Displaced Syrians at a workshop organized by medical volunteers affiliated with a Turkish-registered Syrian relief organization aimed at spreading awareness of Covid-19 at a camp near the Syrian town of Atme close to the border with Turkey in Idlib province on March 16, 2020. Photo: AFP / Aaref Watad

All over the world, governments are advising their populations on best practices to avoid coronavirus contagion, namely to avoid gatherings and to thoroughly wash hands throughout the day.

But what do you do when you do not have adequate clean water or soap, or the space to self-quarantine?

That is the situation of millions of refugees and internally displaced populations in Syria, Yemen and beyond.

In the Eastern Mediterranean nation of Lebanon, where one in every four people is now a refugee, this vulnerable population is uniquely exposed to the global pandemic.

“It’s large families sharing tents, lots of babies and children being already sick most of the time due to the cold and dampness and flooding and lack of good warm clothes,” said an international volunteer working for an NGO active in Lebanon’s Beqaa Valley.

Though no cases have yet been recorded of a Covid-19 infection in the region’s camps, humanitarian workers are already bracing for the storm.

Yet humanitarian groups face major challenges in implementing even the most basic preventative measures, such as hand-washing.

Moreover, refugees often “self-diagnose or self-medicate rather than going to a doctor,” due to the fear of high costs and a lack of information on where and how to benefit from help at affordable prices, the volunteer told Asia Times.

“It’s a bad cocktail for sure,” they said on condition of anonymity.

No safety net

Muhammad H Zaman, a professor of biomedical engineering and international health at Boston University who has spent significant time in Lebanon, warned that a lack of safety nets for people with no agency was leaving the whole world at risk.

“We have to recognize that these people are unable to do the two most fundamental things: social distancing and hand-washing,” he told Asia Times.

Even beyond ethical reasons, the international community has economic and public health reasons to support them, he argues.

In informal tent settlements scattered across Lebanon’s eastern Bekaa Valley, refugees as a rule have no access to running water, instead lugging drinking water to their homes and paying for large containers to be filled.

In Lebanon’s cramped Palestinian camps of Sabra and Shatila, where multiple generations often live in one-room apartments with scarce ventilation, recent years have seen an influx of Syrian-Palestinians, making conditions even more claustrophobic.

“These are places people cannot self-isolate,” Zaman said.

Lebanon has already moved to shutter schools, restaurants, cafes and bars, and on Wednesday will shutter its national airport until March 29, in a bid to prevent the Italian scenario.

No data, no cases?

While Syria remarkably has yet to report any Covid-19 cases, it and Yemen stand out as the most vulnerable in the region.

“In both countries, the health system has been decimated by the war, with qualified medical staff fleeing the country, hospitals being relentlessly attacked and the remaining systems being strained by diseases enhanced by conflict such as cholera, diphtheria and dengue fever in Yemen,” said Bassoul.

In Yemen, 70% of the population already lacks access to clean water, rendering Covid-19 outbreaks in neighboring Saudi Arabia and Oman cause for major concern.

Syria’s neighbors have also all reported coronavirus cases among their own citizens, ranging from just over a dozen in Turkey to more than 100 in Lebanon.

Thus far, there have been no known cases among the refugee populations. But in the absence of testing and a lack of data, that could mean very little.

“More testing in any country is revealing more prevalence,” said Zaman, who expects it is only a matter of time before Covid-19 cases surface in the camps.

“There is no scientific reason to expect that would not be the case,” he said. “The burden of testing is on the person.”

In Jordan, Lebanon and Turkey, each hosting more than one million Syrian refugees, humanitarian organizations are bracing for such a scenario.

“Though refugees’ access to healthcare varies among these three countries – with Lebanon being the weakest link – it’s doubtful that the national healthcare systems will be able to carry the refugee caseload in addition to its own one,” said Joelle Bassoul, regional media manager at Save the Children.

Lebanon has only one public hospital, but healthcare is overwhelmingly privatized, and in the context of a months-long financial crisis, even a bus ticket to reach care could prove insurmountable.

“With Turkey hosting more than three million refugees, Lebanon having the highest per capita in the world, and Jordan having refugees in remote camps like Zaatari and Azraq,” Bassoul said, “an outbreak among the refugee population could well be a disaster.”

Alison Tahmizian Meuse

Alison T Meuse is the Asia Times Middle East editor and correspondent.