Scoping the impact of COVID-19 on the nexus of statelessness and health in Council of Europe member states.

BACKGROUND: Stateless communities in Europe include ethnic Russians in the Baltic States, recent migrants, refugees, Roma, and other members of minority groups. Increases in COVID-19 infection have been observed in many European countries, including reported outbreaks in groups that include people and communities affected by statelessness, who often live in congested and sub-standard unhygienic conditions, work in informal sectors which hampers their adherence to public health measures (self-isolation/physical distancing/hand sanitation), or who are detained in immigration detention centres. The impact of COVID-19 on stateless people in Europe (estimated to be at least 600,000) is currently under researched, and there is an imperative to understand their experiences and situation, in order to generate evidence based measures, responses and actions to protect those most at risk.
METHOD: In order to better understand their unique position during the COVID-19 pandemic, we conducted a scoping review to explore and assess the nexus between statelessness and health during COVID-19 in Europe. Literature was found representing ten Council of Europe countries (Bulgaria, Denmark, Greece, Italy, Romania, Russia, Slovakia, Ireland, Ukraine and the United Kingdom), with 15 publications representing multiple countries. Four publications specifically focused on stateless people. The remainder focused on populations which include people disproportionately affected by statelessness both in the migratory context and those in situ (minority groups including Roma and ethnic Russians, and refugees and migrants).
RESULTS: Three themes emerged from the analysis (Environmental determinants of health; access to healthcare services; and racism and vilification), with higher level abstraction centring on the nexus between existing adverse environmental determinants of health, compounded barriers to access healthcare during COVID-19; and the concerning rise in hate crime and scapegoating of minority populations during the COVID-19 emergency. Whilst the right to healthcare is a fundamental human right, with universal application and with access to healthcare services ensured to every human being without regards to race, religion or other criteria, including nationality status, this appears not to be the case for populations affected by statelessness during the COVID-19 health and state emergency. The right to a nationality (and realisation of the right to health and access to healthcare/public services) in the current pandemic times is crucial in a targeted effective and culturally sensitive public health response.
CONCLUSION: The hidden nature of statelessness, coupled with the marginalisation of stateless people, exacerbates the structural underpinning and interplay between statelessness, human rights, health rights and right to nationality during the COVID-19 pandemic. The review further highlights the need to protect stateless people. We further cannot underestimate the need for sensitive legal, health and social response measures to tackle disease transmission in vulnerable groups, continued statelessness of people in Europe, and hate crime, xenophobia and discrimination of those perceived to be at risk of contagion.

Introduction

On March 11th 2020, the WHO announced that the global outbreak of COVID-19 is a pandemic (World Health Organization (WHO) 2021).There is currently a global call for an inclusive rights based response, ‘leaving no one behind’ in the COVID-19 response, and particularly the most marginalised [(World Health Organization (WHO) 2021; Orcutt et al., 2020; Migration, 2020)]. Success in countering the COVID-19 pandemic centres on the inclusion of all populations in domestic, European and international responses (Orcutt et al., 2020). However, this global emergency has further highlighted the existing health disparities, exclusion, and the multiplicity of barriers to healthcare experienced by marginalised populations, including migrants, refugees and stateless people [(Orcutt et al., 2020; Lau. et al., 2020; Varga, 2020; Dauvrin et al., 2012; European Union Agency For Fundamental Rights (FRA) 2016; Kirby, 2020; European Union (EU) 2014; European Roma Rights Centre (ERRC) 2013)]. We focus here on stateless people. António Guterres, the UN High Commissioner for Refugees (UNCHR) at the time in 2011, described statelessness as the world's “most forgotten human-rights problem” (Open Society Foundations 2013). Given the hidden nature of statelessness, coupled with the marginalisation of stateless people, the impacts of COVID-19 on these people is far reaching, and potentially catastrophic given their experiences of adverse social, environmental and structural determinants of health (van Gilder Cooke, 2011; M. Institute on Statelessness and Inclusion (ISI) 2020). There are rising concerns around the structural underpinning of statelessness, human rights, health rights and right to nationality worsening as the COVID-19 pandemic takes hold [(M. Institute on Statelessness and Inclusion (ISI) 2020; M. Institute on Statelessness and Inclusion (ISI) 2020)]. Statelessness leaves many politically and economically marginalised, discriminated against and at risk of hate speech, exploitation and abuse, detention, insecurity and restricted movement, with catastrophic consequences for their health and well-being, and livelihoods, particularly now during this public health crisis (M. Institute on Statelessness and Inclusion (ISI) 2020). Many, due to their work and home environments are unable to self-isolate, socially distance and adhere to the recommended hygiene measures [(M. Institute on Statelessness and Inclusion (ISI) 2020; Orcutt. et al., 2020)]. Their experiences are at risk of being omitted or indeed misinterpreted (M. Orcutt et al., 2020; M. Institute on Statelessness and Inclusion (ISI) 2020).

On May 11th 2020, António Guterres’ successor Filippo Grandi, warned that the stateless risk being left further behind in the response to COVID-19 (M. Institute on Statelessness and Inclusion (ISI) 2020) and issued a series of recommendations to urge States to respond to their needs and ensure their coverage in the COVID-19 response (M. United Nations High Commissioner for Refugees (UNHCR) 2020). These UNHCR recommendations included a focus on accessibility of health services, particularly COVID-19 testing and treatment regardless of legal status; enabling people to access services without fear or risk of arrest or detention; including them in accessible information campaigns; minimising risks of statelessness due to lack of documentation during the pandemic; addressing arbitrary immigration detention; ensuring response measures do not fuel racial discrimination, hate crime and xenophobia; and extending COVID support packages to all, regardless of legal status. This was followed by a joint statement by 84 civil society organisations released on May 27th 2020 (M. United Nations High Commissioner for Refugees (UNHCR) 2020) which stated; “. Of note is that despite assurance to include migrants, refugees and displaced populations in the COVID-19 responses, measures do not necessarily reach them, particularly in the case of stateless people due to their hidden non-citizen legal status (Minority Rights Group International, 2020). A later update on the COVID −19 preparedness and response was released by UNHCR (M. Institute on Statelessness and Inclusion (ISI) 2020) on June 9th 2020 and advised on global and regional emergency responses measures to ensure access to healthcare (including COVID-19 testing) in a non-discriminatory manner. UNHCR also called on the EU to step up its role in the protection of refugees, forcibly displaced and stateless people, inside and outside its borders, including through adequate health and socio-economic service access, financial support and the empowerment of refugees and stateless people to support the response.

Statelessness in Europe, as elsewhere, remains, largely, a largely hidden phenomenon, due to the incompleteness and sparsity of data, particularly regarding inter-generational statelessness, and immigration detention (M. United Nations High Commissioner for Refugees (UNHCR) 2020). There are an estimated 600,000 stateless persons in Europe today, with over 80% living in Estonia, Latvia, the Russian Federation and Ukraine (European Network on Statelessness (ENS) 2017). Stateless populations in Europe are commonly members of minority groups which include ethnic Russians, and Romani communities, as well as refugees and migrants (European Network on Statelessness (ENS) 2017). Of note is that not all stateless people are without residence status or identity documents. Some stateless people may be recognised as stateless and granted international protection by a host country, and others, for example, ‘non-citizens’ in the Baltic States have a specific legal status under national law and are granted most socio-economic rights in line with nationals.

The impact of COVID-19 on stateless people in Europe is currently under researched. Increases in COVID-19 infection have been observed in many European countries, including reported outbreaks in stateless communities. The disproportionate impact of COVID-19 on the physical and mental health of minority groups is already well established (European Union Agency For Fundamental Rights (FRA) 2016). Populations affected by statelessness are hampered in their access to public health information, and informed health policies and responses during emergencies such as COVID-19. Many live in congested and sub-standard unhygienic conditions, work in informal sectors, which hampers their adherence to public health measures (self-isolation/physical distancing/hand sanitation), or may be detained in immigration detention. For example, Romani and Traveller populations, especially children and women, who do not have residence status, identity documents and are living in relative poverty remain extremely vulnerable to the consequences of COVID-19 (inter-generational statelessness, evictions, homelessness, poverty, gender based violence, consequences of non-citizenship, interrupted schooling, health risks) (Villani et al., 2021; Varga, 2020). Many are at risk of exclusion from and/or face significant obstacles in accessing COVID-19 testing and medical care (Varga, 2020; M. United Nations High Commissioner for Refugees (UNHCR) 2020). In many EU countries, healthcare for migrants with irregular residence status (amongst whom many are stateless or at risk of statelessness) is restricted to emergency care services only (Dauvrin et al., 2012). During this public health crisis, some stateless people may also refrain from accessing health services for fear that their lack of residence or nationality status can put them at risk of immigration detention or deportation. There is an imperative to understand the distinct experiences and situation of stateless persons and communities during the pandemic in order to generate evidence-based measures, responses and actions to specifically protect and respond to their needs. Hence, in order to better understand the unique position of European stateless populations during the COVID-19 pandemic, we conducted a scoping review to explore and assess the nexus between statelessness and health.

Material and methods

Scoping review methodologies are becoming progressively favoured across a variety of disciplines in recent years, and are generally used when a topic has not been extensively reviewed in order to map and describe extant information across a wide range of sources, designs and methodologies (Kirby, 2020; Levac et al., 2010; Arksey. and O'Malley, 2005). A rapid scoping review of extant literature on statelessness, health and COVID-19 in the 47 Council of Europe (CoE) member states was conducted using a six-stage step by step protocol to identify and analyse all relevant available sources of information (Levac et al., 2010; Arksey. and O'Malley, 2005; Landa et al., 2010). This iterative framework was as follows; (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarising and reporting the results. The underpinning research question was: ’ Key objectives were to map and describe all literature pertaining to the:

Barriers in access to healthcare faced by stateless people both generally and in relation to COVID-19, and how these may be similar to – or differ from – other minority and marginalised groups.

Impact of these barriers on health outcomes taking an intersectional approach to identify the different factors that may impact on the health rights and outcomes of stateless people.

Identification of common themes across different European/CoE countries to inform recommendations for policy responses that are relevant regionally and internationally.

Identification of the health nexus with statelessness that require further focused research and attention.

A comprehensive search of empirical and grey literature was independently conducted by one author (CB) using agreed detailed MESH terms (i.e. all categories of stateless person relevant to the European context, CoE member states; health, COVID), combined using Boolean terms and in English for the period 01–01–2020 to 12–04–2020. See Table 1 using the PICo framework. Searches were conducted using Liverpool John Moores University's electronic library (Pubmed, EBSCO, Web of Science, MEDLINE, PsycINFO, CINAHL, and Scopus).

Table 1

PICo Search Framework.

PICo concepts	#	Searches
Stateless populations of any age or gender, professionals working with stateless people and communities.
Population	1	migrant* OR stateless* OR ”irregular alien*” OR Refugee* OR Irish Traveller * OR Roma* OR “Romani*” OR “Gypsy*” OR Ethnic Russian*non-citizen* undocumented migrant* irregular migrant* Roma, Ashka(e)li and Egyptian’ * unknown nationality* undetermined nationality
Experience relating to COVID-19; health; health rights; general health; physical health; mental health; sexual and reproductive health, gender; health needs; health rights; health outcomes; barriers to access of health services; health policies and practices
Phenomena of Interest	2	(COVID* AND health* AND policy OR policies OR guideline* OR document* program* OR programme* OR service* AND scheme* OR law* OR legislation* OR regulation* AND OR* resolution* OR communication OR directive AND Health* AND need* OR right* OR outcome* OR status* OR access* OR health right* OR health disparity* AND gender* OR Sexual Orientation and Gender Identity (SOGI) AND child* OR elder)
Context relevant to stateless persons in Council of Europe member states
Context	3	(community* OR settlement* OR camp* OR halting site* OR direct provision* OR reception centre* OR direct provision* OR asylum accommodation* OR hotspot* OR refugee camp* OR detention setting* OR “prison*” OR “immigration detention*”) AND (Europe* OR Council of Europe *OR EU* OR Europe* country* OR Europe* union* OR Europe* region* OR Albania* OR Andorra* OR Armenia* OR Austria* OR Azerbaijan *OR Belgium OR Belgian* OR Bosnia and Herzegovina* OR Bulgaria* OR Croatia* OR Cyprus OR Cypriot OR Czechia* OR Czech Republic OR Denmark OR Danish OR Estonia* OR Finland OR Finnish OR France OR French OR German* OR Greece OR Greek OR Georgia* OR Hungary OR Hungarian OR Iceland* OR Ireland OR Irish OR Italy OR Italian* OR Latvia* OR Lithuania* OR Liechtenstein* OR Luxembourg* OR Malta OR Maltese OR Moldova OR Monaco OR Montenegro OR Netherland* OR Holland OR Dutch OR North Macedonia OR Norway OR Norwegian* OR Poland OR Polish OR Portugal OR Portuguese OR Romania* OR Russia* OR San Marino OR Serbia* OR Slovakia* OR Slovenia* OR Spain OR Spanish OR Sweden OR Swedish OR Switzerland OR Swiss OR Turkey OR Turkish OR “United Kingdom” OR England OR English OR Scotland OR Scottish OR Wales OR Welsh OR “Northern Ireland” OR “Northern Irish” OR Ukraine* OR Baltic* OR Albania* or North Macadonia)
Included literature
Research Type		• Quantitative • Mixed methods • Review • Qualitative • English language • Commentary or editorial • Grey literature • Policy briefs • Published between 01 and 01–2020 and 23–10–2020
Combining searches:	4	S1 AND S2 AND S3

Exclusion criteria centred on records found referring to other population groups; professionals not working with stateless people, studies that do not report health rights or experiences relating to COVID-19; Facilities or settings outside of the 47 CoE remit, languages other than English, published outside of the specific timeframe of the COVID-19 pandemic. Records were managed using EndNote, with duplicates removed manually. The title and abstract were independently screened by two members of the team (CB/MCVH). Following this process, all records deemed relevant were procured for review of the full text version. A second screening of the full text for each record was independently conducted. Studies were excluded at this stage if found not to meet the eligibility criteria. Reference lists were also manually searched by the team to identify any relevant studies not retrieved. See Fig. 1.

Fig. 1

Flow Chart.

Following application of exclusion measures, 30 records were charted and thematically analysed by two members of the team (CB/MCVH), as per Levac et al. (Levac et al., 2010). This process of documentation and analysis of information generated specific themes pertaining to stateless persons and communities affected by statelessness, health situation, healthcare access and uptake, health literacy and health outcomes during COVID-19 in the 47 CoE member states. A spreadsheet was created to chart relevant data (data collection categories, year of publication, author, location, method and aim, key findings and conclusion) and identify commonalities, themes, and gaps in the literature. We conducted a trial charting exercise of several records as recommended by Daudt et al. (Daudt. et al., 2013), followed by a team consultation to ensure consistency with the research question and the purpose of the scoping review. Based on this preliminary exercise, we developed prior categories, which guided the subsequent extraction and charting of the data from the records. All records were charted and analysed by two members of the team (MCVH/CB) in consultation with author two (NM), with any disagreements around theme allocation and stateless/group affected by statelessness resolved through discussion. Where additional data extraction categories emerged, consultation of the team (CB/MCVH/NM) guided decisions around allocation and reporting. To avoid imposing pre-existing frameworks onto the data, themes were developed using line-by-line inductive coding. Due to the predominance of commentaries, editorials, and variety of source material, validated quality assessment was unable to be conducted.

Results

Literature pertaining to stateless people specifically and populations disproportionately affected by statelessness was found representing ten Council of Europe countries. These were Bulgaria, Denmark, Greece, Ireland, Italy, Romania, Russia, Slovakia, Ukraine and the United Kingdom. Additionally, 15 publications were included which referred to multiple countries. Four publications specifically referred to the term stateless, and specifically discussed stateless people, and the remainder focused on groups disproportionately affected by statelessness in Europe. In order to present distinct information pertaining to statelessness, we present the review in two sections; firstly, a broader section of 26 records pertaining to groups captured in the search parameters who are disproportionately affected by statelessness, followed by a specific section presenting the four publications specific to the situation and experience of stateless people during the COVID-19 pandemic. This is in order to avoid any conflation between stateless people and wider groups disproportionately affected by statelessness i.e. refugees, migrants, Romani groups, ethnic Russians and other minority groups. See Table 2 which presents the charted records. We present the analysis in a series of themes, and for illustrative purposes where possible, quotes are presented from the included qualitative studies.

Table 2

‘Charted records’.

Citation	Type of Record	Population affected by statelessness	Country (Countries)	Method	Finding/Conclusion
J.G. Júnior., J.P. de Sales., M.M. Moreira., W.R. Pinheiro., C.K.T. Lima., M.L.R. Neto., 2020. A crisis within the crisis: The mental health situation of refugees in the world during the 2019 coronavirus (2019-nCoV) outbreak. Psychiatry Res 288: 113,000.	Journal: Letter to Editor	Refugees	Multiple	Description of the factors that can worsen the mental health of refugees as a result of the COVID-19 pandemicLiterature review	The difficulties faced by refugees with the COVID-19 pandemic are potentiated by the pandemic state. There are several risk factors common to coronavirus and psychiatric illnesses as overcrowding, disruption of sewage disposal, poor standards of hygiene, poor nutrition, negligible sanitation, lack of access to shelter, health care, public services, and safety. These associated with fear and uncertainty create a closed ground for psychological sickness and COVID-19 infection.
S. Logar., S. Leese., 2021. Childhood detention during COVID-19 in Italy: building momentum for a comprehensive child protection agenda. Int Health. doi:10.1093/inthealth/ihaa050	Journal Article -Commentary	Minor migrants	Italy	Overview of current situation within the Italian childhood detention system, and how this needs to be assessed in light of the pandemic	The COVID-19 pandemic calls for a comprehensive childhood protection plan for the prison and detention system.
C. Mesa Vieira., O. H. Franco., C. Gómez Restrepo., T. Abel., 2020. COVID-19: The forgotten priorities of the pandemic. Maturitas, 136, 38–41. doi:10.1016/j.maturitas.2020.04.004	Journal Article -Commentary	Prison and homeless populations; Migrants	Multiple	Overview of the difficulties faced for chosen population during the pandemic	The distinct risk factors and health needs experienced by these populations must be included in COVID-19 responses.
R. Armitage., L. Nellums., 2020. COVID-19 and the Gypsy, Roma and Traveller population. Public Health 185: 48.	Journal: Letter to Editor	Roma and Travellers	Multiple	Examination of the factors which place population at higher risk of COVID-19 contraction	Marginalised populations should be included in the public health response, and their needs met
R.S. Bhopal., 2020. COVID-19: Immense necessity and challenges in meeting the needs of minorities, especially asylum seekers and undocumented migrants. Public health, 182, 161–162. doi:10.1016/j.puhe.2020.04.010	Journal: Letter to Editor	Asylum Seekers and Undocumented Migrants	UK	Overview of COVID impact on migrant populations	The needs and environments of this population needs to be recognised and addressed appropriately during the pandemic
R. Milkova., C. Larkins, 2020. Roma Childrens participants: shaping responses to COVID-19 in the EU and Bulgaria. University of Central Lancashire. http://clok.uclan.ac.uk/33616/1/4%20Roma%20Children%27s%20Participation%20-%20Covid-19%20and%20the%20EU.pdf	Report	Roma children and teens	Multiple	Survey with Roma teens who assess their view on the impact of COVID for them and their families	Preliminary results indicate that participatory practices that enable Roma children's participation in designing public health policy, services and responses are limited and pre-existing inequalities are deepening particularly during the pandemic.
E. Tsourdi., 2020. COVID-19, Asylum in the EU, and the Great Expectations of Solidarity. 32(2), 374–380. doi:10.1093/ijrl/eeaa023	Journal Article- Legal Commentary	Asylum Seekers	Greece	Gives a overview of situation in Greek refugee camps and details how COVID has affected the legal process of migration and human rights	Asylum seekers on Greek islands’ ‘hotspots’, where most are accommodated, face un-sanitary conditions. There is one shower for every 500 people, and one toilet for every 160. To collect their meals, they must queue in line for hours, with hundreds of other people around them. The situation is no better on the mainland. Refugee camps and accommodation facilities in Ritsona, Malakasa, and Kranidi were placed into quaran-tine in the course of April 2020 after hundreds of asylum seekers tested positive for COVID-19
K. L. Ramírez-Cervantes., V.Romero-Pardo., C. Pérez-Tovar., G. Martínez-Alés., M. Quintana-Diaz., 2020. A medicalized hotel as a public health resource for the containment of Covid-19: more than a place for quarantining. Journal of public health (Oxford, England). doi:10.1093/pubmed/fdaa129	Journal Article- Empirical Study	Migrants	Spain	Survey conducted with those who required hospitalisation in Hotel hospitals.	59% of those treated were migrants, with a poor housing meaning they could not quarantine effectivelyOvercrowding and poor housing make it very difficult to follow the guidelines for COVID-19 prevention
M.Aragona., A. Barbato., A. Cavani., G. Costanzo., C. Mirisola., 2020. Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties. Public Health 186: 52–56.	Journal Article- Empirical Study	Refugees	Italy	Estimation of the impact of the COVID-19–related lockdown on service utilisation and follow-up adherence in an Italian mental health outpatient service for migrants and individuals in socio-economic difficulties.Retrospective Cross-sectional study	All patients who visited the mental health outpatient service in the months of February and March in the years 2017–2020 were included in the study. To compare service utilisation before and after the lockdown, the number of patients who visited the mental health outpatient service for psychiatric interview were recorded. Follow-up adherence was calculated as the percentage of patients who visited in February and subsequently attended a follow-up visit in March of the same year.The number of patients who visited the outpatient service between February 2017 and February 2020 was continuously increasing. In March 2020, fewer patients visited the service for psychiatric interview, in line with the introduction of lockdown measures. In addition, the number of the patients who visited in February 2020 and returned for their follow-up visits in March 2020 declined from approximately 30% over the same months in 2017–2019 to 17.53% in March 2020.
S. Hargreaves., B. Kumar., M. McKee.,L. Jones., A.Veizis., 2020 .Europe's migrant containment policies threaten the response to covid-19. The BMJ (Clinical research ed.) 368: m1213.	Journal: Editorial	Migrants	Greece	Overview of the barriers faced by migrants during the pandemic	Reports that in parts of the Moria camp in Greece, outside the formal reception centre, there is one tap (and no soap) for every 1300 migrants and people are living amongst rubbish with poor or no sewagesystems. The numbers of showers and toilets are well below the recommended minimum standards for an emergency setting,with up to 5000 people without any access to water,showers, toilets, or electricity.It is imperative that migrants contained in camps and other high risk settings in Europe are included in national surveillance and response planning and activities. There must be zero tolerance of xenophobia and racism towards migrant groups.
E. Raju., S. Ayeb-Karlsson., 2020. COVID-19: How do you self-isolate in a refugee camp? International Journal of Public Health 65(5) 515–517.	Journal: Commentary	Refugees	Greece	Examination of the factors which directly influence refugees’ ability to adhere to COVID-19 guidance	Emphasises the necessity for international efforts to adopt a social protection strategy for marginalised and vulnerable populations.
H. H. P. Kluge., Z. Jakab., J.Bartovic., V. D'Anna., S.Severoni., 2020. Refugee and migrant health in the COVID-19 response. Lancet, 395(10,232), 1237–1239. doi:10.1016/s0140–6736(20)30,791–1	Journal: Commentary	Refugees	Multiple	Detail of the living conditions for refugees and migrants and the issues they face in complying to COVID-19 guidelines	An inclusive approach to refugee and migrant health that leaves no one behind during the COVID-19 pandemic should guide public health efforts. Refugees and migrants must be included in national public health systems, with no risk of financial or legal consequences for them.
I.I. Kassem., 2020. Refugees besieged: The lurking threat of COVID-19 in Syrian war refugee camps. Travel Med Infect Dis. DOI: 10.1016/j.tmaid.2020.101736	Journal: Letter to Editor	Refugees	Multiple	Examination of the circumstances in Syrian Refugee camps and how their population are at a higher risk of COVID-19	An increased support is needed globally for disenfranchised and vulnerable populations. Transparent and thorough investigations along with pre-emptive and inclusive control measures are urgently required to prevent and/or control the dissemination of COVID-19 in Syrian and other refugee camps worldwide.
D. Nott., 2020. The COVID-19 response for vulnerable people in places affected by conflict and humanitarian crises. Lancet, 395(10,236), 1532–1533. doi:10.1016/s0140–6736(20)31,036–9	Journal: Commentary	Refugees	Multiple	Details the need for more help for those in vulnerable areas in regards to healthcare and sanitation	N/A
P. Peprah., 2020. Ageing out of place in COVID-19 pandemic era: How does the situation look like for older refugees in camps? Archives of Gerontology and Geriatrics 90 104,149.	Journal: Letter to the Editor	Refugees	Multiple	Examination of the implications of lockdown on vulnerable ageing refugees	Information needs to be accessible to all, and delivered in culturally and linguistically responsive ways in order to reduce the level of misinformation amongst older refugees. Complex terminologies should be avoided, and social protection strategies need to be in place to limit the life threatening consequences of COVID-19 amongst older populations.
A.Neef., 2020. Legal and social protection for migrant farm workers: lessons from COVID-19. Agric Human Values, 1–2. doi:10.1007/s10460–020–10,086-w	Journal: Commentary	Migrant	Multiple	Examine the difficulties faced by migrant workers and how they access healthcare	A higher emphasis needs to be placed on the human rights of migrant workers and an assurance of legal and healthcare rights are adhered to
L.C.N. Wood., D. Devakumar., 2020. Healthcare access for migrant children in England during the COVID-19 pandemic. BMJ Paediatr Open 4(1).	Journal: Commentary	Migrant Children	UK	Examine migrant children's access to healthcare in the UK	A number of conclusions and recommendations were presented including:• All migrant children must have the same access to healthcare as British nationals with immediate and ongoing effect. • All migrants must have access to NHS healthcare for ALL necessary treatments and preventative healthcare without cost during the course of the COVID-19 pandemic and ongoing. • A firewall between the NHS, justice services and immigration must be urgently established. • The healthcare surcharge for non-EEA migrants requires urgent review due to the risk of impoverishment of low-paid workers and their dependents during a season of severe economic instability. • Research into the risks of COVID-19, social determinants of health, systemic racism, hostile policies and hostile indifference towards migrant health outcomes must be ongoing and considered through a child rights framework.
M. Matache., J. Bhabha., 2020. Anti-Roma Racism is Spiralling during COVID-19 Pandemic. Health & Human Rights: An International Journal 22(1) 379–382.	Journal: Commentary	Roma Populations	Romania	Details the measures taken against Roma populations and their impacts	To prevent the spread of COVID-19 in all communities, government responses must be informed by human rights principles that protect the most vulnerable, both in the short term and thereafter. An essential aspect of this approach is to seriously and vigorously tackle the structural, racial, and social inequalities that continue to expose Romani people to greater risks of poor health, in times of emergency as much as outside of them.
I. Gherghel., M. Bulai., 2020. Is Romania ready to face the novel coronavirus (COVID-19) outbreak? The role of incoming travelers and that of Romanian diaspora. Travel Med Infect Dis, 34, 101,628. doi:10.1016/j.tmaid.2020.101628	Journal: Letter to Editor	Roma Populations	Romania	Details travel restrictions within migratory populations in Romania	Increased migratory populations and a vulnerable health system result in the recommendation for stricter travel measures in order to prevent the spread of COVID-19 between countries,
Q. Alemi., C. Stempel., H. Siddiq., E. Kim.,2020. Refugees and COVID-19: achieving a comprehensive public health response. Bull World Health Organ, 98(8), 510–510a. doi:10.2471/blt.20.271080	Journal: Editorial	Refugees	Multiple	Examination of what is needed to provide a comprehensive public health response to COVID-19 within refugee populations	As resources are constrained, agencies and professionals serving refugees should consider giving priority to screening vulnerable subgroups to manage comorbidities more effectively, encourage patients to reduce high-risk behaviour, provide treatment and reduce transmission rates; Encourage care providers and leaders to dispel fear and stigma; Ensure mental health implications are also taken into consideration
J.J. Amon., M. Wurth., 2020. A Virtual Roundtable on COVID-19 and Human Rights with Human Rights Watch Researchers. Health Hum Rights, 22(1), 399–413.	Journal: Virtual Roundtable	Refugees	Multiple	Discussion amongst experts from a variety of countries detailing how COVID is effecting the refugees in those areas and references xenophobia against refugees.	Challenges are posed in all countries and settings for those trying to ensure refugees’ human rights are upheld during the COVID-19 pandemic
E. Holt, 2020. COVID-19 lockdown of Roma settlements in Slovakia. Lancet Infectious Diseases 20(6): 659.	Journal: Commentary	Roma people	Slovakia	Details the governmental actions taken against Roma settlements in Slovakia	In April 2020 the government sealed off 6000 people in five separate settlements in the towns of Krompachy, Bystrany, and Zehra in the east of the country after infections were identified.Use of the Armed Forces was condemned by local Roma Organisations, and reports of a lack in basic provisions and food were brought forward.
I. Nechepurenko., 2020. For migrants in Russia, virus means no money to live and no way to leave. June 24th 2020. Available at https://www.nytimes.com/2020/06/15/world/europe/russia-coronavirus-migrant-workers.html	Online News Article	Migrants	Russia	To detail the struggle for migrant workers who are stranded in Russia, with poor conditions and increasing COVID rates.	The discrimination long endured by the migrants may have become even more pronounced during the coronavirus crisis, with basic health care sometimes denied them. This needs addressing at a governmental level
V. Heaslip., J. Parker., 2020 Breakdown of the issues faced by Gypsy, Roma and traveller communities during the COVID outbreak. August 18th 2020. Available at https://theconversation.com/the-hidden-impact-of-coronavirus-on-gypsy-roma-travellers-141015	Online News Article	Roma and Travelling communities	UK	Breakdown of the issues faced by Gypsy, Roma and traveller communities during the COVID outbreak	The population's specific ethnicity needs to be included in Public Health England's reports on COVID-19 health disparities, meaning full impact will remain hidden.
J. Villani., P. Daly., R. Fay., L. Kavanagh., S. McDonagh., N. Amin. 2021. A community-health partnership response to mitigate the impact of the COVID-19 pandemic on Travellers and Roma in Ireland. Global Health Promotion, March 3rd 2021 doi:10.1177/1,757,975,921,994,075.	Journal Article- Empirical Study	Roma and Travelling communities	Ireland	Evaluation of three community and partnership-led responses to health promotion strategies and health inequality for the Roma and Traveller communities during the first 3 months of the Pandemic (March-May2020)	COVID-19 crisis has also exacerbated gender inequities as Travellerwomen have been disproportionately exposed to risks, especially those living in socioeconomicallyfragile circumstances.Community-health partnerships between minority groups’ organisations and healthcareprofessionals represent a viable approach to mitigate the disproportionate effects of a pandemic onTravellers and Roma.
Citation	Type of Record	Statelessness persons and communities	Country(Countries)	Method	Finding/Conclusion
Institute on Statelessness and Inclusion (ISI)., 2020. Impact Report 2020. June 2020, ISBN: 9789082836677Available at info@institutesi.org	Report (Online)	Stateless People	Multiple	Overview of all the issues faced by stateless people during the pandemic	In the context of a global pandemic, stateless persons are more vulnerable than ever. The relationship between the state and the stateless vacillates between enforced invisibility and targeted persecution, and unless this relationship is urgently challenged, the COVID-19 impact on the stateless will be immense and – for many - irreversible. There are an estimated 15 million stateless persons worldwide, whose urgent needs must be highlighted, to ensure they are included in COVID-19 preparedness, response and mitigation efforts.ISI commit to 4 steps: Ensure; Call out, challenge and demand; Stand in solidarity; and Strengthen collaboration and ties
N. Murray., 2020. Stateless People and COVID-19: What happens to people with no nationality in a public health crisis? 25th May 2020. Available at https://www.rosalux.de/en/news/id/42,332/stateless-people-and-covid-19?cHash=9fab12f49e9b0268e4dde0481acc4a26	Report (Online)	Stateless Populations	Multiple	Explanation of the issues faced by stateless populations, and the vast issues around this.	Stateless populations are at increased risk of contracting COVID-19 due to poor sanitation and lack of basic healthcare. Additionally an increase in racism and vilification reduces mental wellbeing
I. Garza,. 2020. How can we ensure access to health for the stateless during times of COVID-19? 31st May 2020. Available at https://oneill.law.georgetown.edu/how-can-we-ensure-access-to-health-for-the-stateless-during-covid-19/	Online Article	Refugees; Stateless populations	Multiple	Overview of the issues around accessing healthcare when stateless	Improvements need to be made in ensuring access to healthcare, sanitation, food, safe shelter and education
United Nations High Commissioner for Refugees., R2P, 2020. Access of stateless persons to medical care during the COVID-19 and assessment of the economic and social impact of the lockdown measures. https://reliefweb.int/report/ukraine/access-stateless-persons-medical-care-during-covid-19-and-assessment-economic-and	Report- Empirical Study	Stateless Populations	Ukraine	Assessment of stateless peoples’ access to healthcare and servicesSurvey carried out with 189 stateless people living in 13 regions of the Ukraine	92% reported not having a family doctor of their choice43% went to a medical institution to sign a declaration, but they were refusedThe majority of those interviewed (73%) need humanitarian assistance such as medicines and medical supplies, food and hygiene items, etc.31% of respondents reported that their financial situation would not suffice even for food during the lockdownAn improvement needs to be made on providing easily accessible healthcare for stateless people

Section I: groups disproportionately affected by statelessness

This section presents the impacts of COVID-19 on groups disproportionately affected by statelessness during the COVID-19 pandemic, and recognises explicitly that these published records describe or refer to the challenges that these groups face, and so, by analogy, some stateless people will also face. Three themes emerged from the analysis of this literature, and are relevant for refugees, migrants, Romani people and ethnic Russians, with higher level abstraction centring on the nexus between existing adverse environmental determinants of health, compounded barriers to access to healthcare during COVID-19; and the concerning rise in hate crime and scapegoating of these groups during the COVID-19 emergency.

Environmental determinants of health

From the review carried out, 16 publications detailed the complex environmental circumstances groups disproportionately affected by statelessness reside in, and how these circumstances leave their inhabitants at a greater risk of contracting COVID-19 and other health conditions. Of the publications analysed, 15 of these specifically discussed how sanitation, communal habitation and detention status directly implicate an individual's ability to adhere to the public health guidance around isolation, increased sanitation and quarantining during the pandemic. A selection of publications focused on migrant and refugee populations, with eight studies specifically detailing the public health issues associated with refugee camps or detention settings. Across all eight studies, the living conditions within immigration detention or camp settings were deemed fundamentally detrimental to the health of those who inhabit them. Hargreaves (Hargreaves et al., 2020) described the conditions in the Moria camp (Greece) as having ‘one tap, with no soap for every 1300 migrants, and people living amongst rubbish with poor or no sewage systems’. Personal hygiene is also hard to maintain ‘with up to 5000 people currently without any access to water, showers, toilets or electricity’ (Hargreaves et al., 2020). Taking these factors into consideration, the ability of migrants and refugees to adhere to the stricter sanitation and distancing requirements as a result of the COVID-19 outbreak is questionable within these settings (Tsourdi, 2020; Kluge et al., 2020; Nott, 2020). Raju (Raju and Ayeb-Karlsson, 2020) furthers this by discussing the ‘temporary’ nature of refugee camps as being a key issue in the prevention of COVID-19 and other infectious diseases. This is due to the environment's infrastructure having never been designed to house large numbers of people. long term, resulting in a lack of sanitation facilities and physical space for their inhabitants (Raju and Ayeb-Karlsson, 2020). Peoples environmental lack of space can be seen to heavily affects their ability to comply with the World Health Organizations (WHO)’s COVID-19 guidelines of two metres physical distancing, and thereby increases the populace's risk of infection (Logar and Leese, 2021; Vieira et al., 2020; Ramírez-Cervantes et al., 2020).

Environmental factors and their public health implications within Roma and Traveller populations are represented by two studies. Armitage explains how the communities’ ‘living conditions also reduce engagement of these groups with mitigation measures, such as regular hand washing, physical distancing and accessing health care’[34]. To expand on this, for some of these groups, for example, in the UK, there are a broad range of additional factors that have been heavily implicated by the introduction of COVID-19 restrictions. Many Roma and Traveller communities in the UK, for example, reside on private or local authority authorised sites, which have limited or no permanent fuel and waste disposal provisions (Heaslip and Parker, 2020). The communities’ reliance therefore on gas canisters and external fuel sources is integral to their ability to provide a safe and comfortable environment within their living space, as well as heat water, make meals and heat their homes. Additionally, the majority also rely on accessing external sanitation and waste disposal facilities. The global restrictions placed on travel and containment of many settlement sites, has resulted in communities being unable to access fuel, and experiencing difficulty when trying to dispose of their waste. As well as the practical difficulties in accessing basic provisions, the enforcement of social distancing within these communities can be difficult to comply with, as for many, they do not have the available space to do so. Heaslip and Parker also detail that ‘these communities often have a very strong family culture, and many live in large, extended family groups. This culture is an important protective mechanism against the harsh stigma and discrimination they face in wider society’ (Heaslip and Parker, 2020) which further reduces their likelihood to maintain social distance guidelines, without feeling it is detrimental to community values and traditions.

A further prominent barrier was discussed in Junior's publication, which highlights the issues around language and access to information. Many may find they have difficulty accessing information due to their environmental circumstances (e.g. no internet, media or health care information in some settings), or may not be able to understand information due to a language barrier (Júnior et al., 2020). Additionally, amongst certain groups, the level of literacy is lower than the national average, further reducing health message comprehension if only distributed via written sources (Armitage and Nellums, 2020). The limitations in travel have meant that for many migratory populations, they have found themselves stranded in other countries, or for those who rely on travel for work, they have suffered a significant reduction in income and employment (United Nations High Commissioner for Refugees, 2020; Gherghel, 2020; Nechepurenko 2020). This lack of income and permanent residency puts them in an intensely vulnerable position, particularly during the pandemic.

Access to healthcare services

Nine studies detailed the issues faced by groups disproportionately affected by statelessness in accessing healthcare services during the COVID-19 pandemic. In some countries, access to healthcare is made dependant on having certain identity documents and/or residence status, which many stateless people do not have. This issue is one that has only been exacerbated during the COVID-19 pandemic, with many being further hindered when trying to access healthcare, an even more vital resource given the understanding of increased risk of COVID-19 for this population. Wood discusses the requirements within the UK for migrant populations to access healthcare, and how for many who are included in specific fee-exemption groups, adult and child migrants are able to register for healthcare services, regardless of immigration status (Wood and Devakumar, 2020). However, Wood explains how ‘all individuals outside of these exemption groups, including undetected international human trafficking victims, non-EEA migrants with a visa for less than 6-months stay and those without lawful residence (including visa overstayers) may be charged for NHS care at 150% tariff. This includes charges for maternity and paediatric care’ (Wood and Devakumar, 2020). The healthcare charges in many countries, can be seen as a fundamental barrier to the likelihood of some people accessing them when needed, as many do not have the ability to pay for medical care. The ability of groups disproportionately affected by statelessness to access healthcare is a recurrent theme throughout the literature, although there are publications that highlighted the particular increased vulnerability of the elderly. Evidence suggests that older people in particular are at a higher risk of developing severe complications, morbidity and mortality related to the coronavirus, and the provision for healthcare for these individuals should be prioritised (Peprah, 2020).

As well as physical health implications associated with being a member of a group disproportionately affected by statelessness, studies have looked at the mental health impact on specific groups during the COVID-19 outbreak. Junior et al. conducted a literature review, which showed that primarily, the difficulties faced by refugees on a daily basis are exacerbated by the pandemic state, with many of them unable to alter their environment to reduce the risk of contamination (Júnior et al., 2020). This inability to control their circumstances can lead to anxiety and fear, and an increase in poor psychological health, which cannot be addressed due to the limited healthcare facilities, and reduced access to mental health resources. The uptake of mental health services within the immigrant population in Italy prior to, and during, the COVID-19 lockdown has been examined by Aragona et al. who reported a 12% reduction in patients attending follow up appointments during March 2020 (when compared to the same time period in previous years) within an Italian mental health service (Aragona et al., 2020). This reduction was seen as detrimental to treatment completion and posing an increase in risk for potential relapse amongst vulnerable patients (Aragona et al., 2020). Four publications made reference to the importance of recognising the mental health implications of the pandemic, and subsequent lockdown restrictions in some capacity.

During the COVID-19 pandemic, healthcare provision has seen a huge increase in demand resulting in a further reduction in available health service provision for groups disproportionately affected by statelessness. The demand on non-governmental organisations addressing gender-based violence increased during the pandemic. This is highlighted in a recent study examining Roma and Traveller families in Ireland which found that ‘NGOs’ reports revealed that Traveller women have been impacted by a rise in domestic violence during the pandemic’ (Villani et al., 2021). Increased restrictions have further reduced the number of voluntary organisations able to access refugee camps and detention facilities, for example. These organisations are often heavily relied upon to provide basic medical care, counselling and other aid (Raju and Ayeb-Karlsson, 2020), and their inability to attend is creating further issues for those who require their assistance.

This is also the case for governmental services and drop-in centres, which have seen a huge reduction in volunteers and supplies as a direct result of the enforced quarantine. Many of these are the only source of healthcare provision for groups disproportionately affected by statelessness, particularly if they do not have the required documentation to attend mainstream healthcare and services as previously mentioned.

Racism and vilification

Four records examined the societal implications faced by groups disproportionately affected by statelessness as a result of the COVID-19 pandemic. All four touched on an increased level of racism towards their specified population. Matache and Bhabha specifically detail the increase in anti-gypsyism stating that ‘From Slovakia to Romania and Bulgaria, states have enacted disproportionate or militarized measures targeting Romani neighbourhoods or towns. Some of these measures are driven by a racist narrative that casts Roma as a collective health and safety threat. The Bulgarian government has imposed particular measures, including road blocks and police checkpoints, on several Romani neighbourhoods despite no evidence of COVID-19 positive test results there.’ (Matache and Bhabha, 2020) The deliberate segregation of Roma populations is further exemplified by Holt who presented the instances in Slovakia where the government sealed off entire Roma communities, and introduced military personnel to carry out testing amongst the population (Holt, 2020). This containment approach and the increased military involvement is argued to have increased stigma, fear and discontent towards Roma populations from other communities, and has caused distrust amongst Romani people towards the authorities.

This vilification is not exclusively reported amongst Romani populations, with studies reporting that fear of stigma or increased restrictions amongst refugee communities, is thought to be one of the primary reasons refugees are failing to report infections, and thereby increasing positive COVID-19 outcomes within their communities (Kassem, 2020; Amon and Wurth, 2020). Additionally, the underlying fear of segregation, prosecution or deportation, further deters stateless persons from accessing much needed health care (Bhopal, 2020; Alemi et al., 2020). Kaseem described how ‘COVID-19 has ignited fears in many communities and reactions to patients or potential carriers of the virus have not been always charitable. Furthermore, it is well known that certain hosting countries established curfews and implemented deportations of unregistered refugees even before the onset of the pandemic’ (Kassem, 2020). This ‘heavy handed’ approach directly impacts on whether refugees will seek medical attention, as well as potentially increasing the risk of further mental health implications for the communities who feel stigmatised.

Section II: stateless people and communities

This section describes literature where the specific impacts of the COVID-19 crisis on stateless people are the central focus, as distinct from the wider populations they may belong to, discussed in Section I. Of the four publications that specifically referred to the experience of stateless populations, all described the difficulties faced as a result of the lack formal documentation and residence or nationality status. The requirement of many countries to have such documentation in order to access healthcare is underscored within the publications. A survey carried out by Ukrainian NGO, Right to Protection (R2P), found that 43% of stateless persons in Ukraine surveyed during the pandemic were denied access to a family doctor due to lack of identity documents (United Nations High Commissioner for Refugees, 2020). Additionally, the Institute on Statelessness and Inclusion reported that there is almost no access to healthcare in Ukraine for stateless persons with chronic diseases or disabilities due to lack of documents, and undocumented people can only seek emergency treatment (M. Institute on Statelessness and Inclusion (ISI) 2020).

As well as access to healthcare, publications reported how travel restrictions have impacted on migrant populations, leading to stateless people being stranded in other countries. Furthermore, for those who are reliant on travel in order to earn a living, the restrictions in place have meant that many are now out of work and stranded in neighbouring countries, unable to return until restrictions are lifted (United Nations High Commissioner for Refugees, 2020). For stateless people who do not have required identity documentation, this is a further issue when trying to prove their residence status, or country of origin. The Institute on Statelessness & Inclusion state that “In the context of COVID-19, movement restrictions should not be based solely upon citizenship, but also take due account of other factors – such as ties to, or residence in a state. States should ensure that stateless persons with strong ties to a territory, including residence status, are allowed to return.”

Stateless people who are detained in immigration detention centres often have complex cases where specialist legal advice is needed; however, due to the lockdowns in place as a result of the pandemic, there has been less access to legal advice, support services and detainee visits. In Belgium, for example, NGOs have been unable to visit or provide legal assistance to detainees (M. Institute on Statelessness and Inclusion (ISI) 2020), resulting in prolonged detention and further risk of exposure to the virus due to the environmental factors associated with this type of facility.

The theme of segregation of particular ethnic and cultural groups, particularly Romani populations, is again highlighted in North Macedonia and other countries in the Western Balkans, with publications reporting extreme hardship, police violence, ethnic profiling and hate speech having increased in prevalence since the COVID-19 outbreak and ensuing restrictions were put in place (Murray, 2020). Murray's publication specifically references stateless persons, and states that ‘Undocumented and stateless women and girls, for example, are at disproportionate risk of domestic abuse and exploitation. There must be urgent investment in guaranteeing equal access to civil documentation and nationality rights as an integral part of the wider fight against discrimination in all its forms’ (Murray, 2020).

The Institute on Statelessness & Inclusion, when discussing examples of xenophobic, and discriminatory actions in Bulgaria states that “these drivers of exclusion, could have lasting implications for the treatment of vulnerable populations – minorities, migrants and refugees who face the brunt of racism and xenophobia. When these groups are also stateless, their nationality is contested or they face the risk of arbitrary deprivation of nationality, the impact can be even greater. The relative invisibility of vulnerable groups, especially the stateless who are also legally invisible, both catalyses and reinforces structural discrimination and unequal treatment, leading to further marginalisation. As the pandemic compounds pre-existing discrimination, it also lays bare the need for deeper rooted reform, which involves addressing systemic discrimination rooted in racism, xenophobia and patriarchy” (M. Institute on Statelessness and Inclusion (ISI) 2020). The combination of factors which can contribute to stateless persons being overlooked during this pandemic, are ones which need to be addressed in order to ensure health equality (Garza 2020).

Discussion

The scoping review represents a unique and first step toward mapping available literature on the situation of groups disproportionately affected by statelessness, and where possible stateless people and communities during COVID-19 in CoE countries. It focuses on an important topic, namely the nexus between health and statelessness during this public health emergency. We have presented a broad overview for experts and stakeholders in the field, based on records published during the COVID-19 timeframe that specifically focused on statelessness and health; and literature published during this period on groups who are ‘disproportionately affected by statelessness’ (i.e. refugees, migrants, Roma, ethnic Russians and other minority groups). Its contribution to the field is twofold. Firstly, it summarises and highlights the extraordinary risk of health rights violations experienced by stateless people and the wider groups they belong to during the pandemic, and, secondly, it draws attention to what is still a clear lack of specific empirical evidence on stateless people themselves, their experiences, and their health disparities within the experiences of the wider population groups they belong to, and the lack of State attention being paid to this issue.

Strengths centre on the thoroughness of the review approach in terms of its multi-layered strategies to locate all forms of information specific to stateless people and inclusive of groups disproportionately affected by statelessness. We recognise the presence of limitations centring on its restriction to published material in the English language, and the relative lack of data sources with only nine European countries within the 47 countries in the CoE represented. The review has highlighted a severe lack of research focus specifically on the health situation of stateless persons and communities, with only four publications explicitly referencing stateless persons during the COVID-19 pandemic times.

Whilst the right to healthcare is a fundamental human right, with universal application, and with access to healthcare services ensured to every human being without regards to race, religion or other criteria, including legal status, this appears not to be the case for groups that include stateless persons during the COVID-19 pandemic. The right to a nationality (and realisation of the right to health and access to healthcare/public services) in the current pandemic times is crucial in a targeted effective and culturally sensitive public health response. The review further highlights the need to protect stateless people. We further cannot underestimate the need for sensitive legal, health and social response measures to tackle disease transmission in vulnerable stateless groups, continued statelessness of people in Europe, and hate crime, xenophobia and discrimination of those perceived to be at risk of contagion.

The review reveals a lack of targeted provision of information and services to support their right to health and help seeking, barriers to access to health services (language, health literacy and logistical), and the presence of discriminatory systems and multiple oppressions faced by groups that include stateless people in Europe during this health emergency. Wider social, structural and environmental determinants of health centre on the significant rise in evictions, scapegoating and hate crime during COVID-19, poor and congested living conditions, lack of sanitation and hygiene, and chronic ill health and stress, all of which compound health disparities during the pandemic. The review further highlights health vulnerabilities pertaining to context, whether in densely populated areas, such as camps, collective shelters and informal settlements, or in immigration detention settings. Furthermore, the long-term negative impacts of racism, xenophobia and antigypsyism on the institution of citizenship and law and policy in this area, may increase the number of new cases of statelessness that emerge in the years to come.

It is now an imperative that the situation of stateless people is addressed. The protection of stateless people in Europe from the catastrophic effects of COVID-19 warrants a multi-dimensional legal, health and socio-economic response. The right to a nationality (and full realisation of the right to health and access to healthcare/public services) in the current pandemic times is crucial in the public health response. The requirement for an inclusive human rights and public health response is further underpinned by the joint statement by UN bodies emphasising that the “primary focus should be on the preservation of life, regardless of status”[17]. Given the deadly nature of COVID-19 in people with underlying health conditions, alongside the unique health risks and discrimination already evidenced in stateless communities, this is an imperative. Assurance of health rights during and after COVID-19 includes the upholding of protection of life and health for all via mitigation measures in camps, shelters, settlements, immigration detention settings; right to information, equal treatment and non-discrimination of all, irrespective of their immigration and citizenship status; the non-discriminatory provision of essential medicines, prevention, and treatment in a non-discriminatory manner; right to privacy of medical records; the support of right to work and social protection; State commitment to combat racism, xenophobia, antigypsyism and stigma; and the upholding of norms of due process in immigration and international protection processes which may not increase risk to health and life due to transmission of COVID-19 (Nechepurenko 2020). Public health information must be communicated in a timely manner as government guidance changes, the correct language, using visual means is useful, presenting practical information, and reaching all stateless persons in Europe (Zolberg Institute 2020). Stateless persons and their communities, no matter the setting, must be provided with personal protective equipment (masks) and other basic necessities (handwash, soap, clean water).

Measures should focus not only on the immediate prevention of transmission and containment of outbreaks of COVID-19 amongst stateless communities and wider population groups, but centre on leveraging the COVID-19 pandemic to secure policy reform and the end of historical exclusion of stateless persons. Inclusive polices and measures to support all during COVID-19 does not necessarily translate to inclusion in practice, given the often precarious residence and nationality status of stateless persons, contributing to a reluctance or fear of help seeking grounded in mistrust of authorities, fear of detention or deportation (M. Institute on Statelessness and Inclusion (ISI) 2020). Statelessness determination procedures, other immigration, nationality, and international protection procedures, and civil registration and documentation procedures must continue during this public health emergency. States are further advised to address the risk of arbitrary detention faced by stateless persons with full access to rights and services whilst providing sufficient housing, health and social care supports on release [(European Network on Statelessness (ENS) 2017; Byrne et al., 2020)].

Lastly we cannot underestimate the transmission routes of disease within the wider public health dimensions, nor can we continue to ignore the need for informed and culturally sensitive health and social response measures to tackle the potential for discrimination against those perceived to be a cause of contagion. Scapegoating particularly in the case of Roma is a serious concern. The State enactment of disproportionate or militarised measures targeting Romani neighbourhoods or towns (for example in Bulgaria and Slovakia) based on an antigypsyist narrative exemplifying Roma as a health threat are to be condemned [(Matache and Bhabha, 2020; Organization for Security and Co-operation in Europe (OSCE) 2020; Milkova and Larkins, 2020; Council of Europe (CoE) 2020)]. Notwithstanding the health harms in disease spread, the mental health impact of statelessness and its detrimental impact on access to healthcare cannot be underestimated and requires dedicated action planning [(M. United Nations High Commissioner for Refugees (UNHCR) 2020; United Nations (UN) 2020)]. Additional impacts regarding gender based violence during COVID-19 restrictions cannot be ignored.

Conclusion

Whilst the right to healthcare is a fundamental human right, with universal application and with access to healthcare services ensured to every human being without regards to race, religion or other criteria, including nationality status [(United Nations High Commissioner for Refugees (UNHCR) 2008; Rechel et al., 2013)], the review underscores that this appears not to be the case for groups disproportionately affected by statelessness. Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) stipulates everyone's right to healthcare and States are under an obligation to respect this right by “refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and irregular migrants” (UN Committee on Economic, Social, and Cultural Rights (CESCR) 2000). Environmental, social and structural determinants of health that fuel the health disparity of these groups (Marmot et al., 2012) including the rise in hate crime and scapegoating are crucial to address during and beyond COVID-19.