soap can be a challenge. In this region, disease modellers have adopted an assumption that the COVID-19 attack rate will double every 2.3 days, compared to every 4 days for the surrounding population, and infect 20% of the IDP population within the first 6 weeks (causing 240,000 cases and 14,328 deaths) compared to 0.4% of the surrounding host population (16,384 cases, 978 deaths) within the first 8 weeks.19 In South Sudan Protection of Civilian (POC) camps set-up in UN peace-keeping compounds, for example, space is so scarce that some people have been temporarily housed in stifling warehouses.20 Residents have also often been told that they must accommodate eight people in one tent, meaning that some people are asked to share with strangers or relatives that it is culturally inappropriate to live with. In urban areas where many refugees self-settle such as Kampala, Uganda, more than 70% of households sleep in a single room.21 Just over half of Africa’s urban population of 500 million has access to piped water.21 Shelter is one of the highest burdens on displaced people, hosts and aid providers’ financial resources, and affects security and health.22 Loss of income due to COVID-19 may expose displaced people living in rented accommodation to a heightened risk of eviction and the possibility that people would have to travel or move in with other people, further increasing transmission risks. THREATS FROM COVID-19 MEDICAL COMPLICATIONS AND DISRUPTIONS TO HEALTH SERVICES The health of people who migrate depends greatly on structural and political factors that determine the impetus for migration, the conditions of their journey, and their destination. 23 Displaced people of all ages are more likely to suffer from poor health than non-displaced people, particularly when they have been uprooted for a long time and live in severe conditions. While it is not yet clear what the medical effects of COVID-19 will be in low income and humanitarian settings, forcibly displaced people are expected to be at higher risk of developing severe disease. Globally, older people and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness from COVID-19 and die from the disease. Most forcibly displaced populations have the benefit of younger age distributions,24 however, they face additional risks of severe disease because of COVID-19’s interaction with highly prevalent co-morbidities. These include non-communicable diseases such as hypertension and diabetes which are often more prevalent in low- than high-income settings, with a far lower treatment coverage, as well as undernutrition, tuberculosis and HIV.25 Mal- and under-nutrition, which is particularly prevalent among young and older IDPs, is a major contributor to higher mortality rates among IDPs than the general population in most humanitarian crises.22 While most cases of COVID-19 among displaced populations detected to date appear to have been managed in dedicated hospital quarantine and isolation facilities,26 such facilities are expected to become shortly overwhelmed. Forcibly displaced peoples’ abilities to manage co-morbidities, diagnose COVID-19 infections, monitor need for higher level interventions and receive intensive care for severe complications will be affected by their overall access to healthcare. Displaced peoples’ access to services outside of settlements is typically beset by difficulties navigating, reaching and paying for healthcare services and communicating with KEY CONSIDERATIONS: COVID-19 AND FORCED DISPLACEMENT IN THE MIDDLE EAST AND EAST AFRICA Contact: a.wilkinson@ids.ac.uk 7