In an embattled enclave in Syria, doctors have seen patients die from what looks like the coronavirus but are unable to treat them because they lack beds, protective gear and medical professionals. A refugee camp in Bangladesh is so cramped that its population density is nearly four times that of New York City, making social distancing impossible. Clinics in a refugee camp in Kenya struggle in normal times with only eight doctors for nearly 200,000 people.
As wealthy countries like the United States and Italy struggle with mass outbreaks of the coronavirus, international health experts and aid workers are increasingly worried that the virus could ravage the world’s most vulnerable people: the tens of millions forced from their homes by violent conflict.
Refugee camps across Africa, the Middle East and Asia are packed with traumatized and undernourished people with limited access to health care and basic sanitation, perfect breeding grounds for contagion. Extended families jam into tarpaulin shelters with mud floors. Food, water and soap are often lacking. Illnesses, from hacking coughs to deadly diseases, go untreated, facilitating their spread.
The coronavirus, which has already infected hundreds of thousands of people around the globe, could rip through these camps with devastating speed and mortality.
“If we think this is a big issue in the U.S. and Europe, we haven’t seen anything yet if Covid gets into the refugee population,” said Adam Coutts, a public health researcher at Cambridge University. “People can’t even wash their kids, let alone wash their hands.”
So far, the number of confirmed coronavirus cases among refugees is low, but that may be the result of a lack of testing. Testing is severely limited, and refugees are rarely a priority.
Doctors treating refugees in Syria and Bangladesh say that in recent weeks they have treated and lost patients with symptoms consistent with the virus.
“To think that it is not in refugee and displaced populations is a bit naïve,” Mr. Coutts said.
If the virus is present, the camps are profoundly ill-equipped to handle it.
Many camp clinics are already struggling to fight outbreaks like dengue and cholera, leaving them without the resources to treat chronic conditions, such as diabetes or heart disease. The coronavirus, which has no vaccine or agreed upon treatment regimen for Covid-19, the respiratory disease it causes, could be even more devastating, medical experts warn.
“We are preparing for the worst,” said Avril Benoit, the executive director of Doctors Without Borders in the United States, which has deployed teams to work with refugees around the world. “We know that in the places where we work we are underequipped and understaffed.”
Daily life in a refugee camp is an ideal incubator for infectious disease. Many lack running water and indoor sanitation. People often stand in line for hours to get water, which is insufficient for frequent showers, much less vigilant hand washing.
“If it came into the camp, it would be a disaster,” said Ahmadu Yusuf, a community leader in the Bakassi camp in northeastern Nigeria, most of whose residents fled Boko Haram, the militant group. “It would be more devastating than the insurgency that brought them here.”
Refugee life also makes social distancing, the health mantra in the West, impossible.
In crowded, poor places like Gaza or the urban slums of Indonesia and India, which began the world’s largest lockdown in response to the virus this week, keeping six feet away from everyone else is difficult. Refugee settlements are often even denser.
A refugee camp in Lesbos, Greece, was built for 3,000 people but now has 20,000 and almost no sanitation.
“The one thing that everyone is stressing in combating the coronavirus is to create social distance but that is precisely what is impossible for refugees,” said Deepmala Mahla, the regional director for Asia for CARE, the humanitarian aid agency. “Where do you go to create space? There is no space.”
Nor are there adequate health systems. The same conflicts that have displaced huge numbers of people have decimated medical facilities, or forced people to live in places where there are none.
The war in Syria has sent more than a million refugees into Lebanon, which is facing an economic crisis. Many live in cramped, squalid conditions and suffer from acute poverty.
Jawahir Assaf, 42, lives with her four children in a tent with 18 other people in a refugee camp in Lebanon’s Bekaa Valley. A nearby slaughterhouse draws rats, which sometimes bite the children.
For years, she and the other camp residents survived by working on nearby farms or trading basic commodities. Now, the threat of the coronavirus keeps them confined with no income.
“After 13 days, we are running out of food,” she said.
Many refugees also suffer from poor nutrition and other health conditions that could leave them particularly vulnerable. In Bangladesh, where about 860,000 Rohingya Muslims fled to escape persecution in Myanmar, the authorities fear that the coming rainy season will cause sewage to overflow into flimsy shelters and possibly spread the coronavirus.
“We are scared that the virus is killing many people around the world,” said Marjuna, an 18-year-old Rohingya refugee in the Kutupalong camp. “We don’t know how to stop it.”
A lack of information in the camps has elevated the sense of panic among people already primed for anxiety. In Bangladesh, the government has limited mobile internet access for many Rohingya, creating an information vacuum that has allowed rumors to flourish:
Eating garlic or the pennywort leaf will ward off the virus, Rohingya refugees have been told. The faithful will stave off disease. Those who test positive should be killed to stop the contagion.
Humanitarian workers say they have been regarded with suspicion as possible carriers of disease. At least two have been attacked, according to camp staff.
“We are trying to correct the misinterpretations, but the lack of mobile networks makes it very difficult to get out the right messages about health and hygiene,” said Marie Sophie Pettersson, a program specialist for United Nations Women, a gender equality agency, in the Rohingya camps.
Aid agencies that have contended with donor fatigue at a time when the number of displaced people is at a record high are worried that health and economic crises in the West will mean less money for refugees. Some fear that people in wealthier nations will worry less about people in poor ones when they feel threatened at home.
“As world leaders brace for the worst within their borders, they must not abandon those living outside them,” Jan Egeland, the secretary general of the Norwegian Refugee Council, said in a statement.
Aid workers warn that the spread of the virus in the West could also hamper the ability of aid organizations to respond. Travel restrictions make it harder for aid workers to reach threatened areas.
Others are hopeful that the pandemic will generate global empathy.
“When we’re suddenly concerned about our own safety, it might help us understand what a Rohingya woman might be feeling,” said Ms. Mahla of CARE. “Regardless of our financial status, our borders, our caste, color or gender, we are all in the same boat, fighting the coronavirus.”
Lockdowns imposed by governments to slow the virus’s spread have been punishing for refugees who struggle to find food.
In Lebanon, where most Syrian refugees live in cities, Nisrine Muhra, 35, said her son and daughter, 10 and 13, used to sell tissues on the street in Beirut, but have been forced to stay home. Her husband, a day laborer, risked going out to look for work but was chased off by soldiers.
The family is three months behind on their rent and living on oil, bread and herbs, with no cash for protective gear and sanitizers.
“Instead of buying masks, it’s better to buy bread for my children,” she said. “We’re not going to die from corona, but from food shortage.”
Hannah Beech reported from Bangkok and Ben Hubbard from Beirut. Abdi Latif Dahir contributed reporting from Nairobi, Kenya; Ruth Maclean from Dakar, Senegal; and Hwaida Saad from Beirut.