Maskur Has/SOPA Images/LightRocket/Getty Images World Report Rohingya refugees off the coast of Indonesia He says that the pandemic has put a great deal of pressure on populations that were already over-stretched. In 2019, 1·9 million residents of the Indian state of Assam were left out of the National Register of Citizens. “They have been told they are not citizens, because they cannot prove, through a process that is both arbitrary and discriminatory, that they have been in Assam since before 1971”, explains de Chickera. “They have expended all their resources trying to appeal the decision, getting more and more into debt, and then COVID-19 arrives, and they are not eligible for state relief because they are now viewed as being non-citizens.” By contrast, Sudan has distributed food to vulnerable families during the pandemic without requiring identification. The atmosphere in Malaysia appears to have become more hostile towards immigrants and refugees. A photograph of a sign outside a mosque in Johor state telling Rohingya they were not welcome went viral. At the end of February, 2021, more than 1000 Rohingya were deported from Malaysia to Myanmar. “There is a real fear among refugees and migrants in Malaysia that if they try to access COVID-related care, they will be detained”, said de Chickera. Many countries shifted services online during the pandemic, which has been 1530 problematic for stateless people without stable internet connections. 25 of 45 European countries have confirmed plans to vaccinate stateless populations against COVID-19. They will have to overcome vaccine hesitancy in some communities, including among Roma, who have good reason to distrust the authorities. Countries with small numbers of stateless people might simply vaccinate them along with the general population. However, some nations are actively discriminating against non-citizens. The president of the Dominican Republic has said that those without documents will be excluded from the COVID-19 vaccination campaign, resulting in concerns for the 210 000 residents of Haitian origin who had their nationality rescinded in 2013. An incomplete campaign could be costly, particularly as the Dominican Republic has reported by far the most cases of COVID-19 of any nation in the Caribbean. Most countries with sizeable state­ less populations are unlikely to be able to start mass vaccination campaigns this year. Furthermore, the number of stateless people living in the country might be unknown. Issuing information on the vaccines in languages that minority groups can understand might not be a priority. “There is a very real risk that a lot of stateless people will not get the vaccine”, de Chickera told The Lancet. UNHCR is working to ensure that this does not happen. “There are two key considerations”, explains Ann Burton, Chief of the Public Health Section at UNHCR. “The first is whether or not stateless populations are mentioned in national plans. The second is whether they are able to get vaccinated, even if they are mentioned.” Countries that require a national identification number for those who wish to obtain a vaccination could issue temporary numbers to irregular populations. The COVAX Facility aims to ensure that all participating nations have enough vaccines to cover 20% of their population. For cases in which supplies are limited, many governments might not prioritise non-citizens. Gavi, the Vaccine Alliance, has set up a humanitarian buffer, to be deployed in places which have not included populations of concern in national vaccine plans. “The buffer is designed as a last resort, to ensure access to COVID-19 vaccines in settings when there are unavoidable gaps; for example, if the plans do not allocate vaccines to displaced people, including refugees, and asylum seekers”, explains Burton. “It could potentially be used for stateless populations as well.” The diverse nature of statelessness means interventions need to be tailored. Ethnic Russians in Latvia are deprived of political rights, but they are well documented, with full access to health care. They are unlikely to be missed by public services. The same cannot be said of uninsured Roma living in ramshackle settlements, or stateless people who are part of undocumented migrant communities. Murray stresses the importance of extending visas and residency permits during periods of emergency, such as pandemics. “If you regularise stays as, for example, Portugal has done, then you remove a lot of the barriers for accessing health care, state aid, and vaccination drives”, she said. “It is a straightforward measure and it would make a big difference.” Talha Burki www.thelancet.com Vol 397 April 24, 2021