imperative embedded in last of these: prevention of pandemic spread and consequent health and economic disruptions requires recognition that 'we are all in it together' and 'noone is safe until everyone is safe'.

Ensuring more resilient and responsive health systems for all requires recognition of À and action on À the important principle that all populations need to be included in public health responses. As long as the health needs of migrants and refugees remain underserved, poorly treated or of low priority, the entire world remains vulnerable. In this sense, this group is the 'canary in the cage' À its degree of protection from pandemics serves as a litmus test for the competence of the global system of health security.

The authors have nothing to disclose.

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