Findings

Pandemic magnifies existing health and socio-economic challenges in world’s most fragile states

The world’s most fragile states prioritised in the DEC appeal are spread across Africa, Asia and the Middle East but they share certain characteristics: their experience of prolonged conflict and displacement means their healthcare systems and social and economic structures were already weak and have been further weakened by the Covid-19 pandemic.

For those living in these fragile states, the experience of the pandemic has similarities too. Layered on top of multiple existing yet devastating issues which were significantly affecting people's lives before the outbreak of the pandemic, the virus is viewed as ‘one additional problem’. For many people, while they know Covid-19 exists and see people becoming unwell, their greatest concerns remain feeding their family and keeping them safe from conflict.

But this ‘additional problem’ is wreaking havoc on already vulnerable populations, causing increased economic hardship and hunger against a backdrop of reduced funding for humanitarian aid. Covid-19 vaccines, while helpful, will not solve these issues in the short- or medium-term.

Icon: Survey
DEC member survey
A survey of 48 country directors and senior staff working for DEC member charities or their local partners in the seven appeal locations shows in the starkest terms how Covid-19 is affecting the world’s most fragile states:
98% agreed or strongly agreed that the pandemic had worsened the humanitarian crisis where they work.
98%
73% said that the humanitarian situation was the worst it had been there in the last 10 years.
73%
92% expected the humanitarian crisis in their country to get much worse in the coming months.
92%
Agreed
Strongly Agreed

Covid-19 cases and deaths are underreported due to lack of data, stigma and fear

Official figures on Covid-19 cases and deaths do not reveal the true picture of how the disease has affected people across the world’s most fragile states. Lack of testing and capacity to analyse tests is widespread. For example, in November 2020, Afghanistan carried out just 400 tests per day, for a country of 40 million people. In the absence of accurate records, anecdotal evidence, such as the number of graves being dug, is often used instead as a way of indicating mortality.

Social stigma adds to the challenge of gaining a full picture of infection rates as many are reluctant to go to hospital through fear of being labelled as a Covid sufferer. Instead, they either die at home or go to hospital too late, with deaths commonly attributed to other causes. In some communities, there is denial of the existence of the virus or belief that it doesn’t affect African people, for instance, reducing inclination to seek tests or assistance.

Fear plays a role too with people believing they may contract the virus if they go to health facilities and, in places such as Syria and Yemen, fear of being caught in crossfire or violence during conflict adds further to a reluctance to go to hospital.

Patients with Covid-19 receive medical care and oxygen at a health centre in Idlib province, Syria, in December 2020. The centre, supported by a local partner of World Vision is the only such centre in western Idlib. Credit: Karam Almasri/DEC
Patients with Covid-19 receive medical care and oxygen at a health centre in Idlib province, Syria, in December 2020. The centre, supported by a local partner of World Vision is the only such centre in western Idlib. Credit: Karam Almasri/DEC

Fragile health services are being disrupted and overwhelmed

In some fragile states, healthcare services have been overwhelmed by people seeking help for Covid-19 symptoms, particularly in places like Yemen where, at the outset of the pandemic, facilities were already decimated by war with only 50% in operation. Capacity is now understood to have reduced even further as healthcare workers become ill from the virus or are too scared to work due to lack of PPE.

At the outset of the pandemic, facilities in Yemen were already decimated by war with only 50% in operation.

In other places, existing health problems are getting worse or go untreated as people choose not to attend health facilities due to fear. Mother and baby clinics and routine vaccination programmes have been disrupted by the pandemic in several fragile states including Syria, Somalia and DRC1 leading to the possibility of future health problems.

In the UK and other developed countries, the elderly and those with multiple existing conditions which affect immunity have been most at risk from the virus. In fragile states, people do not reach the same ages as people in wealthier countries. For example, in South Sudan, the average age of death is 57. But this does not mean that younger people in fragile states are not vulnerable to the virus or to the disruption caused to routine health services: they are often old before their time due to poverty, malnutrition and the stresses of conflict, or suffer illnesses which put them at risk such as TB and HIV.

Icon: Survey
DEC member survey
79% said that Covid-19 had overwhelmed health systems there, including 46% who strongly agreed.
79%
Agreed
Strongly Agreed

The poorest people in the world have no economic safety net

The world’s most fragile states were already in a perilous economic situation, but lockdowns and pandemic mitigation measures have made the poorest people in the world’s most fragile states even poorer.

Many people work in an informal economy, particularly those who have been displaced, and lockdowns and closed borders have prevented them earning a living. Many families rely on remittances from relatives working abroad but many have found they can no longer rely on income sent from abroad as so many people have lost their jobs in the global downturn, and there is no safety net.

Chanda*, 40, sits with her children in her makeshift home in a camp for displaced people near Mogadishu, Somalia, in May 2020.
Chanda*, 40, sits with her children in her makeshift home in a camp for displaced people near Mogadishu, Somalia, in May 2020. Credit: Ismail Taxta/DEC

Currencies have been devalued, reducing purchasing power, while food and fuel prices have risen. Basic goods are becoming beyond the reach of ordinary people, making it harder for families to feed themselves, with some surviving on one meal a day. South Sudan, for example, has faced price rises and hyper-inflation, with food prices rising 42% between August and September alone.

In situations of greater poverty, households are more at risk of turning to negative ways of providing income, with evidence of increased child labour and child marriage in some places.

Icon: Survey
DEC member survey
96% said the economic impact of Covid-19 had affected people’s ability to buy food and other essentials.
96%
Agreed
Strongly Agreed

As hunger levels rise, the spectre of famine looms

As a result of the secondary economic impact of the pandemic, hunger is rising and the spectre of famine looms in a number of the world’s most fragile states.

In December 2020, the Integrated Food Security Phase Classification (IPC) reported that six counties in South Sudan are on the brink of famine, with indicators showing that they were reaching Phase 5 – the worst classification possible – with ‘famine likely’ or ‘catastrophe’ conditions.2

In Yemen, in December 2020, IPC figures indicated that 45% of the analysed population were facing high levels of acute food insecurity (IPC Phase 3 or above) despite ongoing humanitarian food assistance and approximately 16,500 people were in ‘catastrophe’ conditions (IPC Phase 5).3 This is projected to rise by June 2021 to 5 million in the Emergency category (IPC Phase 4) and 47,000 in Phase 5.

Afghanistan and DRC have also been highlighted as being at high risk of famine by the UN.4 In Afghanistan, 5.5 million people face emergency levels of food insecurity – which means they are one step away from famine. DRC is also thought to be at risk of famine and, according to the World Food Programme, is the largest hunger crisis in the world with 21.8 million people who are food insecure – around a fifth of the total population.5

Icon: Survey
DEC member survey
85% agreed or strongly agreed that the Covid-19 pandemic and its secondary effects are leading to a steep rise in childhood malnutrition where they work.
85%
83% agreed or strongly agreed that without increased funding, thousands are likely to die from hunger in their country in 2021.
83%
Agreed
Strongly Agreed

Conflict and coronavirus prove a deadly combination

Conflict and Covid-19 are a deadly combination. Conflict causes huge displacements of people and the impact of Covid-19 for them has been “particularly severe” because they have more difficulty in accessing livelihoods, decent housing and essential services than the general population. A major report concluded: “Despite repeated calls for a global ceasefire and the hopes raised, the pandemic has aggravated the situation in many countries where conflict displacement is rife.”

In Idlib in northwest Syria, more than half the population is now displaced.

In the first half of 2020, there were 1.47 million new displacements in Syria due to conflict and violence. In Idlib in northwest Syria, for example, more than half the population is now displaced, living in crowded camps with an increased vulnerability to Covid-19 which has led to a spike in cases in recent months.

Brothers Jamal*, 7, and Qasim*, 10, walk through the mud at camp for people displaced by the civil war in Idlib province, Syria, in December 2020. Credit: Karam Almasri/DEC
Brothers Jamal*, 7, and Qasim*, 10, walk through the mud at camp for people displaced by the civil war in Idlib province, Syria, in December 2020. Credit: Karam Almasri/DEC

In other fragile states such as Yemen, food insecurity is more severe in areas with active fighting or bordering areas with limited access, and this particularly affects displaced people and other marginalised groups.7 Lack of food can affect the body’s immune system, making it less able to counter illness and viral diseases.

Other countries that have suffered from conflict-related displacement include DRC, with 1.42 million displaced in the first half of 2020. Displaced populations here and in other places such as Somalia are largely dependent on food aid, so delays in aid delivery caused by measures being put in place to prevent the spread of Covid-19, as well as a lack of funding, are having an impact. People living in camps are also more likely to have informal jobs or rely on securing work day-to-day so are particularly vulnerable to the economic impact of the pandemic, especially the loss of job opportunities and increases in food prices.

Violence and conflict prevent people from seeking healthcare if they have to cross frontlines to get there. People caught up in violence travelling to health facilities will turn around and go home.

Icon: Survey
DEC member survey
94% agreed or strongly agreed that the pandemic has disproportionately affected displaced people.
94%
Agreed
Strongly Agreed

Aid funding falls as humanitarian needs rise

As wealthier nations grapple with the health and economic effects of the virus at home, funding for humanitarian aid is being reduced against a backdrop of rising need. In December 2020, the UN predicted a record 235 million people globally will need humanitarian assistance and protection in 2021, a near 40% increase on 2020 which is “almost entirely from Covid-19” just when humanitarian aid budgets face “dire shortfalls”.8

Humanitarian needs in the world’s most fragile states 2020 and 2021

Country Fragile state index ranking Population size (millions) No. people (millions) in humanitarian need in 2020 No. people (millions) in humanitarian need in 2021 % increase in humanitarian need from 2020 to 2021 % population in humanitarian need in 2021
Yemen 1 30.5 24 24.3 1% 80%
Somalia 2 15 5.2 5.9 13% 40%
South Sudan 3 12 7.5 8.3 10% 69%
Syria 4 17 11 13 18% 76%
DRC 5 103 15.9 19.6 23% 19%
Afghanistan 9 40 9.4 18.4 96% 46%

There are wider concerns too that progress made over the past two decades in reducing global poverty levels will be lost.10 The pandemic has had a serious impact on the ability of NGOs to carry out their ongoing life-saving work, with aid programmes needing to shift to the Covid-19 response.

Covid-19 prevention measures have also made delivering aid more time-consuming, with aid workers needing to put on and remove PPE, and more costly, requiring more personnel to carry out work in a socially distanced manner. Lockdowns and travel restrictions have made it harder to reach people in need of assistance too.

Icon: Survey
DEC member survey
63% said they were having to cut back on their vital aid delivery due to a reduction in funding in 2021.
63%
Agreed
Strongly Agreed

2021: a year of hard choices

Many hard choices face aid agencies working in the world’s most fragile states during the year ahead.

One area of focus for 2021 will be to help provide health services to care for people who become ill from the virus as well as maintain routine vaccination programmes and mother and baby clinics, while also ensuring water and sanitation systems continue so that disease outbreaks can be prevented.

The true socio-economic impact of the pandemic may only start to be seen in 2021 and beyond, but already levels of hunger are rising fast.

Humanitarian relief efforts also need to support displaced populations who are dependent on food aid. In places like South Sudan, for example, 7.5 million people currently rely on food assistance to survive. Furthermore, 800,000 people were affected by flooding in late 2020 and about half are displaced, making them vulnerable to the transmission of coronavirus as they shelter in crowded camps or informal settlements. Displacement due to conflict and climate-related disasters such as flooding is predicted to increase in many places.11

The global economic downturn and restrictions on travel and trade are having a severe effect on the poorest communities who often work in the informal economy or as day labourers and have no economic or social security net. The true socio-economic impact may only start to be seen in 2021 and beyond. But already levels of hunger are rising fast and famine looms ever closer in Yemen, South Sudan, DRC and Afghanistan.

Cousins Hadia*, 7, and Gamila*, 11, collect water from a tank in a displacement camp near Aden, Yemen, in July 2020. Yemen is at risk of famine in the coming year. Credit: Alaa Aldwaley/DEC
Cousins Hadia*, 7, and Gamila*, 11, collect water from a tank in a displacement camp near Aden, Yemen, in July 2020. Yemen is at risk of famine in the coming year. Credit: Alaa Aldwaley/DEC

No indicators are going in a positive direction and there will not be enough money to provide all the vital services needed against a backdrop of reduced funding for humanitarian aid. There are going to be real hard choices about which of the most basic human needs to address: choosing between providing clean water to fight disease outbreak or treat infant malnutrition; choosing to provide medical care for Covid patients or deliver food aid to displaced people living in camps.

No indicators are going in a positive direction and there will not be enough money to provide all vital services.

One aid worker described the vicious circle: “If we don’t have more funding at least to provide basic food to keep infected people at home, they will have to go out to get more food and they will spread the disease.”

Another explained the precarious nature of life in the world’s most fragile states: “We need just two simultaneous crises and a reduction of humanitarian assistance to go into a famine situation.”

Vaccine rollout offers hope but is not a panacea

The initial aim of the Covax initiative12 – a global collaboration to support all countries, regardless of wealth, get access to coronavirus vaccines – is to have two billion doses available by the end of 2021, which should be enough to protect high-risk and vulnerable people, as well as frontline healthcare workers. Subject to funding availability, the poorest countries will receive enough doses to vaccinate up to 20% of their population in the longer term.

But vaccines will not be a silver bullet. Existing immunisation programmes have been hit hard by the pandemic, with routine childhood vaccinations cancelled or delayed, and this could lead to other disease outbreaks. Vaccine rollout will be challenging too in fragile states where travel restrictions and violence hinder safe passage for health workers and patients, and it could take well into 2022-3 to deliver vaccines.

Nonetheless, some DEC members, and the Red Cross in particular, are likely to play a role in many countries supporting health authorities with vaccine roll-out by delivering information and awareness raising campaigns to help with community engagement and mobilisation. Some may also be able to provide logistical support, particularly accessing places which are hard to reach such as frontlines and areas controlled by armed groups. Some DEC members will play a role too in advocating for fair and equitable access to vaccines.




How DEC Appeal funds are helping

In the first three months (July – October 2020) of the DEC-funded response to the coronavirus pandemic in the world’s most fragile states, DEC funds were primarily spent on health projects (26%), including isolation and treatment centres, supporting fragile health systems and providing PPE to frontline medics. There was a secondary focus on water, sanitation and hygiene activities (25%), such as providing clean water, handwashing stations and hygiene kits. Other priorities include supporting livelihoods (18%) and providing food (8%).

Examples of the types of aid DEC members delivered over the first three months include providing more than 10,000 health and frontline workers with PPE in Syria, and more than 21,000 households there with soap, cloths and buckets. In Somalia, DEC members supported 21 health centres and set up or supplied 78 handwashing stations, while in Yemen 10,000 people received food parcels.

Icon: Survey
DEC member survey
88% agreed or strongly agreed that humanitarian action had helped prevent the spread of Covid-19 there.
88%
Agreed
Strongly Agreed
*Names changed to protect identities.