Safeguarding refugee health in a global pandemic

October 26, 2021

Orange tinted photo of a woman carrying a travel bag on her shoulder
By Karen Shih

For Venezuelan refugees seeking to escape the economic meltdown in their home country, the arrival of a global pandemic was yet another major hurdle in their quest for safety and stability. Most countries focus on their own citizens in times of crisis—leaving vulnerable migrant populations behind.

“This pandemic has exposed many of the inequities in our society in general, and especially for the health care system,” says Associate Professor Diana Bowser. “Low-income, immigrant and refugee populations that don’t have access to health care are most vulnerable in a pandemic.”

Luckily for the 1.8 million Venezuelans who have settled in neighboring Colombia, the Colombian government’s more inclusive approach has likely saved lives.

“Under the Colombian constitution, any resident is entitled to health care. There are levels, but at a minimum, every resident, including Venezuelans, can access basic care for emergencies,” says Professor Donald Shepard, though they have less access to health insurance and comprehensive care.

In a new study, Bowser and Shepard of the Institute for Global Health and Development collaborated with Arturo Harker Roa of Colombia’s Universidad de los Andes to examine the impact of COVID-19 on Venezuelan migrants living in Colombia. They focused on use of health care services as well as adherence to public health guidelines such as wearing masks and staying at home, from spring to fall of 2020. The study was funded by the nonprofit Elrha, which seeks to solve global humanitarian problems.

They took a three-pronged approach. One paper used a national Colombian health database to compare Venezuelans’ and Colombians’ utilization of health services. Another examined self-reported COVID symptoms and adherence to masking and social distancing measures via telephone surveys. A third delved into people’s movement and its impact on COVID cases using anonymous cell phone data. 

“In any migration crisis, there are a lot of assumptions made by policymakers and the host population about the behaviors of refugees,” says Harker Roa. “But our findings can provide evidence and inform policymakers as they decide on strategies for promoting access to health services for refugees in Colombia.” 

A key finding of the health services utilization paper, led by Shepard, was that Colombians had 10 times the rate of reported COVID-19 cases compared to Venezuelans—contrary to the researchers’ expectations.

“Venezuelans tend to be poorer and often work in manual labor or delivery jobs, rather than white collar jobs that allow them to work from home, so we expected their case rates to be higher,” Shepard says. However, official COVID case numbers rely on positive tests, and since testing was largely limited to those with better access to health insurance—Colombians—the data were likely skewed.  

“It reminds us that in many parts of the world, the officially reported cases are just the tip of the iceberg,” Shepard says.

For hospitalizations, Venezuelans had almost the same rate as Colombians, indicating that patients with the most serious health needs were able to receive care.

“It’s impressive,” says Shepard. “It’s one thing for a policy to exist on paper but these numbers show what was happening in reality.”

Bowser led the telephone survey of more than 8,000 Venezuelans and Colombians across 60 municipalities. She found that both groups were highly influenced by community members on behaviors like wearing masks, social distancing and signing up for COVID-19 testing.

The findings indicate that the public discourse about individual decision-making in a pandemic is less important than the actions of a community. “In reality, we do what people around us do. If communities are doing the right thing, people will do the right thing,” Bowser says.

One surprising finding was that Venezuelans were just as compliant with public health measures as Colombians, which was contrary to the researchers’ hypothesis. The researchers had initially thought that lack of information and lack of hand sanitizer or soap and water, as well as poorer living and working conditions, would keep the Venezuelans from being able to follow the guidelines. But since Venezuelans and Colombians share a common language, Spanish, and the Colombian government actively promoted the guidelines within migrant communities, both populations were able to follow important public health measures.

The third part of the study was led by Jamie Jason ’20, MS’21, then a MS in Global Health Policy and Management student who examined daily aggregate mobility data from cell phone companies, provided by the United Nations Development Program, to determine correlation with COVID-19 cases and deaths. These data grouped Colombians and Venezuelans together. 

Weekend activities turned out to be an important indicator for COVID-19 cases. Cities with specifically less weekend mobility enjoyed six times the reduction in COVID cases compared to cities with just general reductions.

That’s because when people leave the house on weekdays, they’re often going to work or shopping for essentials in more structured environments conducive to masking and social distancing. However, people engaged in riskier behaviors on weekends during social activities, with bigger gatherings and lower compliance with public health guidelines.

“Since COVID-19 can spread quickly during crowded indoor gatherings, it's important for governments to enact stay-at-home measures and isolation policies during weekends to reduce the impact of riskier weekend behavior," says Jason. He was one of several student researchers on the project, including PhD candidate Priya Agarwal-Harding, Anna Sombrio, MS’20, and several students in Colombia.

Now, the researchers hope local policymakers can use their data and findings to more effectively reach vulnerable populations, especially as the vaccine is being rolled out.

“Experts in political science and economics will be eager to use our data to analyze and understand what’s happening across the country,” says Harker Roa. “We have a track record of evidence-based policymaking in Colombia, so this study has a good chance of being heard by policymakers.”

A new step taken by the Colombian government in February 2021, after the conclusion of the study, makes its health care system even more inclusive. Around 1 million Venezuelans are now eligible to officially register with the government under a new permit that allows them to sign up for insurance and access higher tiers of health care.

Harker Roa says it’s a step in the right direction, and “a very progressive policy. But the financial risk of the system is really high.”

For Bowser, who has dedicated her career to finding the most vulnerable populations and making sure they have the most services available, there’s room for optimism.

“It’s hard for governments because opening health care services is an expensive budgetary issue,” she says. “But you’ll see in the case of Colombia, expanding services to some of the vulnerable patients may save them money in the end, with less people getting sick and coming in for emergency services. It makes sense long term.”