Internally displaced people in Lagos: environmental health conditions and access to healthcare in the context of COVID-19

ABSTRACT The paper documents environmental health conditions and healthcare access challenges faced by internally displaced people (IDPs) from Borno State living in informal settlements in Lagos, Nigeria, in 2020, during the early stages of the COVID-19 pandemic. This qualitative study with 32 IDPs suggests a high vulnerability to COVID-19. Their accommodation often lacked basic sanitation including water and toilet facilities; overcrowding and high population density restricted ability to adhere to social distancing; and IDPs experienced serious consequences from lockdown, as the majority depended on daily wages, and did not receive food packages or other support from the State. Finally, there were obstacles to accessing healthcare. We highlight the importance of an integrated approach, consolidating the efforts of communities, non-governmental organisations, environmental and public health, and international organisations to address the health and well-being issues of IDPs in urban informal settlements.


Introduction
Africa supports a disproportionate number of internally displaced people (IDPs): worldwide, around 40%of all IDPs are in Africa, where nearly 17 million people fled their homes by the end of 2018 because of wars, violence, and climate change (Internal Displacement Monitoring Centre [IDMC], 2019a). The ongoing Boko Haram insurgency in Nigeria caused mass population displacement, resulting in 2.2 million officially registered IDPs by December 2018, with most lacking food, adequate health assistance and shelter (IDMC, 2019b). There are 32 official, government-run camps for IDPs in Borno, and about 200 unofficial settlements in Maiduguri and beyond (IDMC, n.d.). Whilst there is evidence that in South and Eastern Africa urban-dwelling refugees report higher health and environmental satisfaction than their camp-dwelling counterparts (Crea et al., 2015), there is little direct data on the living conditions and health care access of IDPs living in urban informal settlements and alongside local populations in Nigeria. This paper aims to fill this gap, by mapping the environmental health conditions and health care access of IDPs from Borno State living in Lagos in 2020. This was prior to the introduction of vaccines in Lagos in 2021: a point when preventative public health measures were crucial in controlling the pandemic.
In general, 'migration and health are inextricably linked' (Abubakar et al., 2018), and the health needs of refugees and IDPs are typically poorly met (Miliband & Tessema, 2018). Poor and overcrowded living conditions lacking basic facilities can impact health in terms of ability to prepare safe food, manage pests and avoid infection and injury. Sustaining good personal hygiene, adequate ventilation and distancing to limit the spread of communicable diseases is often impossible (World Health Organization Regional Office for Europe [WHO], 2019): issues essential to the prevention and management of , 2020). Further, pandemic response measures such as lockdowns and social distancing were likely to create challenges for IDPs in Lagos, both in terms of environmental health conditions -many live in informal housing -and income, given the reliance on small, daily cash wages (Ukomadu & Akwagyiram, 2020).
Evidence from sub-Saharan Africa shows that public health services are frequently poorly equipped for epidemics including tracking new conditions (Huber et al., 2018). Access to the healthcare system in Nigeria is limited by a lack of resources -both financial and human as there is a shortage of medical staff (Odusola et al., 2016) -and by the poverty of the population who cannot pay for services. Access to healthcare is based on out-of-pocket (OOP) payments or insurance schemes, limiting access. OOP payments are a common means of accessing the healthcare system for over 90%of the population in Nigeria (WHO, 2015), and a key contributor to household poverty (Aregbeshola & Khan, 2018). Accessibility of healthcare for IDPs in this respect is likely to be similar to other groups that experience multidimensional poverty, which, at least in North-Eastern Nigeria, comprise 17% of the population compared with 23% of IDPs living in poverty (Admasu et al., 2021, p. 12).
However, IDPs are excluded from the measures to increase healthcare access in Lagos. Lagos State Government set up the Lagos State Community-Based Health Insurance Scheme (CBHIS) in 2007 to broaden the State Health Insurance Framework to provide social health protection coverage for the poor, informal sector population as well as underserved communities. Under this arrangement, the scheme is to be scaled up to every local government in the State to create the stimulus for demand for health insurance across the State (Lagos State Primary Health Care Board, 2020). However, vulnerable groups, including IDPs, may never benefit from the scheme as they are not formally recognised and may not be financially capable of making OOP contributions. On 27 March 2020, the Lagos State Government introduced a food relief package 'to cushion the effect of the lockdown on the poor and most vulnerable people in the state' (Okon, 2020); however, it has reportedly not been delivered to many people in need and officials often neglect those who live in informal settlements (Olajide, 2020).
To explore issues of healthcare access and environmental health conditions of IDPs in Lagos during the COVID-19 pandemic, we conducted a qualitative study to understand people's lived experiences.

Methods
The research was conducted in the Debojo community in the Ibeju Lekki area of Lagos State and included two waves of interviews -in June -July 2020 (23 participants), and in September 2020 (9 participants). Participants (18 male, 14 female) were aged between 18 and 49 years; all were displaced from Borno and Adamawa states and had lived in Lagos for at least two years. The majority (29) were married and had children.
Face-to-face semi-structured interviews were conducted in Hausa, Kibaku, English or 'pidgin' language as appropriate, with informed consent. Interviews were audio-recorded. An interview guide included questions on living conditions; ability to economically provide for themselves and their families; and access to health facilities nearby. Several questions focused on the experiences of the COVID-19 lockdown including the ability to adhere to COVID-19 guidelines and interventions. Research was approved by the University of Birmingham Ethics Committee [ERN_18-1522].
The data were analysed using content analysis, following open coding by all the authors. Key themes were around the decision to live in Lagos city rather than in camps; economic challenges; living conditions; and government support and access to healthcare. In considering environmental conditions, we refer to the Sphere COVID-19 Guidance (Sphere, 2022). These standards emphasise overcrowding and exposure to risks with respect to communicable disease outbreaks.

The decision to live in Lagos city
The decision to move from north-east Nigeria to Lagos and not stay in IDP camps was primarily based on concerns relating to camp life. Participants said that they wanted their children to have a sense of belonging to a family and to a home (even temporary) and live a 'normal' life; some reported safety concerns associated with camps; finally, they considered that life in a city would provide opportunities for work.

Economic challenges
It is widely recognised that displacement lowers economic well-being. A study in Jos, Nigeria, revealed that 'displacement affected IDPs' level of income and their ability to meet their basic needs' (IDMC, 2021, p. 11), which echoes with our research. Following displacement, most male respondents became Okada riders (commercial motorcyclists) Over half of interviewed Okada riders earn below 500 naira (1.1. Euro) daily. This was the only possible source of income as previously all informants were farmers and lacked the networks or skills to enter the informal employment market in Lagos.
Most of the women were unemployed (one was a petty trader) and had little option but to stay at home and care for their children. They also perceived it to be dangerous for women to go outside their living accommodation in the informal settlements.
During the lockdown Okada drivers were not allowed to work causing financial distress and hunger. One of the participants said, ' . . . since the lockdown, I haven't been doing anything, so I have been staying at home and there was nothing to eat' (male, 37 years old). People exhausted savings: 'From the savings, I had before the lockdown and right now, it has finished. I am totally zero' (male, 40 years old).

Living conditions
Overcrowding was reported as serious. When people first moved to Lagos, they often lived up to 18 people in a room, but later most of the participants were able to rent a separate room for their families, which still could not provide any privacy or social distancing. From the sample, most rented one room for a family, and two people shared a room with others. As one of the participants mentioned: What kind of distancing do you want to do for people you are living together inside the house? (laughing) . . . When you come out of our room like this, another person is outside waiting (male, 36 years old, June 2020).
Most of the shelters lacked basic amenities such as water and toilet facilities. Thirteen respondents have to walk up to 40 minutes to fetch water from a borehole for drinking or cooking, otherwise they depended on purchased 'sachet water'. Half of all participants had a toilet facility they share with other households. Most of the participants said they could boil water if needed, using firewood, gas, or a kerosene stove.
These issues combined to make living conditions injurious to health. For example, a lack of electricity forces cooking to be undertaken on open fires which increases air pollution, which, in turn, leads to respiratory diseases amongst vulnerable groups. In addition, the use of naked flames in overcrowded and poorly constructed shelters increases the risk of fire.

Government support and access to healthcare
IDPs had to rely on themselves and their families to settle in Lagos, and do not have support from the government, although officials were reported to be aware of the situation: As a result of this conflict, those legal advisers have tried their best to talk to the government. Sometimes, the government officials come and check the area, but they will not do anything about it. You know that they are coming but after that, you will not see anything. Since the government already knows about us, they can try to come and support us concerning health or anything (. . .). They should do it (male participant, January 2020).
None of our respondents in July 2020 reported receiving any food package or any other support from the government. The only help mentioned was from the community church, which provided some food packages brought by other citizens.
Access to healthcare is also compromised. IDPs cannot access private healthcare as they do not have sufficient money and cannot cover OOPs, and State health centres are located far away and/or do not provide the necessary care: You are not fit to go to private [healthcare]; it's government. And in the government hospital, they won't answer you. (. . .) Even if children will be passing stools and vomiting, they will just be looking at them. They will say 'It is not your turn'. But they will attend me in a private hospital as long as I have money (female, February 2020).
COVID-19 exacerbated these issues as people had even less money, and many medical centres closed. There were fears and a lack of trust in the healthcare which prevented some people attending hospital, even those who needed regular check-ups, as a respondent commented: . . . because of this Coronavirus (. . .) I stopped going, so I am afraid of going to the hospital (male, 35 years old).
In some cases, fear was related not only to the risk of catching COVID-19 but also to being diagnosed with COVID-19 and locked in hospital for two weeks.

Discussion
This study focuses on one area of Lagos, and sheds light on the situation and the challenges displaced populations were facing in the COVID-19 crisis. As the United Nations High Commissioner for Refugees (UNHCR) stated, "80% of the world's refugee population and nearly all the IDPs live in low-to middle-income countries, many of which have weaker health, water and sanitation systems and need urgent support" (United Nations High Commissioner for Refugees [UNHCR], 2020). Whilst there have been calls for basic needs and healthcare support for Nigerian IDPs (The Lancet, 2015, Ijeoma et al., 2021, there are few studies on these issues. IDPs in Lagos's informal settlements had potentially high vulnerability for COVID-19, other communicable and chronic diseases and injury. Their accommodation often lacks basic sanitation, the population density is high, and conditions are poor and do not allow for social distancing; all likely to lead to difficulty in adhering to protection measures (Ekumah et al., 2020). There were concerns regarding security in informal settings and limitations on the ability of women to work outside the home. While such conditions are not uncommon for the permanent population in some poor areas of Lagos, IDPs have specific vulnerabilities because of their status. They have limited access to healthcare as they do not benefit from the Lagos State CBHIS, cannot access private treatment, and the nearby medical centres have limited resources. In addition to the long-term challenges of displacement, IDPs also experience serious consequences of lockdown as most of them depend on daily wages. IDPs have not benefitted from state-led interventions. This presents IDPs in Lagos with a desperate situation, on which has been layered the impacts of COVID-19 restrictions, an inability to adhere to preventative measures and a lack of support.
There are both short-and longer-term implications of these difficulties for IDPs' mental and physical health, with evidence that poor housing and sanitation are associated with health outcomes linked to increased child mortality (Tusting et al., 2020). Ekumah et al. (2020) have documented how reduced access to the basic necessities of life -water, sanitation facilities, and food storage -can lead to a lack of adherence to COVID-19 control measures in sub-Saharan Africa and have called for coordinated connections between upstream, midstream and downstream interventions and genderand age-sensitive support from individual to population levels.

Conclusion
When most of the international aid resources geared towards refugees are used to support those who live in camps, we argue that a more nuanced approach is required, including greater attention to the needs of the displaced who live independently. Whilst we must be aware of the acute health impact and implications of COVID-19, it is vital that we also continue to pay attention to wider ongoing social and economic impacts on vulnerable populations. In megacities such as Lagos with a large number of people living in informal settlements, it is crucial whilst planning COVID-19 interventions to ensure that the implications are considered both in terms of the immediate impact for the poorest and most vulnerable in society, but also for the longer-term impact on future generations and for the social cohesion and well-being of wider society. Our research highlights the importance of developing an integrated approach consolidating the efforts of the communities, non-governmental organisations, public health, and international organisations to address the health and well-being issues of IDPs in urban informal settlements.