Miranda A, Mohan A, Carla dos Santos Costa A, Hussaini M, Adnan A, Dapke K, Phadke R, Bassey E, Ahmad S, Essar M, Ahmad S, Tsagkaris C, Aborode A, Hashim H. Pandemic preparedness strategies with an eye on displaced populations in Yemen: Efforts and challenges on hand. Harvard Public Health Review. 2021; 31.
This article aims to comment on pandemic preparedness strategies, especially for refugees and internally displaced persons (IDPs) in Yemen, and the obstacles that may hinder their success. Yemen is currently undergoing the largest humanitarian crisis worldwide, with 283,000 refugees from the Middle East and Africa, and 3.6 million internally displaced inhabitants. Basic needs including food, water and shelter have been compromised, in the setting of political unrest and financial instability. The effects of healthcare discrimination and inadequate healthcare facilities have intensified in the setting of the COVID-19 pandemic, where healthcare resources are of the utmost significance. This amounts to a wake-up call for concerned international bodies and charitable organizations to intensify their efforts in view of the rising infection rate. Since March 2020, numerous endeavors have been made by the United Nations High Commissioner for Refugees (UNHCR) and partners, such as the International Organization for Migration (IOM) and the Yemen Red Crescent Society (YRCS), with the objective of mitigating the situation in Yemen. Improving relationships between Yemeni citizens and migrants, and strengthening collaboration with foreign governments may help secure the health and wellbeing of the displaced population amid the ongoing COVID-19 pandemic.
Yemen is undergoing the largest humanitarian crisis worldwide, with over 24 million (80%) citizens in need of aid and 3.6 million internally displaced inhabitants. The country also hosts about 283,000 refugees fleeing conflicts from the Middle East and Africa [1, 2]. Yemen was already facing a great humanitarian crisis before the COVID-19 pandemic. More than 80% of Yemen’s population lacks access to food, fuel and health care facilities rendering them vulnerable to diseases that have been eradicated elsewhere in the world. Because of the ongoing war in Yemen, the health-care system is in shambles. Yemen reported the first cases of COVID-19 on 10th April 2020.  As of January 19, 2021, the Government of Yemen (GoY) have reported 2,117 confirmed COVID-19 cases and 613 deaths . Due to the ongoing conflicts and the fragile state of Yemen’s health system, the country’s testing capacity is limited. Hence, it is estimated that the real number of cases is much higher . The current pandemic has posed additional challenges to the pre-existing crisis, as curbing the transmission rate requires large-scale humanitarian efforts. This article aims to comment on pandemic preparedness strategies targeting refugees and internally displaced persons (IDPs) in Yemen, and the challenges that may hinder their success.
Since March 2020, numerous endeavors have been made by the United Nations High Commissioner for Refugees (UNHCR) and partners, such as the International Organization for Migration (IOM) and the Yemen Red Crescent Society (YRCS), with the objective of mitigating the situation of health crisis during COVID-19 in Yemen and meeting the needs of refugees. In March 2020, IOM launched the first healthcare center within Al Junaifah, Yemen’s largest displacement camp; this facility is expected to fulfil the essential medical requirements of 5,000 displaced families . This facility will be able to better combat the infectious diseases and provide support to people suffering for chronic diseases. Moreover, there are two mobile clinics within, and two mobile clinics in settlements neighbouring, Al Junaifah; these mobile clinics also serve as ambulances for patients’ transfer to the healthcare center or to other referral facilities . By November 2020, IOM had established eight mobile health teams throughout Yemen and were working on the construction of an isolation center for COVID-19 patients in Al Mardaa, Marib .
The IOM continues to play an active role in meeting the needs of refugees in order to ensure the quality of treatment for the displaced. IOM, in cooperation with the Government of Yemen (GOY) provides medical supplies to 17 health facilities throughout the country. Registration of stranded migrants, to facilitate their voluntary return to safer environments, is being conducted in parallel . Similar efforts by the UNHCR have led to the establishment of 5 clinics across the country .
Increasing the awareness of COVID-19 among refugees and IDPs is currently a priority for the IOM and UNHCR, which organized seminars and distributed informative materials in camps (door-to-door) and in health centers. All gatherings involving sizable crowds have been suspended. The organizations also provide hygiene kits and personal protective equipment (PPE) for the refugees and IDPs’.[8,9,116-7,9] Trainings for health professionals and community healthcare workers (CHWs) regarding the identification and management of refugees and IDPs at risk of COVID-19 were also conducted which helped them train better to combat the health crises during the ongoing pandemic[86-119]. In addition, UNHCR has multiplied its 24/7 hotlines, while only appointment-based, high-priority, in-person interviews are being conducted .
Currently, only 50% of Yemen’s healthcare facilities are completely functional, rendering efficient referral systems from the displacement camps difficult . This is compounded by the increasing hostilities and political instability in Yemen. The turmoil has caused major highways to become inaccessible, along with increasing administrative impediments and the disruption of basic needs. If this continues, the displacement may extend into Marib Al Wadi and Hadramaut, where widespread desert landscapes and scarce humanitarian facilities will precipitate large-scale humanitarian responses .
Adding to the misery, migrants and refugees do not have access to the free national healthcare services . Healthcare discrimination, especially to refugees, continues to occur in the country . The pandemic has further aggravated this situation. Refugees are being scapegoated as carriers, when they do not even have access to shelter, let alone basic healthcare . As tribal conflict has become more frequent, more Yemenis have become internally displaced with a subsequent constraint in their access to healthcare .These conditions, in addition to the famine in Yemen, have forced migrants to seek help from smugglers, who had previously mistreated them despite the promise of a safe return home . Hence, regulatory measures addressing discrimination are necessary; however, it is debatable whether the authorities would be able to enforce these in an already conflict-stricken country.
Yemen’s economy is highly dependent on the revenues of its limited oil and gas reserves; the COVID-19 outbreak and crash in global oil prices have forced the country to be more dependent on foreign aid. However, the donors’ domestic economies have limited their capacity to provide aid. As of December 2020, no donor has indicated a willingness to provide continuing support to Yemen . IOM’s health program in the country still lacks USD 30M , compromising health assistance and its efficacy in certain locations. Access to healthcare for refugees across Yemen is already limited: in Marib, 84% of migrants are completely deprived of healthcare resources. Thus, this funding shortage is alarming as it can lead to increased mortality among refugees and IDPs, particularly in the setting of a COVID-19 outbreak . Strengthening collaboration with foreign governments to increase political stability and ensure adequate funding is pivotal in this regard. For the long run, it is highly crucial for the GoY to diversify their income sources to ensure financial stability, and therefore coverage of fundamental domains such as healthcare.
Vaccination is another important challenge that the refugees around the world are facing. To date, 51 – or 57 percent of the 90 countries currently implementing national COVID-19 vaccination policies have included refugees in their plans.  Even though Yemen is expected to receive an initial supply of 2.3 million doses through COVAX , an initiative launched by WHO to make vaccine available to the world’s most vulnerable, it will take a long time to make the vaccine available to each and every Yemen refugee as more than half of the vaccine doses have been bought by high-income countries that are expected to be manufactured in 2021, even though they only account for 13% of the population.  It is impossible to stop the pandemic unless a minimum of 70 percent of the population has acquired immunity.  Hence, it is important to understand that it is not possible to break or sustainably slow the transmission of the virus if displaced people are excluded from the vaccine rolls plans. It will possess a high risk of continued transmission of the virus in these populations with spillovers into the general population.
Moreover, refugees have a higher mortality rate than the residents of the nation in which they have asylum. They are at higher risk of stress and infectious diseases because they often live in overcrowded camps with poor sanitation. There is no general agreement regarding the ethical basis for the rights of the migrants and the obligations of the host countries and of the international community. There is a lack of effective global governance for public health, despite UN Sustainable Development Goals principle of ‘leave no-one behind’ which is inclusive of migrants and refugees 2]. A strategy aimed at understanding the needs of the marginalised people during the COVID-19 pandemic and proposed solutions was published by WHO but it must be followed as well, taking into account the position of health determinants of refugees. 
While numerous efforts have been made by the GoY, IOM and UNHCR to provide adequate healthcare for refugees and IDPs, several challenges continue to threaten their success. This amounts to a wake-up call for concerned international bodies and charitable organizations to intensify their efforts in view of the rising infection rate. Improving relationships between Yemeni citizens and migrants, and strengthening collaboration with foreign governments may help secure the health and wellbeing of the displaced population amid the ongoing COVID-19 pandemic.
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