healthcare providers amidst fragmented landscapes of care.23 In such circumstances, displaced populations in both the Middle East and East Africa may be expected to rely heavily on local and transnational cultural and linguistic social networks which share practical information about how best to access health services 27 and help fund healthcare-seeking.28 29 The greater interventional capabilities of delivering outreach and home-based services to populations in camps and settlements may enable implementation of decentralised case management services for COVID-19,30 if such an approach is eventually adopted. Challenges in coordinating activities across government and humanitarian programmes, however, should be anticipated. 31 Moreover, evidence from previous epidemics, including Ebola outbreaks in West Africa and the DRC, has highlighted the excess mortality and morbidity caused by the suspension of routine essential health services when a system is overwhelmed by epidemic response. Indirect deaths can exceed those attributed to the infectious disease.32, 33, 34 In Lebanon, where most hospital care is privatised, refugees tend to use the main, public hospital in Beirut for their services. However, according to some local observers, its allocation and reputation as a facility to quarantine and treat COVID-19 patients led to a decrease in health services utilisation, with unknown effects on refugee health and health-seeking. Elsewhere in East Africa, isolation units built to contain recent epidemics of cholera and Ebola have been repurposed for COVID-19 control. INDIRECT HEALTH EFFECTS OF COVID-19 LOCKDOWNS Difficulty of reaching and closure of health facilities: In Jordan and Uganda, temporary movement restrictions severely hampered refugee and host populations' access to key health services, including for chronic diseases.35 Gender-based violence: During pandemics, as in other types of crises, women may be exposed to greater violence, including in their roles as healthcare workers.36 South Sudanese refugees and humanitarian actors in Uganda worry that COVID-19 measures are risking gender-based violence and early marriages, both because of the ways programmes are being interrupted and because of the inevitability that lockdown measures will push women and families into further poverty, with early marriage historically used as a coping measure in moments of crisis and poverty. Mental health: The psychological impact of being unable to work, attend school or access care because of COVID-19, feeling disconnected from others, movement restrictions as well as the stigma and violence associated with their enforcement (discussed below) is likely to increase anxiety, depression and other forms of distress that displaced people are already at higher risk of. 37 Anxiety about COVID-19 may be further compounded by the challenges displaced people face accessing public health information because of a lack of internet connectivity in some camps or settlements or when information is not available in the languages displaced people speak.38 In Iraq, 49% of IDPs surveyed in sites across the country reported psychological trauma, stress and anxiety since the beginning of the COVID-19 pandemic.39 Since lockdown measures began, KEY CONSIDERATIONS: COVID-19 AND FORCED DISPLACEMENT IN THE MIDDLE EAST AND EAST AFRICA Contact: a.wilkinson@ids.ac.uk 8