Migrant-Health Inequity as a Consequence of Poor Siracusa Principles Implementation in the COVID-19 Era

The coronavirus disease 2019 (COVID-19) pandemic is a global public health emergency. The pandemic has prompted a highly complex and disparate situation regarding national responses through its different waves and viral variants. Such responses vary considerably in nature and scale and instigate to a greater extent uncoordinated and inconsistent public health responses. Social distancing approaches – national and regional lockdowns, quarantine, and isolations – are predominantly used. Under the International Covenant on Civil and Political Rights (ICCPR), the governments of different countries may restrict certain rights during public emergencies that threaten the life of the nation to the extent that they are “strictly required by the exigencies of the situation”.1 To this end, the governments of different nations used and continue to adopt social distancing approaches to contain the spread of the COVID-19 outbreak while simultaneously maintaining the flow of essential workers, goods, and necessary services to avoid the collapse of their economy and public health system. The Siracusa Principles dictate that restrictions on the rights of individuals or a group of individuals for the sake of public health safety should be strictly necessary, adopting the least intrusive means to reach their objective.2 Such restrictions should also be provided for by law, be proportionate, of limited duration, and subject to review against abusive applications.3 Additionally, these public health measures must also be evidence-based and neither arbitrary nor discriminatory.1 The breakout of Middle East respiratory syndrome (MERS), Ebola, and other emerging infectious diseases requiring measures such as quarantine for control, incited the request for epidemiological, geographical, and cultural consideration before implementing a quarantine or other social distancing measures.4 Other bioethical principles have been proposed to supplement or complement the Siracusa Principles. For example, Upshur5 further suggested that the following criteria should also be considered to implement social distancing measures successfully. (1) An ethically sound quarantine must limit harm – The Harm Principle; (2) Liberty restriction in a manner proportionate to the goal of disease control – The Proportionality Principle; (3) Compensation for those quarantined in exchange for their sacrifices for the public good – The Reciprocity Principle; and (4) be enacted by public health authorities who communicate the justifications for their actions and allow for processes of appeal – The http://ijtmgh.com Int J Travel Med Glob Health. 2021 Dec;9(4):155-160 doi 10.34172/ijtmgh.2021.26 TMGH IInternational Journal of Travel Medicine and Global Health J


Introduction
The coronavirus disease 2019 (COVID-19) pandemic is a global public health emergency. The pandemic has prompted a highly complex and disparate situation regarding national responses through its different waves and viral variants. Such responses vary considerably in nature and scale and instigate to a greater extent uncoordinated and inconsistent public health responses. Social distancing approaches -national and regional lockdowns, quarantine, and isolations -are predominantly used. Under the International Covenant on Civil and Political Rights (ICCPR), the governments of different countries may restrict certain rights during public emergencies that threaten the life of the nation to the extent that they are "strictly required by the exigencies of the situation". 1 To this end, the governments of different nations used and continue to adopt social distancing approaches to contain the spread of the COVID-19 outbreak while simultaneously maintaining the flow of essential workers, goods, and necessary services to avoid the collapse of their economy and public health system.
The Siracusa Principles dictate that restrictions on the rights of individuals or a group of individuals for the sake of public health safety should be strictly necessary, adopting the least intrusive means to reach their objective. 2 Such restrictions should also be provided for by law, be proportionate, of limited duration, and subject to review against abusive applications. 3 Additionally, these public health measures must also be evidence-based and neither arbitrary nor discriminatory. 1 The breakout of Middle East respiratory syndrome (MERS), Ebola, and other emerging infectious diseases requiring measures such as quarantine for control, incited the request for epidemiological, geographical, and cultural consideration before implementing a quarantine or other social distancing measures. 4 Other bioethical principles have been proposed to supplement or complement the Siracusa Principles. For example, Upshur 5 further suggested that the following criteria should also be considered to implement social distancing measures successfully. (1) An ethically sound quarantine must limit harm -The Harm Principle; (2) Liberty restriction in a manner proportionate to the goal of disease control -The Proportionality Principle; (3) Compensation for those quarantined in exchange for their sacrifices for the public good -The Reciprocity Principle; and (4) be enacted by public health authorities who communicate the justifications for their actions and allow for processes of appeal -The Transparency Principle. These principles were at the time proposed to expatiate on and supplement the Siracusa Principles.
For the most part, emergency measures such as the lockdowns and restrictions on travel and work established by public health authorities globally have respected and continue to respect the Siracusa and bioethical concepts. 6 Nevertheless, there is extensive evidence that some governments worldwide have used such public health measures to justify restrictive and exclusionary regulations towards migrants -asylumseekers, refugees, and undocumented migrants. 7,8 Global Demography of Migrants Over 258 million people in the world do not live in the country in which they were born (international migrants), representing approximately 3.5% of the world's population. 9 In 2017, 64% of international migrants were living in a developed country. 9 Asia and Europe have the most international migrants: 80 and 78 million, or 61% of all migrants, and North America is in the third position with 58 million international migrants. 9 Table 1 provides some facts and figures on international migrants in 2020.
Economically, migrants contribute in three aspects in their host countries. First, immigrants in most host countries have higher labor force participation and employment rates than native-born workers. 9 However, they often take jobs with poor conditions and meager pay that natives do not or are reluctant to take. Third, the estimated contribution of immigrants to gross domestic product (GDP) is 7% on average, making their net fiscal contribution positive generally but limited. 9 Migrants also make civic-political contributions, and the extent to which they make such contributions depends on the policy settings of the host country at the national, subnational, and local levels. 10 Migrants can be involved in governance and politics at different levels, undertake volunteer work, including supporting fellow migrants to integrate into new communities. 10 The contributions of migrants in a host country can be classified into three levels ( Table 2).

Global, National Lockdown and Social Distancing Measures
Although it was a recommendation from the World Health Organization to implement various approaches, including national lockdown and other social distance measures, every country's lockdown has been different. Using the COVID-19 government response stringency index, a team at Oxford university's Blavatnik School of Government assigned stringency ratings to compare countries' policy responses to the COVID-19 pandemic ( Figure 1).
The application of COVID-19 lockdown measures does not only vary across countries but within countries. Within country variations, especially vis-à-vis migrants, are perpetuated by restrictive and exclusionary policies. 11 Such restrictive and exclusionary policies and programs are underpinned by not-so-new but enforced, reinvigorated, and adapting pre-existing systemic inequality drivers such as nationalism and xenophobic stigma. 12 In the context of the COVID-19 pandemic, these drivers have metamorphosed into COVID-19 nationalism and COVID-19-related xenophobic stigma, respectively, fomenting discriminatory and segregation-laden policies and programs. 13 Indeed, these transformed social structures have contributed toward sustaining and even exacerbating the health inequity of migrants. 14 Therefore, emergency powers, combined with pre-existing societal stigma, exacerbate discrimination against migrant groups. 1 In this paper, we discussed how the social distancing measures practiced globally to curb the spread of the pandemic, through national lockdowns, isolation, and quarantine, have exacerbated the health inequities of migrants globally. The arguments and discussions were framed within the context of the Siracusa Principles for addressing public health emergencies. We argue that while applying Table 1

Estimated number of international migrants 272 million
The estimated proportion of the world population who are migrants 3.5% The estimated proportion of female international migrants 47.9% The estimated proportion of international migrants who are children 13.9%

A region with the highest proportion of international migrants Oceania
The country with the highest proportion of international migrants United Arab Emirates

Global international remittances (USD) 689 billion
Number of refugees 25.9 million Number of stateless persons 3.9 million the Siracusa Principles to prevent and manage diseases, the implementation of national lockdowns, social distancing and other public health care measures should also be ethically and equitably implemented apropos asylum-seekers, refugees, and foreign-born migrant populations.

Social Distancing or Social Exclusion?
The term social distancing was originally promoted by the World Health Organization (WHO) in 2008 as a public health approach to prevent the spread of the influenza virus. Isolation and quarantine are two of the oldest social distancing and disease-control methods in existence. However, the advent of the COVID-19 pandemic has seen the WHO promote the term as an important strategy to curb the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus by encouraging people to distance themselves from each other physically. In addition to quarantine and isolation, national and regional lockdowns have been used as methods of social distancing to confine people to their own homes, restrict travel out of an affected area, and keep people at a designated facility. Social (physical) distancing entails reducing interactions at random and limiting social interactions within a social network. Due to quarantine and border closures, loss of contact with family and community networks can lead to isolation-related anxiety 15 and undermine social connection feelings. 16 Nevertheless, as a manner of speaking, social distancing is more likely associated with stigma or social classification, something with negative connotations, which needs to be avoided. 17 Social distancing scenarios, especially quarantining, usually involve social networks-people grouped by characteristics (guarantees): (1) family members, (2) people of a similar age, (3) local communities with limited inter-community interaction, and (4) small social groups of mixed characteristics from various locations-i.e., quarantine bubbles. 18 The quarantine bubbles, which usually have people of all ages and from various backgrounds who interact, apply to the asylum-seekers, refugees, and foreign-born migrant populations, especially those living in asylum camps.
While all forms of the social distancing measures are purported to reduce the severity of the COVID-19 pandemic, the guarantee and social bubble approaches were found to be the most effective at flattening the curve in the first two COVID-19 waves. 19 However, irrespective of the social distancing approach adopted, there is some degree of isolation(ism) involved. According to Sikali,20 social distancing can potentially increase social rejection, enhance impersonality and individualism, and lose a sense of community. Therefore, social distancing security measures are assumed to dissolve the relationship between people and their perception of empathy toward others. 21 Furthermore, applying social distancing approaches, primarily through enacted policies such as the quaranteam approach, tends to enforce social classification, segregation, and inequity.
Many countries have employed quarantine bubbles or guarantees to isolate asylum-seekers and refugees during the outbreak of the COVID-19 pandemic. Nevertheless, it is difficult to draw the line and decide, especially regarding vulnerable populations such as migrants, when the social distancing measure is no longer just about the virus but about building up walls to "protect your people"-exclusionary nationalism. Nationalists also used the enforcement of social distancing among certain groups of people as an approach to keep a group of people away from the general population. 13 For instance, the construction of refugee camps and the use of repatriation centers to keep asylum-seekers and refugees from integrating with the general population during the COVID-19 pandemic is well documented. 11 In Cape Town, South Africa, a group of refugees used to dwell in and around the Central Methodist Mission situated at the center of Cape Town Central Business District, during the COVID-19 lockdown, were moved and quarantined in a Military site far away from Cape Town's Central Business District during the height of the first wave of the COVID-19 pandemic. 22 Are we seeing a situation where social distancing as a disease prevention strategy is weaponized to enforce segregation and inequality on asylum-seekers and refugees?
Asylum seekers and refugees worldwide live in a continuum of conditions, from well-established camps and collective centers to make-shift shelters or non-encampment-living in the open. While being an asylum-seeker or refugee fundamentally comes with structural and socio-economic challenges, in the context of the COVID-19 pandemic, the experiences of the different sets of asylum-seekers and refugees did not vary significantly. For instance, in most parts of the world, asylum-seekers and refugees live in either make-shift or established refugee camps and often share facilities and live in close quarters with other residents. Such conditions make it challenging to observe social distancing guidelines. Moreover, in countries where asylum camps are used to isolate asylum-seekers and refugees, these structures, in the context of the COVID-19 pandemic, are used as ruses to alienate further this group of people from the political, economic, and social goings-on of the host country.

The Siracusa Principles and Health Inequity Among Migrants
According to the Siracusa Principles, social distancing measures should be voluntary whenever possible, and when or where it is impossible, they should be enforced using the least intrusive means available. Unfortunately, during the COVID-19 pandemic, misuse of emergency public health powers has been evident. For instance, in the United States, lockdowns in prisons as a social distancing measure and restrictions on access to abortion were reported. 6 When protecting a community's health requires that individual liberty and autonomy be restricted, as is the case during the COVID-19 pandemic, the principle of reciprocity obliges governments to provide the people living within their borders with the necessities of life. 23 During lockdown isolations and quarantine, these necessities would include being housed in safe, humane conditions and receiving high-quality medical care and psychological support. Unfortunately, the literature suggests that asylum seekers, refugees, and foreign migrants are not usually offered these rights and privileges. 11 Instead, these migrants are usually segregated or quarantined in overcrowded, unhygienic conditions away from nationals.
According to Bohnet and Rüegger, 24 many governments are reluctant or unable to provide adequate housing and sanitation to refugees. In most countries, especially in lowand middle-income countries, asylum seekers and refugees are placed in refugee camps in deplorable states; overcrowded, have poor sanitary conditions, and lack health care services and social amenities. 11 In South Africa, most asylum seekers and refugees who are not living in refugee camps live in overpopulated settlements and Townships where social distancing is challenging, and there is a lack of appropriate social and health service delivery. These Townships usually carry the brunt of the COVID-19 outbreak and infections but receive less attention apropos COVID-19-related social and health resources and services. While the social distancing measures of quarantine and isolation usually apply to citizens and foreign migrants alike, the latter group suffers more health and socio-economic impact. Nevertheless, based on the principle of reciprocity, they are not offered the requisite requirements and resources to lead humane lives, thus enhancing inequity.
To ensure the legitimacy of the social distance, their use must be made sincerely-Transparency Principle. The public has a right to know the legitimate public health reasons for restricting liberty. Most public health authorities have attempted to fully and honestly disclose their reasons for adopting the social distancing measures to gain community participation. Such transparency enhances public trust and buy-in of the proposed containment measures. However, evidence indicates that asylum seekers, refugees, and foreign migrants are less informed of what is going on in the country as information is usually not shared in languages they are familiar with. 24 Without such language considerations, some migrant populations remain less informed on the reasons behind the adopted public health measures and their implementation.
Consequently, asylum seekers, refugees, and foreign migrants seek information from less credible sources exposing them to conspiracy theories, disinformation, and misinformation. For instance, South Africa has many refugees, asylum seekers, and migrants from the Republic of Congo and other French-speaking African countries. However, since the inception of the COVID-19 pandemic, the COVID-19 pandemic information has never been shared in, or translated to the French language. This kind of noninclusion can incite feelings of being alienated from the fight against the COVID-19 pandemic in a combined effort and undermines the Transparency Principle. Distributive justice requires that officials limit the extent to which the personal and economic burdens of a public health threat fall unfairly upon individuals living within the borders of the countries. Nevertheless, there is a preponderance of evidence suggesting that minority groups, people in poor socio-economic circumstances and asylum seekers, refugees, and foreign migrants disproportionately carry such personal and socio-economic burdens. 25 The Reciprocity Principle should address such inequitable distribution of resources and amenities as fairly and equitably as possible. Governments and national and international organizations should stockpile medical supplies, COVID-19 vaccines, and food and make them available to their populations equitably. For instance, while several countries have received a good portion of and others even hoarding the COVID-19 vaccines, 26 asylum seekers, refugees, and foreign migrants within different countries have received lesser consideration for receiving the vaccines despite that they experience disproportionate social and biological vulnerabilities to the COVID-19 pandemic. 25 The COVID-19 pandemic requires solidarity among nations and collaborative approaches within the different nations that set aside traditional values of self-interest and territoriality to consider groups such as asylum seekers, refugees, and foreign migrants. The goal should be that the fight against the COVID-19 pandemic should also be 'migration-aware, ' a term describing interventions, policy, and systems that embed migration as a central concern in their design. 27 The Siracusa Principles were initially being conceptualized from the perspective of individuals whose freedom is restricted. Its consequences relate to discrimination experienced by communities subjected to quarantines, detention, and lockdown when others were not exposed to the same conditions. 6 The Siracusa Principles did not capture the other side of the phenomenon, where exceptions to restrictions risk health, not freedom of movement. The other side of social distancing, such as quarantine, relates to being 'essential workers. ' For instance, in Canada, when the COVID-19 pandemic was declared in March 2020, temporary migrant agricultural workers were required to continue working as essential workers to avoid any disruptions in the food supply chain, which increased work demands leading to multiple reports of abuse. 28 In fact, according to Bart,29 "throughout this  crisis, foreign workers have emerged as a critical force in the COVID-19 response, by providing vital services and by maintaining food production, health and safety and security". It was also observed that foreignborn workers in essential services (migrant key workers) formed an integral part of the essential workforce in many European countries during the pandemic. 30 The perverse aspects of social distancing and lockdown measures is that foreign migrants are not considered for special restrictions on freedom of movement and other liberties. Instead, they are excluded from such public health protections. For example, in meatpacking plants in the United States, where the risks of transmission to a mostly immigrant workforce are enormous, the industry received mandatory continuance when hundreds of others were shut down. 6

Conclusion
The paper illustrates how the application of social distancing measures during the COVID-19 in most countries around the world failed to follow the Siracusa Principles, thus enforcing the health inequities of migrants. We propose that while applying social distancing measures, the benefits to the public should outweigh the burdens or harms placed on individuals and at-risk populations such as asylum seekers, refugees, and migrants to mitigate further health inequities. Consequently, social distancing and other measures against the COVID-19 should be 'migration-aware' or migration-sensitive. Finally, we suggest that further research efforts should focus on carefully balancing the application of social distancing to achieve their public health goals while mitigating their impact on populations such as migrants.