The world’s refugees remain last in line for covid-19 vaccines
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o703 (Published 29 March 2022) Cite this as: BMJ 2022;376:o703
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Jannat Bahar, a 45 year old single mother of eight children, sits behind a wooden grocery stand in the Rohingya refugee camp in Mewat, a small town in the Indian state of Haryana. Bahar fled to India several years ago but still cannot speak Hindi, India’s lingua franca. “When the covid vaccination drive was held in my camp, some people came to explain why it was necessary,” she says. “But I didn’t understand a word.” Over four months since the vaccine drive to reach the 1750 refugees living in Mewat, Bahar remains unvaccinated.
Mir Khan, 72, a labourer and Hindu Pakistani refugee living in Anganwa camp in Jodhpur, says that vaccination became a means of stigmatising the refugees who worked as day labourers as they were not initially offered vaccines when host nationals were. “Many people in the camp were unable to get even daily wage work because their employers feared that they might spread infection,” he says.
Two years into the pandemic, 34.7% of the world’s population have not had a single dose of vaccine.1 For vulnerable groups such as refugees and internally displaced persons—85% of whom are hosted in low and middle income countries—the disparity in comparison with the citizens of the countries they live in is stark. India, for example, has 500 million unvaccinated people,2 one of the world’s highest numbers. Many of these unvaccinated people are the nation’s most marginalised (57% of the eligible population are fully vaccinated).1 In India, reliable data do not exist on the number of unvaccinated refugees as they are not accorded official status under Indian law.
In a November 2020 paper,3 the World Health Organization’s Strategic Advisory Group of Experts on Immunization recommended the prioritisation of “low income migrant workers, refugees, internally displaced persons, asylum seekers, populations in conflict settings or those affected by humanitarian emergencies, vulnerable migrants in irregular situations, and nomadic populations” for allocation of covid-19 vaccination by nation states. This was followed a year later when WHO announced its strategy to achieve global covid-19 vaccination by the end of 2021 and 70% total population coverage by mid-2022. The first target was not met, with 98 countries not having vaccinated 40% of their population by the year’s end.
A December 2021 report by the United Nations High Commissioner for Refugees (UNHCR) found that many of the countries hosting the most refugees have made little progress towards the mid-2022 WHO target.4 According to UNHCR data 2 730 839 refugees and asylum seekers have been fully vaccinated out of 3.25 million in 66 countries. Countries with large disparities between citizens and refugees included Morocco (where 35% of refugees were vaccinated as of September 2021, compared with 60% of Moroccan nationals) and Egypt (where 10.3% of refugees had been vaccinated compared with 20% of nationals).
In transit countries, such as those in the western Balkan region, refugees often do not stay long enough in the camps to get all recommended vaccines. And Ann Burton, head of UNHCR’s public health section, adds that camp refugees’ location in rural areas means they often fall foul of “the known urban-rural divide in vaccine access.”
“Refugees in many settings have faced extra challenges in accessing covid-19 vaccines,” says Jozf Bartovic of WHO. “They face challenges in access because of state entitlement, language, and financial barriers while crowded living conditions put them at higher risk of virus exposure.” He adds that for societal, geographical, and biomedical reasons, vulnerable groups are at higher risk of experiencing burdens from the covid pandemic.
Forgotten people
India is not a signatory to the 1951 UN Refugee Convention or the 1967 Protocol Relating to the Status of Refugees, meaning that refugees within India lack the legal status or official documentation needed to access healthcare. Initially during the pandemic, every state government required official documentation to access covid-19 vaccines.
It took civil action to secure vaccines for Khan and his fellow refugees in Anganwa camp. Universal Just Action Society (UJAS), a non-governmental organisation (NGO) set up by a Pakistani Hindu migrant, lobbied the administration of Jodhpur, the chief minister of Rajasthan state, and the prime minister until the Rajasthan High Court directed the Rajasthan government to include refugees under the category of “vulnerable groups” who needed to be vaccinated, even though they may not have the required identification. “It took us five months and intense awareness building,” says UJAS head Hindu Singh, who adds that communities without this grassroots advocacy might struggle to access healthcare.
The same pattern has been seen in other countries such as Egypt, Morocco, and South Africa.5 In Greece, says Bartovic, this identification problem was tackled by giving refugees and migrants with no legal status temporary social security numbers to allow them to be vaccinated, but few countries followed suit.
Burton highlights three key barriers to refugees accessing vaccines: trust in authorities, political pressures, and structural and transport related problems in reaching vaccine drives. “The vaccine might be available in these contexts but refugees cannot take time off to travel or have money to spend on transport.” Refugees The BMJ spoke to cited access to doctors and vaccine centres as the most common reason they were not vaccinated. Fewer said it was unaffordable or outright distrusted the vaccine.
Bahar had heard rumours that covid vaccines could shorten one’s lifespan. But what seemed to put her off most was the lack of proof of vaccine status afterwards, without which some employers would not let her work for them. “Without a certificate, what is the point of the vaccine?” she said.
Bartovic says vaccine misinformation in refugee camps is a parallel “infodemic” but warns about “over-diagnosing hesitancy” at the risk of disregarding structural barriers to vaccine access for refugees.
For instance, when over 100 000 Rohingyas were internally displaced and hundreds killed following riots in Myanmar in 2012, the ones who were able to flee to India were greeted by organisations offering help, many of them charities headed by fellow Muslims, with aid coming mostly in the form of food and clothes packets. “But neither Islamic charities nor international agencies really understood what we needed,” Kyaw Min, Rohingya leader and founder of Rohingya Human Rights Initiative, says.
With Indian government public messaging written and in Hindi (and therefore incomprehensive to illiterate Rohingya speakers), Kyaw Min’s grassroots NGO developed six videos in the Rohingya language to raise awareness about covid-19 and vaccines and Kyaw Min used his own and his families’ vaccinations as a way of publicly demonstrating their safety to community members. UNHCR data also find that language has been a predictor for vaccine access, with Arabic speaking refugees in Egypt and sub-Saharan Africa more likely to be vaccinated.
In Uganda, in the absence of government campaigns to reach the nation’s 1.5 million refugees, 34 refugee led organisations have conducted sensitive vaccine information campaigns led by refugee communicators.5 These included conversations with refugees with disabilities in Kampala about covid-19 vaccines and the Somalis Refugee Integration Network’s translation and door-to-door refugee led leafleting of Somali refugees in Uganda to tackle vaccine myths and misinformation.
Says Bartovic, “We need to focus on approaches that mobilise the resources and assets within refugee and migrant communities. We also need to invest in language support and health literacy initiatives.”
With vaccine supply no longer the choke point, Burton says that structural problems such as cold chain distribution to rural areas as well as refugee led messaging should be the focus if we want to achieve vaccine equity for the world’s marginalised people.
Footnotes
Commissioned, not externally peer reviewed
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: This project was funded by the European Journalism Centre, through the Global Health Security Call. This programme is supported by the Bill and Melinda Gates Foundation.
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