Persistent COVID-19 Vaccine Inequity Has Significant Implications for Refugees and Other Vulnerable Migrants
Globally, access to COVID-19 vaccines has been uneven. More than one year since vaccines became widely available in high-income Western countries, many lower-income countries have struggled with supply and have notably low rates of vaccination. With each new wave and each new variant, this gap has widened. As of April 2022, approximately 65 percent of the world’s population had received at least one dose of a COVID-19 vaccine; among low-income countries the rate averaged 15 percent. In fact, as of February 2022, more booster shots had been administered in wealthy countries than total doses in low-income countries.
This disparity has particularly acute consequences for the world’s 26.6 million refugees, 85 percent of whom live in developing nations. On paper, many of these refugees and other internationally displaced people have long had access to the vaccine. As of June 2021, 98 percent of the 126 countries hosting at least 500 refugees had planned to include them in vaccine distribution, in commitments made either through formal vaccination plans or to the UN High Commissioner for Refugees (UNHCR). But while there appears to be will from many national governments to extend vaccines to refugees, a gap remains in individuals’ ability to actually access them.
Largely, refugees are in countries with underfunded public institutions, meaning that even in the best of times their access to essential services is limited. In many countries, refugees’ lack of identity documents represents a barrier to health-care access, as does the large numbers of individuals who might qualify as refugees but have not applied for protection or who for other reasons lack status. In major refugee-hosting countries such as Iran and Pakistan, vulnerable individuals have been estimated to number in the millions, but their lack of legal status leaves then excluded from formal vaccination schemes. People who have fled war but are unauthorized in their new countries might also distrust authorities or have legitimate fears of being targeted for arrest or deportation, which can prevent them from seeking vaccination. Governments have also shown a preference for prioritizing populations such as the native born and have targeted them for vaccine outreach, with the result that vaccine sites are placed far from where refugees live. Meanwhile UNHCR, which is responsible for vaccinating many refugees, has reported severe underfunding. In September 2021, the agency reported having only one-third the budget it predicted it would need to respond to the COVID-19 crisis, with a shortfall of nearly U.S. $617 million.
Yet at root, the global inequity of vaccine distribution is to blame. The Gavi-led COVAX initiative responsible for distributing vaccines to all countries irrespective of their wealth had initially promised to ship more than 2 billion doses by the end of 2021. It missed this target by a wide margin. As of April 2022, the initiative had shipped slightly more than 1.4 billion doses to 145 countries, 90 percent of which were lower income. High-income countries in North America and Europe, where leading vaccines were developed, were quick to reserve the output for their residents, while COVAX was slower to secure financing and supply. Even developing countries with vaccine production capacity, such as India, placed restrictions on exports as they responded to new domestic outbreaks. Among the top refugee-hosting countries, rates of vaccination for the overall population range widely, from 77 percent in Germany to just 13 percent in Sudan.
All the while, economic and social repercussions of the pandemic have meant that many refugees are now more vulnerable than before the global health crisis started. Many have lost jobs or had their employment opportunities drastically reduced, leading to difficulties in securing basic needs. Furthermore, pressure on hospitals has meant that forcibly displaced migrants are less able to access not only COVID-19 related health-care services, but also treatments for other medical needs. Twenty-two percent of the world’s refugee population lives in camp settings where social distancing is virtually impossible; even though officials’ worst fears about outbreaks in these locations have not been realized, many watchers have remained concerned about the prospect of continued spread. And migrants of all kinds have been easy scapegoats, accused of spreading the COVID-19 virus—further marginalizing people forced to flee conflicts or disaster.
With the pandemic now in its third year, societies are developing new ways of coping. But the global recovery is marred by unequal vaccine access. This article examines the persistent disparity in access to vaccination against COVID-19 for refugees and other forcibly displaced people in Asia and Africa. Given the global nature of the virus and the fact that variants that emerge among small populations can spread worldwide, inequities have consequences not only for vulnerable individuals but the planet as a whole.
In Asia, Large Unregistered Population Has Been Left Out
According to UNHCR, every government in the Asia-Pacific region has either explicitly included refugees in its vaccine campaign or has provided country-level assurances of its intention to vaccinate refugees. However, many countries have not signed the 1951 Refugee Convention and lack formal refugee frameworks, leaving large numbers of individuals without access to services. Vaccination rates remain uneven, and many forcibly displaced people have found themselves on the sidelines.
Pakistan and Iran Face Challenges with Unregistered Afghan Populations
Pakistan hosts 1.4 million Afghan refugees according to official records, plus as many as 2 million more unregistered migrants from Afghanistan and smaller numbers from Bangladesh, Myanmar, and the Chinese region of Tibet. Registered refugees have been formally included in the government’s vaccination program, and 59 percent of the country’s population has received at least one dose (there are no publicly available statistics about refugees’ vaccination rates).
However, the large population of unregistered Afghans and others without formal papers—including many Pakistani natives who live in rural areas—has been unable to take advantage of the vaccination program. Some migrants have also expressed skepticism about the origins of the pandemic and may be reluctant to seek out a vaccine. Many have said that they have not been approached as part of government or nongovernmental vaccination campaigns.
Following the Taliban’s takeover of Afghanistan last year, approximately 300,000 Afghans arrived in Pakistan seeking safety, according to government officials, about two-thirds entering without authorization. Pakistan’s government announced it would provide vaccines to new entrants from Afghanistan at border crossings, however the country was generally resistant to welcome the new arrivals and it is unclear how many jabs were put into arms.
Iran, the other major destination for people forcibly displaced from Afghanistan, hosted an estimated 3.6 million refugees and other vulnerable migrants as of 2021. Of these, however, nearly 2.3 million lacked legal status. The country has reportedly been hard hit by the pandemic, and also limited its public-health response by refusing to accept vaccines produced in the United States or United Kingdom. According to UNHCR, nearly 500,000 foreign nationals—including refugees and Afghans without legal status—had been vaccinated as of November, which would amount to approximately 14 percent of the total. By contrast, 67 percent of the total Iranian population had received at least one dose at that time.
In Bangladesh, Slow Rollout for Rohingya Refugees
Bangladesh hosts nearly 900,000 refugees from Myanmar, most of them ethnic Rohingya who since 2012 have fled the military-led crackdown in their native Rakhine state. Living in camps, which are heavily manned by security forces and with little access to the outside world, these refugees have long struggled to access health care. Longstanding health-care challenges became more acute with the onset of the pandemic.
Bangladesh witnessed a dramatic surge in COVID-19 cases in 2021, but the government included refugees in its vaccination drive only that August. By February, about 307,000 had received their first shot, including about 5,800 of the 18,000 refugees on the cyclone-prone island of Bhasan Char, where the government has been encouraging many Rohingya to relocate (reportedly moving some against their will). These numbers are notably smaller than the 57 percent of the country as a whole that had received a jab as of that period. Although the country’s immunization drive continues, it remains slow, predominantly due to the lack of available vaccines.
India Contends with High Caseloads
India has recorded the second highest number of total confirmed COVID-19 cases globally and the third most confirmed deaths, although the actual numbers are estimated to be much higher. Seventy-two percent of Indians had received at least one dose of a COVID-19 vaccine as of April, and in January officials began distributing booster shots to priority groups such as frontline workers and certain individuals over 60 years old.
India is home to more than 217,000 refugees, most of whom are from neighboring Sri Lanka and Tibet and are assisted by the government. Approximately 47,000 are under the purview of UNHCR, chiefly from Afghanistan and Myanmar (mostly of the persecuted Chin and Rohingya ethnic groups) or the Middle East and Africa. Partly because India has no formal refugee law, refugees have traditionally lived on the fringes with very limited access to health care and other essential services. When COVID-19 cases surged, access to these supports became nearly impossible. Most refugees rely on government clinics and hospitals for treatment, and their access is often facilitated by UNHCR India and its partners, however these agencies were ill equipped to deal with refugees’ needs as hospitals collapsed under the weight of high infection rates during the Delta surge around April and May 2021.
The result has been slow vaccination for refugees and other displaced people in India. As of January 2022, approximately 49,000 refugees and asylum seekers had been vaccinated, a rate of 23 percent. Yet demand for vaccines is strong: A survey by the Migration and Asylum Project (MAP) in 2021 revealed that more than 60 percent of the refugee respondents were interested in getting vaccinated, despite doubts similar to those voiced by the rest of India’s population.
Countries in Southeast Asia were generally late to extend their vaccination plans to refugees and other vulnerable migrants, and a combination of factors has contributed to a mixed uptake. In Thailand, the vaccination drive for refugees and other displaced people started only in October 2021. Aid organizations played a role in mobilizing resources and lobbying the government to offer support to vulnerable communities, however the process has been slow and vaccination numbers low, especially among the nearly 554,000 stateless people. Another issue was delays in delivering millions of doses donated by the United States to be administered by the COVAX initiative; the episode illustrates the bureaucratic hinderances that can hamper vaccine rollout. In this case, the Thai organization tasked with helping distribute the doses could not obtain the government’s permission to do so, leaving the doses and would-be recipients in limbo for several months.
In Indonesia, the 13,200 refugees registered with UNHCR—more than half of whom are from Afghanistan—have access to the private and national vaccination program, and as of January slightly more than 7,400 refugees had received at least one vaccine. Still, efforts to vaccinate refugees occurred relatively late in the year and at least initially the only refugees eligible were those in areas where at least 70 percent of the population had received a first dose; as of early November, this represented just six of the country’s 34 provinces.
The Malaysian government opened its national vaccination program to all residents irrespective of documentation, including the nearly 187,000 registered refugees, asylum seekers, and stateless individuals, the vast majority of whom are from Myanmar. Still, legal status presents a barrier to vaccination: As many as 4 million migrants lack legal status, and among this population many have expressed fear that they will be arrested and deported if they come forward. Their concerns are not without reason—the government said in early 2021 that it would not make immigration-related arrests for anyone seeking COVID-19 testing or treatment, but reversed the decision a few months later and arrested more than 2,000 people.
Sub-Saharan Africa: Paltry Access to Vaccination Regardless of Status
By and large, the countries with the lowest vaccination rates are in sub-Saharan Africa. Many African countries rely on the COVAX initiative run by Gavi, which is a public-private global health partnership seeking to increase access to immunizations in lower-income countries. As a result, they have been especially affected by the global inequitable vaccine distribution. Continent-wide, just 21 percent of Africans had received even a first dose as of April 2022. Yet short supply is not the only challenge; governments have struggled to administer available doses because of supply chain limitations and other issues. For instance, officials in South Sudan have faced challenges distributing vaccines because of lack of road connectivity. Elsewhere, individuals’ lack of identity documents, access to the internet, technological capabilities, and awareness of COVID-19 have contributed to low rates of vaccination. Countries across the continent also contend with weak public-health systems.
Uganda, which hosts the largest refugee population in Africa (nearly 1.5 million people), has generally provided services for refugees and included them in its COVID-19 vaccination drive very early on. However, persistent administrative, logistical, and physical barriers to vaccine access have posed challenges. For instance, refugees without identification cards have had to undergo the cumbersome process of obtaining a letter from the prime minister’s office. Even if they have ID, refugees must fill out a registration form and receive a vaccination card written in English, which many refugees do not speak. At times, vaccines have only been available on certain days, and refugees have not had always reliable information about where they can be obtained. Just 8 percent of Uganda’s population had received at least a first dose as of November 2021, but among refugees the rate was less than 1 percent.
Many other countries on the continent face a similar situation. Ethiopia hosts close to 783,000 refugees and has included them in its vaccine rollout plan. But the Ethiopian government, which since late 2020 has been waging a brutal conflict in its northern Tigray region, is struggling with vaccinating its population in general, due to public hesitancy and limited supply. As of November 2021, fewer than 7,500 refugees had received a jab.
Similarly, South Africa hosts approximately 250,000 refugees and asylum seekers, but many forcibly displaced people live in unauthorized status due to legal and bureaucratic barriers. The government began including unauthorized migrants in its vaccination program only in December 2021.
Due in large part to short supply and distribution challenges, refugees in sub-Saharan Africa are nowhere close to being vaccinated on par with their counterparts in other parts of the world. Still, things are slowly changing. Since January, African countries have been able to request vaccines directly from the World Health Organization (WHO) instead of receiving vaccines as and when they became available. This new distribution model is likely to accelerate the rate of vaccination on the continent, potentially including among refugees and other vulnerable populations. A ramp-up will have to happen to meet the WHO goal of vaccinating 70 percent of the continent’s population by the middle of 2022.
New Crises Underscore Complicated Picture
More than two years of repeated COVID-19 outbreaks and variants across the world have demonstrated that any large unvaccinated population could become a breeding ground for the next mutation. Increasing access and availability of vaccines therefore has global consequences.
Just as important is the need to safeguard some of the most vulnerable populations in the world. With situations deteriorating in countries including Afghanistan, Myanmar, and Ukraine, the coming years will likely see an unprecedented number of people forced from their homes and their countries. Safeguarding refugees and other vulnerable migrants against COVID-19 will result in stronger protection regimes for the world writ large.
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