We interviewed humanitarian aid expert Paul Borsboom about the effect of COVID-19 in refugee camps, and how to stop the spread of the virus there. “Worldwide, public health is such a big concern these days. But we’re failing if we don’t offer refugees and displaced people the protection they need. They are trapped. We need to offer them a way out. For them, and for everyone else.”

(2015, the Greek-Macedonian border. Refugees want to cross the border into Macedonia. © Arie Kievit)

Paul Borsboom, a civil engineer by training, started working as an emergency responder in the Balkans in the 90s, just after the war. As a WASH expert (water, sanitation, and hygiene), he ensures that refugees have access to clean drinking water, toilets and soap – necessities in the fight against all infectious diseases. He has worked in refugee camps in Greece, Iraq, South Sudan, Haiti, and Northern Uganda.

Worldwide, there are nearly 71 million refugees and displaced people, twice as many as there were in 2000. Following COVID-19 guidelines – keeping distance, staying inside – is nearly impossible for them. Are the big refugee camps sufficiently prepared to prevent infection?

Not really. The camps are meant to temporarily protect people fleeing from armed conflict or natural disasters. The well-run camps have basic amenities: housing, food, water, healthcare. But it comes down to keeping a lot of people close together, which increases the chances of spreading diseases. Cholera, Ebola, and now COVID-19, spread through these camps like wildfire. It’s the Catch-22 of refugee camps: taking in people who are fleeing dangers while exposing them to a new set of risks and insecurities.

What can we do to prevent the spread of an infectious disease like COVID-19 in refugee camps?

Paying even more attention to clean water, sanitation, and hygiene. We need to build barriers that keep the disease out, by providing clean and safe drinking water, clean latrines, functioning sewage and drainage systems, by collecting trash, by constructing spaces for people to wash themselves and their clothes. We need to provide sufficient soap so people can wash their hands often.

The Sphere Minimum Standards outline the basic needs for humanitarian response: a minimum living space of 3.5 square meters per person; 7 to 15 liters of water per person per day; a minimum number of water points and latrines per number of users. That’s the hardware side of the equation. The software is equally important: campaigning to inform adults and children why they need to wash their hands and use latrines. If these basic amenities and services aren’t in place, camps will be hotbeds of infection in no time. That’s why the COVID-19 crisis is much more acute in informal camps where mainly non-registered refugees live without sufficient oversight and assistance, like in slums.

Are these amenities in place in most of the ‘official’ camps?

The flow of refugees after disasters, particularly natural disasters like earthquakes or floods, often starts too quickly to allow time to set up adequate camps. People start running, often for days, even weeks, ending up in fields or on a hill with nothing but a tarp held up by sticks. In the beginning, it’s a case of making do – bringing in water by truck while the people there don’t even have a roof over their heads. Then humanitarian response starts gathering steam, and the situation improves by the week. But sometimes, like in Iraq where we knew in advance the battle for Mosul was about to begin, we built the camps before displaced people arrived.

Is a lack of space, and the danger of infection that comes with it, something you see in every refugee camp?

Refugee camps like those in Northern Uganda are the exception. The Ugandan government approached the issue differently, they let go of the notion of temporary protection. The government knew that South Sudanese refugees wouldn’t return quickly considering the nature of the conflict in South Sudan. Instead, they offered refugees plots of land where they could settle. The refugees live there, in their own homes, spread out. It’s not really a camp, more of a settlement. Families have a 50 by 50-meter plot, which makes it a lot safer and easier to maintain physical distancing and to stay confined. People have the space to keep their distance while also growing and selling their own crops, making them less dependent on food aid.

Most refugee camps remain in place much longer than intended, about 15 years on average. Some camps are demolished, others turn into permanent villages or cities. Some Palestinian refugee camps are 70 years old. Humanitarians need to take these long lifetimes more into account in managing and designing camps. It’s a tough balancing act: ensuring the best protection and amenities while preventing people from staying longer than necessary, or longer than they want to. Most people want nothing more than to return home – but only if it’s safe.

Refugees are often young. Does it make them less prone to COVID-19 risks?

Not necessarily. Young people have ended up in intensive care in the Netherlands too. I’m not a health expert, but I can say that refugees’ immune systems are weakened by lack of nutrition, bad hygiene, and a lack of adequate healthcare. And weak immune systems are much more vulnerable to infection.

How do you implement physical distancing in a full camp?

The first thing is to break down the social and cultural walls around proximity. In African, Arabic and Caribbean countries, people live their lives out on the street. Physical contact in greeting each other is much more important than it is in Europe. Cramped spaces in the camps only exacerbate that. Displaced people are stuck with each other. People in the Netherlands are struggling with social distancing. Imagine how tough that is in a refugee camp. And that’s ignoring the fact that going to the market is a question of survival for people in the camps. Still, it’s essential to throw up infection barriers and to impose restrictions. It’s crucial to raise awareness of hygiene standards and infection risks, to provide spaces to quarantine individuals, to reduce visits between households and families. It’s crucial to enable people to keep their distance.

But you need to do all this without further harming their dignity. That, I think, is the greatest challenge. Dignity and solidarity are the key principles of any humanitarian response, but both are becoming increasingly hard to find these days. The horrible way people are living in Greek refugee camps is simply beyond words. The reception, meant to reduce suffering, is exacerbating it instead. It’s creating a crisis within a crisis.

Will COVID-19 change future responses in refugee camps?

The importance of clean water, sanitation and hygiene will only increase. How can we reduce physical interaction between people cramped together? You can do it militarily and disciplinarily. But those tactics don’t work in a refugee camp. So many of their freedoms have already been taken away. The SAD acronym captures it well. Safety: protect people against the immediate danger they are fleeing from. Access: offer everyone, but especially minorities and vulnerable groups, access to basic services like healthcare. And dignity: treat people humanely.

“People fled danger only to end up in a trap, unable to escape from the virus. Of course refugees are living in fear.”

The D of dignity will become more important. As the number of refugees and displaced people grows, and as the world speaks only of refugees as flows and streams, instead of individual people like you and I, emergency responders will need to safeguard that dignity more and more. Each and every person deserves to live life in dignity.

How can we safeguard dignity in a refugee camp?

By speaking to people there as if they are people. Not victims, not as a group, not as refugees. By involving them in the day-to-day operations of the camp itself, harnessing their talents as farmers, doctors, engineers, plumbers, builders, teachers. We should pay them for that work. We can give them cash support, money for them to use and manage. By listening to them. By asking them what would be best for them, given the extremely challenging circumstances they find themselves in.

Refugees are rarely asked for anything other than their papers. Usually, they are only on the receiving end: they receive instructions, interdictions or aid items. Ask them how they can best maintain distance from others, and how you can help them do that. Ask them why they did or didn’t wash their hands. Use their answers and their talents to improve responses. That’ll help you make far more progress than just ordering them around.

Do you think COVID-19 is refugees’ biggest concern in the camps? How does it compare to the tragedies and traumas they have lived through?

You can be sure that refugees in places like Lesbos are living in fear. The virus is an invisible enemy. You want to escape, but you’re stuck together in close quarters with a fence locking you in. They can’t go anywhere, they can barely keep their distance from other people around them. That leads to panic and riots – already present in so many camps.

With or without COVID-19, people in refugee camps live their lives under constant pressure. They’ve been traumatized, they’re cooped up closely, have little to no future prospects, no place of their own, inadequate housing. There are tensions between ethnic groups and nationalities, between families adrift, between young men, between men and women. Gender-based violence is a huge problem in refugee camps. COVID-19 comes on top of all of that. It’s the most painful situation imaginable: people fled danger only to end up in a trap, unable to escape from the virus.

“Refugees are rarely asked for anything other than their papers. Usually, they are only on the receiving end: they receive instructions, interdictions or aid items.”

COVID-19 is also a massive headache for emergency responders and camp managers trying to keep all those tensions under control. Ensuring good hygiene and washing hands, to prevent the spread of infection, are the priorities for now. Those are the best ways to limit infection, as we’ve seen with cholera epidemics. Limiting interaction between families, between living spaces, in markets, schools, health centers. Ensuring safe funerals, because these too are part of life inside a refugee camp.

What should Europe do for trapped refugees, especially considering we’re in the middle of our own fight with COVID-19?

We need to offer refugees trapped in the camps a way out. In the first place, this means spreading refugees over EU member states. It’s a question of decency, the only human thing to do. It’s also a question of fulfilling our obligations under international laws and conventions. And it’s what Cordaid stands for, too: caring for one another! It’s what we’re doing for refugees, displaced people, and others in distress in countries like Iraq, Uganda, Sierra Leone, Central African Republic, DR Congo, and Afghanistan.

But in this day and age of COVID-19, it’s also a question of common sense and self-interest. If we don’t adequately assist the millions of people who are on the run for their lives, if we abandon them to their fate, it’ll be even harder to control the spread of the virus. If we allow people who should be treated or placed in quarantine to continue to roam and languish away, we’re increasing the risk factor for everyone else as well. With its inhumane and degrading asylum policies Europe – including the Netherlands – shoots itself in the foot. Worldwide, we’re so concerned with public health these days. And so focused on strengthening public health systems. We failing to do that if we don’t protect the most vulnerable group – refugees and the displaced – in a humane way.

What should the Netherlands do?

As a European member state the Netherlands shares in the duty to end the deplorable conditions in Greek refugee camps. Especially now, during this time of crisis. The Netherlands should take in children that have been left to fend for themselves in Lesbos. We could put refugees that are languishing in Lesbos up in the hotels or cruise ships left empty because of the virus. We should act! The Netherlands is especially duty-bound to itself to ensure humane reception for refugees in its own Kingdom. In the Netherlands, but also for the tens of thousands of refugees from Venezuela that are seeking refuge in degrading conditions on Dutch territory in Aruba, Bonaire and Curacao. Together with other aid organizations and academics, we called upon Prime Minister Mark Rutte to take urgent action.

Many people worldwide hope that the global COVID-19 crisis will change societies for the better. What do you hope for?

People in the Netherlands have forgotten how good life actually is. We have forgotten that we have and that we want too much. We expect and even demand to do everything we like, simply because it’s possible. We’ve forgotten that too much of a good thing is clouding life’s essentials: living in freedom, safety, and good health. And with a bit of luck, enjoying the essentials with the people you love.

I hope this crisis makes us relate to what we have more responsibly. That the time we spend reflecting on our lives during lockdowns leads to more compassion. More solidarity. With people living in poverty in the Netherlands, and with the 70 million people displaced from their homes, that have nowhere to go and have lost everything. It won’t cost us a thing, it won’t impinge on rights or freedoms. In fact, quite the opposite – it multiplies them.

(Interview by Frank van Lierde, translated by Steven Lanting. Read our previous COVID-19 interview with health expert Jos Dusseljee, about the impact of the pandemic on health systems in sub-Sahara Africa).

Visit Cordaid’s Humanitarian Aid web page.