According to the World Health Organisation, older people are at highest risk from COVID-19. This is because those over the age of 60 are most vulnerable to developing co-morbidities and are among the most vulnerable in terms of direct virus impact and indirect impact from infection prevention and control measures. Older people living in refugee settlements face particular difficulties accessing basic WASH services, limiting their ability to implement hygiene measures aimed at preventing the transmission of COVID-19. These contexts are also extremely challenging for the implementation of social distancing and self-isolation measures due to overcrowded and inadequate housing.
Kyangwali refugee settlement is located in Kikuube District, Western Uganda, and is home to more than 120,000 refugees. This article is based on repeat in-depth interviews conducted in Kyangwali settlement with 24 older refugees who had fled DRC within the previous five years. The 50 interviews were conducted in March and December 2020 before and during the COVID-19 pandemic and discussed older refugees’ access to potable water, hygiene and sanitation. An additional 26 interviews were carried out with key stakeholders.
Access to WASH services prior to COVID-19
From our research, it is apparent that even prior to COVID-19 access to WASH for older refugees was challenging, with access to water the most important and cross-cutting component.
Water, including potable water, is commonly available from wells, natural springs, taps and tanks. Other access to clean water, such as bottled water, is very limited due to cost. This makes access to water dependent on the efficiency of public distribution, availability of natural resources, and income to buy clean water or to pay someone to collect water. Although most of the settlement zones had water taps, frequent water shortages hindered effective access. Our research showed that it was common for older refugees to move to neighbouring zones within the settlement in search of water. This produces additional hardships as the older refugees have to walk longer distances and navigate steep terrain to reach natural springs. Fetching water in these conditions is a daily activity that puts stress on their already deteriorated physical condition.
The most disadvantaged were the oldest refugees, who suffered reduced mobility and those living without the support of younger relatives. Due to the disruption caused by displacement, it is very common to observe older refugees living alone or with others of a similar age or with much younger relatives, such as grandchildren.
“I fetch 30 litres of water per day… It is very difficult for me to carry the water. I rest twice before reaching the house.” (71-year-old male refugee)
The location of older refugees’ households matters in terms of quantity and quality of water services. For instance, those living in areas where public distribution of water is effective were satisfied with the quantity and, usually, the quality of water. However, those who lived in areas of water shortages or where water springs were far from their homes reported rationing their consumption of water due to access difficulties. Even though natural sources are available for everyone, in practice inequalities emerge in terms of consumption and use of water, affecting the most disadvantaged.
Water quality was also a problem reported by most older refugees that used wells.
“We drink that water because we think it is potable, but other people say it is not. We suffer typhoid when we drink that water.” (60-year-old female refugee)
Access to soap is limited and most interviewees said that they had received soap only once or twice during the four to five years they had lived in the settlement.
Impact of COVID-19
Priority actions in the emergency humanitarian response to COVID-19 include increasing handwashing facilities, hygiene promotion and community awareness-raising on WASH practices to reduce transmission. Like the pre-pandemic WASH interventions, these emergency responses affected older refugees in particular ways. Soap distribution increased in the settlement, with most respondents receiving bars of soap every two months. For some interviewees the procedure for receiving cash and soap was divided into two steps which occurred in different locations in order to slow down the queue and avoid mass gatherings; for older refugees, however, investing an entire day in queuing outdoors to access cash and soap meant they experienced physical fatigue and over-exposure to the sun.
Access to water remains a challenge for older refugees. Although older refugees have implemented strategies to try to meet their WASH needs, these strategies have wider impacts on their lives. For instance, rationing water for drinking and bathing may have consequences on their nutrition and health; it also impinges on their hygiene:
“Water availability is the same as before COVID-19. We have reduced the use of water to be able to wash our hands. We wash our clothes from the well, not from home. We have reduced the amount for drinking and bathing.” (88-year-old male refugee)
Since the beginning of the COVID-19 pandemic, humanitarian operations across Uganda have been affected. Communicating COVID-19 health messages in refugee settlements like Kyangwali where several different languages are spoken, and when mass gatherings are banned, has been very challenging. Community leaders – who understand their community’s needs and are used to engaging with community members – were trained by humanitarian actors to disseminate information on WASH measures. This approach to disseminating health information appears to be effective for older refugees, who reported that they know and trust their community leaders. As a result of these strategies, understanding of good practice seems to be growing and is producing positive results.
Community engagement in public health services, such as the distribution of jerry cans and the dissemination of information, has been key to reaching more people and delivering services efficiently. Partnerships with community leaders to deliver humanitarian actors’ services have resulted in good practice, particularly for those – mainly older refugees – who have mobility issues and chronic diseases. However, where leaders are also poor, some cash incentives may support engagement. Monitoring and accountability systems also need to be in place to ensure equal distribution of commodities and services for the most vulnerable.
Access to, and use of, WASH services for older refugees partially improved during the COVID-19 pandemic in Uganda, although some barriers remain. Sanitation and hygiene issues were addressed by increasing the distribution of soap and jerry cans to refugee households. While most older refugees reported receiving enough soap for their monthly sanitation and handwashing facilities, however, the continued shared use of latrines by two or more households was still an issue for some families. Implementation of stricter handwashing was impeded when access to clean water was not also increased. Some older refugees did not receive more or better access to water and continued to drink from natural springs and wells where the quality is unchecked. Although a strategy on the provision of handwashing facilities to the refugee community has been implemented, there are other factors such as distance and time for fetching water that impinge on older refugees’ effective access to water.
Older refugees need access to good quantity and quality of water from an improved water source, available when needed and free of charge, along with increased access to soap and handwashing facilities. Building awareness of the particular WASH needs of older refugees will contribute to improving their access to essential services in times of pandemic and beyond.
PhD Candidate in Human Geography, University of Dundee
Professor of Human Geography, School of Social Sciences, University of Dundee
 WHO (2020) ‘Older people are at highest risk from COVID 19, but all must act to prevent community spread’ www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/statements/statement-older-people-are-at-highest-risk-from-covid-19,-but-all-must-act-to-prevent-community-spread bit.ly/WHO-statement; Help Age International (2020) ‘Protecting older people during the Covid 19 pandemic’ www.helpage.org/what-we-do/protecting-older-people-during-the-coronavirus-covid19-pandemic/ bit.ly/HelpAge-refugees
 Stakeholder interviews were conducted with international organisations, public sector, NGOs and academia working on humanitarian issues in Uganda.