The Lebanese government's Covid-19 vaccination program risks leaving behind marginalized communities, including refugees and migrant workers, Human Rights Watch said today. Despite the government's promises of an equitable program, the effort has been tainted by political interference and a lack of information.
United Nations data shows that Syrian and Palestinian refugees have died from Covid-19 at a rate more than four and three times the national average, respectively. Yet, according to the government's online Covid-19 vaccine registration and tracking platform, only 2.86 percent of those vaccinated and 5.36 percent of those registered to receive vaccinations are non-Lebanese, even though they constitute at least 30 percent of the population.
"With one in three people in Lebanon a refugee or migrant, a third of the population risks being left behind in the vaccination plan," said Nadia Hardman, refugee and migrant rights researcher at Human Rights Watch. "The government needs to invest in targeted outreach to build trust with long-marginalized communities or the Covid-19 vaccination effort is doomed to fail."
Between February and March 2021, Human Rights Watch spoke to 21 Syrian refugees, 6 Palestinian refugees, the caretaker labor minister, and staff from the United Nations Refugee Agency (UNHCR), the United Nations Relief and Works Agency for Palestine Refugees (UNRWA), the International Organization for Migration (IOM), and the Anti-Racism Movement (ARM), a grassroots collective in Lebanon that fights discrimination.
The Health Ministry has said that it aims to vaccinate 80 percent of the population by the end of 2021 and that the national vaccination plan covers everyone living in Lebanon, regardless of nationality. The first phase of the vaccine rollout prioritizes healthcare workers and those over age 75, followed by those over 65, and then those over 54 who suffer from certain underlying health conditions.
However, the government has so far only stated its intention to purchase seven million doses, enough for about half the country's population. The vaccine rollout has been slow, with only 233,934 doses administered as of April 5 in large part due to the limited quantity of vaccines available. Lebanon has so far received almost 300,000 doses of the Pfizer vaccine, and on March 24 received 33,600 doses of the AstraZeneca vaccine through the COVAX facility, a global pooled procurement system that aims to provide lower-income governments with enough doses for 20 percent of their populations by the end of 2021.
The AstraZeneca doses lead to the addition of new priority groups, including teachers and workers in productive sectors (sectors that produce products such as agriculture and manufacturing), to the vaccination rollout starting in April, the caretaker Health Minister Hamad Hassan said. As of April 5, only 3,638 Palestinians and 1,159 Syrians have been vaccinated, though 19,962 Palestinian refugees and health workers and 6,701 Syrian refugees are eligible in the first phase of the vaccine rollout.
To speed up the vaccine rollout, the Health Ministry has allowed the private sector to import additional vaccines. Some politicians have already started securing vaccines for their constituents, raising fears that the distribution of vaccines will be based on political affiliation rather than transparent, evidence-based distribution criteria that apply equally to everyone in Lebanon, leaving marginalized groups behind.
Trust in the government's vaccination plan was further eroded by a scandal around politicians jumping the vaccine line and getting vaccinated in parliament, in secret. The World Bank representative in Lebanon has threatened that "any violation of the criteria established for priority groups to be vaccinated" would be "dealt with" by the bank, which is financing much of Lebanon's vaccine rollout and partnering with the International Federation of Red Cross and Red Crescent Societies (IFRC) to monitor the effort.
Given the limited supply of vaccines and the slow pace of vaccinations, some nongovernmental groups have started to secure funding to buy vaccines specifically earmarked for refugees.
Syrian refugees interviewed by Human Rights Watch raised fears of arrest, detention, or even deportation if they registered through a government-managed platform, especially if they do not have legal residency in Lebanon. Due to restrictive Lebanese residency policies, only 20 percent of an estimated 1.5 million Syrian refugees in Lebanon have the legal right to live in the country, leaving the vast majority vulnerable to arbitrary arrest, detention, harassment, and even deportation.
Although the 200,000 Palestinian refugees do not face the same fears over arrest and deportation, many have very little trust in the Lebanese government, which has systematically discriminated against them and barred them from getting government social services, including health care. They can get health care only through the private sector, which charges prohibitively high fees, or through international organizations like UNRWA.
Mistrust of the Lebanese government runs so deep that Palestinian refugees told Human Rights Watch they fear that even if they were to register, they would not actually receive the vaccine and would have to pay a fee they could not afford.
Migrant workers, many of whom are working in Lebanon under the exploitative kafala (sponsorship) system, either had no information whatsoever about the vaccine or expressed mistrust of the Lebanese authorities.
To ensure equitable vaccine distribution despite the huge supply shortages, Lebanese authorities should follow the World Health Organization (WHO) SAGE values framework for the allocation and prioritization of Covid-19 vaccines, which offers guidance on the prioritization of groups when vaccine supply is limited. The SAGE guidance calls for ensuring national equity in vaccine access, particularly for groups experiencing greater burdens from the pandemic, such as people living in poverty, especially extreme poverty, and low-income migrant workers and refugees, especially those living in close quarters who are unable to physically distance.
The United Nations has warned that "in the absence of effective firewalls between health and public services and immigration authorities, data collection and information sharing related to Covid-19 vaccinations may also further raise fears among migrants in an irregular situation."
"Lebanon was initially praised for its inclusive plan to vaccinate everyone living on its territory, but it has quickly become clear that there are serious gaps in the plan's implementation," Hardman said. "If Lebanon wants to achieve equitable vaccine distribution this year and kickstart the economy, it will need to ensure that everyone has access to information."
Availability of Vaccines
Lebanon confronts external challenges facing many lower-income countries in obtaining Covid-19 vaccines. Human Rights Watch and many others are supporting a proposal by South Africa and India to the World Trade Organization to temporarily waive some intellectual property rights rules until "widespread vaccination is in place globally."
The waiver of these rules under the Agreement of Trade-Related Intellectual Property Rights (TRIPS) would allow more international collaboration in the manufacture of the vaccines and other medical products - without authorization from the companies that created them - and could speed production and availability of vaccines worldwide. The World Trade Organization considered the proposal when it met in March, but most rich Western countries, including the UK, US, EU, and Australia, continue to oppose the waiver.
Lack of Information Among Refugees, Migrants
In addition to problems around vaccine supply and equitable distribution, the Lebanese government has failed to provide accurate and up-to-date information for Syrian and Palestinian refugees, as well as migrant workers, about the vaccine and how to register to be vaccinated, and reassure them that vaccination efforts will be firewalled from immigration enforcement activities.
As of April 5, only 17,891 Syrians registered for the vaccine, and only 1,159 had received the vaccine.
None of the Syrian refugees that Human Rights Watch interviewed had registered through the online platform. Seventeen Syrian refugees did not know of the existence of the online platform and nine did not know that they were entitled to register, believing it was just for Lebanese citizens. People interviewed said they had heard rumors they had to pay for the vaccine, and several said they did not know where the vaccination centers were, and suspected they would not be able to afford the transportation to get there. Three said they had heard the vaccine is not safe and could lead to fatalities.
Even when told that they were eligible to register and receive the vaccine free, nearly all expressed fears regarding the consequences of registering with a government-led application that could lead to arrest, detention, or deportation for lacking legal residency. Several had heard rumors that registering for the vaccine was somehow linked to a government plan to send them back to Syria.
Human Rights Watch's findings mirrored those of the International Rescue Committee and the Lebanon Protection Consortium, who reported on February 26 that based on 883 household level interviews with Syrian refugees in North Lebanon and the Beqaa, "extremely few [Syrian] refugees appear to have information on the Covid-19 vaccine" and observed "high levels of vaccine hesitancy."
Syrians' lack of legal status has affected their ability to move freely due to the ubiquitous checkpoints that predate Covid-19, making it very difficult for them to access services such as health care. Discriminatory movement restrictions imposed by some municipalities on Syrian residents further marginalize the refugee population and impede their access to services. Syrian refugees have been particularly hard hit by Lebanon's economic crisis, which has left 89 percent of Syrian refugees living in extreme poverty - up from 55 percent the year before.
The Palestinian refugees that Human Rights Watch spoke with also lacked awareness about the government's vaccination plan and their eligibility and expressed fear that they would be discriminated against in the rollout, given the Lebanese government's history of discriminating against them in access to virtually all social services.
A 39-year-old Palestinian woman living in Rashidieh refugee camp said:
Nobody has come to explain anything to us. It is not like the beginning of pandemic when people came to explain [about the coronavirus] to us... Even I didn't trust the vaccine and it was only when I knew someone who received the vaccine overseas that I changed my mind… There is no awareness-raising - instead rumors are spreading on WhatsApp. Nothing has been explained properly. It is essential that the positive side of the vaccine is explained so people understand.
A UNRWA spokesperson told Human Rights Watch that the low registration rates among Palestinian refugees could be attributed to a lack of trust in the vaccine and a reluctance to take the vaccine in centers located outside the camps.
There is mixed messaging from the Lebanese authorities on whether migrant workers are included. While the national Covid-19 committee, responsible for devising the plan, has publicly stated that everyone in Lebanon can register regardless of nationality, the Health Ministry has said that it does not have the funds to inoculate migrant workers.
The caretaker Labor Minister Lamia Yammine told Human Rights Watch that Lebanon has about 500,000 registered migrant workers and estimates many more undocumented workers. The IOM confirmed to Human Rights Watch that it is "looking at ways to support the vaccine roll-out to ensure migrants can be reached, including the procurement of doses."
In a positive step, the vaccination registration platform enabled undocumented people to register without having to submit an ID number, but it remains to be seen whether those who are eligible for vaccination according to the plan will be given appointments.
There are also other significant barriers for migrant workers. The ARM found in research conducted in March that migrant workers lacked accurate information about the vaccine itself and about the process of receiving it in Lebanon. Some migrant workers told ARM that they fear the Lebanese government will not give them the "good vaccine," demonstrating the low trust between the community and the government. The IOM has provided assistance to a group of migrant workers over the age of 55 with additional health issues to help them register for vaccination.
The Health Ministry has said that it does not have the funds to inoculate migrant workers, but caretaker Labor Minister Yammine has expressed her commitment to ensuring that all migrant workers can access the vaccine. Yammine said that she is working with the IOM on developing a plan to gather data about undocumented workers, ensure that all migrant workers can register, raise awareness about the vaccine among employers and migrant workers, and obtain funding.
In a letter to Human Rights Watch, the IOM office in Lebanon also recommended that "Governments offer solutions to remove some of the main barriers faced by some categories of migrants: including administrative or legal (e.g. requirement for documentation proving residence, work permit, ID…); financial (e.g. high costs sometimes required for accessing health service); and cultural and informational (e.g. use of channels and languages for communication on public health matters that are not adequate for migrant populations)."
In the joint guidance issued alongside regional human rights mechanisms, the United Nations Committee on Migrant Workers has suggested that "Communication messages and public information campaigns should make clear that migrants in irregular situations will not be penalized or targeted for immigration enforcement when seeking access to Covid-19 vaccination."
Recommendations for Raising Awareness
The Lebanese authorities should build confidence in the vaccines and the national strategy by providing accessible information about the vaccines and how to register for them, and reassuring refugees and migrant workers that under no circumstances will their information be used to target them for arrest or deportation, now or at any point in the future, nor will they have to pay for the vaccine, Human Rights Watch said.
More broadly, donor governments should push Lebanese authorities to review their coercive policies against marginalized groups that have contributed to an environment of fear and mistrust at a time when that trust is most needed. This lack of trust could easily undermine national vaccine rollout efforts.
Information about Covid-19 vaccines should be accessible and available in multiple languages, including for those with low or no literacy. Communication materials should utilize plain language to maximize understanding.
To facilitate access to vaccines for those without identity documents, including undocumented migrant workers and refugees, the authorities should consult with community members to identify other ways they can confirm their identities. This could include allowing witnesses to attest to a person's identity or having the person sign a statement attesting to their identity and eligibility.
In addition, governments should focus on community-based approaches to raise awareness and dispel myths for people to change their behavior. This is critical as past experiences in public health crisis response show that sustained behavior change over a long period depends on strong partnerships between all stakeholders, in particular women and religious leaders.
Community health systems can also monitor for potential adverse events from vaccination. Without a system in place to respond immediately and investigate such reports, unfounded rumors can form as a result of unrelated illnesses or deaths in people who have been vaccinated. Failing to address such events will strengthen vaccine hesitancy and undermine vaccination efforts. Developing strong ties to communities and community leaders can also help increase accountability if, for example, vaccines are mishandled or distributed in ways that contradict the priority criteria.
To overcome obstacles in reaching vaccination centers for marginalized groups who may not be able to afford transport to local hospitals, governments should consider providing mobile clinics in partnership with aid groups operating on the ground.
The WHO has recommended that "as countries gear up to deploy Covid-19 vaccines, they will need to design and implement monitoring systems to measure the progress and effectiveness of these programmes. This involves measuring vaccine uptake and coverage among the overall population, as well as among the at-risk populations prioritized for vaccination." Governments with refugee and migrant populations should ensure that data is disaggregated with separate recording and reporting of vaccinations administered to specific populations, including those living in camps or camp-like settings for refugee and internally displaced people.
International standards
Discrimination on the basis of national origin or residency status is contrary to international law and, in particular, would violate Lebanon's obligations under the Convention on the Elimination of All Forms of Racial Discrimination (CERD) and the International Covenant on Economic, Social and Cultural Rights (ICESCR). Indirect discrimination refers to laws, policies, or practices that appear neutral but have a disproportionate impact on the exercise of human rights. Any differential treatment based on national origin or immigration status can only be justified as nondiscriminatory if it pursues a legitimate aim and is proportionate to its achievement.
Governments are responsible for providing information necessary to protect and promote rights, including the right to health. Upholding the right of unhindered access to information is key to overcome vaccine hesitancy and to counter misinformation and mistrust, some of which are rooted in cultural stigma and taboos.
A rights-respecting response to Covid-19 needs to ensure that accurate and up-to-date information about the virus, vaccines, access to services, service disruptions, and other aspects of the response to the outbreak is readily available and accessible to all. Health authorities should provide regular health information briefings and public service announcements to counter misinformation, help calm panic, restore public confidence, and encourage people's assistance in the crisis.
