TUNAYDBAH CAMP, Sudan — On a sweltering afternoon in late January, a man lay alone in a hut near the entrance to a compound of tents that serve as a health clinic in Tunaydbah refugee camp in eastern Sudan. As a suspected COVID-19 case in the under-resourced camp, aid workers have isolated him to avoid the spread of the virus with the hope that this does not turn into a severe case.
Though there have only been a handful of confirmed COVID-19 cases in the refugee camps of Tunaydbah and Um Rakuba — which are currently hosting over 60,000 people who have fled violence in northern Ethiopia, aid workers believe that cases are going undetected.
Humanitarian actors at the camps are overwhelmed with the needs of the constant influx of people arriving, and have limited funding. COVID-19 is just one of many challenges burdening the camps, and in many ways, remains deprioritized.
With limited testing, no official isolation centers, and very few COVID-19 protocols in place, aid workers worry about their ability to manage the pandemic response if there is a sudden rise in severe cases.
“There is no respect of social distancing, no use of masks,” said Luca Pigozzi, medical team leader at Médecins Sans Frontières Holland’s health clinic in Tunaydbah camp. “In general, there is a lack of awareness.”
Limited testing and isolation facilities
Upon arrival at the camps, refugees receive a health examination which includes screening for COVID-19, however tests are only administered to those that have multiple COVID-19 symptoms, said Dr. Amna Idris Elfaki, a medical doctor with Alight.
The World Health Organization estimates that over 80% of COVID-19 cases in Africa are asymptomatic and aid workers believe that the restricted testing strategy used at the camps is undoubtedly letting cases pass through.
"At the end of the day, it's an extremely challenging situation ... ensuring social distancing looks nice on paper, but it's very difficult to implement."— Julian Zakrzewski, Sudan country director, Danish Refugee Council
The Sudanese state where the camps are located, Al-Qadarif, already has limited testing capacity, said Javanshir Hajiyev, program team leader at Mercy Corps. The nearest laboratory is three hours away from Tunaydbah camp and about an hour and a half away from Um Rakuba, meaning health workers at the camp depend on government representatives to pick up samples. Typically, it takes about one to two days to receive test results after the sample is collected.
Health workers at Um Rakuba started collecting COVID-19 samples from people in the camps at the end of December 2020, Hajiyev said, adding that because of the emergency nature of the crisis, “we are establishing services as it goes.”
Tunaydbah camp’s first confirmed case is isolated in a tent about 500 feet (152 meters) away from other camp residents, with a separate bathroom. Family members are also isolated and health workers monitor them for symptoms. Um Rakuba camp has had four confirmed cases so far, that receive medical care in a fenced-off area with about 20 tents.
There are no official COVID-19 isolation centers in the camps, which would allow a severe case to receive oxygen support on-site, meaning that severe cases must be sent to area referral hospitals — which are also underresourced. This also raises ethical questions around whether or not confirmed cases should be sent to urban areas with even higher population density, Hajiyev said.
Humanitarian actors have drafted plans for isolation centers in the camps and are working through the details such as land allocation and the assignment of health workers, said Ahmed Eljuzuly, head of program for Alight, adding that personal protective gear is already available for health workers and that WHO plans to provide support to these centers.
MSF is currently constructing a 30-bed tent hospital in Um Rakuba, which will have an additional 10 isolation beds. It expects the hospital will be operational in about one month and will have the capacity to provide oxygen support.
COVID-19 protocols largely absent
Masks are scarce in the camps and are mostly worn by aid workers. People arriving from Ethiopia are given one disposable mask when they register at the border, said Seda Kuzucu, senior emergency coordinator in Sudan at the United Nations High Commissioner for Refugees.
Though MSF said it recently started providing cloth masks in Tunaydbah camp to people most at risk of developing severe cases of COVID-19, most people need to purchase their own additional masks. This is a challenge as many people have no source of income and are still wearing the same clothes they wore when they fled Ethiopia.
Organizations such as the International Organization for Migration, United Nations Population Fund and the United Nations International Children’s Emergency Fund, are training volunteers from the refugee communities as hygiene promoters and holding awareness sessions, among other activities, but hand washing stations are not widely accessible around the camps.
Social distancing is also a challenge as most people often have to wait in line for hours to receive basic necessities, such as food, blankets, kitchen utensils, and tents. Bathrooms and water points are also a source of crowding.
“The COVID-19 protections here are very weak. Look at how everyone is crowded together in lines,” said Esayas Belay, one of the people living in the camp, pointing to a line where new arrivals had been waiting all day to register for the camp, some huddled together under umbrellas to avoid the sun.
Omer Mohamed Ahmed, a protection officer with Alight, and one of the aid workers who encourages social distancing during food distributions, said there is some skepticism about COVID-19 among people he has spoken with, adding that COVID-19 is not always a priority for the populations who might have more urgent concerns.
“In an emergency situation like this, they are more focused on receiving food,” he said.
Beyond COVID-19, health workers at the camps also struggle with managing other basic health concerns, hindered by limited fuel supplies to run generators, inadequate laboratory services, drug shortages, limited options for referral of patients to health facilities outside the camps, and language barriers.
"I think we need to be realistic about what we can expect in a camp. I think what is important is that there are checks and facilities to identify cases, a proper tracking system in place and an isolation unit," said Julian Zakrzewski, Sudan country director for the Danish Refugee Council. "At the end of the day, it's an extremely challenging situation ... ensuring social distancing looks nice on paper, but it's very difficult to implement."