COVID-19 impact on health and livelihoods in a complex emergency

Even as COVID-19 vaccines are being approved and started to being rolled out, the pandemic is far from over. Compared to the escalating case numbers in parts of the Global North, confirmed COVID-19 cases have remained relatively low in Somalia, with 4714 cases and 130 fatalities attributed to the disease by December 2020, which may be partially attributed to limited testing and reporting capacity. While it is too early to comment on the full impact of the pandemic in the country, it is possible to provide some insights into its secondary effects to livelihoods as a result of public health measures, which have become a primary concern for much of the population. 

Almost immediately following the confirmation of the fist COVID-19 case in mid-March 2020, a multisectoral emergency task force and isolation facilities were established, and health workers deployed at airports. Border crossings were closed, in-country movements restricted, and comprehensive Risk Communication and Community Engagement (RCCE) strategies implemented, before curfews were put in place and large events prohibited. While most of these restrictions were lifted five months later, confirmed COVID-19 cases did not significantly increase since.

Globally, the pandemic has not only impacted people’s health, but importantly work, income and education, disproportionally affecting the most socio-economically vulnerable populations, including migrants, refugees and internally displaced persons (IDPs). While public health measures such as lockdowns and human behaviour are often discussed as a determinant for disease risk, socio-economic factors have proven to be an important determinant of health. These disproportionally affect vulnerable populations are often unable to physically distance, ‘work from home’, and even before the pandemic lacked access to healthcare and personal protective equipment (PPE). Pre-existing poor health conditions, which put people more at risk of the disease, may be caused or exacerbated by crowded, poor living conditions and a lack of sanitation. These factors play a role in the risk of severe COVID-19 disease, the ability to adhere to preventive measures, and the impact of public health approaches to lives and livelihoods. 

As part of a collaboration between the University of Nairobi, Africa’s Voices Foundation (AVF) and the University of Cambridge, we conducted a remote qualitative study through semi-structured conversations with hard-to-reach IDPs (n=13) and host populations (n=22) in Baidoa and Mogadishu in Somalia, gathering people’s lived experiences and responses to the pandemic, using a two-way SMS system developed by AVF and Lark Systems. I share here some of our findings, which indicate that public health measures adopted in Somalia in response to COVID-19 limited people’s ability to cope, affecting their resilience against the impact of future disasters, including any further impact of the ongoing pandemic.

Displacement pathways

Disasters, environmental degradation and conflict have caused significant displacement in Somalia, both internal and cross-border. In a country with an estimated 15 million people, over 2.6 million people are internally displaced due to the ongoing complex emergency. While conflict has caused many to leave their homes, the majority (72 per cent) is displaced as a result of disasters caused by natural hazards exacerbated by climate change and environmental degradation. In 2020, after the first COVID-19 case was confirmed in the country by mid-March, rural areas were affected by floods and a locust infestation. Heavy rains in the summer caused hundreds of thousands more people to leave their homes.

Even with internal movement officially restricted during the pandemic, our results show that new movement dynamics occurred. The loss of work and income due to public health measures caused additional displacement: “I lost my job and now I joined the IDPs of Baidoa” a school teacher told us in July 2020 during one of our conversations, having left his rural home and livelihood, asking for assistance. Another respondent left Mogadishu after losing his street vending job following lockdown and curfews, and returned to his birthplace Marka, from which he had been internally displaced in 2017 due to conflict. 

The Somali Diaspora is one of the largest sources of funding to the country, counting over two million people, including both refugees and migrants, with the majority living in neighbouring countries. COVID-19 disproportionally affected migrant workers globally, as their living and working conditions put them more at risk of the disease, and more likely to lose unstable jobs and income, often lacking unemployment benefits, while travel became impossible. As family members of our participants abroad were affected by COVID-19, either by losing jobs, falling sick, dying, or unable to return to the country, remittances were lost. “The person I relied upon for my income has passed away in the United Kingdom because of COVID-19”, shared a young mother who moved in with her in-laws in Mogadishu to be able to provide food for her infant child. 

Compound risks

As authorities and supporting agencies feared uncontrollable spread of COVID-19 in Somalia, where many people live below the poverty line, strict measures were put in place to restrict movement and prevent crowding. It is however unclear to what extent these measures have been effective in limiting disease spread in Somalia. Our study showed that, even among our small sample, people had either been infected themselves or had family members who had been sick with COVID-19, indicating perhaps a much larger burden of disease than shown by official data. Most participants were well aware of risk of disease and related public health measures, however many considered the negative outcomes of these measures to be much more impactful, especially to the poorest populations, including the displaced. Many people, including restaurant staff, teachers and street vendors, lost their jobs and income: “I used to sell watermelon in the streets to earn a little, that has now stopped due to coronavirus (…), everyone is afraid of the virus because [it is] easily transmittable”, one IDP respondent let us know.

Syndemics – two or more disease clusters exacerbating negative health outcomes - are common in displaced populations, as immunity against infectious disease is often impacted by the stress and exhaustion of displacement, exacerbated by malnutrition, living conditions and limited access to health services. COVID-19 can be considered a syndemic, as the disease is more severe for people with underlying health conditions, while it affects people from poor socio-economic backgrounds more severely, especially the displaced who often live in crowded and unsanitary conditions, with income depending on daily wage labour and movement, affecting their ability to isolate or quarantine. In Somalia, health services are limited. As pointed out by one of our host-population participants, COVID-19 is not the main concern for many people, but instead “one of the health challenges is that the hospitals don't have enough medicine [for other diseases]”.

The blanket imposition of public health measures without considering local risk contexts exacerbates health and livelihood challenges to the most vulnerable populations, affecting jobs and remittances, while even resulting in new displacements. In complex emergencies where there is a lack of data on hard-to-reach displaced populations, it is essential to take into account their lived experiences, and the use of new technologies, such as the remote messaging modality we adopted for our study, can support the development of more inclusive responses. 
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This study was a collaboration between Dr Salome Bukachi at the University of Nairobi, Zakaria Sheikh and colleagues at Africa’s Voices Foundation, and Dr Sharath Srinivasan, Dr Luke Church, Dr Freya Jephcott and the author at the University of Cambridge.

About the author

Dorien Braam is Director of Praxis Labs, a global research collective focusing on displacement, protection, labour migration and health. She currently researches the risks of zoonotic disease transmission in displaced populations at the Disease Dynamics Unit, University of Cambridge as PhD Candidate funded by the Gates Cambridge Trust. She previously worked with the United Nations, Netherlands Government and INGOs across Asia, Eastern Africa and Europe. During 2020 she led a remote qualitative study into responses of internally displaced and host populations to the COVID-19 pandemic in Baidoa and Mogadishu in Somalia, with a team of researchers from the University of Nairobi and Africa's Voices Foundation (AVF).

This article is part of the IOM Series on The COVID-19 Pandemic, Migration and the Environment.