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Unspoken inequality: How COVID-19 has exacerbated existing vulnerabilities of asylum-seekers, refugees, and undocumented migrants in South Africa

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Abstract

An estimated 2 million foreign-born migrants of working age (15-64) were living in South Africa (SA) in 2017. Structural and practical xenophobia has driven asylum-seekers, refugees, and undocumented migrants in SA to abject poverty and misery. The Coronavirus Disease 2019 (COVID-19) containment measures adopted by the SA government through the lockdown of the nation have tremendously deepened the unequal treatment of asylum-seekers and refugees in SA. This can be seen through the South African government's lack of consideration of this marginalized population in economic, poverty, and hunger alleviation schemes. Leaving this category of our society out of the national response safety nets may lead to negative coping strategies causing mental health issues and secondary health concerns. An effective response to the socioeconomic challenges imposed by the COVID-19 pandemic should consider the economic and health impact of the pandemic on asylum-seekers, refugees, and undocumented migrants. Résumé On estime que 2 millions de migrants internationaux en âge de travailler (15-64 ans) vivaient en Afrique du Sud en 2017. La xénophobie structurelle et pratique a conduit les demandeurs d'asile, les réfugiés et les migrants sans papiers en Afrique du Sud à la pauvreté et à la misère. Les mesures de confinement de la maladie coronavirus 2019 (COVID-19) adoptées par le gouvernement sud-africain à travers le confinement de la nation ont considérablement approfondi le traitement inégal des demandeurs d'asile et des réfugiés en Afrique du Sud. Le gouvernement sud-africain ne tient pas compte de cette population marginalisée dans les programmes économiques, de lutte contre la pauvreté et de lutte contre la faim. Le fait de laisser cette catégorie de notre société hors des filets de sécurité nationaux d'intervention peut entraîner des stratégies d'adaptation négatives qui causent des problèmes de santé (Continued on next page)
C O M M E N T A R Y Open Access
Unspoken inequality: how COVID-19 has
exacerbated existing vulnerabilities of
asylum-seekers, refugees, and
undocumented migrants in South Africa
Ferdinand C. Mukumbang
1*
, Anthony N. Ambe
2
and Babatope O. Adebiyi
3
Abstract
An estimated 2 million foreign-born migrants of working age (1564) were living in South Africa (SA) in 2017.
Structural and practical xenophobia has driven asylum-seekers, refugees, and undocumented migrants in SA to
abject poverty and misery. The Coronavirus Disease 2019 (COVID-19) containment measures adopted by the SA
government through the lockdown of the nation have tremendously deepened the unequal treatment of asylum-
seekers and refugees in SA. This can be seen through the South African governments lack of consideration of this
marginalized population in economic, poverty, and hunger alleviation schemes. Leaving this category of our society
out of the national response safety nets may lead to negative coping strategies causing mental health issues and
secondary health concerns. An effective response to the socioeconomic challenges imposed by the COVID-19
pandemic should consider the economic and health impact of the pandemic on asylum-seekers, refugees, and
undocumented migrants.
Keywords: COVID-19, Asylum-seekers, Refugees, Undocumented migrants, Mental health, South Africa
Résumé
On estime que 2 millions de migrants internationaux en âge de travailler (1564 ans) vivaient en Afrique du Sud en
2017. La xénophobie structurelle et pratique a conduit les demandeurs dasile, les réfugiés et les migrants sans
papiers en Afrique du Sud à la pauvreté et à la misère. Les mesures de confinement de la maladie coronavirus 2019
(COVID-19) adoptées par le gouvernement sud-africain à travers le confinement de la nation ont considérablement
approfondi le traitement inégal des demandeurs dasile et des réfugiés en Afrique du Sud. Le gouvernement sud-
africain ne tient pas compte de cette population marginalisée dans les programmes économiques, de lutte contre
la pauvreté et de lutte contre la faim. Le fait de laisser cette catégorie de notre société hors des filets de sécurité
nationaux dintervention peut entraîner des stratégies dadaptation négatives qui causent des problèmes de santé
(Continued on next page)
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data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: mukumbang@gmail.com
1
Burden of Disease Research Unit, South African Medical Research Council,
Cape Town, South Africa
Full list of author information is available at the end of the article
Mukumbang et al. International Journal for Equity in Health (2020) 19:141
https://doi.org/10.1186/s12939-020-01259-4
(Continued from previous page)
mentale et des problèmes de santé secondaires. Une réponse efficace aux défis socioéconomiques imposés par la
pandémie du COVID-19 devrait tenir compte de limpact économique et sanitaire de la pandémie sur les
demandeurs dasile, les réfugiés et les migrants sans papiers.
Background
South Africa (SA) has been a preferred destination for
many migrants from other parts of Africa, particularly
those from the Southern African Development Commu-
nity (SADC) countries. An estimated 2 million foreign-
born migrants of working age (1564) were living in SA
in 2017, representing 5.3% of the South African labor
force. Between 2012 and 2017, there was a 1.4% increase
in international migrants of working age in SA [1]. Un-
officially, the foreign-born migrant population in SA
today is estimated to be around 4.2 million [2].
SAs commitment to upholding human rights and the
rights of asylum-seekers and refugees make the country
an attractive destination for people fleeing their home
countries in the quest for a more dignifying and humane
existence. The economy of SA, which is one of the most
advanced on the African continent, has contributed to
the exponential increase in the number of people seek-
ing asylum from the continent and the world at large.
The unprecedented flow of asylum-seekers and refu-
gees into SA has compromised the governments stance
to adhere to its commitment towards upholding human
rights while delivering its promise to uplift the socio-
economic welfare of its citizens; especially those that still
feel the brunt of apartheid a system of institutionalized
racial segregation. While there is the political will to ac-
commodate and cater for asylum-seekers, refugees, and
undocumented migrants in SA, the increasing economic
and financial woes of the country has led to the govern-
ment adopting and frequently changing laws that in
many ways, have impacted negatively on the lives of these
foreign-born migrants.
The South African Refugees Act provides the right for
asylum-seekers and refugees to work and study, to ac-
cess medical services and life-saving treatment and free-
dom of movement [3]. SAs considerate assertion to
these rights partly accounts for the influx of asylum-
seekers and refugees. However, failure to regularize the
national asylum system, bureaucratic inefficiency, and
corruption have engendered issues such as lack of
personnel capacity and logistics to deal with the volume
of asylum-seekers and refugees, consequently, creating a
backlog in the processing and adjudication of the docu-
ments [35]. To this end, many foreign-born mi-
grants remain undocumented and/or asylum-seekers for
years, and those with refugee status find it difficult to
obtain documents like the refugee identity or travel
document [4].
The difficulty in obtaining or renewing documents on
time makes it challenging for most asylum-seekers and
refugees and, of course, impossible for undocumented
migrants to gain any meaningful and long-term em-
ployment even if they are qualified. Most of them are
relegated to the informal sector and nudged to reside
in underprivileged communities. Foreign-born mi-
grants are, therefore, more likely to be informally
employed and face precarious employment conditions
[1]. According to the African Centre for Migration
and Society [1], a foreign-born migrant with the same
age, gender, and level of education, belonging to the
same population groupand living in the same place
as a South African, has a higher probability of being
employed than a South African. Therefore, there is
the conception in most communities where these
foreign-born migrants reside and work that they deprive
South Africans of employment and other business oppor-
tunities and are a strain on the limited social services and
amenities, constituting the main drivers of xenophobia [6].
To avoid the killing of foreign-born migrants by the gen-
eral population, the South African government enacted
bylaws that make it challenging for foreign-born migrants
to gain employment in SA. The abovementioned struc-
tural and practical xenophobia have plunged foreign-born
migrants living in SA into abject poverty and misery [6,7].
Most asylum-seekers, refugees, and undocumented
migrants entering SA come from regions with en-
demic malaria, HIV, and TB infections [810]. In
addition to these infections, there is equally a huge
burden of non-communicable diseases among foreign-
born migrants living in SA [11]. Migration also in-
volves going through certain stages involving lack of
preparedness, difficulties in adjusting to the new en-
vironment, the complexity of the local system, lan-
guage difficulties, cultural disparities and adverse
experiences, which can cause distress and anxiety to
the foreign-born migrants with a negative impact on
their mental well-being [12]. Despite this high disease
burden, foreign-born migrants face various challenges
accessing preventative and curative healthcare services
including the lack of migration-aware and mobility-
competent health systems programs [11].
Main text
Unspoken inequality
On the 23 of March 2020, President Cyril Ramaphosa
announced a nation-wide lockdown to help curb the
Mukumbang et al. International Journal for Equity in Health (2020) 19:141 Page 2 of 7
spread of the Coronavirus Disease 2019 (COVID-19)
epidemic in SA [13] and to enable the health systems to
prepare for the increasing influx of moderate to severe
COVID-19 cases [14]. In addition to the national lock-
down, other social distancing measures such as isolation
of individuals infected with the SARS-CoV-2 virus and
quarantining of those who may have been exposed to or
were in contact with an infected person are also encour-
aged or enforced [15]. In spite of these containment
measures, SA has the highest number of infections with
SARS-CoV-2 in Africa with more than a 100,000 cases
and 2000 deaths reported as of the middle of June 2020
[16]. While these containment measures are estimated
to have negatively affected all those living in SA, asylum-
seekers, refugees, and undocumented migrants dispro-
portionally experience the negative impacts of the pan-
demic because of existing vulnerabilities affecting this
population Fig. 1[17].
Before the lockdown containment measures, foreign-
born migrants living in SA had relatively weakened so-
cial support structures, bleak socio-economic prospects,
unequal access to health care and social services, precar-
ious housing conditions, tenuous living and working
conditions, and higher risks of exploitation and abuse
[18]. The lockdown containment measures worsened
their conditions as they found themselves suddenly job-
less, being evicted from their homes, hunger insecure,
and trapped in dormitories or camps where adequate
physical distancing is impossible [19]. These conditions
have created and continue to fuel feelings of uncertainty,
distress, anxiety, fear, anger, and hopelessness; condi-
tionsconsideredasprecursorsandprodromesof
mental health illnesses such as anxiety and depression
[20,21], and secondary health concerns neglect of
self-care, respiratory infections, HIV, and substance
abuse [22]. Studies conducted in other countries have
demonstrated that nation-wide lockdown is associated
with depressive symptoms, anxiety symptoms, and
sleeping disturbances [23,24].
Organizations working with foreign-born migrants
during the COVID-19 pandemic containment measures
have raised concerns regarding the arrest and detention
of foreign-born migrants [25], their placement in, and
subsequent repatriation from camps and shelters. There
are also reports that foreign-born migrants are more
likely to be arrested for minor offenses during the lock-
down period and less likely to be released on bail be-
cause of expired documentation [25]. The closure of the
Department of Home Affairs, which is responsible for
renewing and issuing refugee permits, asylum permits,
and residence permits, has made many foreign-born mi-
grants vulnerable to harassment and extortion by law
enforcement agents who are likely to ignore the mora-
torium on arrests of all those whose permits expired
during the lockdown [2]. Migrants are consequently less
willing to seek testing or care for COVID-19 symptoms
as they are afraid of being detained or deported. These
repatriation centers and prison stations are also prone to
overcrowding, making it challenging to practice social
distancing and recommended hygiene measures [26].
Under such conditions, these foreign-born migrants are
at heightened risks of contracting COVID-19 but tend
not to seek care when they notice the signs and symp-
toms of COVID-19, which makes them more likely to
spread or die from the disease.
During the mandatory nationwide lockdown, asylum
seekers, refugees, and undocumented migrants found
themselves trapped indoors leading to the feeling of iso-
lation [27]. Isolation, scarcity of resources, and the lack
of social contacts may have created and continue to fuel
Fig. 1 Crisis impacting foreign-born migrants Adapted from United Nations [17]
Mukumbang et al. International Journal for Equity in Health (2020) 19:141 Page 3 of 7
a negative impact on peoples emotions and psycho-
logical well-being [28,29]. Also, with an increasing num-
ber of cases in SA, there has been a significant increase
in the stigmatization of anyone remotely related to
COVID-19. Stigma and discrimination that stems from
COVID-19 can occur when people associate it with na-
tionality or being a foreign-born migrants and can lead
to further social avoidance, denial of health care, and
perhaps even violence fueling secondary health concerns
[30]. Stigma also makes people feel isolated; even to the
point of feeling abandoned and increases the chances of
anxiety and depression [31].
Although lockdown is comparatively easier for people
who live in houses with big gardens, it is harder for
those who live in crowded homes and camps, sharing
their living spaces and toilets with non-relatives and
strangers such as is the condition of most asylum-
seekers, refugees, and undocumented migrants living in
SA [32]. Under these conditions, the risk of abuse (emo-
tional and sexual), exploitation, and violence are height-
ened. Evidence shows that foreign-born migrants living
under such circumstances in sub-Saharan Africa have
consistently poorer physical and mental health outcomes
than others [33].
To address some of the socio-economic hardship
that the COVID-19 pandemic containment measures
have placed on the South African population, the
South African government adopted various economic
and hunger alleviation measures. First, the govern-
ment announced the COVID-19 Social Relief of Dis-
tress grant of R350 ($20) to all South Africans who
are unemployed including those who lost their job as
a result of the COVID-19 pandemic for a period of 6
months from May 2020. Secondly, the South African
government increased the value of the child and so-
cial support grants until October 2020. Thirdly, the
government pledged a Business Relief Fund of
R500 million ($30 million) for businesses that may
have their operations affected by the COVID-19 pan-
demic. Finally, the government is providing tax
subsidies for small businesses and individuals and
lowering contributions to the Unemployment Insur-
ance Fund (UIF).
While these strategies are commendable, it is unclear
how asylum-seekers, refugees, and undocumented mi-
grants living in similar or worse situations are being con-
sidered. Not only are they no longer able to acquire
finances through work of any kind, but they also are not
being considered in any of the governments plans to
mitigate the impact of the lockdown measures. For in-
stance, the African Centre for Migration and Society [1]
report indicates that foreign-born migrants of working
age living in SA are more likely to own a business and
be employers. Unfortunately, most of these businesses
owned by asylum-seekers, refugees, and undocumented
migrants, although their operations are equally affected
by the COVID-19 crisis, are not considered for the Busi-
ness Relief Fund as they are automatically excluded
based on the qualification criteria businesses must be
100% South African owned, at least 70% of employees
must be South Africans and recipients must be tax com-
pliant [34].
For asylum-seekers and special-permit holders who
were employed in the formal sector and who paid the
mandatory taxes into unemployment before the lock-
down measures were imposed, their UIF payments are
not being paid while the South African employees in the
same companies receive theirs [35]. The argument for
non-payment of foreign-born migrants' UIF is that the
electronic system used by the UIF does not recognize
foreign passport numbers [35]. The Department of Em-
ployment and Labour made these payments to help indi-
viduals cope with the worst effects of the national
lockdown. For the South African citizens, the UIF pro-
vided some relief, as this income replacement allowed
them to take care of their families. However, the socio-
economic situation of refugees, asylum-seekers and
special-permit holders not receiving the UIF has deterio-
rated further.
The South African government also embarked on
providing food parcels to those who are threatened
by food insecurity. During these food distribution
campaigns, it has been observed that foreign-born mi-
grants form a significant number of attendees [36].
Similar to accessing the Social Relief of Distress grant
of R350 ($20) and receiving UIF payments, a South
African national ID or special permit is required to
receive food parcels, which foreign-born migrants are
unlikely to possess. [36]. In this way, asylum seekers,
refugees, and undocumented migrants are excluded
from the governments food relief programs [37].
The South African Department of Home Affairs an-
nounced they will ensure that anyone whose immigration
status permit expires before the end of the lockdown
period will not be penalized as long as they present
themselves to a refugee reception office within 30 days
of the lockdown ending. Nevertheless, some asylum-
seekers have been undocumented for months and even
years prior to the national lockdown [4]. These undocu-
mented migrants are most vulnerable to harm and infec-
tion with COVID-19 as they are most likely to be
homeless and their access to basic human rights and ser-
vices is particularly limited. Consequently, the lockdown
containment measures can potentially increase their vul-
nerabilities regarding mental health and secondary
health concerns as people who are homeless are already
prone to mental health issues and problems in physical
health [12] due to neglect of self-care, leading to the
Mukumbang et al. International Journal for Equity in Health (2020) 19:141 Page 4 of 7
prevalence of respiratory infections, HIV, and substance
abuse.
There is an overall poor engagement of SAs public
healthcare system with migrants, therefore, testing and
treatment responses within public health systems fail to
engage with asylum-seekers, refugees, and undocu-
mented migrants [38]. As discussed earlier, undocu-
mented migrants are also usually reluctant to seek
medical and other assistance due to their lack of docu-
mentation for fear of possible arrest, detention, and even
deportation. According to Kruger [39], where someone
suspected of having symptoms related to the SARS-
CoV-2 infection refuses to take a test, an enforcement
officer should apply to a magistrate for a warrant to
compel such testing. Unfortunately, this cannot be
applied to undocumented migrants as individuals are re-
quired to provide information on their nationalityand
identification details to take a SARS-CoV-2 test in most
parts in South Africa [2]. Therefore, early detection, test-
ing, diagnosis, contact tracing, and seeking care for
Covid-19 becomes challenging for undocumented
migrants, thus increasing the risk of outbreaks among
migrants and the general population, as COVID-19 is as-
sociated with clusters and outbreaks [14]. Their exclu-
sion from accessing testing, treatment, and the palliative
measures put in place during this COVID-19 period will,
ultimately, undermine the governments efforts to curb
the spread of the virus.
Call to action
Some civil societies such as the Scalabrini Centre of
Cape Town are working to address the conditions of
asylum-seekers and migrants. The Scalabrini Centre
of Cape Town is a non-governmental organization
based in Cape Town, SA that provides specialized
services for refugee, migrant, and South African
communities. For instance, the Centre has, in coord-
ination with the major banks of SA, managed to not
freeze the bank accounts of asylum-seekers and refu-
gees whose permits got expired during the period of
the national lockdown. This is meant to permit them
to have access to their finances to buy food and pur-
chase other essential goods and services. Unfortu-
nately, many foreign-born migrants with expired
permits report that their accounts are still fro-
zen. Also, the Scalabrini Centre of Cape Town has
recently won a Court Order that may ensure some
of SAs asylum-seekers and special-permit holders to
be able to apply for the COVID-19 Social Relief of
Distress grant. Other non-governmental organiza-
tions have focused on hunger alleviation by provid-
ing food parcels.
While the efforts made by these civil societies to allevi-
ate hunger and provide some relief to the economic
situation of asylum-seekers, refugees, and undocumented
migrants are commendable, these efforts are not sustain-
able without the governments support. According to the
United Nations [17], four basic tenets should drive ef-
forts to support foreign-born migrants in the era of
COVID-19 and moving forward: (1) Their exclusion is
costly in the long-run whereas their inclusion pays off
for everyone. (2) The response to COVID-19 and pro-
tecting the human rights of migrants are not mutually
exclusive. (3) No-one is safe until everyone is safe. (4)
Migrants are part of the solution. The International
Labour Organization (ILO) also confirms that the inclu-
sion of foreign-born migrants in national COVID-19
policy responses can help to ensure the realization of
equality and social justice [40]. Equality and social just-
ice could be achieved by engaging with and including
migrant-led organizations, civil societies, international
organizations, and researchers working with migrant
groups towards developing programs that consider
migrants.
ILO also suggests that governments should include
asylum-seekers, refugees, and undocumented migrants
in their national income and related policy responses.
To achieve this, foreign-born migrants living in SA
will require their status in SA to be legalized as many
forms of access are contingent upon having
proper documentation, such as access to healthcare,
education, food parcels, banking services, unemploy-
ment benefits, social grants, or even, at times, free-
dom of movement. The COVID-19 pandemic and its
implications necessitate an inclusive approach, which
leaves no one behind because our individual and col-
lective wellbeing is precariously interconnected. In the
era of the COVID-19 pandemic, a narrow citizenship
approach will be inadequate in dealing with an inter-
twined sociality.
The South African government should also extend ac-
cess to health services and social protection coverage to
this category of our society [40]. For instance, provide
healthcare to foreign-born migrants irrespective of
migration status. The International Organization for
Migration [21] also reiterates its call to ensure that
foreign-born migrants and displaced persons are in-
cluded in governmentsplans for mental and psycho-
social support provision in the context of COVID-19
and moving forward.
Conclusion
The response to COVID-19 and ensuring the health and
well-being of asylum-seekers, refugees, and undocu-
mented migrants are not mutually exclusive. The first
step to effectively address the socioeconomic and psy-
chosocial impact of the COVID-19 pandemic and lock-
down on foreign-born migrants while reducing
Mukumbang et al. International Journal for Equity in Health (2020) 19:141 Page 5 of 7
inequities between them and local communities involves
developing policies that take their realities into account.
Although these migration-aware and mobility-
competent policies do not necessarily translate in prac-
tice, the South African government should engage with
and include migrant-led organizations, civil society,
international organizations, and researchers working
with migrant groups in the development of appropri-
ate responses. Leaving this category of our society out of
the national response safety nets may engender negative
coping strategies leading to mental health issues, and
secondary health concerns.
Abbreviations
COVID-19: Coronavirus Disease 2019; ILO: International Labour Organization;
SA: South Africa; SADC: Southern African Development Community;
UIF: Unemployment Insurance Fund
Acknowledgments
We wish to acknowledge Dr. Peter Delobelle for reading and commenting
on an earlier version of this manuscript. We are also immensely greatful to
the reviewer who provided valuable and constructive comments to improve
the quality of the submission.
Authorscontributions
FCM conceived the original idea and wrote the first draft of the manuscript
as well as the final document. ANA and BOA critically reviewed the paper
and contributed important intellectual content. All authors read and agreed
on the final manuscript.
Funding
No funding was received.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated
or analyzed during the current study.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they do not have any competing interests.
Author details
1
Burden of Disease Research Unit, South African Medical Research Council,
Cape Town, South Africa.
2
Department of History, University of the Western
Cape, Cape Town, South Africa.
3
Child and Family Unit/Social work,
University of the Western Cape, Cape Town, South Africa.
Received: 10 June 2020 Accepted: 10 August 2020
References
1. African Centre for Migration & Society. Fact sheet on foreign workers in
South Africa: overview based on statistics South Africa data (20122017).
Johannesburg: ACMS; 2020. http://www.migration.org.za/fact-sheet-on-
foreign-workers-in-south-africa-overview-based-on-statistics-south-africa-
data-2012-2017/. Accessed 4 June 2020.
2. Garba NWF. Covid-19 in South Africa: whither migrants? - African
arguments. African arguments; 2020. https://africanarguments.org/2020/06/1
7/covid-19-in-south-africa-whither-migrants/. Accessed 30 July 2020.
3. Consortium for Refugees and Migrants in South Africa. Protecting refugees,
asylum seekers and immigrants in South Africa. Johannesburg; 2008. www.
cormsa.org.za. Accessed 4 June 2020.
4. Masuku S. How South Africa is denying refugees their rights: what needs to
change. The conversation; 2020. https://theconversation.com/how-south-
africa-is-denying-refugees-their-rights-what-needs-to-change-135692.
Accessed 30 July 2020.
5. Masuku S, Rama S. A case study of government and civil societies
collaboration and challenges in securing the rights of Congolese refugees
living in Pietermaritzburg, KwaZulu-Natal, South Africa. S Afr J Sci. 2020;116:27.
6. Choane M, Shulika LS, Mthombeni M. An analysis of the causes, effects and
ramifications of xenophobia in South Africa. Insight Afr. 2011;3:12942.
7. Ogunnoiki AO, Adeyemi AA. The impact of xenophobic attacks on Nigeria-
South Africa relation. African J Soc Sci Humanit Res. 2019;2:118.
8. Faturiyele I, Karletsos D, Ntene-Sealiete K, et al. Access to HIV care and
treatment for migrants between Lesotho and South Africa: a mixed
methods study. BMC Public Health. 2018;18:668.
9. Pindolia DK, Garcia AJ, Huang Z, et al. Quantifying cross-border movements
and migrations for guiding the strategic planning of malaria control and
elimination. Malar J. 2014;13:169.
10. Vearey J. Moving forward: why responding to migration, mobility and HIV in
south(ern) Africa is a public health priority. J Int AIDS Soc. 2018;21:e25137.
11. Vearey J, Modisenyane M, Hunter-Adams J. Towards a migration-aware
health system in South Africa: a strategic opportunity to address health
inequity. South Afr Health Rev. 2017;2017:198.
12. Virupaksha HG, Kumar A, Nirmala BP. Migration and mental health: an
interface. J Nat Sci Biol Med. 2014;5:2339.
13. South African Government News Agency. President Ramaphosa announces
a nationwide lockdown | SAnews; 2020. https://www.sanews.gov.za/south-
africa/president-ramaphosa-announces-nationwide-lockdown. Accessed 22
July 2020.
14. Blumberg L, Jassat W, Mendelson M, et al. The COVID-19 crisis in South
Africa : protecting the vulnerable. South African Med J. 2019Epub ahead of
print 2020. https://doi.org/10.7196/SAMJ.2020.v110i9.15116.
15. Moodley K, Obasa A, London L. Isolation and quarantine in South Africa
during COVID-19 : draconian measures or proportional response? South
African Med J. 2020;110:1. https://doi.org/10.7196/SAMJ.2020v110i6.14842.
16. Mayne ES, Scott L, Semete B, et al. The role of serological testing in
the SARS-CoV-2 outbreak serological testing. South African Med J. 2020;
17:1821.
17. United Nations. COVID-19 and People on the Move,https://www.un.org/sites/
un2.un.org/files/sg_policy_brief_on_people_on_the_move.pdf. (23 June
2020, Accessed 22 July 2020).
18. Merry L, Pelaez S, Edwards NC. Refugees, asylum-seekers and
undocumented migrants and the experience of parenthood: a synthesis of
the qualitative literature. Glob Health. 2017;13:117.
19. Botes WM, Thaldar DW. COVID-19 and quarantine orders: a practical
approach. South African Med J. 2020;110:1Epub ahead of print 22 April
2020. https://doi.org/10.7196/samj.2020v110i6.14794.
20. Batterham PJ, Christensen H, Calear AL. Anxiety symptoms as precursors of
major depression and suicidal ideation. Depress Anxiety. 2013;30:90816.
21. International Organization for Migration. IOM reiterates importance of
addressing mental health impacts of COVID-19 on displaced and migrant
populations | International Organization for Migration; 2020. https://www.
iom.int/news/iom-reiterates-importance-addressing-mental-health-impacts-
covid-19-displaced-and-migrant. Accessed 22 July 2020.
22. Mukhtar S. Psychological health during the coronavirus disease 2019
pandemic outbreak. Int J Soc Psychiatry. 2020;66:512 002076402092583.
23. Gualano MR, Lo Moro G, Voglino G, et al. Effects of Covid-19 lockdown on
mental health and sleep disturbances in Italy. Int J Environ Res Public
Health. 2020;17:4779.
24. Choudhari R. COVID 19 pandemic: mental health challenges of internal
migrant workers of India; 2020. https://doi.org/10.1016/j.ajp.2020.102254.
25. Ntshidi E. 130 people arrested in Soweto for breaching lockdown laws,
other offences. Eyewithness news; 2020. https://ewn.co.za/2020/05/11/
police-arrest-130-people-in-soweto-for-breaching-lockdown-laws. Accessed
22 July 2020.
26. Mahtani S. We need to decongest Africas prisons urgently. For everyones
sake. - African arguments. African arguments; 2020. https://
africanarguments.org/2020/03/30/decongest-africa-covid-19-prisons-
urgently/. Accessed 22 July 2020.
27. Madhi S, Gray GE, Ismael N, et al. COVID-19 lockdowns in low- and middle-
income countries : success against COVID-19 at the price of greater costs.
South African Med J. 2020;1:46.
Mukumbang et al. International Journal for Equity in Health (2020) 19:141 Page 6 of 7
28. Cerbara L, Ciancimino G, Crescimbene M, et al. A nation-wide survey on
emotional and psychological impacts of COVID-19 social distancing. Eur Rev
Med Pharmacol Sci. 2020;24:715563.
29. Basok T, George G. Migrant workers face further social isolation and mental
health challenges during coronavirus pandemic. The conversation; 2020.
https://theconversation.com/migrant-workers-face-further-social-isolation-
and-mental-health-challenges-during-coronavirus-pandemic-134324.
Accessed 30 July 2020.
30. Turner-Musa J, Ajayi O, Kemp L. Examining social determinants of health,
stigma, and COVID-19 disparities. Healthcare. 2020;8:168.
31. Rose T, Joe S, Lindsey M. Perceived stigma and depression among black
adolescents in outpatient treatment. Child Youth Serv Rev. 2011;33:1616.
32. Ray SC. Editorial: Covid-19 special collection. African Journal of Primary
Health Care and Family Medicine, vol. 12; 2020. https://doi.org/10.4102/
PHCFM.V12I1.2466.
33. Bempong NE, Sheath D, Seybold J, et al. Critical reflections, challenges and
solutions for migrant and refugee health: 2nd M8 Alliance expert meeting.
Public Health Rev. 2019;40:3.
34. Business Insider South Africa. Prime less 5% for honest small businesses
and plus 10% for chancers: Covid-19 help details. Business Insider South
Africa; 2020. https://www.businessinsider.co.za/help-for-my-business-during-
the-coronavirus-disaster-in-south-africa-2020-3. Accessed 22 July 2020.
35. Business Insider South Africa. UIF Covid-19 payout trouble: these are the
most common problems holding back the cash. Business insider South
Africa; 2020. https://www.businessinsider.co.za/how-to-avoid-uif-problems-2
020-5. Accessed 22 July 2020.
36. Reuters. Migrants and those without ID face hunger in South Africa. New
York post, 2020; 2020. https://nypost.com/2020/05/20/migrants-and-those-
without-id-face-hunger-in-south-africa/. Accessed 23 July 2020.
37. Bornman J, Oatway J. South Africa: migrants excluded from government
food aid. All Africa; 2020. https://allafrica.com/stories/202005130663.html.
Accessed 23 July 2020.
38. Vearey J. Healthy migration: a public health and development imperative
for south(ern) Africa. South African Med J. 2014;104:6634.
39. Kruger P. Compelled testing for the novel coronavirus compelled testing :
SARS-CoV-2 compelled testing : general position. South African Med J. 2020;
110:12.
40. International Labour Organization. Protecting migrant workers during the
COVID-19 pandemic: recommendations for policy-makers and constituents;
2020. https://www.ilo.org/wcmsp5/groups/public/-ed_protect/-protrav/-
migrant/documents/publication/wcms_743268.pdf. Accessed 22 June 2020.
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Background: The current ongoing pandemic outbreak of COVID-19 (Coronavirus Disease 2019) has globally affected 213 countries and territories with more than 2.5 million confirmed cases and thousands of casualties. The unpredictable and uncertain COVID-19 outbreak has the potential of adversely affecting the psychological health on individual and community level. Currently all efforts are focused on the understanding of epidemiology, clinical features, mode of transmission, counteract the spread of the virus, and challenges of global health, while crucially significant mental health has been overlooked in this endeavor. Method: This review is to evaluate past outbreaks to understand the extent of adverse effects on psychological health, psychological crisis intervention, and mental health management plans. Published previous and current articles on PubMed, EMBASE, Google Scholar, and Elsevier about psychological impact of infectious diseases outbreaks and COVID-19 has been considered and reviewed. Comments: COVID-19 is leading to intense psychosocial issues and comprising mental health marking a secondary health concern all around the world. Globally implementing preventive and controlling measures, and cultivating coping and resilience are challenging factors; modified lifestyle (lockdown curfew, self-isolation, social distancing and quarantine); conspiracy theories, misinformation and disinformation about the origin, scale, signs, symptoms, transmission, prevention and treatment; global socioeconomic crisis; travel restrictions; workplace hazard control; postponement and cancellation of religious, sports, cultural and entertainment events; panic buying and hoarding; incidents of racism, xenophobia, discrimination, stigma, psychological pressure of productivity, marginalization and violence; overwhelmed medical centers and health organizations, and general impact on education, politics, socioeconomic, culture, environment and climate - are some of the risk factors to aggravate further problems.
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In the midst of an unprecedented public health crisis, extraordinary containment measures must be implemented. These include both isolation and quarantine, either on a voluntary basis or enforced. In the transition from voluntary to mandatory isolation, conflicts arise at the intersection of ethics, human rights and the law. The Siracusa Principles adopted by the United Nations Economic and Social Council in 1985 and enshrined in international human rights legislation and guidelines specify conditions under which civil liberties may be infringed. In order for isolation processes in South Africa to claim legitimacy, it is important that these principles as well as national laws and constitutional rights are embedded in state action.