Volume 6 Issue S2, November 2020, pp. 70-82

Introduction: Two billion people are currently affected by complex humanitarian emergencies (CHEs) resulting from natural disasters and armed conflict. Many have been displaced into crowded camps with poor access to water, sanitation, and health care. Humanitarian response is challenging under these circumstances, raising concern about the impact of COVID-19 on crisis-affected populations. Methods: This article examines CHEs in the Democratic Republic of Congo, Bangladesh, and Yemen, where protracted crises have displaced millions of people. Through use of a conceptual model, we examine barriers and facilitators to an effective COVID-19 response in these complex settings, and explore the future impact of the pandemic on crisis-affected populations. Results: Younger populations, who tend to have less severe COVID-19 disease, and existing response mechanisms, including educational health messaging, may facilitate the COVID-19 response in some CHEs. However, pre-existing chronic illnesses and malnutrition, coupled with poor access to health care and limited water/sanitation infrastructure, may increase COVID-19 infection rates and mortality. Exacerbated health care shortages, food insecurity, interrupted immunizations, increased insecurity, and worsened poverty may have a particularly severe impact. Discussion: A wide-reaching global response, incorporating the voices of marginalized populations, is needed to effectively and equitably respond to this global pandemic. Given the potential future deployment of Canadian troops to CHEs, an understanding of the COVID-19 response and pandemic implications in CHEs is critical for Canadian Armed Forces members.

Introduction : Deux milliards de personnes sont touchées par des urgences humanitaires complexes (UHC) attribuables à des catastrophes naturelles et des conflits armés. Bon nombre sont déplacées dans des camps surpeuplés où l’accès à l’eau, à l’hygiène et aux soins de santé est largement insuffisant. La réponse humanitaire pose problème dans ces circonstances, ce qui soulève des questions sur les répercussions de la COVID-19 dans les populations touchées par des crises. Méthodologie : Le présent article porte sur les UHC en République démocratique du Congo, au Bangladesh et au Yémen, où des crises prolongées ont suscité le déplacement de millions de personnes. Grâce à un modèle conceptuel, les chercheurs ont examiné les obstacles et les incitations à une réponse efficace à la COVID-19 dans ces contextes complexes et ont exploré les futures répercussions de la pandémie sur ces populations. Résultats et discussion : Les populations plus jeunes, qui ont tendance à être atteintes d’une COVID-19 moins grave, et les mécanismes de réponse existants, y compris les messages pédagogiques en matière de santé, pourraient faciliter la réponse à la COVID-19 lors de certaines UHC. Cependant, les maladies chroniques préexistantes et la malnutrition, couplées à l’accès largement insuffisant aux soins de santé et au peu d’infrastructure d’approvisionnement en eau et d’assainissement peuvent accroître les taux d’infection à la COVID-19 et la mortalité. L’exacerbation de la pénurie de soins, l’insécurité alimentaire et l’aggravation de la pauvreté peuvent avoir des conséquences particulièrement graves. Une réponse mondiale d’envergure, intégrant les points de vue des populations marginalisées, s’impose pour répondre à cette pandémie mondiale de manière efficace et équitable. Étant donné le déploiement potentiel des troupes canadiennes vers des UHC, il est essentiel que les membres des Forces armées canadiennes comprennent les réponses à la COVID-19 et les conséquences de la pandémie sur les UHC.

Two billion people are currently living in fragile and conflict-affected states.1 By early 2019, armed conflict and insecurity had driven a record 70.8 million people from their homes and one in every 45 people worldwide were expected to need humanitarian assistance and protection in 2020.2 Many displaced individuals are sheltering in overcrowded camps with poor access to water, sanitation and hygiene (WASH), and health care facilities.3

A complex humanitarian emergency (CHE) combines natural disasters and man-made elements, such as armed conflict, with pre-existing vulnerabilities to create a crisis that requires a large-scale, multi-agency humanitarian response.4 CHEs are typically characterized by extensive violence, lack of governance, population displacement, and extensive economic and societal damage as well as significant security risks.4,5 Fragile states are characterized as having a combination of exposure to risk and insufficient coping capacity of the state, system, and/or communities to manage, absorb, or mitigate those risks.6 Fragility increases vulnerability to violence, the breakdown of institutions, displacement, humanitarian crises, and other emergencies. CHEs often involve the displacement of large numbers of people, including those defined as refugees (people who have fled war, violence, conflict, or persecution and crossed an international border to find safety in another country)7 and internally displaced people (IDPs), those who flee for safety but stay within their own country and remain under the protection of their own government.8

Within CHEs, communicable diseases, such as acute respiratory infections and diarrheal illnesses, are often the major killers, and their control is dependent on clean water, adequate sanitation, appropriate shelter, immunization, and availability of trained health workers.9 However, implementation of these control measures is often challenging in CHEs. For instance, it is recommended that camp size not exceed 10,000–12,000 people, or that camps be subdivided into independent units of no more than 1,000 people, in order to manage and control communicable diseases.9 As outlined later in this article, many CHE camps are overcrowded, making it exceedingly difficult to implement control measures that would more effectively limit spread of communicable illnesses.

On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic.9 As of August 7, over 19.1 million infections and more than 715,000 deaths had been reported across 188 countries.10 In this article, the COVID-19 pandemic in CHEs is considered using three case studies: Democratic Republic of Congo (DRC), Bangladesh, and Yemen. Through these case studies, the authors propose a conceptual model they believe is pragmatically helpful in understanding how barriers and facilitators to the COVID-19 response relate to each other, while also highlighting the potential future impact of COVID-19 on vulnerable populations.

How is COVID-19 in CHEs relevant to Canadians? As emphasized by WHO’s Dr. Ahmed Al Mandhari, “This is a global pandemic, and the only way to fight it is to do so together. No one is safe until everyone is safe.”11 As long as there are uncontrolled COVID-19 outbreaks in this era of globalization, Canadians will continue to be at risk. Additionally, evidence suggests that, within Canada, COVID-19 is disproportionately affecting lower income neighbourhoods and ethnic minorities.1214 Some of these marginalized Canadians share similar COVID-19 response barriers (e.g., inadequate housing, lack of access to health care) and anticipated outcomes (e.g., economic burden, food insecurity) with individuals and families living in CHEs. Therefore, the conceptual model is also pertinent to vulnerable populations in Canada, and the authors believe the COVID-19 response must take an equity lens that incorporates the voices of marginalized populations both domestically and globally.

How is COVID-19 in CHEs relevant to the Canadian military? As of June 2020, the Canadian Armed Forces (CAF) had approximately 2,000 members deployed abroad, including in the DRC.15 Previously, the Canadian military has deployed to Jerusalem/Palestine, Niger, Uganda, South Sudan, Jordan, Lebanon, Israel, and Syria.16 As part of United Nations (UN) missions, Canadian military operations may be active in, or intersect with, CHEs. Guidelines for military involvement in humanitarian operations,17,18 as well as for civil–military coordination in the context of COVID-19, have been published.19 While some operations have been paused and others adapted in light of the pandemic, the reality of our new COVID-19 “normal” may be that Canadian troops are going to deploy to CHEs, or similar contexts, in order to contribute to the global fight against COVID-19, or to address security threats that arise from, or are exacerbated by, the pandemic. Should these deployments occur, understanding the response to, and implications of, the COVID-19 pandemic in these contexts will be key to protecting both the military personnel and the crisis-affected population.

Democratic Republic of Congo

Decades of armed conflict and political instability have resulted in a protracted humanitarian crisis in the DRC. With pervasive poverty, a fractured health care system, and limited public health infrastructure, the population is highly vulnerable to communicable disease epidemics. DRC is also home to the largest population of IDPs in Africa, with 5.01 million internally displaced, in addition to hosting 517,000 refugees.2 With conflicts expected to continue, an estimated 15.9 million people are projected to need humanitarian assistance in DRC in 2020.2

One of the most insecure areas of DRC, Ituri and North Kivu, has been experiencing an Ebola virus outbreak since August 2018. The number of Ebola cases has now surpassed 3,300 with over 2,200 deaths, making it the second largest Ebola epidemic ever.20 Security incidents have hindered the Ebola response, reducing operational capacity, rendering some health zones inaccessible, and likely increasing transmission.21,22 Up to 80% of documented attacks targeted Ebola treatment structures or response personnel. The Ebola response has also been hindered by lack of institutional trust and misinformation,23 and conflict events are thought to have reversed an otherwise declining phase of the Ebola epidemic trajectory.24

Simultaneously, DRC is also experiencing its worst measles outbreak in recent history, with more than 209,000 cases between January and October 2019, and 4,189 deaths.2 Because of disrupted water supplies and population movement, cholera has also become endemic to eastern DRC and the country now accounts for 5%–14% of annual cholera cases worldwide.25

Bangladesh – Rohingya refugee crisis

An estimated 855,000 Rohingya refugees reside in 34 camps within the Cox’s Bazar District of Bangladesh. The Rohingya people have faced repeated violence in Myanmar, with large numbers of refugees intermittently flowing into Bangladesh, including the well-publicized migration beginning in August 2017.26 Considered a stateless people, the Rohingya have been subjected to discrimination, targeted violence, crimes against humanity and other human rights violations.27

The Rohingya are living in crowded conditions with 4–8 people per shelter, and although currently stable, the situation remains fragile with respect to providing basic needs.28,29 Eighty-eight percent of refugees are vulnerable to food insecurity (disruption of food intake or eating patterns because of lack of money and other resources),30 with limited opportunities to produce food, restricted movement, and limited access to food and income. Only 29% of refugees have access to piped chlorinated water and only 32% of households reported hand washing following handling children’s feces.29 Both the refugees and the local population are facing high rates of unemployment as well as environmental concerns including pollution, deforestation, water shortages, cyclones, and annual monsoons.29

With 129 health posts serving the Rohingya refugee camps, at least 13 more primary health care centres would be needed to meet minimum standards.31 Prior to COVID-19, 20%–25% of reported diseases in Cox’s Bazar were acute respiratory illnesses, complicating identification of COVID-19 from other respiratory infections.32 Furthermore, over two-thirds of deaths occur at home, making it difficult to identify and track causes of death.33

Yemen

Conflict in Yemen escalated significantly in March 2015. The ongoing war and resulting severe economic decline created the world’s largest humanitarian crisis,34 with the UN estimating that 100,000 people have died in Yemen in the last five years.35 Two-thirds of the population, including 12 million children, are in need of humanitarian assistance or protection,34,36 and 3 million people remain IDPs.34 Parties to the conflict have impeded delivery of humanitarian aid, food, and medical supplies; they have targeted attacks on hospitals and civilians and recruited child soldiers, among other violations of international law.37

The protracted crisis in Yemen has caused widespread poverty, food insecurity, loss of livelihoods (means to secure the necessities of life), and reduced access to education. Two million children across Yemen are missing education as schools close due to damage from armed conflict, hosting of IDPs, or occupation by armed groups.34 Increased prices and lack of basic infrastructure has limited the ability to access safe water and hygiene items, exacerbating the risk of communicable diseases.38 The health care system has been critically affected, with 49% of health centres not functioning due to shortages of staff, supplies and funding, or limited access.34,39

Adding to the complexity, three years ago, Yemen faced the worst cholera outbreak in modern times,35 and in April 2020, once-in-a generation flooding caused injuries and infrastructure damage, exacerbated malnutrition, and increased the spread of disease, including cholera, malaria, dengue, and diphtheria.35,40 Given the state of poor health care, underlying malnutrition and disease, modelling published by the UN suggests that over 55% of the Yemeni population will be infected with COVID-19, 300,000 will require hospitalization, and over 42,000 will die.35 Data submitted to the United Nations at the end of June 2020 noted a rapid increase in the number of COVID-19 cases, with an alarming 25% of confirmed COVID-19 cases having died.41

Facilitators for COVID-19 response

The above case studies will now be used to illustrate the barriers and facilitators to COVID-19 response in CHEs and the impact the pandemic may have on CHE-affected populations. A number of facilitators to COVID-19 response in CHEs are noteworthy (see Figure 1). For instance, since older aged individuals tend to have higher COVID-19 related morbidity and mortality,42,43 one factor that may be protective for Yemeni, Congolese, and Rohingya populations is their age distributions. In general, their populations are quite young – in DRC, 41% of the population is under the age of 15 years and the median age for the whole population is only 18.8 years.44 Similarly, over half of the Rohingya refugee population is less than 18 years of age, and the median age for those living in Yemen is 20.2 years.45 However, it is important to note that transmission rates are reportedly higher for household contacts of older school-aged children, aged 10–19 years (18.6% vs. 11.8%),46 and thus, children may play an important role in COVID-19 transmission even if they experience less severe disease overall.

Figure 1. Conceptual model for barriers and facilitators to COVID-19 response in CHEs with anticipated future impact of COVID-19 on the lives of crisis-affected populations

CHE =complex humanitarian emergency; WASH = water, sanitation, and hygiene.

Additionally, because Yemen, Cox’s Bazar, and the DRC have been managing other epidemics (cholera in Yemen;47 Ebola,20 cholera25 and measles2 in DRC; diphtheria in Cox’s Bazar),33,48 response teams and screening measures were already in place when the COVID-19 pandemic started. In CHEs, infrastructure set up for previous outbreaks can be rapidly switched to focus on COVID-19. For instance, 33 cholera-response teams in Yemen were rapidly transitioned to detect and respond to COVID-19,48 task shifting for Rohingya community health workers allowed COVID-19 information to be disseminated more quickly,28 and in DRC, the hand washing and temperature screening stations already in place for Ebola served equally well for the COVID-19 pandemic. In comparison, in many other contexts, including Canada, it took longer for proper screening measures to be implemented.49

Barriers to COVID-19 response

Social determinants of health describe the interrelationship between the personal, social, economic, and environmental factors that influence an individual’s health status and the health of a population. Populations living in CHEs are likely to experience a complex range of factors that negatively impact their health given the wide-ranging effects of crisis on many, if not all of the social determinants of health. For instance, in CHEs, there are a number of barriers to a timely and effective COVID-19 response (see Figure 1). Cox’s Bazar, DRC, and Yemen have all been affected by the mass population displacement characteristic of most humanitarian crises.50 This usually results in overcrowded living conditions such as those previously described for Rohingya refugees,26 and in DRC, ongoing movement is limiting access to public health messaging. Overcrowding and continued displacement make physical distancing techniques, promoted to limit the spread of COVID-19, nearly impossible in many crisis settings.

Compounding overcrowded living conditions, many people affected by CHEs also face limited access to adequate WASH, compromising their ability to protect themselves and their families from COVID-19. For instance, in Cox’s Bazar, only 29% of refugees have access to piped chlorinated water,29 in Yemen, lack of basic infrastructure has limited access to safe water and hygiene,38 and in DRC, only 42% of the population has access to clean water with only 20% reporting access to basic sanitation.51 The elevated COVID-19 infection rates reported from cruise ships earlier in the epidemic were attributed to sub-standard hygiene and crowded conditions52 – conditions that are even more extreme and problematic in refugee and IDP settings.

While the younger Rohingya, Congolese, and Yemeni population distributions may offer some protection against severe COVID-19 infections and COVID-19 related deaths, this benefit may be counterbalanced by high rates of malnutrition and chronic diseases. Yemen and DRC had two of the top three worst food crises in 2019.53 In Yemen, conflict has driven food prices nearly 150% higher, more than 20 million people are food insecure, and 3.2 million people require treatment for acute malnutrition.54 One hundred percent of Rohingya refugees are reliant on food assistance to sustain daily nutritional requirements.29 The link between undernutrition and immune health has been well established: individuals who are undernourished can have compromised immune systems that may increase the risk and/or severity of infections.55 As a result, many crisis-affected populations may be at risk for higher COVID-19 infection rates as well as higher morbidity and mortality due to elevated levels of malnutrition. In conjunction with malnutrition, two other chronic diseases will likely exacerbate the impact of the COVID-19 pandemic in CHEs – human immunodeficiency viruses (HIV) and tuberculosis (TB). Both Myanmar and the DRC are among the top countries worldwide affected by the combination of HIV, multidrug-resistant TB, and HIV/TB co-infection,56 and DRC ranks eleventh in the world in terms of TB burden of disease.57 Untreated or undertreated HIV and TB in CHEs such as Yemen, Cox’s Bazar, and the DRC will likely not only increase COVID-19 infection rates, but also virus-related mortality.

Despite a heightened need during the coronavirus pandemic, lack of health care providers, poorly functioning health care systems, and limited public health infrastructure will further compromise the COVID-19 response in CHEs. For example, in Yemen, where two-thirds of the population cannot access health care,39 and there are only 10 health workers per 10,000 people,23 resources and capacity to detect and treat COVID-19 are limited. Similarly, in DRC, there is only one health care worker and eight hospital beds per 10,000 people,58 far below the recommended standard, and limited centralized COVID-19 testing results in significant delays. In previous more localized epidemics, the international response has been much more robust, including in the 2010–2011 Haiti cholera outbreak where more than 1,000 aid organizations responded59 and in the 2014–2015 Ebola outbreak in West Africa, to which $3.6 billion was donated by top donor countries.60 However, given the global nature of the current pandemic, the limited quantities of supplies (such as tests and personal protective equipment [PPE]) and travel restrictions, the international community will be much more restricted in its ability to support COVID-19 responses in CHEs.

Strong leadership, clear and consistent communication, as well as honesty and trust in the authorities are instrumental to an efficient and effective epidemic response. However, Yemen, DRC, and the Rohingya crisis are all characterized by poor governance, as is the case with many CHEs.50 In these settings, mistrust and lack of access to information will likely hamper efforts to control COVID-19. In eastern DRC, mistrust and misperceptions around Ebola disrupted the response, including targeted attacks on treatment centres and health care personnel.2124 Mistrust of the quality of health services in the Rohingya refugee camps has been documented prior to COVID-19. Recent consultations with Rohingyas have identified concerns about not being treated due to distancing rules, a lack of treatment for conditions other than COVID-19, and rumours that those who contract the virus are being killed.61 Furthermore, in conflict-affected areas, the pandemic may be used to weaponize public health protection measures, and armed combatants may seek to gain popular support and/or control the pandemic response by directing protection and mitigation measures to their own members, areas under their control and/or to populations that support them.39,62 While responding to a pandemic of this magnitude is always difficult, dynamic complexities surrounding governance, lack of transparency, and armed rebel factions, will undoubtedly introduce additional challenges that will likely cause further suffering and loss of life.

In CHEs, the impact of the COVID-19 pandemic may be particularly severe, resulting in acute exacerbations of chronic food insecurity, inadequate access to health care, and ongoing human rights abuses (see Figure 1). It is also anticipated that the pandemic will disrupt routine childhood vaccinations, restrict educational opportunities, and lead to further economic deprivation among populations who already face severe poverty. These disruptions make it likely that COVID-19 could reverse some of the humanitarian and development gains made in recent years.6365

COVID-19 related restrictions are already impacting global food supplies as well as the availability and affordability of safe and nutritious foods.66 The UN World Food Programme predicts that by the end of 2020, COVID-19 could double the number of people facing acute food insecurity, with the majority of those living in conflict-affected countries.67 Transportation and economic restrictions, export bans and border closures, job loss-related diminished purchasing power, and threatened agricultural production will all contribute to increased food insecurity.68 Malnutrition, worsened by food insecurity, will further increase the risk of contracting not only COVID-19, but also other infections such as measles, pneumonia, malaria and diarrheal illness, particularly among younger children.69

Health care response to the COVID-19 pandemic will need to be coordinated with existing programs and system-strengthening initiatives in order to meet both pre-existing- and pandemic-related needs. It is critical that systems be inclusive of the most vulnerable populations, including IDPs, refugees, and other marginalized groups. Evidence from past epidemics demonstrates that outbreak containment diverts resources from routine health services, including maternal care, treatment of other diseases, and immunization programmes.70 Routine immunization services have already been disrupted or halted in 53% of countries, affecting approximately 80 million children under the age of 1 year.71 In countries supported by the Global Alliance for Vaccines and Immunizations, over 24 million people are at risk of missing critical vaccinations such as measles, cholera, polio, typhoid, rotavirus, and meningitis.71 This is particularly worrisome since the overcrowded living conditions and lack of adequate WASH can exacerbate rapid spread of these highly communicable illnesses. Furthermore, concerns have been raised over equitable access to COVID-19 vaccines when they do become available. Access to COVID-19 vaccination in CHE settings will require affordable access and distribution to those most in need, rather than those most able to pay. The global competition observed for COVID-19 tests and PPE is likely to be even more fierce for vaccination. With declining funding and limited ability to advocate for themselves in the global market, people affected by CHEs are at risk of being neglected when COVID-19 vaccines are eventually distributed.

Sustaining and improving health care and public health systems will also require increased funding at a time when many donor nations are facing their own economic challenges. In northern Yemen, major donors began to reduce or suspend aid as the pandemic began, just as additional support was most needed.39 With so few health care providers in DRC, Yemen and Cox’s Bazar at baseline, should a proportion of the workforce be unable to work due to COVID-19 infection, the strain on already limited health care systems could be overwhelming.

On March 23, 2020, the UN Secretary-General called for a global ceasefire to allow humanitarian assistance in light of the COVID-19 pandemic.72 Despite this potential opportunity to move peace agendas forward and in the midst of urgent calls for the UN Security Council to address COVID-19 as a threat to global peace and security,72 conflict and insecurity continues in many areas. In Yemen, all parties to the conflict have continued fighting, with resultant civilian casualties and loss of infrastructure.72 Blame for spreading COVID-19 is also escalating tensions,39 and the pandemic is being used as a recruitment opportunity in Yemen, where Houthi activists are using the media to tell potential recruits that, “it is better to die a martyr in heroic battles than dying at home from the coronavirus.”62 There is further concern that human rights abuses are being committed under the guise of pandemic response. For instance, in Yemen, some migrants are facing discrimination as disease carriers, resulting in physical and verbal harassment, denial of health care, and forced quarantine without food, water, or other essential services.11 There is additional worry that rates of sexual and gender-based violence are increasing as a result of COVID-19, highlighting the unique ways in which women and girls are affected by the pandemic, and how these can increase vulnerability to violence.3,73 While the pandemic could serve as a turning point for cooperation and advancement of peace agendas, early days suggest that COVID-19 will be more likely to destabilize, thereby compromising supply chains, health care provision, social structure, and economic markets – all of which will ultimately increase civilian suffering.

CHEs were already dealing with a learning crisis prior to COVID-19, with many children unable to access formal education. Now, due to the pandemic, schools have been closed in more than 160 countries, affecting 1.5 billion children and youth.74 With disrupted education for 80% of students globally,39 loss of learning is especially concerning in light of further human capital loss and reduced economic opportunities in the long term. As the Ebola outbreaks demonstrated, the impact of lost education often has the most devastating consequences in countries where educational access is already challenging, and where school dropout rates are high.74 From a workforce perspective, although younger populations are believed to experience less morbidity from COVID-19, patients experiencing severe COVID-19-related illness and death in Yemen appear to be younger than those seen earlier in the pandemic in Europe.75 Similarly, early reports from Brazil, Mexico, and India showed increased mortality among younger populations.76 Higher infection rates and more severe illness among younger patients has the potential to affect the future workforce, potentially exacerbating the economic burden of COVID-19. Although COVID-19 is expected to decrease the global gross domestic product (GDP) by 1.9% in 2020, these effects will be felt unevenly, with those in CHEs likely to experience some of the greatest effects.39 Many people in CHEs survive on small daily earnings, and will be unable to adhere to COVID-19 imposed restrictions without a total loss of income. Already facing considerable poverty, even a small reduction in income for those living in CHEs may have significant impacts – reducing access to food, health care, WASH, and other essential supplies.

The pandemic also has the potential to create positive impacts for CHE populations. Digital innovations may find new ways to support CHE populations, such as the first-ever virtual reproductive health training (MISP) conducted in Bangladesh.77 Social welfare programs may be increased, as was the case in more than 190 countries. The humanitarian sector has been working to move away from programs run by an ever-changing rotation of expatriates, and COVID-19 travel restrictions could encourage more roles to be taken up by local citizens and displaced populations themselves.78

COVID-19 will additionally impact humanitarian responders. For example, an April 2020 survey found that almost all humanitarian operations had been impacted by the pandemic, yet only a small number were stopped completely.79 Furthermore, there have been reports of backlash against both international and national staff as vectors for the virus.79 Anecdotally, many responders also face difficulties related to travel restrictions and quarantine rules when entering a new country or returning home, as well as a responsibility to respond to the pandemic in their own country, all of which make it more difficult to respond in international settings.

It is important to note that, with the WHO having just declared COVID-19 a global pandemic in March 2020 (at this writing, less than five months ago), it is still relatively early in what is expected to be a prolonged pandemic. The data presented here, and the authors’ conceptual model, is based on available evidence at the time of writing. With second and subsequent COVID-19 waves anticipated, it remains to be seen how the pandemic and its global response will evolve.

Overcrowded living conditions with inadequate WASH, ongoing conflict and political instability, poor health care infrastructure, and poverty make those affected by CHEs more vulnerable to the COVID-19 pandemic. Not only are these populations at risk of COVID-19 infection, but they will also likely be impacted by a myriad of secondary effects that could be detrimental to their health and well-being in the months to years ahead. Given current globalization, the authors believe that a wide-reaching, equity-based response that includes the perspectives of vulnerable populations, such as those affected by CHEs, is the only plausible way to address the COVID-19 pandemic. Otherwise, Canadians will be at risk as long as the pandemic continues in international contexts. Finally, Canadian military members may be deployed to CHEs in the future to assist in the fight against COVID-19, or to mitigate insecurities arising from, or exacerbated by, the pandemic. As such, an understanding of the COVID-19 response and implications of the pandemic in CHEs is essential to ensuring success of those operations.

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