Maya Beney
Note:
Information provided is correct as of the time of writing (January to February 2021).
Introduction
This paper is a response to the growing disparity in the COVID-19 vaccine rollout between wealthier and poorer nations, and the emergence of ‘vaccine nationalism’ which involves the hoarding of supplies by richer countries. Developing states have had have limited access to the COVID vaccine, with a study by Duke University predicting that if high-income countries continue to prioritise their procurement of the vaccine to the detriment of other nations, most people in low-income countries will be waiting until 2024 for their first dose.
There have already been some international attempts at ensuring more widespread distribution, such as the COVAX scheme (which has 190 participating nations). By the end of 2021, it aims to vaccinate at least 20% of each participating nation’s population. However, Duke University has underlined that these efforts have been undermined by wealthier participating countries who have signed separate deals with pharmaceutical companies. This reduces the total number of vaccines available for COVAX, thus restricting vaccine supply to poorer nations who rely entirely on the scheme. This paper has chosen to focus on the region NWS due to Syria’s status as one of these low-income COVAX participants, and because of its high population of IDPs (an estimated 2.7 million) caused by the Syrian civil war. IDPs also have varying living situations, some of which are precarious or short-term and can therefore make vaccine distribution more difficult.
This paper firstly examines how the alienation of NWS from the Syrian Arab Republic’s government is a problem for the acquisition of vaccines in the region, and how it renders it more difficult for IDPs to receive doses. The COVAX scheme primarily functions through allocating doses to individual member states, but it is unlikely that the Syrian government will provide vaccines that they have received to NWS which is controlled by opposition forces. COVAX has already attempted to address this issue by reserving 5% of vaccines as a ‘humanitarian buffer’, which will be used in emergencies and to support NGOs’ work, including with refugees. However, one should note that this 5% stockpile/buffer does not specify what proportion of this percentage would be used immediately to vaccinate IDPs, and may therefore not be enough to reach OCHA’s aim of covering 20% of the population. COVAX has also signed a ‘memorandum of understanding’ with the International Organisation for Migration (IOM) which focuses on increased collaboration on vaccination efforts for refugees and displaced persons. Despite this, it should be noted that refugees and IDPs are in distinct legal categories since the latter remain in their country of origin; the paper argues that there is the risk that through this one-size-fits-all approach, which contains no clear promises or pledges, the necessary number of vaccines will not reach displaced people in NWS.
To combat these problems of low supply and IDPs’ alienation, this paper highlights the importance of monitoring countries’ bilateral trade deals, as well as incentivising greater participation in the COVAX scheme to augment the amount of vaccines available for lower-income countries. COVAX should also create a specific clause earmarking a percentage of its vaccines for IDPs to strengthen their right to be immunised at the same time as other Syrians.
In addition to the difficulties around acquiring the vaccine, there are also significant logistical challenges surrounding the transportation and storage of doses in NWS. This paper will focus on the distribution of the Oxford-AstraZeneca vaccine as its main advantage is that it can be kept at 2 to 8°C (around the temperature of the average refrigerator) and can therefore be administered in pre-existing healthcare settings. However, it still requires cold chain storage from the factory to the administration site, otherwise the jab will be rendered ineffective. There are currently five cold storage rooms in NWS, but they are heavily reliant on a constant supply of electricity to maintain cold temperatures. Additional storage capacity will also be needed for the high volume of vaccines, including in local health centres such as CCTCs where they will be administered.
This paper also considers previous successful immunisation programmes in NWS, such as polio vaccinations; in 2020, the WHO/ UNICEF vaccinated 815,000 children against polio. Multi-dose vials of polio vaccines can be stored for up to six months at temperatures between 2°C and 8°C, the same as the Oxford-AstraZeneca COVID-19 vaccine. The COVID-19 vaccine can be stored in the same cold storage facilities used for polio vaccines before they are transported to local health centres or by mobile health teams to IDP communities. However, policy suggestions will also note that the COVID-19 vaccine rollout will be on a much larger scale than the polio immunisation programme, as the eventual aim is to cover the entire adult population, rather than only young children.
This paper recommends that measures to increase cold storage capacity and generator facilities should be implemented as soon as possible by UNICEF and SIG (Syrian Immunization Group). This can be achieved by purchasing more reefer containers or alternatively by keeping the ones COVID-19 vaccines will be transported in. Although cold rooms have the advantage of being able to store greater supplies of vaccines, and would be a better long-term solution if annual COVID-19 immunisation programmes become necessary, reefer containers are less expensive and are more easily transported. Further, this must be supplemented by increased generator capacity to ensure that there is a constant supply of electricity to maintain constant cold temperatures. Both solar and diesel generators should be used, with the latter being prioritised for more unstable regions such as the Idlib governate as they can be more easily evacuated.
The second challenge after vaccines have safely reached NWS is their distribution and administration to IDPs. Due to a decrease in funding, eight CCTCs have been deactivated over the past month. The January 2021 UNOCHA report warns that ‘further imminent gaps risk disrupting services, including for… primary health centres in the coming months’. Mobile health teams will probably administer the majority of vaccinations as they can travel to different regions, although measures would need to be implemented to guarantee their safety and ensure cold temperature storage. In contrast to the polio vaccination programmes which are intended for children younger than five years old, and are thus primarily aimed at mothers who are their main caregivers, IDP recipients of the COVID-19 vaccine will include older adults regardless of gender, and may include primary income earners who cannot take much time off work. It is therefore vital that vaccination services are easily accessible to IDPs who may be living far away from CCTCs.
This paper recommends a joint strategy of ensuring that there are enough medical facilities and assistants to administer vaccines, while also making sure that IDPs can reach these healthcare provisions. The first step in achieving this is increasing funding from developed countries to the Syria Cross-border Humanitarian Fund (SCHF), which is necessary for maintaining existing programming for healthcare services while preparing for the vaccine rollout. Secondly, vaccine preparations by UNICEF and SIG should prioritise mobile health teams to ensure that all IDPs can be reached. Temporary vaccination spots in rural communities can be achieved using smaller vaccine containers that do not require generator capacity; for example, the Arktek Passive Vaccine Storage Device can store up to 6,000 vaccines for a month, at a temperature between 0 to 10°C using only a single load of ice. Careful vetting of neighbourhood safety is also necessary to ensure the safety of aid workers on outreach programmes.
Finally, the issue of vaccine acceptance is addressed, as it should not be assumed that all IDPs will accept the offer to be immunised. Misinformation about the pandemic and the vaccine is already rife, with aid workers warning that even convincing people that the virus is real is proving to be a challenge. Misinformation has travelled through social media channels, one Twitter account with 98,000 followers warning that if the virus does not kill them, the vaccine would. The WHO has stated that it is collaborating with media platforms such as Google, WhatsApp, and YouTube to ensure information from official sources appears first in searches. However, aid workers warn that many people in NWS are unwilling to believe what NGOs such as the UN are saying, recommending instead that frontline workers are given the task of convincing people that vaccination is safe.
The final recommendation is that misinformation is tackled by trusted actors ‘on the ground’, such as aid workers who have direct interaction with IDPs, rather than through relying on ‘official’ sources of information. This can be achieved using through previously used methods such as travelling in local neighbourhoods in trucks and relaying details over the inoculation program over a megaphone, or through pamphlets and door-to-door approaches. Following WHO guidance, aid workers and information guides should focus on highlighting the importance and safety of vaccinations, rather than attempting to dispel all COVID-19 myths as this can result in misinformation being reinforced instead. Local IDP community leaders – for example, imams or those involved in running IDP camps – should also be given the chance to act as examples to encourage others to accept the vaccine, demonstrating that it is a safe procedure.
This paper concludes that the future COVID-19 immunisation programme among IDPs in Northwest Syria presents considerable challenges, from the first step of acquiring vaccines to its acceptance by its intended recipients. Policy suggestions have been outlined at the global, regional, and individual level to offer an idea of the scale of the task ahead, but also to hopefully demonstrate that there are implementable solutions based on international co-operation, regional management, and awareness raising among IDPs. Further research should examine the situation for IDPs in Northeast Syria where supplies are controlled or withheld by the government. A reassessment of policy suggestions for NWS may also be needed as the situation evolves over the next few months.
The full paper can be downloaded below: