An aid worker provides protective face masks to migrants in Greece.Credit: Manolis Lagoutaris/AFP/Getty

There are 70 million refugees, displaced people and asylum seekers around the world. Close living quarters, significant underlying health problems and limited access to sanitation and medical care mean that COVID-19 — which has no known treatment and has brought some of the best health systems in the world to their knees — poses an outsized threat to these communities.

Although there are some reports of refugees testing positive for the virus, as of mid-April, there are no known COVID-19 outbreaks in major refugee camps, according to advocates and responders contacted by Nature. But many aid groups fear that it is only a matter of time before the disease strikes. According to advocacy groups, host nations have been slow to enforce preventative measures. And experts fear that aid organizations will struggle to rally and respond.

Disease epidemics exact a heavy toll on displaced people, but the coronavirus pandemic poses a new kind of threat, says Annick Antierens, a strategic adviser to the medical department for Doctors without Borders, an international medical-aid organization, in Brussels. “Any kind of epidemic is never good, but particularly not this one, where physical distancing is impossible and home isolation is a joke.”

Nature spoke to people in three major encampments across the world who are either involved in assessing the risk COVID-19 poses to refugees or who are working on the frontline to protect them, to ask how camps are preparing for the pandemic.

Models and rumours in Cox’s Bazar, Bangladesh

Nearly 600,000 Rohingya people now live in the Kutupalong-Balukhali Expansion Site in Cox’s Bazar, Bangladesh, having fled Myanmar after persecution increased in 2017. It is one of the world’s biggest and most densely populated refugee camps. And it is the first to be used in a model of COVID-19, says Paul Spiegel at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.

The simulations driving the world’s response to COVID-19

Spiegel and his team created a model that projects outcomes at the camp using data, primarily from China, on age, case severity and case fatality rates for the outbreak. The analysis1 was posted on 26 March, and has not been peer reviewed.

The group modelled outcomes in low-, moderate- and high-transmission scenarios. There are five hospitals (run by non-governmental organizations and foreign governments) with a total of 340 beds in the encampment at Cox’s Bazar. The worst-case scenario exhausts that capacity just 58 days into the outbreak, and would result in more than 2,000 deaths. Theo Vos, an epidemiologist at the University of Washington in Seattle, who was not involved with the study, says that the modelling approach has limitations, including an assumption of a constant basic reproduction number (R 0 ), a metric used to measure the transmission of a disease. In reality, Vos says, R 0 for the coronavirus has varied over time.

Spiegel says the results — even for the worst-case scenario — are probably underestimates. The toll the virus will take on groups with poor underlying health and malnutrition is still unknown. And when on-site hospitals are overwhelmed with COVID-19, the deaths from other diseases such as malaria might spike. “The death rate could be higher,” Spiegel notes. A spokesperson for the United Nations High Commissioner for Refugees (UNHCR), says that the organization has used the Johns Hopkins model to guide their response alongside partner humanitarian organizations.

Although COVID-19 has not yet taken hold in Cox’s Bazar, it is having an impact. An aid worker who asked not to be named, because the humanitarian environment is sensitive and they cannot speak on behalf of the organization they work for, says that local NGOs have decreased the number of staff going into camps to reduce the risk of bringing in the virus. Exceptions are made for staff who provide crucial services, such as health care and food distribution. Some programmes that supported a large number of residents, including education and mental-health counselling sessions, have been stopped or reduced in size.

Hunted, haunted, stateless and scared: the stories of refugee scientists

The aid workers still allowed in are training trusted community leaders, such as leaders of youth and women’s groups, teachers and religious leaders, to explain facts about the virus to residents rather than having aid workers do it directly. And, according to UNHCR, the coronavirus response might interfere with preparations for monsoon rains, expected in June.

In the midst of these complications, aid workers are grappling with a unique communication challenge. In September 2019, Bangladesh restricted access to cell-phone service at the site. Residents are unable to communicate with each other quickly, or to access reliable information online. This has boosted the spread of misinformation among Rohingya residents about the virus. NGOs surveyed the residents and found that they believed inaccurate rumors, for example that health-care workers will kill those infected with the virus, and that the disease is not communicable. Aid groups fear that as a result, residents will be reluctant to get medical attention when they encounter COVID-19-like symptoms.

A plan to move the elderly in Greece

Five Aegean islands off the coast of Greece host refugees and asylum seekers from the Middle East and south and central Asia before they can enter the country. They arrive at the island entry points, where Greece has facilities for about 6,000 people awaiting asylum decisions. But the camps have swelled to nearly 40,000 people over time. Many are living in rudimentary encampments among the olive groves with limited access to running water and toilets.

Refugees and displaced highly vulnerable to COVID-19

“They are living in tents, makeshift camps and carton boxes. It’s a highly overcrowded situation,” says Apostols Veizis, director of the medical operational support unit in Athens, Greece, for Doctors without Borders. Veizis co-wrote an editorial2 in the British Medical Journal in March, calling on European governments to include migrants in their response plans, and to vacate the island camps as a precautionary measure.

Other groups, including Human Rights Watch and the International Rescue Committee, have issued a similar call.

Although other parts of the world are prioritizing social distancing and lockdowns to slow the spread of coronavirus, the options are limited in a refugee camp. “There’s not really an ability to self-isolate or quarantine within these communities,” says Devon Cone, a senior advocate at Washington DC-based Refugees International, a group that advocates for displaced people.

Volunteers distribute cleaning supplies to people at a refugee camp in Mogadishu, Somalia.Credit: Sadak Mohamed/Anadolu Agency/Getty

Instead, in response to the pandemic, Doctors without Borders is prioritizing additional water and sanitation facilities at the camps in Greece. Veizis says there is a plan to protect about 2,400 high-risk residents — those over 60 and those with chronic conditions — by moving them to hotels on the mainland. And in April, the EU pledged €350 million (US$377 million) to support refugees and asylum seekers, including those in Greece.

Midwives teach hand-washing in Somalia

In Mogadishu, Somalia, gynaecologist Deqo Mohamed read updates from the US Centers for Disease Control and Prevention and the WHO through February, March and April. She’s concerned about the 300,000 people from within the country who have been displaced by conflict and natural disasters to camps along the so-called Afgooye corridor. As of early April, the UNHCR said that the nation’s 2.6 million internally displaced people were at high risk of catching the virus.

Coronavirus latest

Unlike many others, these encampments outside Mogadishu are built on private land, with ‘gatekeepers’ who police entry, including by health-care workers. That means that the government does not have access to these spaces, nor do international humanitarian groups. Mohamed, who has worked alongside her Somali mother and sister to provide health services to displaced women in the region for years, has pivoted to training midwives and medical students to communicate social distancing, hand-washing and other hygiene information to communities at 12 sites, to prepare for the pandemic. She has closed her clinics in Mogadishu and the corridor except for deliveries and emergency cases. As part of the national response, Mohamed says she is part of an international team of Somali doctors and those from the diaspora who are helping the government create a national call center that can triage calls from people who have COVID-19 symptoms by phone, so people can avoid leaving their homes to visit a clinic.

“We don’t have medical staff who are ready to handle COVID-19, we don’t have PPEs, we don’t have testing, we don’t have ventilation sites. Name it. Everything that the rest of the world is fighting for in COVID-19, it is actually zero in our site,” she says.