A South Asian perspective on the failures of global and national public health policies
South Asia, home to around a quarter of the world’s population and 40% of the world’s poor, is being hit hard by the coronavirus pandemic. The global response to the pandemic has focused mainly on containment of the contagion and “flattening the curve” through testing and strict social distancing, but these universal approaches fail to take account of resource limitations in countries in South Asia and ignore the realities of vulnerable populations, such as low-income migrants, internally displaced people (IDP) and refugees.
Urban migration and forced displacement have a long history in South Asia and escalated in the postcolonial decades. In India alone around 100 million people move internally for work. South Asia hosts one of the highest populations of refugees in the world, including three million Afghan refugees in Pakistan, and more than a million Rohingya refugees in Bangladesh; and reported around four million new IDPs from conflicts and disasters in 2018 alone. 
Around a million Nepalis migrate on a circular basis to India to work, and another two million to other labour destinations such as the Gulf States and Malaysia; this activity represents about 30% of Nepal’s GDP.  South Asian economies benefit extensively from their cheap labour, yet the migrants themselves remain invisible to the State; they do not have access to basic services and are subject to growing hostility and ill-treatment. Most are in low-paying and insecure jobs without social security benefits; they are part of the informal economy, which accounts for nearly 80% of total employment in South Asia.
Migrants in insecure work already have poorer health outcomes, in part due to their inability to access healthcare services and information, and their lack of documentation and financial protection. [3,4] Fear of detention and deportation further limits their access to services. This was evidenced in the National Register of Citizens in the Indian state of Assam that preceded covid-19 outbreak in India and rendered 1.9 million people stateless, with significant burden of ill-health.
The same factors make them particularly vulnerable to covid-19 transmission. Living in cramped conditions, without access to water, and employed in sectors that place them at close proximity to others, not only increases their susceptibility to infection, it makes global public health messages, such as washing hand, social distancing and isolation, meant to slow the spread impossible to follow. Further, their transient life, moving from place to place for work, and lack of a permanent address means that they are difficult to trace and track in efforts to contain the virus.
Covid-19 has amplified the inequalities migrants face. Lockdown measures announced at short notice in some countries in South Asia left millions of migrants without jobs, shelter, and on the brink of starvation. An estimated 12-18 million jobs have been lost in Pakistan, a million in the garment industry in Bangladesh, and 400 million workers in India are at risk of destitution. Closure of worksites and eviction by landlords triggered a mass exodus of migrants, who were forced to make long journeys on foot to their home villages often across borders. Examples of the ill treatment these migrants have been subjected to on their journeys abound; they have been sprayed with chemical disinfectants and denied support, and the impact of this on their physical and mental health will potentially be worse than the threat of the virus itself.
Enforcement of lockdown, without measures to address the economic and food insecurity of migrants, will further increase their vulnerability with damaging long-term health consequences. Some countries in the region, including India, Sri Lanka and Pakistan, have announced relief measures and economic stimulus packages. However, most migrants do not have required documents to access this support. For example, the Pakistan’s relief packages targeting the poor rely on the national socio-economic registry and national identification card that migrants do not have.
Covid-19 has disrupted migration patterns; this may result in concentrated outbreaks and, given barriers to testing and healthcare, greater mortality among this group. Border closures and restrictions have had a complex impact, increasing the return of workers and forcing many to cross at unofficial border points. The covid-19 outbreak in Iran prompted more than 163,000 Afghans to return in a three-week period, while another 70,000 Afghans left Pakistan between April 6 and 8. The closure of Nepal-India border left hundreds of workers returning to Nepal stranded in crowded temporary shelters and open fields at the western and Southern border, with some swimming across a river in a desperate attempt to get home. The International Organisation of Migration warns that these changing migration patterns could potentially lead to transmission among returnees on crowded buses, at border crossings and in quarantine settings, and “the seeding of new clusters in areas of return”, where the majority will be in rural areas that are ill-equipped to monitor, test or treat covid-19 cases, or offer general care.
Prioritisation of covid-19 in some countries has come at the cost of primary healthcare services such as immunisation, reproductive health, health promotion and nutritional and disease control programmes. Nepal government issued a statement on 3 April 2020 for indefinitely postponing the scheduled distribution of vitamin A. In Pakistan, despite a rise in polio cases, the national polio immunisation campaign has been halted in the Khyber Pakhtunkhwa province. Even before covid-19, immunisation drives in IDP and refugee camps had been affected by security concerns and frequent travel across the Pakistan-Afghan border, resulting in a shared polio reservoir. Interruption of these services will contribute to indirect mortality through vaccine-preventable and treatable conditions, declining nutritional indicators of migrants’ children, unsafe abortions and resurgence of tuberculosis and other infectious diseases. 
UN bodies, including the UN migration agency and World Health Organization, have urged that the rights and health of refugees, migrants and the stateless must be protected in national covid-19 responses. Strategies must be designed to address migrants’ needs, and this requires a rights-based public health approach that focuses attention on the social determinants and needs of different categories of migrants.
Given the regional implications, countries in South Asia must “act in unison” to conceive public health for the entire region.  The Covid-19 Emergency Fund created by South Asian Association for Regional Cooperation (SAARC) is a promising step. However, an effective response requires greater regional cooperation, facilitating safe passage, and strong political commitment to universalise health and social protection, continue primary care and guarantee socio-economic rights. Ignoring poor migrants and those in informal economies nationally will not only erode lives but also impede national economic and social recovery from covid-19.
Anuj Kapilashrami is senior lecturer in gender and global health policy at the Centre for Global Public Health, Queen Mary University of London, London, UK
Anns Issac is technical officer at the Asia Pacific Observatory on Health Systems and Policies, New Delhi, India
Jeevan Sharma is senior lecturer in South Asia and International development at the School of Social and Political Science, University of Edinburgh, Edinburgh, UK
Kolitha Wickramage is the Migration Health Research and Epidemiology coordinator at the Migration Health Division, the UN Migration Agency, Manila, Philippines
Ekatha Ann John is researcher at Centre for Global Public Health, Queen Mary University of London, London, UK
Divya Ravindranath is postdoctoral fellow at the Indian Institute of Human Settlements, Bengaluru, India
Roomi Aziz is technical lead in health data and communication at Pathway to Impact, Punjab, Pakistan
Patrick Duigan is the regional migration health advisor, Regional Office for Asia and the Pacific, International Organization for Migration, Bangkok, Thailand
on behalf of the Migration Health South Asia network
Competing interests: None declared
The opinions expressed are those of the authors and do not necessarily reflect the views of the International Organization for Migration (IOM), the United Nations Migration Agency and the Asia Pacific Observatory on Health Systems and Policies (APO).
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