Ukrainian refugees and vaccination challenges

We are facing two huge crises: Ukraine and the pandemic. But no one is putting them together.

Being among the most marginalised and vulnerable, refugees and internally-displaced people have been especially at risk during the pandemic. Individuals fleeing conflict zones, persecution or structural violence find themselves in dire circumstances, which rarely allow them to maintain hygiene or social distancing.

In regular conditions it is these measures, along with vaccination, which provide best results in protection from Covid-19 infection. In refugee crises, vaccination alone becomes essential as possibly the only feasible intervention.

Although many countries have by now developed vaccination strategies that include refugees and other displaced, these groups have often been the last to receive vaccines, for various reasons. These include shortages in the low- or middle-income countries which have tended to host the majority of displaced people. They also include insufficient or inappropriately delivered information, discriminatory administrative practices, failure to distribute vaccines in remote humanitarian settings and hesitancy towards them.

Rethink on vulnerability

Just as the United Nations Refugee Agency (UNHCR) reported some progress on Covid-19 vaccine access and uptake across host countries, another major refugee crisis appeared. Since the escalation of the war in Ukraine which began in February, over 3.2 million people, the vast majority women and children, have fled to Poland, Hungary, Moldova, Romania and Slovakia. Within the European Union as a whole the number may be as high as seven million.

Taken with the pandemic, this massive inflow of people in such a short time could pose major challenges, for the prevention of additional outbreaks and to vaccination practices and priorities. Perhaps however because experiences over the past two pandemic years have brought about a rethink on vulnerability by agencies in Europe involved in vaccine delivery, some are now offering vaccination to Ukrainian refugees. This is in marked contrast to displaced people from other parts of the world, who have typically faced administrative difficulties and feared arrest, detention or deportation if they have presented themselves or their children for vaccination.

This does not mean that Ukrainian refugees are not at risk of vaccination-related discrimination. The strict Covid-19 regulations in some European countries have meant that individuals without vaccination certificates have been barred from using public transport or finding decent accommodation. Many have thus been forced to sleep in train or bus station waiting rooms, in addition to the trauma and hardships of flight.

Vaccine hesitancy

One might think that this lack of vaccination certificates, at least, could be easily solved, if European countries are making vaccines available for Ukrainian refugees. But this is compounded by widespread vaccine hesitancy among them. Before the war broke out, Ukraine had one of the lowest Covid-19 vaccination rates in Europe. Over 56 per cent of the adult population did not plan to be vaccinated, mostly due to widespread mistrust of government authorities.

Such sentiments were not new, as indicated by low childhood immunisation against polio, measles and diphtheria before the pandemic in Ukraine. This bears on Europe’s regional goals, in the framework of the World Health Organization, of eliminating measles and rubella and maintaining polio-free status.

It is not hard to imagine the possible consequences of a large influx of unvaccinated adults and children for a neighbouring country which had already faced the pandemic burden, where Covid-19 vaccination coverage was also relatively low or where some vaccine-preventable childhood diseases, such as measles, were still endemic. In efforts to avoid potential discrimination, some experts have warned against refugees being viewed as a likely channel for the spread of Covid-19 to host countries, since the virus causing the disease is already present. More outbreaks in such circumstances could however facilitate the emergence of new variants, with unforeseeable consequences.

If they remain unwilling to be vaccinated, there is a risk of Ukrainian refugees being blamed for a future outbreak, as refugees have been in the past. Vaccines offered to refugees might acquire additional socio-cultural meanings in the host countries. They might become framed as part of a social exchange system or ‘the gift relationship’—an institution that pervades all aspects of society, through which social relations are built between individuals or groups, and which entails an obligation to give, to receive and to reciprocate.

Refusing vaccines in this context, implying the rejection of the gift, could be negatively interpreted in host countries. The potential damage to social relationships would be all the greater if this were to be represented as the wellspring of a future lockdown or an overwhelming of the health system.

Tailoring provision

The authorities in host countries will have to acknowledge the importance of addressing vaccine hesitancy—not only among local populations but also, perhaps differently, among Ukrainian refugees. In the context of a refugee crisis, vaccination campaigns could also be marginalised, given the many pressing needs which might seem more urgent. Forced displacement results in psychological traumas which will challenge mental health services, especially given linguistic and cultural differences.

On the other hand, programmes of psychological support to refugees could also provide a means of addressing the sources of their vaccine hesitancy, rooted in mistrust of state vaccination systems. Vaccine refusal has frequently been the cause of social disputes and divisions. It is reasonable to assume that it could have the same, if not more extreme, effects in a refugee emergency unfolding during a pandemic.

It is important that vaccination programmes not be neglected because of other priorities. Ways will have to be found of appropriately tailoring provision to the needs, fears and vulnerabilities of refugee populations, in this very sensitive situation.