Situation assessment of statelessness, health, and - COVID-19

 
Situation
assessment of
statelessness,
health, and
COVID-19
in Europe
Acknowledgements
         The research was commissioned by the European Network on Statelessness (ENS) and sponsored
         by the Rosa-Luxemburg-Stiftung with funds of the Federal Ministry for Economic Cooperation
         and Development of the Federal Republic of Germany. This publication or parts of it can be used
         by others for free as long as they provide a proper reference to the original publication.

         The report was researched and written by Marie-Claire Van Hout (Public Health Institute,
         Liverpool John Moores University), Charlotte Bigland (Public Health Institute, Liverpool John
         Moores University), and Nina Murray (European Network on Statelessness).

         The research team would like to thank and acknowledge all participants of the research,
         research country partners, and the Expert Advisory Group (EAG). The content of this report is
         the responsibility of ENS and its authors and should not be construed as reflecting the views of
         funders or EAG members.

         April 2021

Situation assessment of statelessness, health, and COVID-19 in Europe                                       2
Foreword
The COVID-19 pandemic is more than a health crisis. As its repercussions continue to unfold, it has
developed into a rights crisis that affects all of us. Yet, it does not affect all of us equally.

Since the onset of COVID-19, I have urged                               and extreme vulnerability to human rights            necessity for prioritisation on sound medical
authorities across Europe to ensure that                                abuses. I believe that States should step up         evidence and the individual urgency of the
healthcare systems meet the needs of the                                efforts to put an end to the perpetuation of         case. Health is a human right and must be
entire population, including the marginalised                           statelessness, in line with existing international   treated as a public good, not a special benefit
and disadvantaged. I therefore welcome this                             standards. They should ensure, in particular,        or a commodity.
research as the first of its kind to explore the                        that children born on their territory and who
extraordinary vulnerabilities and rights violations                     would otherwise be stateless are granted             Authorities should therefore strive to identify and
experienced by stateless persons in relation to                         the nationality of the State concerned. This         address the specific and interrelated barriers
health. It exposes a troubling lack of recognition                      is possibly one of the most effective tools          to realising stateless people’s right to health
of the fact that statelessness continues to                             to curb the number of stateless persons in           that the report identifies. Beyond their lack of
constitute a powerful barrier to accessing                              Europe. I will continue to highlight human           legal status, these include multiple forms of
healthcare across Europe. Filling this gap is ever                      rights violations resulting from statelessness       discrimination, fear and mistrust of authorities,
more urgent in the current pandemic context.                            in my future work, whether at national level         digital exclusion, and the lack of access to
                                                                        or in multilateral contexts, and to support the      adequate health information. To guarantee
In most countries, legal status and formal                              authorities in identifying and implementing          the right to health for all requires adequate
documentation are prerequisites for                                     effective solutions.                                 resourcing, and proactive research and outreach
accessing quality healthcare. They are also                                                                                  to ensure that diverse stateless populations
prerequisites for gaining access to important                           COVID-19 has demonstrated that the right to          participate and are made visible in health
social determinants of health, including                                health cannot be protected at an individual          policymaking. I therefore highly appreciate
employment, social protection, and adequate                             level. It requires effective systems that provide    this valuable research on the nexus between
housing. Over 500,000 stateless persons in                              for inclusive prevention, treatment, and             statelessness and health inequalities and
Europe, many belonging to minorities, do                                rehabilitation for all, leaving no one behind        encourage States to take its recommendations
not enjoy the fundamental human right to                                and ensuring that structural inequalities are        to heart in their efforts to build inclusive and
recognition everywhere as a person before                               not magnified over time but disrupted and            resilient healthcare systems for all.
the law. Children continue to be born and to                            addressed. I have called on Council of Europe
grow up without a nationality, in yet another                           Member States to ensure non-discriminatory           Dunja Mijatović
generation of persons who are compelled                                 access to all pandemic response and                  Council of Europe Commissioner for
to live a life of destitution, marginalisation                          vaccination programmes, and to base any              Human Rights

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                          3
“As Roma advocacy coordinator and                                       “The research explores how the ongoing           “Stateless communities have continually been
member of the research Expert Advisory                                  COVID pandemic has affected stateless            overlooked and hidden from the public eye.
Group, it was important for me that not                                 individuals and outlines the shocking reality    With the measures implemented in response
only fundamental rights, but also cultural                              of how one of the world’s most vulnerable        to Covid-19, this marginalised community
rights be considered. I also advised                                    populations can be left behind in such           has become even more isolated, magnifying
specific reference to antigypsyism since                                situations. It defines vastly important areas    the inequalities they face. The inclusion of
statelessness and antigypsyism are                                      that are worth further exploring to make sure    stateless communities in Covid-19 responses is
intertwined. Hopefully, the report will raise                           everyone is safe and has the right to health.”   essential for a successful pandemic recovery,
awareness whilst creating more concrete                                                                                  and this research is critical in informing
actions. Bringing our voices together is                                                                                 needs and rights-based policies to ensure
crucial and knowing that the starting point                                                                              that stateless people are not left behind.”
of stateless people is strength, we support                             Nowras Rahhal
this respectfully and wholeheartedly.”                                  Individual ENS Member & Stateless Activist

                                                                                                                         Anila Noor
                                                                                                                         Managing Director, New Women Connectors
Michelle Mila Van Burik Bihari
Individual ENS Member & Roma Activist

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                 4
Contents

Acknowledgements                                                        2    Stigma, scapegoating and hate crime                      19
                                                                             Vaccination roll out: universal?                         19
Foreword                                                                3
                                                                             Conclusions                                              20
Background                                                              6
Statelessness and the Right to Health                                   6    Recommendations                                          22
The COVID-19 health emergency                                           8    1. The Right to Health                                   23

Rationale for the research                                              10   2. Access to COVID-19 testing, treatment, and vaccines   23

Method                                                                  10   3. Immigration, nationality, international protection,
                                                                                and civil registration procedures                     23
Results                                                                 11   4. Addressing discrimination, racism and antigypsyism    24
The nexus between                                                            5. Health information and digital inclusion              24
statelessness and health                                                12
                                                                             6. State aid and humanitarian response packages          24
Impact of COVID-19 on the health and healthcare access
of stateless people                                                     13   7. Addressing the invisibility of statelessness whilst
                                                                                upholding the right to privacy                        25
Environmental determinants of health and COVID-19                       14
                                                                             8. Support for civil society                             25
Operationalisation of public health guidance                            15
                                                                             9. Further research                                      25
Health emergencies, morbidities, and mortalities of
stateless people during COVID-19                                        15   References                                               26
The role of civil society and best practices in supporting
the health response                                                     16   Annex I: Methodology                                     30
Institutional mistrust and fear of data sharing between
                                                                             Annex II: EAG Members & Country Partners                 33
healthcare and immigration authorities                                  17
Legal and immigration processes                                         17   Annex III: Data Collection Instruments                   34
Socio-economic exclusion, and lack of access to government
support packages                                                        18   Endnotes                                                 42

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                      5
Background

                                                                        Statelessness and the Right to Health
                                                                        Statelessness was described by António Guterres, the UN High
                                                                        Commissioner for Refugees (UNCHR) in 2011, as the world’s “most
                                                                        forgotten human-rights problem” (van Gilder Cooke, 2011). Article 1
                                                                        of the 1954 Convention Relating to the Status of Stateless Persons
                                                                        defines a stateless person as “a person who is not considered as
                                                                        a national by any State under the operation of its law“. UNHCR
                                                                        estimates there are millions of stateless people in the world, but the
                                                                        true extent of statelessness globally is unknown, as fewer than half of
                                                                        countries submit data on their stateless populations. 1 Some people
                                                                        are born stateless, whilst others become stateless over the course of
                                                                        their lives. The main causes of statelessness include discrimination
                                                                        (including antigypsyism), gaps or conflicts in nationality laws, state
                                                                        succession, and deprivation of nationality.

                                                                        When a person lacks a nationality, they lack the rights and duties
                                                                        attached to belonging to a State, which leads to violations of many
                                                                        other human rights, including the right to health. 2 According to the
                                                                        World Health Organization, “the enjoyment of the highest attainable
                                                                        standard of health is one of the fundamental rights of every human
                                                                        being”, with “health“ being defined as “a state of complete physical,
                                                                        mental and social well-being and not merely the absence of disease
                                                                        or infirmity”. 3 The 1948 Universal Declaration of Human Rights (UDHR)
                                                                        refers to health as part of the right to an adequate standard of living
                                                                        (Article 25), which is also recognised in the International Covenant
                                                                        on Economic, Social and Cultural Rights (ICESCR). Article 12 ICESCR

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                         6
stipulates everyone’s right to healthcare and                           does not prescribe a particular mechanism         Many stateless people have never crossed
States are under an obligation to respect this                          for determining statelessness. At the time of     borders and find themselves stateless in their
right by “refraining from denying or limiting                           writing, 12 European States have established      “own country“ (referred to as “in situ stateless
equal access for all persons, including                                 dedicated statelessness determination             persons“). In the Balkans and countries of the
prisoners or detainees, minorities, asylum                              procedures in law to provide protection to        former Soviet Union, many Roma and other
seekers and irregular migrants”. The right to                           stateless people under the 1954 Convention.6      minority groups remain stateless or at risk
the highest attainable standard of health also                          In addition to the two statelessness-specific     of statelessness because of discrimination
falls within other international human rights                           conventions, many other human rights treaties     and the legacy of state succession.9 Others
treaties. 4 It spans environmental determinants                         set standards for the protection of stateless     find themselves stateless in a migratory
of health, standards of healthcare, and                                 people, avoidance of statelessness, and the       context, for example, stateless refugees
rights to privacy and medical confidentiality.                          right to a nationality. At regional level, the    are among those seeking asylum in many
The right to health is closely linked to the                            European Convention on Nationality and            European countries.10 Statelessness in Europe
fulfilment of other rights, which stateless                             the Council of Europe Convention on the           therefore disproportionately affects migrant,
persons are often denied such as the right                              Avoidance of Statelessness in Relation to         refugee, and minority groups, including Roma
to education, social security, and food.                                State Succession are two key instruments          and ethnic Russians living in the successor
According to the Committee on Economic                                  for the prevention of statelessness. In the       states of the Soviet Union and Yugoslavia.
and Social Rights, the right to healthcare is                           UN framework, the Universal Declaration           UNHCR reported that there were 527,959
“indispensable for the exercise of other rights”                        on Human Rights, the Convention on the            stateless persons in Europe in 2019, based
5
  with universal application and with access to                         Rights of the Child, and the Convention on        on information provided by governments
healthcare services ensured to every human                              the Elimination of all forms of Discrimination    and other sources, although this is likely an
being without regards to race, religion, or                             against Women, amongst others, all contain        underestimate.11
other criteria, including legal status (UNHCR,                          provisions to guarantee the right to a
2008; Rechel et al., 2013).                                             nationality. Thus, all European States have       Statelessness prevents many of those
                                                                        obligations under international law towards       affected from accessing fundamental
The two most important international                                    stateless people and the eradication of           rights (human, civil, social, cultural, and
instruments addressing statelessness are                                statelessness, regardless of whether they are     political) creating or exacerbating significant
the 1954 Convention relating to the Status                              party to the core statelessness conventions.7     marginalisation and exclusion spanning
of Stateless Persons, which provides the                                                                                  access to healthcare, education, housing,
definition of a stateless person and the                                Statelessness in Europe8, as elsewhere,           employment, and other civil rights such
international legal framework for the                                   affects both migrants and refugees, and           as birth and marriage registration. Due to
protection of stateless people, and the 1961                            people who have lived in the same place for       the lack of domestic legal frameworks to
Convention on the Reduction of Statelessness,                           generations, but it remains a largely hidden      identify and solve statelessness, including
which sets rules around conferral and                                   phenomenon, due to the incompleteness and         mechanisms to determine who is stateless
withdrawal of nationality. Whilst the 1954                              sparsity of data. Disaggregated data and          and due protection under the 1954
Convention establishes the international                                data on stateless people held in immigration      Convention, stateless people’s enjoyment
legal definition of a “stateless person” it                             detention are particularly lacking (ENS, 2019).   of rights varies significantly from country

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                        7
to country.12 The right to access healthcare                            care for people without identity documents,      marginalisation and discrimination stateless
and social security is usually contingent on                            including due to an inability to register with   people face, potentially worsens the impacts
residence or legal status. In the migratory                             a general practitioner (UNHCR and R2P,           of COVID-19 (ISI, 2020a; ISI 2020b; Murray,
context, people recognised as stateless                                 2020). Undocumented migrants in the UK also      2020).
(in countries with mechanisms to grant                                  face many barriers to accessing healthcare,
protection under the 1954 Convention) are                               including fear and mistrust and lack of          States’ obligations under international
usually permitted access to healthcare and                              understanding, according to a recent study.14    law continue to apply in crisis situations
social security in line with nationals (for                                                                              such as COVID-19 except to the extent
example, in Spain, France, Italy and the UK).13                                                                          that relevant treaty obligations have been
Stateless people recognised as refugees                                 The COVID-19 health emergency                    formally derogated from, through notification
or holding subsidiary protection status, are                                                                             to the relevant international authorities
also usually granted access to healthcare in                            On 11 March 2020, the World Health               (International Commission of Jurists, 2020).
line with nationals. However, where stateless                           Organization (WHO) reported that the             In line with Article 11 of the European Social
migrants hold a temporary residence permit,                             global outbreak of the corona virus disease      Charter, which enshrines the right to health,
or a form of “tolerated“ or irregular stay,                             (COVID-19) was a pandemic (WHO, 2019).           the European Committee of Social Rights
they will often face significant challenges                             At the time of writing, there are a reported     (ECSR, 2020) has stated:
in accessing healthcare. In situ populations                            36,607,500 cases of COVID-19 in Europe
affected by statelessness who lack identity                             with 830,948 deaths (ECDC, 2021). Europe
documents and/or legal status will also face                            was the epicentre of the pandemic for a                In times of pandemic, during which
significant barriers to accessing healthcare.                           large part of 2020. Success in countering        the life and health of many people are
                                                                        the COVID-19 pandemic centres on an
                                                                                                                         under serious threat, guaranteeing the
Healthcare for migrants in an irregular                                 inclusive rights-based response, “leaving
                                                                                                                         right to protection of health is of crucial
situation is generally restricted to emergency                          no one behind“, with the inclusion of all
                                                                        populations in domestic, European, and           importance, and governments should
care through emergency care services
only (FRA, 2016). In the Netherlands, several                           international responses (Orcutt et al., 2020;    take all necessary steps to ensure that it
studies report that whilst undocumented                                 Orcutt et al., 2020a; Lancet Migration, 2020).   is effectively guaranteed. In light of this,
persons have the legal right to access                                  Particularly vulnerable populations during       States Parties must ensure that the right
“medically necessary“ healthcare; individuals                           COVID-19 include ethnic minorities, homeless     to protection of health is given the highest
may not be aware of this right. They may                                people, migrants, refugees, asylum seekers,
                                                                                                                         priority in policies, laws and other actions
be wrongly denied access or experience                                  stateless persons, and Roma communities
                                                                        (Lau et al, 2020; Varga, 2020; Kirby, 2020;      taken in response to a pandemic.
discrimination; they may fear data-sharing
between authorities; and may be unable to                               UNHCR and R2P, 2020). Stateless people
pay medical charges (Hintjens, Sigemann and                             have been highlighted by UNHCR and others
Staring, 2020; International Institute of Social                        as a group at particular risk of being left
Studies, 2020). Studies in the Ukraine have                             behind in the COVID-19 response. The invisible
also reported a lack of access to medical                               nature of statelessness, coupled with the

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                     8
Despite these assurances, there are rising                              (including language, health literacy, and           Stateless people’s navigation of this public
concerns around the structural underpinning                             logistical barriers), and discrimination by         health crisis, and their experiences are also
of statelessness, human rights, health rights                           healthcare providers (Zolberg Institute, 2020;      at grave risk of being omitted or indeed
and the right to nationality worsening as the                           Varga, 2020; Murray, 2020). During a public         misinterpreted in the global response (ISI,
COVID-19 pandemic takes hold (ISI, 2020a;                               health crisis, stateless people in particular       2020a; ISI, 2020). There are identified gaps in
Murray, 2020; ISI, 2020b).                                              may also refrain from accessing health              government engagement with marginalised
                                                                        services for fear that their lack of residence or   communities and in the availability of
Statelessness is linked to political and                                legal status can put them at risk of detention,     translated and targeted COVID-19 risk
economic marginalisation and discrimination                             deportation or further discrimination (UNHCR        communications across Europe (Maldonado
(including antigypsyism and other forms of                              and R2P, 2020; Murray, 2020).                       et al., 2020). Despite government assurances
racism). Many stateless people in Europe                                                                                    to include marginalised populations,
face hate speech, exploitation and abuse,                               Significant health risk factors are also linked     including Roma, migrants, and refugees in
detention, insecurity, and restricted movement,                         to the contexts in which many stateless             comprehensive COVID-19 responses, State
with serious consequences for their health and                          people live and work. For example, densely          public health guidance and measures do
well-being and livelihoods, particularly during                         populated areas, factories, camp settings,          not necessarily reach them, particularly in
a public health crisis (ISI, 2020; Murray, 2020).                       collective shelters and informal settlements,       the case of stateless people due to their
Wider social, structural and environmental                              and immigration detention settings. All these       invisibility (Varga, 2020; ISI, 2020; Zolberg
determinants of health experienced by                                   settings have been linked to an inability to        Institute, 2020; Council of Europe, 2020). They
stateless people are worsened during COVID-19                           adhere to public health guidance, including         may not have full access to public health
and centre on the significant rise in evictions,                        to self-isolate during illness (Raju and Ayeh-      information, or be included in health policies
scapegoating and hate crime during COVID-19,                            Karlsson, 2020; Armitage and Nellums, 2020;         and responses during emergencies such as
poor and congested living conditions, lack                              Hargreaves et al, 2020; Varga, 2020; Heaslip        COVID-19, and without legal rights and access
of sanitation and hygiene, chronic ill health                           and Parker, 2020; Milkova and Larkins, 2020).       to essential services, including healthcare
and stress, overrepresentation in informal                              Stateless people, especially children and           and public funds, many stateless people in
sectors where no work means no pay, and                                 women, who lack residence status and/or             Europe are at risk of exclusion from access
lack of access to social security, humanitarian                         identity documents and live in relative poverty     to COVID-19 testing, contact tracing, and
and government aid packages, all of which                               are at significant risk of social consequences      medical care (UNHCR and R2P, 2020; Junior et
compound their health disparity, and                                    of COVID-19 (such as inter-generational             al, 2020; Varga, 2020; Hargreaves et al., 2020;
potentially grave outcomes.                                             statelessness, evictions, homelessness,             Raju and Ayeh-Karlsson, 2020; Armitage and
                                                                        poverty, gender based violence, interrupted         Nellums, 2020; Heaslip and Parker, 2020; Wood
These risk factors are exacerbated for many                             schooling, lack of access to online schooling,      and Devakumar, 2020; Paprah, 2020; Parry-
stateless people in Europe due to barriers                              health risks) (Raju and Ayeh-Karlsson, 2020;        Davies and RAPAR, 2020; Aragona et al., 2020).
to accessing knowledge around rights and                                Armitage and Nellums, 2020; Hargreaves et al,
entitlements to support their right to health                           2020; Varga, 2020; Heaslip and Parker, 2020;
and help seeking, as well as institutional                              Milkova and Larkins, 2020; OSCE, 2020; UNHRC,
mistrust, barriers to accessing health services                         2020).

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                     9
In relation to Roma populations in particular,                                 Member States will need to make            Rationale for the research
there have been widespread reports of                                   decisions on which groups should have
lockdowns in Roma settlements, rising hate                              priority access to the COVID-19 vaccines so       Whilst the literature base is growing, the
speech against Roma, and reports of State                               as to save as many lives as possible. These       impact of COVID-19 on stateless people in
enactment of disproportionate or militarised                            decisions should be driven by two criteria:       Europe is currently under researched, and
measures targeting Romani neighbourhoods                                to protect the most vulnerable groups             there is an imperative to understand their
or towns (for example in Bulgaria and                                   and individuals, and to slow down and             experiences and situations. The European
Slovakia) based on a racist and antigypsyist                            eventually stop the spread of the disease.        Network on Statelessness (ENS) responded to
narrative exemplifying Roma as a health                                                                                   this need and sought and was granted funding
threat (Holt, 2020; Matache and Bhabha, 2020;                           (European Commission, 2020)
                                                                                                                          from the Rosa-Luxemburg-Stiftung Geneva for
OSCE, 2020; Milkova and Larkins, 2020; Council                                                                            this project.
of Europe, 2020).
                                                                        At the end of 2020, the International
Given the deadly nature of COVID-19 in all                              Organisation for Migration (IOM) stated that      Method
people with underlying health conditions,                               COVID-19 vaccination plans must include
alongside the unique risk factors and                                   migrants, regardless of their migration
                                                                                                                          The research team conducted a rapid
discrimination already affecting stateless                              status, in government vaccine deployment
                                                                                                                          situation assessment (mixed method
communities, anti-discrimination measures                               plans (IOM, 2020; PICUM, 2020). This was
                                                                                                                          consisting of a survey, interviews and focus
are vital to a comprehensive public health                              supported by two later press releases from
                                                                                                                          groups) to explore and assess the nexus
response (Murray, 2020). Notwithstanding                                the European Centre for Disease Prevention
                                                                                                                          between statelessness and health during
the health harms in disease spread, the                                 and Control (ECDC) (ECDC, 2020; ECDC,
                                                                                                                          COVID-19 in the Council of Europe (CoE)
mental health impact of statelessness                                   2020a). On 28 January 2021, the International
                                                                                                                          region. The full methodology is detailed in
and its detrimental impact cannot be                                    Romani Union released a press statement,
                                                                                                                          Annex I. The research aim was to better
underestimated and requires dedicated action                            which outlined concerns for equal access and
                                                                                                                          understand the intrinsic link between
planning (UNHCR, 2020a; United Nations,                                 uptake of COVID-19 vaccinations for Romani
                                                                                                                          statelessness and health, and make evidence-
2020). In October 2020, a Communication                                 populations, and the presence of deep
                                                                                                                          based policy recommendations for the short,
by the European Commission on vaccine                                   institutional mistrust and vaccine hesitancy.15
                                                                                                                          medium and long-term, inform responses and
preparedness, referred to including                                                                                       actions to protect stateless people’s rights,
“communities unable to physically distance”                                                                               guide inclusive policies and programmes, and
(such as in “refugee camps”) and “vulnerable                                                                              tailor public health interventions and service
socioeconomic groups and other groups                                                                                     provision accordingly.
at higher risk” (such as “socially deprived
communities to be defined according to
national circumstances”) as “possible priority
groups” for vaccine deployment:

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                 10
Results

                                                                          25 CoE             29 survey        19 in-depth          5 focus
                                                                         countries         respondents        interviews           groups

                                                                        29 key stakeholders completed the survey administered by ENS
                                                                        representing 20 CoE countries (UK; Romania; Czech Republic; Sweden;
                                                                        Georgia; Croatia; France; Netherlands; Kosovo; Greece; Italy; Belgium;
                                                                        Serbia; Ukraine; North Macedonia; Russia; Switzerland; Moldova;
                                                                        Ireland; Portugal). 19 in-depth interviews were conducted with
                                                                        key stakeholders identified by ENS and represent the regional and
                                                                        specific country level perspectives (Germany, Ukraine, Netherlands,
                                                                        Greece, Spain, UK, Italy). Five written reports were submitted by the
                                                                        focus group facilitators in priority countries.

                                                                        It is important to mention that whilst perspectives were provided
                                                                        on the nexus between health and statelessness in general, and
                                                                        some survey and interview responses give insight into the picture
                                                                        of health and healthcare access of stateless people during

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                        11
COVID-19 times, overall there was a lot of                              identification, or health insurance to access    substantiated in stakeholder interviews.
uncertainty from respondents in being able                              mainstream medical care. For example, in         Some examples included:
to answer questions, with many feeling                                  many countries, migrants are only able to
they were ill-equipped or did not have the                              access emergency medical care, with long-         In Romania, stateless people living in
necessary information to comment on                                     term care options available only to those with    government-run facilities are provided with
the specific situation of stateless people.                             certain categories of residence permits and       regular access to doctors and medical
Overall, whilst challenging from a research                             formal documentation. In many countries,          personnel. During COVID-19, newcomers
perspective, this is indicative of the lack                             stateless migrants are among those least          are placed in isolation.
of data and information available in the                                likely to hold identity documents or residence
region on statelessness. This lack of specific                          permits. Financial costs towards medical care
response regarding stateless people further                             are noted by many as being a huge barrier to      In the Czech Republic, in general, if
emphasises that statelessness is an “invisible                          accessing medical care, particularly for those    someone is detained in an immigration
issue“. The full impact of COVID-19 on                                  who may not be able to self-fund care or do       detention setting, emergency care is
stateless people and communities does not                               not hold medical insurance. As an example         provided; but if they are asylum seekers
appear to be recognised or documented. On                               of this, it was reported by a stakeholder from    and housed in a refugee centre, they have
a positive note, data across stakeholders and                           Ukraine that:                                     access to public healthcare.
stateless people were indicative of general
consensus on the situation, with no outliers
                                                                              Only those stateless persons who            Referring to COVID-19 times, a
observed.
                                                                                                                          representative from Greece stated: “Yes,
                                                                        have a permanent residence permit in
                                                                                                                          there is a difference. For people who
                                                                        Ukraine are receivers of free medical care
The nexus between                                                                                                         are living in the camp for settlement or
                                                                        in Ukraine. Others should pay for medical         reception centres, the health services
statelessness and health                                                services. Those persons who apply                 provision was restricted, they didn’t allow
                                                                        for recognition as a stateless person             people to move out of the residence.”
Whilst the right to healthcare is a fundamental
human right, with universal application and                             will not receive free medical services,
with access to healthcare services ensured to                           because they are regarded as temporary            In Ukraine residents of "official"
every human being without regards to race,                              residents in the territory of Ukraine.            accommodation facilities (immigration
religion or other aspects of a person’s identity,                                                                         detention centres, municipal homeless
including nationality status, this appears not                                                                            shelters, etc.) are provided with better
to be the case for stateless people. When                               Survey responses on the differences in health     access to healthcare, as those who run
asked about stateless people’s access to                                service provision for stateless people as         the facilities are responsible for organising
health services in general, a high proportion                           a result of their accommodation settings          healthcare. “Those who live in informal
of those who responded to the survey and                                both in general and during COVID-19 times,        settlements has to apply for medical aid
those interviewed detailed the requirement for                          highlighted marked differences in provision       on a general basis, which in most cases is
people to have legal documentation, formal                              in different countries. This was further          impossible without personal documents.”

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                     12
Representatives from Serbia stated that:                              Impact of COVID-19 on the                        Similar observations were made regarding
  “Roma who are at risk of statelessness                                                                                 the link to the informal economy and
  living in informal settlements have
                                                                        health and healthcare access of                  anecdotal reporting of COVID-19 cases in
  difficulties in accessing healthcare                                  stateless people                                 accommodation centres for asylum seekers in
  services. We have not heard of any                                                                                     Ireland (“direct provision“), Roma settlements,
  mitigating measures that have been taken                              When trying to gain an understanding             and accommodation where migrants live in
  to ensure accessibility of healthcare in                              regarding the prevalence of COVID-19             other countries. Focus group participants
  response to COVID-19 for the inhabitants                              amongst stateless people and communities,        specifically touched on the prevalence of
  of the informal settlements.”                                         the majority of survey respondents and those     essential frontline workers in these population
                                                                        interviewed were unable to provide detailed      groups (migrants, refugees, minority groups),
                                                                        information on this. A small number were         with a specific example being provided by a
One stakeholder who was interviewed                                     able to outline areas where COVID-19 had         focus group participant from the Netherlands:
described how in the UK (prior to COVID)                                impacted on groups in which stateless people
an individual (who, although not formally                               are likely to be represented, such as in the
recognised, was very likely stateless or at                             Czech Republic where immigration detention             A large number of Filipino nurses
least at risk of statelessness) could not                               centres were closed due to an outbreak of        were sent to work on the frontline
access surgery to remove a cancerous                                    the virus; and in Ireland and Germany where      in the hospitals fighting against the
tumour because it was not considered                                    meat plants (in which migrant workers and
emergency care and could wait until the                                                                                  virus in Spain, which resulted in a
                                                                        members of minority groups disproportionately
individual “returned to his country of origin“.                                                                          high fatality record amongst them.
                                                                        make up the workforce) experienced clusters
The likelihood of return for this person was                            of infection. Representatives from Switzerland
very low given his country of origin had at                             also responded that there were indications
that point twice refused to recognise and                                                                                Both the survey responses and interviews
                                                                        that migrant communities may have been
document him for return.                                                                                                 with stakeholders, as well as the focus
                                                                        disproportionately affected by the pandemic.
                                                                                                                         groups, discussed the impact of COVID-19
                                                                        The reasons for this inequality were linked to
Many stakeholders observed during                                                                                        restriction measures on health service
                                                                        a number of factors, including: the population
interviews that as mental healthcare is                                                                                  provision (coverage, access, and availability)
                                                                        containing a higher proportion of individuals
part of secondary (i.e., non-emergency)                                                                                  referring to the general population, groups
                                                                        working within essential sectors such as
healthcare, this adversely affects stateless                                                                             in which stateless people are represented,
                                                                        health services or retail (which remained open
people who are disproportionately affected                                                                               and stateless people specifically. All
                                                                        throughout); these communities typically
by poor mental health and lack of access to                                                                              referred to an overall reduction in health
                                                                        having a more densely populated housing
dedicated mental health support.                                                                                         service accessibility for everyone during
                                                                        situation; and the likelihood of more frequent
                                                                                                                         COVID-19 restrictions on movement and
                                                                        travel between their country of origin and
                                                                                                                         on health system operations, primarily due
                                                                        Switzerland (although in the case of stateless
                                                                                                                         to the reduced availability of in-person
                                                                        migrants, this may be more unlikely as they
                                                                                                                         appointments, and planned procedures being
                                                                        often face barriers to free movement or lack
                                                                                                                         cancelled or rescheduled as health services
                                                                        travel documentation).

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                 13
were overwhelmed. Whilst the general                                    Environmental determinants of                             In refugee camps, medical care
population is affected by disrupted service
provision, groups such as migrants, refugees,
                                                                        health and COVID-19                                is at great shortage. Social distancing
and minorities (and stateless people within                                                                                is almost impossible to be maintained,
them) are disproportionately disadvantaged                              Many of those interviewed described how            and the number of PCR tests done is not
and vulnerable both to physical and mental ill                          conditions of housing impacted on the              enough. NGOs are stopped from entering
health and contracting COVID-19. Cessation                              ability for specific groups disproportionately
                                                                                                                           the camps to provide help or take
of general health services during COVID-19                              affected by statelessness (for example
                                                                        minority groups including Roma, migrants, and
                                                                                                                           interviews. Even when an interview was
surges was described as impacting on health.
                                                                        refugees) to adhere to public health guidance      allowed, according to a participant based
For example, children’s vaccinations ceased
in many countries. The trauma that many                                 relating to social distancing, hygiene,            in the Netherlands, a woman was forced
stateless people have experienced was                                   sanitation and mask-wearing. This was viewed       to take it with her children together in the
described as warranting specialist mental                               as especially difficult during lockdowns           room so that she does not talk honestly
health and medical care and was observed to                             for Roma living in congested settlements           about her domestic violence case.
be worsening during COVID-19.                                           (for example, in Albania), with poor water
                                                                        and electricity supplies; and for migrants
                                                                        who were referred to as often living in large
In terms of specific barriers to accessing                                                                                 Both focus group participants and
                                                                        households in overcrowded apartments. In
healthcare, the reconfiguration of services                                                                                interviewees felt that the environmental
                                                                        this sense, those interviewed described a
during the COVID-19 pandemic was described                                                                                 conditions in which many Romani people live
                                                                        reliance on other members of the community
by many as impacting on the ability of                                                                                     have often been a detriment to their ability
                                                                        to ensure continued supplies of food and
stateless people (and the wider groups                                                                                     to adapt in COVID-19 times, with close living
                                                                        medicines into the settlements or other
in which they are represented (migrants,                                                                                   conditions and lack of income increasing
                                                                        places of accommodation. Some participants
refugees, minority groups) to engage with                                                                                  their risk of contracting the virus, creating
                                                                        referred to stateless people facing lengthy
medical care professionals during COVID-19.                                                                                a stressful living environment. Financial
                                                                        periods of arbitrary detention in conditions
During COVID-19 lockdowns, many countries                                                                                  sustainability was also seen as a factor for
                                                                        tantamount to degrading treatment, and
operated appointments digitally, which was                                                                                 protection from disease, with it being felt
                                                                        conducive to the spread of disease and poor
observed to disadvantage those without                                                                                     that many stateless people may not have
                                                                        mental health.
access to internet, laptops, and confined to                                                                               the financial means to purchase items not
their homes.                                                                                                               provided for free (such as masks or sanitizer).
                                                                        Focus group facilitators from the Netherlands      Focus group participants concurred with
                                                                        highlighted participants’ experiences of the       these findings, stating the importance of
                                                                        reduction in medical care within refugee           financial sustainability to being able to adhere
                                                                        camp settings and immigration detention            to public health guidelines. A participant from
                                                                        centres, which were explained to be a direct       the Bulgaria focus group simply stated:
                                                                        result of restrictions on NGO service providers’
                                                                        access to these settings:

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                    14
You pay to visit the doctor, you pay                              or refugee camp settings). However, when           Health emergencies, morbidities,
                                                                        asked if they felt the public health guidance
for the PCR test, you pay for medicine.
                                                                        was delivered effectively to stateless people, a
                                                                                                                           and mortalities of stateless
We have to pay for masks, gloves etc.                                   number of key themes emerged.                      people during COVID-19

                                                                        Firstly, one significant barrier to campaign       The impact of statelessness appeared to be
Operationalisation of public                                            comprehension was language, with many              ill-considered by some government public
                                                                        publications not being produced in a range         health responses. Of the 29 stakeholders who
health guidance                                                         of languages, and in-person medical advice         participated in the survey, a large number
                                                                        primarily being provided only in a country’s       detailed the increase in emergency health
Many of those interviewed observed that                                 main or official language. Secondly, those         service usage during COVID-19 leading
COVID-19 public health measures were                                    who are without internet access, or who do         some respondents to report overcrowding
targeted at the general population and were                             not access services (such as support groups,       in hospitals and limited access emergency
not reaching the groups to which stateless                              government offices etc.) may not have              care due to restrictions being placed on
people belong; thereby heightening health                               received the full guidance being distributed.      attendance (for example, a requirement to
risks, vulnerabilities, discrimination, and social                      The impact of this is further exacerbated for      present a negative COVID test prior to being
exclusion. The invisible nature of statelessness                        those populations who are not able to access       admitted for emergency care). It was also
was observed to make it difficult to target                             medical services due to lack of residence          reported that in some countries (for example,
health messages specifically to stateless                               status and documentation. However, a               Sweden), a digital ID was required to access
people. Equally relevant, is the lack of                                large proportion of survey respondents and         a COVID-19 test. Most stateless people do
comprehensive data on statelessness in                                  interview participants did feel that with          not have a digital ID so are unable to access
Europe making it difficult to provide evidence                          the exception of those residing in remote          testing. In contrast to this, many other
to inform policy and practice.                                          locations, or who faced language barriers,         countries stated that during the pandemic,
                                                                        most people (regardless of statelessness)          exceptions were made to such formal ID
At the time of interview, no respondents from                           would be aware of the regulations and              requirements, enabling all those requiring
any of the data collection methods reported                             guidelines, if only through word of mouth and      a COVID test or treatment to be seen,
being aware that stateless people were                                  community dissemination.                           regardless of residence or documentation
specifically included in their country or region’s                                                                         status.
COVID-19 information campaigns. That being                              Thirdly, no research participants were able
said, some respondents noted that stateless                             to confirm whether stateless people or             There were some anecdotal reports by
populations were included on some level                                 representatives of communities affected by         those interviewed of hospitals turning
by individual NGOs, or with assistance from                             statelessness were consulted in developing         away those with COVID-19 symptoms and
UNHCR.16 Many instances were described of                               their country or region’s COVID-19 information     without documentation (such as a passport,
NGO-led communication of government health                              and wider response.                                ID card, stateless status, or residence
guidance using remote technologies (visual,                                                                                permit). In COVID-19 times with hospitals
digital, and multilingual mediums) and mobile                                                                              overwhelmed this was observed to heighten
health units (for example, in Roma settlements                                                                             the vulnerability of stateless people to both

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                      15
COVID-19 severe disease, and also general ill-                          direct relief (including food packages and         The Government of Portugal temporarily
health and morbidities. It was also felt by one                         other basic necessities). This was further         granted all migrants and asylum seekers
participant that the additional strain COVID-19                         validated by focus group participants. NGOs        residing in the country with pending
has placed on health services has increased                             were reported by many as having been               immigration applications full access to the
the likelihood of stateless people and other                            actively providing sanitation and hygiene          country’s healthcare services. Other good
groups being dismissed when raising health                              supplies, masks and food aid to those in need      practice government responses mentioned
concerns, resulting in incorrect diagnosis, or                          in many countries, however, this was limited       included new ways of surveillance and
poor-quality care being received. Particularly                          due to overwhelming demand for such items.         monitoring of disease spread via “track and
vulnerable stateless individuals were                                   In Serbia, organisations such as the Red Cross     trace“ Apps; the use of technology to support
described to be the elderly; those living with                          distributed food and basic hygiene items           vulnerable groups; and the extension of
several family or work colleagues in confined                           to the residents of informal settlements.          residence permits and visas so that individuals
spaces; those with existing poor mental health                          However, as a representative from Serbia           could access healthcare during COVID-19
or other identified COVID-19 risk factors or co-                        explained, these packages came with a              times. Support responses were described
morbidities; and women affected by domestic                             requirement that individuals have personal         as difficult to mobilise, and very dependent
abuse. Several UK respondents described                                 documentation, which excluded stateless            on community organisations with existing
instances of severe COVID-19 disease leading                            people or those at risk of statelessness from      trust and credibility with stateless people
to fatalities due to inability to access medical                        such relief measures.                              and groups disproportionately affected
care.                                                                                                                      by statelessness (migrants, refugees, and
                                                                        One example of government intervention             minority groups). The use of cultural mediators
                                                                        in health service delivery was detailed in         and interpreters was deemed as essential.
The role of civil society and                                           Croatia, where essential hygiene products,         Other best practices included free COVID-19
best practices in supporting the                                        running water and electricity were distributed     testing without any requirement for residence
health response                                                         to a segregated Roma community. Assistance         or documentation checks, and the “Patients
                                                                        from the government was also reported in           not Passports“ toolkit in the UK, accessible
                                                                        France, with free masks and sanitiser being        regardless of immigration status. There were
Both the survey and interviews revealed
                                                                        distributed in the streets, as well as increased   some reports of exemptions from medical
that whilst some countries did provide some
                                                                        support being offered in government-run            charges when people present with COVID-19
additional measures for identified vulnerable
                                                                        accommodation centres. However, this was           symptoms, but these were not deemed to
populations such as migrants, minority groups,
                                                                        not available for those outside of official        have been communicated sufficiently by
and the homeless, none specifically targeted
                                                                        procedures, including those with irregular         governments.
stateless people, and the vast majority of
                                                                        residence status or without accommodation.
actions to protect vulnerable groups were
                                                                        Focus group participants from Estonia also
not government-led. Instead, this gap was
                                                                        reported that pensioners in the country had
backfilled by NGOs who operationalised
                                                                        received a one-time delivery of 50 disposable
public health information sharing, community
                                                                        face masks, to help them protect themselves.
support via WhatsApp groups, engaged in the
provision of mobile health units, and provided

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                   16
Institutional mistrust and fear of                                      Civil registration services, such as birth       A small number of respondents detailed
                                                                        registration, were reported to have continued    varying practices with some governments
data sharing between healthcare                                         using adapted formats in many countries          automatically extending temporary residence
and immigration authorities                                             (for example, in France procedures were          permits (for example, Portugal, Croatia and
                                                                        adapted at city levels with cities developing    France) at the onset of national lockdowns
Some interview participants observed                                    specific guidance to ensure continued birth      and restrictions of movement. Others, such
that COVID-19 has amplified institutional                               registrations). However, there were certain      as Switzerland, failed to provide any amnesty
mistrust, thereby exposing stateless people                             time periods during the pandemic when this       to those with expiring temporary residence
and groups disproportionately affected                                  was not always the case. For example, in         permits. One participant from the Netherlands
by statelessness, to increased health risks.                            Moldova, between 15 March-15 May 2020,           focus group who was residing in what they
Cultural and language barriers to accessing                             only registration of deaths took place, with     described as a “refugee camp“ detailed their
medical care were described by many. Roma                               births being backdated after this point. It      experience of delays as a result of COVID-19:
in particular were described as having lasting                          was highlighted by some participants (in
historical experiences of being turned away                             the Netherlands and Serbia), that whilst civil
from hospitals. Both survey and interview                               registration procedures such as birth and              It took me 9 months to have my
respondents described a heightened fear                                 death registrations continued to take place,     case proceeded, during these months I
amongst stateless people and communities                                procedures for the acquisition of nationality    was at risk because I was sharing rooms
of contracting COVID-19 when accessing a                                ceased, resulting in many people being left      and bathrooms with other people and
medical service, as well as fears of refusal of                         “in limbo“ with regards to their nationality
                                                                                                                         it was very risky and hard to be safe.
services, and that information would be shared                          status and, in some cases, access to services.
between the medical practice or hospital and                            COVID-19 restriction measures also impacted      There were loads of cases in the camp
immigration authorities. A resulting reluctance                         on access to lawyers and legal representation.   without proper precautions, so I left.
to access healthcare on the part of stateless
people was observed by many to contribute to                            Additionally, it was reported by the majority
increased levels of ill health.                                         that, where applicable, statelessness            The majority of research participants
                                                                        determination procedures were delayed by         indicated that no attempts had been made
                                                                        COVID-19, with some halting completely, and      by governments to create a firewall between
Legal and immigration processes                                         others moving to online platforms. There were    health and immigration authorities during
                                                                        some reports of ceased or interrupted asylum     COVID-19. One participant referred to Ireland,
Delays in statelessness determination,                                  and residence permit procedures during           where the Irish Government has firewalled
residence permit, and asylum procedures                                 COVID-19; and some reports of extended           their national health service data from other
during COVID-19 were observed by many                                   deadlines. Some governments shifted to online    government departments.
stakeholders. It was highlighted that this in                           renewals of residence permits, potentially
turn had an impact on the universal right                               excluding those without access to the internet   There were also some reports of people being
to health and access to healthcare due                                  or a computer. Digital exclusion was described   released from immigration detention during
to the link between proof of residence or                               by many as impacting severely on those           the pandemic. However, concerns were raised
identity documentation and health rights.                               without access to laptops and the internet.      with regard to the lack of housing and food

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                     17
aid support offered to those released. Others                           working whilst sick and without adequate           Ukraine: “There was no financial support
described extensions so that people could stay                          protection from disease; and inability to          available for anyone.”
on in asylum reception centres. However, it                             access government pandemic employment
was also reported that some asylum reception                            assistance and non-emergency or “medically
centres were shut down during this time due to                          necessary“ healthcare were mentioned. Many         France: “Exceptional financial support
staff shortages.                                                        also described the difficulties in supporting      was proposed to precarious households
                                                                        children’s continued home schooling due to         and young persons who already benefit
When asked what solutions could be                                      lack of space, access to laptops, and internet.    from other financial allowances (requiring
operationalised to support stateless people                             There was a huge variation in the financial        legal stay). These are not applied to
during COVID-19, an overwhelming majority                               assistance made available to people in their       asylum seekers or irregular migrants which
of interview participants recommended that                              country or region. There was consensus across      can include stateless persons. However,
governments grant residence permits and                                 the survey and interview respondents that          persons benefiting from a stateless status
identity documents to all affected. As one UK                           stateless people are impacted by lack of           by the OFPRA could benefit of this support
participant said:                                                       access to public services and social security      if they meet the criteria.”
                                                                        systems. This impacted on their ability to
                                                                        meet their financial and basic needs during
                                                                                                                           Georgia: “Stateless persons were among
     It makes absolute sense for all                                    COVID-19 lockdown measures. Focus group
                                                                                                                           the beneficiaries of the government
those in the legal process or who are                                   participants from Albania reported that whilst
                                                                                                                           anti-crisis/economic recovery plan but
undocumented to immediately be                                          two government financial grants had been
                                                                                                                           unfortunately not all can benefit. There
                                                                        made available during the pandemic, at the
given “Indefinite Leave to Remain“                                                                                         is a distinction between stateless people
                                                                        point of interview, only one had been paid
so that their personal safety                                                                                              with permanent and temporary residence
                                                                        out. Additional examples of responses from
and the safety of the community                                                                                            permits. Those with permanent residence
                                                                        the survey regarding government pandemic
                                                                                                                           permits qualify for assistance, others
generally is on a better footing.                                       support packages, and their eligibility criteria
                                                                                                                           can’t.”
                                                                        include:

                                                                         The Netherlands: “No, only Dutch                  Serbia: “In April 2020, the Government
Socio-economic exclusion, and                                            companies and employees are receiving             brought a decision to pay 100 euros to all
lack of access to government                                             financial support packages; people with           citizens in order to reduce the negative
support packages                                                         a migrant background are often left out,          effects of the epidemic. However, stateless
                                                                         and for Roma it is even worse, they are           persons, persons without permanent
Many participants observed how COVID-19 and                              not being supported financially from the          residence and a valid identity card (the
its restriction measures have exacerbated the                            government in any way for extra help and          vast majority being of Roma nationality
existing discrimination, social exclusion and                            such.”                                            [sic]) were excluded from this measure.”
deprivation experienced by many stateless
people. For example, the impact on living
conditions; loss of informal employment;

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                    18
Stigma, scapegoating and hate                                            “Hate speech against Roma and Travellers         people in the community and ensure dose
                                                                         rose in some countries during the COVID-19       continuity.
crime                                                                    lockdown measures. Politicians would use
                                                                         them as scapegoats for the spread of the         Some detailed observations were made
Some observations were made by research                                  virus based on stereotypes. (ex. Bulgaria        by interviewees about vaccine hesitancy
participants about a prevalence of political                             and Ireland).”                                   and the impact of historical mistrust of
rhetoric blaming Roma or migrants for the
                                                                                                                          State institutions, particularly among Roma
spread of disease. Some participants in
                                                                                                                          communities. One participant referred to a
the survey and during interview reported
anecdotal instances of scapegoating, hate                               Vaccination roll out: universal?                  PICUM (Platform for International Cooperation
                                                                                                                          on Undocumented Migrants) press release,
speech and discrimination against several
                                                                                                                          which highlights the complexities of excluding
groups which are disproportionately affected                            At the time of this assessment, no
                                                                                                                          those who fear to engage with public officials
by statelessness. This was especially the case                          stakeholders were able to provide information
                                                                                                                          for fear of deportation, even when gravely ill
for Roma and Irish Traveller communities,                               around the COVID-19 vaccination protocol,
                                                                                                                          and states:
ethnic Russians, refugees and migrants. Five                            and whether stateless populations would be
out of eight (Romani) participants from the                             included in vaccination programmes.17 One
Albania focus group reported that on social                             participant observed; “the virus is invisible
                                                                                                                                Any vaccination campaign, to be
media they had seen hate speech against                                 and so are stateless people“. Their realities
                                                                        are hidden and forgotten.
                                                                                                                          effective, has to cover virtually everyone.
their communities such as calling them dirty
and being responsible for spreading the                                                                                   Including undocumented people is not
virus. Survey respondents provided further                              The lack of institutional trust among many        only humane, it’s also public health
examples:                                                               stateless populations was observed by             common sense. We’re all in this together,
                                                                        many to be a factor that is likely to hamper      and only together can we win this battle.
  “Not specifically against stateless                                   government roll out of a comprehensive public
  persons. More generally there were some                               health vaccination programme spanning
  negative media reports about persons                                  test, trace, contact, and vaccinate. The
  with migrant background travelling to their                           challenges highlighted in this regard included
  countries of origin (mainly on the Balkans)                           how to address discrimination in access to
  and "bringing in/bringing back" the virus.”                           healthcare, how to reach those invisible to the
                                                                        system, how to secure consent to vaccinate,
                                                                        and how to ensure follow up for second
  “Whilst not definitely a proven link, for the                         doses of vaccinations. A particular challenge
  first time ever, the exterior walls of CPR’s                          highlighted was how to reach stateless
  reception centre for asylum seeker have                               people who are homeless or living in informal
  been vandalised three times with racist                               settlements. NGOs and mobile health units
  and xenophobic messages targeting                                     travelling to communities were seen as crucial
  refugees.”                                                            to vaccination rollouts to reach stateless

Situation assessment of statelessness, health, and COVID-19 in Europe                                                                                                 19
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