Get the Global Dispatches Podcast Apple Podcasts | Google Podcasts | Spotify | Stitcher | Radio Public Mark Goldberg: (00:02) Welcome to global dispatches, a podcast about foreign policy and world affairs. I’m your host, Mark Leon Goldberg, editor of UN dispatch, and in this show, we discuss topical global issues, have conversations with foreign affairs thought leaders and newsmakers, and give you the context you need to understand the world today. Go to globaldispatchespodcast.com to learn more. And now on with the show. Mark Goldberg: (00:31) As I record this, the COVID-19 Coronavirus outbreak is poised to become a pandemic each day, brings news of new cases in new places around the world. So far, COVID-19 has mostly impacted countries with decently functioning healthcare systems. However, a great worry that has been repeatedly expressed by experts and from the World Health Organization is what happens should we see clusters of cases where there is no good health system. This includes poorer countries, particularly in sub-Saharan Africa and also populations in the midst of some humanitarian crisis. To better understand the potential impact of this Coronavirus outbreak on vulnerable populations around the world, including on refugees and displaced people and those impacted by conflict and humanitarian crises, I speak with Dr. Paul B Spiegel. He is the director of the center for humanitarian health at the Johns Hopkins University Bloomberg School of Public Health where he is also a professor. Mark Goldberg: (01:44) As it happens, Paul B Spiegel was in the midst of a project to model scenarios around COVID-19 and the Rohingya refugee population in a region of Bangladesh called Cox’s Bazar. So we do spend a good bit of time talking about that particular humanitarian crisis while also discussing the broader implications of COVID-19 spreading to places already in the midst of a crisis. So a big thank you to the listeners who have suggested this topic. I knew I want to cover some aspect of the COVID-19 situation that was not getting the attention it deserved. And I put a call out on Twitter and several of you recommended that I explore the impact of COVID-19 on refugees and other humanitarian crises and also suggested that I get in touch with Paul Spiegel who turned out to be the ideal interlocutor. So thank you. If you are new to the show, welcome please visit globaldispatchespodcast.com where you can peruse our robust archive of conversations about topical issues in global affairs and you can also use the contact button to get in touch with me if you have suggestions of people I should interview or topics I should cover. Mark Goldberg: (02:55) And for premium subscribers, the bonus episode I’m posting this week is my conversation with Mark Kennedy Shriver. He is the head of the Save the Children Action Network and as his name suggests, a scan of the Kennedy and Shriver clans. His father Sargent Shriver founded the Peace Corps and his mother, Eunice Kennedy, helped start the Special Olympics and in our conversation, he discusses how his family’s legacy of service and public interest work has guided his own life and career. To access that bonus episode and other bonus episodes, you can become a premium subscriber. You can do so by going to patreon.com/globaldispatches or clicking the links in the description field of this episode. Premium subscribers also get access to my daily global humanitarian news clip service called DAWNS Digest. This is a daily email that people in the humanitarian community and the global development community subscribe to start their day. It covers less covered news from around the world, but news that’s relevant to people who kind of care and follow global stories that don’t often make headlines. Mark Goldberg: (04:11) And today’s episode is brought to you by Northwestern University’s online master’s program in global health. You can learn how to make a meaningful difference in places where it is needed the most. Go to sps.northwestern.edu/global or click on the add on globaldispatchespodcast.com to learn more. And if you are interested in learning more about this degree, you can also just send me an email and I’ll point you in the right direction. All right, now here is my conversation with Dr. Paul Spiegel, director of the center for humanitarian health at the Bloomberg School of Public Health at Johns Hopkins University. Dr. Paul Spiegel: (04:53) I’m concerned, as probably everyone is, worldwide now. It’s likely inevitable that a pandemic will, will occur. Although I think a lot of people, understandably as I am hesitant to say 100%, but things are moving very quickly and we’re always concerned about refugees. and I would say refugees is often a broad term depending on how one wants to use it, but refugees internally displaced persons, people that have been forcibly displaced and are often more vulnerable than host communities. and often are a second thought compared to, governments that are dealing with their own nationals and their own nationals that have not been displaced, like internally displaced persons. Mark Goldberg: (05:40) And do we know anything as of now about sort of in terms of the trajectory of the spread of COVID-19 that particularly concerns you in terms of any kind of vulnerable population say in the Middle East? Dr. Paul Spiegel: (05:53) Interesting. You moved to the Middle East, one of my, one of the big concerns I think we have is in Asia and if COVID-19 gets into some of the Rohingya camps in Bangladesh, for example, it would be very, very, very, very bad for a variety of reasons. which I could get to. In the Middle East, the issue is that other than, let’s say the Palestinian camps which are not really camps, they’re cities, there aren’t that many camps in the Middle East. There are some in Jordan, Asraq, and Zaatari, but in the Middle East, for the most part, the population is dispersed amongst the, amongst other populations. So Lebanon, and Jordan, and Turkey, of course, there are camps, but the large majority are, are outside of camps. However, that’s equally concerning because of the access to health care, again, that these refugees would have compared to many of the national population. Mark Goldberg: (06:54) I think for example, in Lebanon, so like almost one in five people at one point was a Syrian refugee in Lebanon. These aren’t people living necessarily in camps, but among the population. But you’re saying that their access to healthcare is reduced or limited compared to the Lebanese nationals? Dr. Paul Spiegel: (07:10) Yes, in general. I mean, I think it’s always important to recognize that their nationals and refugees are not there’s just not one group in terms of socioeconomic status. So the nationals and the refugees there are always groups that are more vulnerable than others. And so there’s a push now and rightly so in terms of equity that in Lebanon for example, a country I know well and, and some would say it’s even one in four as opposed to one in five. I’ve even heard one in three, but certainly there is a, there’s let’s say 20 30% of the population may be Syrian refugees. It is extremely difficult for, in Lebanon where it’s a privatized, society, sorry, it has privatized healthcare system and it’s, it’s difficult to have access. And over time the refugees, the Syrian refugees in Lebanon have used up all their assets. They do try to do some work, but the poverty level is much higher amongst refugees than the Lebanese. But again, just a quick caveat is that there are many vulnerable Lebanese as well, who we should equally be concerned about. And I think if we concentrate in terms of a Coronavirus or any epidemic or in healthcare, we really need to think about those that are most vulnerable. And not necessarily the status of a person. Mark Goldberg: (08:40) So you initially, referenced the Rohingya refugee population in Cox’s Bazar and in Bangladesh, which is what about like 700,000, 600,000 at this point? Dr. Paul Spiegel: (08:53) Depending on which numbers as always, but yes. Mark Goldberg: (08:55) What does the health infrastructure in a place like that look like? Dr. Paul Spiegel: (09:01) It is, it’s a bit ramshackle, but there are amazingly, you know, they’re actually, there have been outbreaks in those camps, but compared to at the beginning when you had so many people coming in, in a poor state and everything was overwhelmed in terms of shelter, in terms of the health care and water and sanitation. Amazingly the mortality rates have not been hugely elevated, compared to what we would have expected, which means that the international community and the government of Bangladesh really have stepped up. that being said that there have been outbreaks including diphtheria, and if there was a significant stressor such as COVID-19 in a place like that, which is, it’s not a camp, but you know, many camps it would overwhelm the, it would overwhelm not just the population but the, the amount of the, the health care workers themselves. And you’re going to need everything from, you’re going to need everything from basic services for people that are a fever and cough to significantly as you get older and you have more and more serious side effects, you’re going to need much more serious care that these camps would not be able to offer. Mark Goldberg: (10:23) Yeah, I mean so at this point, as you said it, you know, it seems somewhat likely, I mean that this could be a pandemic. it’s not out of the realm of plausibility that, you know, this spreads to a place like a Cox’s Bazar. I guess what scenarios do you, can you potentially envision for what, what that might look like? Dr. Paul Spiegel: (10:44) Yeah, we’ve been actually at Hopkins we do have a group that’s been a modeling group and it’s been working of modeling, COVID-19 in, in some parts of China helping in Uganda, Zambia. And we’ve also just finalized, let’s say, different scenarios in the camps in Bangladesh. And some of the scenarios it will depend because, what’s interesting is the demographics in Cox’s Bazar, of course, you have a lot of children and younger people, which are not as, thank goodness, severely affected as older people with chronic diseases. So if you have to look at the demographic profile, which is, perhaps in Cox’s Bazar favor because it’s such a young population, but what’s not in favor of course, is the ability for diseases, particularly respiratory tract infections or respiratory infections to transmit. So in such a highly dense population, any of whom are, are undernourished, it will easily be transmitted. Dr. Paul Spiegel: (11:55) And so what would, some of the scenarios in a place like that is that they would be overwhelmed, there would need to be a significant amount of referrals to the various district hospitals in Cox’s Bazar. But the problem is in some of those hospitals have capacity. But then the problem is you are going to have, it’s not going to be a, an outbreak just amongst the refugees. It’s going to be amongst the nationals as well. And it’s going to be, excuse me, those district hospitals in terms of beds, in terms of where to put people who are suspected and have to be quarantined, it’s going to be overwhelmed. And how a government is going to decide what do we do with, or how do we deal with refugees, how do we deal with our nationals will be very, very difficult. Mark Goldberg: (12:41) Did your modeling scenario identify any potential fatality figures? Dr. Paul Spiegel: (12:47) No, not yet. We’re, we’ve not moved in that direction yet. What we have moved in, is to look at, cause we’re trying to look in terms of preparedness. And so what we’re trying to look at is in different, scenarios, how many, healthcare workers, where you need, what sort of equipment, where you need and how many beds where you need. and I’m not able to just get off the author. I can’t share that with you yet because we literally just finished it two nights ago. I need to go over it and then I want to share it with my colleagues in the UNHCR here and WHO there, but I don’t, I haven’t gone into horrible detail other than it’s very clear that there are not, there would not be enough healthcare workers in beds currently to be able to deal with something like that. And that’s not going to be unique just to there. Frankly, if it’s going to, it’s going to be, we saw how difficult it’s been in China. It’s going to be difficult, in many settings, including in many countries. Mark Goldberg: (13:46) Well, I, I’m, I’m wondering, I mean, that kind of leads me to my next set of questions, which is around what kind of capacity exists right now in the humanitarian system. And you know, by that I mean the constellation of NGOs and UN agencies and government agencies, you know, to deal with an outbreak in a crisis situation, whether it’s in, you know, say, you know, Bangladesh or elsewhere in the world. Dr. Paul Spiegel: (14:11) You know, what’s interesting is that this sort of soda and not all break outbreaks are the same. And so this sort of outbreak in terms of prevention in terms of what is required is very different than an Ebola outbreak for example. So in, and I was talking to some of my, my friends and colleagues at who, but in the Ebola outbreak in DRC and others, you actually have the NGOs and others going and building a big, Ebola treatment units. And we’re here for the, for the most part, you’re going to rely on existing health systems and you’re going to be building up those health systems and so, well, NGOs, and you’re going to have to have a massive prevention effort in terms of trying to mitigate the spread of the disease, which is going to be extremely difficult in places like Cox’s Bazar. And the camps there compared to, other areas that are, are, have less density. And then there’s going to be a need to dramatically increase their referrals to let’s say, the referral system to those hospitals and Cox’s Bazar, which are going to need, more room, more beds, more people to be able to address the amount of people that are going to be very, very sick with complications that are needed to need more serious medical care. Mark Goldberg: (15:33) So it’s interesting that you brought up Ebola because it did seem, at least to me at the time that the, you know, humanitarian system really sort of did kick into gear and did demonstrate a degree of, you know, flexibility and versatility and its ability to, to deal with that. I’m just wondering as you said if, if that kind of versatility exists today in terms of dealing with COVID-19, Dr. Paul Spiegel: (15:59) We’ve been thinking this through in terms of as I said, we can’t just say all, all epidemics are the same. And so Ebola where you’re trying to contain it in an area and it’s not exploding around the world at the same time, it’s much easier to have that classic humanitarian, it’s still complicated, but to have a classic humanitarian response and not just with the clusters but also with the, with the emergency medical teams and really moving and setting up, setting up hospitals and ETUs to the Ebola Treatment Units to really respond. This is going to be very different for a couple of reasons because number one it’s a lot of people are going to be affected and, and thank goodness the majority are not going to have symptoms or they’re going to be very light. So there’s gonna be a tremendous amount of very basic, basic prevention, wash your hands, this sort of thing where it needs to be. Dr. Paul Spiegel: (16:57) The second thing that makes it unique is that it’s pervasive. And so it’s not as if you’re going to have these NGOs and their capacities to move all over the world when you’ve got, it’s going to be in so many different places. And there, that’s number one. Number two is the protective equipment is already going to be because of the immensity and the dummies city of this at this, if we can use that word, there’s just not going to be enough materials masks, particularly for the healthcare workers and for those that are sick. So there’s probably not going to be enough soap enough, enough water to wash hands consistently, masks, gloves, and I would anticipate that the refugee camps, if you’re in a country, that you have, you’re worried about your own nationals, that the refugee camps may not be prioritized. Mark Goldberg: (17:44) That I think speaks to another worry I have about the broader politics of this, you know, as opposed to say the Ebola outbreak where you did see, you know, kind of a global outpouring of support for the effected countries because this is, as you said, so pervasive. I, I can’t imagine that governments will be as willing to say, fund a global response to places that can’t you know, that don’t have the capacity to deal with it themselves. I mean, I, I just, before we talked, looked at the status of that most recent emergency appeal from the world health organization for something like $65.1 million and they’ve received, you know, about $1.2 million of that so far. And, and this is to help countries that would be deeply affected places in sub-Saharan Africa. They don’t have the capacity to deal with it on their own to build up their preparedness. But it just, it’s hard for me at least now to imagine that the funding is going to be there for those countries to, you know, to, to build the capacity that they need. Dr. Paul Spiegel: (18:47) Yeah, I would agree. And it’s, I think it’s rather more, to be crude and trace, self-interest in some of this may be natural, but as a government, you’re first and foremost responsible for your own citizens and there’s not enough protective equipment, that we’ve already spoken of. And then even in terms of prevention, you’re going to be really now maximizing your own health systems to try to deal with your own population. So I think it’s going to, yes, it’s going to be very, very problematic. And so far, for the most part it’s been a COVID infected countries where they have at least functioning health systems. I think when we get, and, and there are functioning health systems and Cox’s Bazar in the camps but not like obviously in China. And then when you move to places like South Sudan or other areas, it’s going to be extremely difficult. And I, as you said, I don’t think you’re suddenly going to see, when you have an outbreak so large in so many different places, it’s not as if the an Edsel and some frontiers of the world are going to be able to move everywhere and respond in the same way as in Ebola. It’s a very different story. Mark Goldberg: (19:59) Um, is there an aspect to this issue, to the intersection of COVID-19 to, you know, humanitarian crises in vulnerable populations that you think is particularly worth emphasizing to the audience? Dr. Paul Spiegel: (20:11) I would say number one is that these, these populations are particularly vulnerable. And so any sort of outbreak that you would have such as COVID-19 after you take into account the demographics of perhaps the younger population, but they will be affected, they will be affected in a much more severe way because they already have more underlying illness than other groups and they don’t have the same social networks and the same money to be able to actually to buy basic ways to treat your, to prevent, such as water, soap, cleansing, materials and for those that are sick, masks. So I think they’re going to sadly suffer disproportionately to others. and then the next thing is I think to emphasize what you were just talking about, unlike when there’s a massive outbreak in a refugee setting or in a nearby setting, and you can send in a lot of the humanitarian NGOs and the UN to deal with that. When you have something so large and so severe there will not be the capacity to deal with this. So I worry despite, there’s clearly going to be an increase in surveillance and I’ve seen already from UNHCR and various UN agencies working in these areas in refugee settings that they’re increasing their surveillance and they’re going to try to increase and get funding for this. But in terms of preparation, I think it’s going to be a, sadly a very, very big challenge. Mark Goldberg: (21:42) And finally in the coming days, and weeks, or even months, what are you looking out for is what will suggest to you one way or another how this outbreak may evolve in, particularly in terms of how it might impact, you know, refugee and other vulnerable populations? Dr. Paul Spiegel: (22:01) I think we need to, we’re going to need to watch how the transmission is changing now. And when, when for the most part, everyone was watching and seeing how the disease was moving to other countries. But if it was mostly from, someone who had been to China, which was the epicenter and you were able to control that, then you could hopefully try to stop the spread. But as we’re seeing in, let’s say, Italy right now and in Iran you’re seeing, COVID-19 getting into those countries and then having its own response chain that is not related to the original person that was infected elsewhere. it’s going to move. So we’re going to see it hopping and moving towards more and more countries. And that’s, I would say, what we need to, we need to look at where our would be the most vulnerable refugee populations and it would be certainly in areas that are very poor where you have a lot of acute malnutrition or a lot of other diseases that refugees are affected by whether they have a huge increase in density of the population. So definitely camps and areas where they are not as spread out. The more spread out refugees are in populations. I would say the better in terms of, they will be mixed in with the national populations and everyone can try to deal with it in a similar way and treat everyone similarly. But if they’re caught into camps and then you have a massive outbreak it would be very worrisome. And I, I, but also maybe just end one of the concerns is that this is clearly not a refugee issue or a disease, but I worry that if they, if it gets into the stigma and discrimination of getting into a refugee population perhaps before it’s in the national population and refugees being blamed for as they often are as vectors of diseases when we’ve often found that that’s not the case. So it could also have a, there could be some negative stigma discriminations that inadvertently occur from this outbreak. Mark Goldberg: (24:11) Well, thank you so much for your time, Paul. This was very helpful. Dr. Paul Spiegel: (24:15) It was a pleasure. Thank you very much for speaking with me today. Mark Goldberg: (24:19) All right. Thank you all for listening. Thank you to Paul. That was very helpful and obviously very timely. Again, this is one of those stories that I think is becoming increasingly relevant in the coming weeks and months as this COVID-19 becomes a pandemic and spreads to vulnerable populations, particularly refugee populations. And I should say when that study that he references regarding the Rohingya refugee population in Cox’s Bazar, Bangladesh gets published. I’ll post it to the home page. All right. Let’s see. Next time. Thanks, bye.