Human Rights Violations and Mistrust among Refugees in South Africa: Implications for Public Health during the COVID Pandemic

Abstract

Despite the open policy of integration, refugees in South Africa have been experiencing increasing exclusion and discrimination in socio-economic development and from social services. State-sanctioned discrimination contributes to mistrust among marginalized groups toward the government and its institutions. However, public trust towards healthcare authorities and government institutions is critical during pandemic outbreaks to ensure the population’s willingness to follow public health initiatives and protocols to contain the spread of a pandemic. Eleven key informants, including refugee community leaders and refugee-serving NGOs, were virtually interviewed about refugees’ access to healthcare in South Africa during the COVID-19 pandemic and the consequences of inconsistent access and discrimination on their trust of public healthcare initiatives. Interviews were analyzed using critical thematic analysis. The results suggest that refugees’ access to public healthcare services were perceived as exclusionary and discriminatory. Furthermore, the growing mistrust in institutions and authorities, particularly the healthcare system, and misperceptions of COVID-19 compromised refugees’ trust and adherence to public health initiatives. This ultimately exacerbates the vulnerability of the refugee community, as well as the wellbeing of the overall population.

1. Introduction

Systemic discrimination and exclusion of indigenous and minority groups has a number of negative consequences. Not only are these populations then less able to access needed resources, but the experience of injustice contributes to increasing mistrust in the government and authorities (Rahn and Rudolph 2005; Wilkes 2015). The pervasiveness of these practices also feed on themselves, increasing levels of discrimination and exclusion over time (Gordon 2016). The current paper focuses on the situation of refugees in South Africa, who experience both systemic and community discrimination, as well as the potential consequences of this discrimination for their long-term integration and relationships with government and communities. This study examines refugees’ experiences of accessing healthcare during the COVID-19 pandemic in South Africa and explores how experiences of inconsistent access and discrimination affect their trust in public healthcare responses to the pandemic.

In South Africa, refugees and asylum seekers, despite different legal status, are permitted to integrate, be self-sufficient, access essential health services and basic primary education, and have the right to employment and legal protection (Refugees Act 1998). However, research indicates that refugees in South Africa have been excluded from accessing a range of essential resources and services, including access to social development programs, employment, and social and health services, as well as the ability to seek asylum protection, citizenship, and permanent residency (Amit 2022; Kavuro 2015; Khan and Lee 2018). It has been argued that these exclusions are an intentional extension of the government’s desire to reduce protections for asylum seekers (Amit and Kriger 2014; Crush et al. 2017). In these circumstances, unlawful practices become policy and law unto themselves, and anti-migrant attitudes increase at all levels, including at the policy, institutional, and society levels (Crush et al. 2017; Zanker and Moyo 2020). Gordon (2016) argued that public hostility towards refugees stirs anti-immigrant violence and prejudice, which jeopardizes the immediate safety of refugees in South Africa and their livelihoods.

The South Africa Constitution stipulates that everyone, including refugees, has the right to have access to healthcare services (Section 27 of Constitution of Republic of South Africa 1996). However, refugees experience exclusion and discrimination in accessing healthcare services (Crush and Tawodzera 2014; Zihindula et al. 2017). This includes discrimination based on documentation and language (Meyer-Weitz et al. 2018; Munyaneza and Mhlongo 2019). Refugee permits and asylum visas indicative of non-citizenship have justified withholding services and discrimination against refugee clients, despite the illegality of this discrimination (Zihindula et al. 2017). Experiences of verbal and physical harassment, as well as a lack of attention to refugees and migrants by healthcare services, have also been widely reported (Crush and Tawodzera 2014; Zihindula et al. 2015). In fact, refugees are often accused of overburdening the country’s strained public healthcare system (Alfaro-Velcamp 2017). This situation of state-sanctioned discrimination contributes to growing mistrust among refugees toward the institutions and communities in South Africa, further increasing their exclusion (Tesfai et al. 2022).

This exclusion and discrimination of refugees cannot be evaluated separately from the structural discrimination vulnerable groups experience, globally, when accessing social services. Structural discrimination refers to institutional practices and policies that disadvantage vulnerable groups; in our case, this refers to refugees and migrants (Corrigan et al. 2004). The practice can be intended and/or unintended discrimination. The former entails rules, policies, and practices at institutions of health that intentionally limit a groups’ rights to access public healthcare. For example, a study by Zihindula et al. (2017) found only five of twelve reviewed health policy documents in South Africa made provision for refugees’ rights to access health services. Furthermore, language barriers, services providers’ hostile attitude, and less attention mounted to medical xenophobia, i.e., deliberate acts of discrimination against refugees (Crush and Tawodzera 2014; Zihindula et al. 2015), contributed to intentional structural discrimination. Furthermore, public and private sector policies can restrict opportunities or the right to access services for minority groups in unintended ways (Corrigan et al. 2004).

South Africa’s response to the COVID-19 pandemic has deepened existing inequalities between refugees and other South African residents, as well as the economic suffering of refugees and asylum seekers (Mutekwe 2022; Mukumbang et al. 2020). Refugees and migrants have also been excluded from the planned response to COVID-19, e.g., only a limited number have benefited from the Social Relief of Distress (SRD) Grant (Tesfai and de Gruchy 2021). Moreover, Refugee Reception Offices were deemed non-essential services and were thus closed as part of the emergency responses taken against the pandemic (Tesfai and de Gruchy 2021). Refugees’ permits and asylum visas are entry documents to social services but could no longer be renewed, resulting in a loss of service access. Despite the DHA periodically extending the validity of expired documents, service providers did not comply and denied refugees services, claiming their documents had expired (Khan and Kolabhai 2021). It is thus not surprising to learn that migrants faced unique barriers during the COVID-19 pandemic, including access to needed health services (Bisnauth et al. 2022).

This paper argues that persistent discrimination and exclusion of refugees and migrants from healthcare services leads to increased political mistrust towards state institutions, including the public healthcare system, which can undermine the success of public health interventions, exacerbating the vulnerability of migrant populations, as well as the wellbeing of the overall population. The aim of this study is, therefore, to examine access to healthcare of refugees in South Africa during the COVID-19 pandemic and the consequences of inconsistent access and discrimination refugees experience on their trust in public healthcare initiatives.

Trust and Public Health

In the simplest terms, having trust in others or in institutions means individuals have a belief or expectation that the others or institutions in which they are embedded will fulfil promises or duties (Alesina and Giuliano 2015). There are two forms of trust, i.e., political and generalized trust. Political trust is also known as institutional trust and refers to trust in the government and its component institutions, such as courts, police, the healthcare system, and other service providers (Bertsou 2019). Generalized social trust is a belief that most people in a society can be trusted (Newton and Zmerli 2011). The belief that most people can be trusted is considered necessary for social engagement and for norms of reciprocity (Newton et al. 2018). Studies show that political and general trust is higher in societies with a low level of corruption, greater justice, and more equality (Clark 2016; Newton et al. 2018). Political mistrust undermines citizens’ compliance with government regulations and institutions (Bertsou 2019). Those who experience discrimination and exclusion have higher levels of mistrust (Lalot et al. 2022); therefore, minority groups in highly unequal societies are more likely to hold low levels of generalized social and political trust.

Research has found strong links between institutional mistrust and the success of public health initiatives. Epidemiological studies regarding Ebola virus disease (EVD) among Western African communities indicated an inverse relationship between political mistrust and acceptance and compliance with public health initiatives intended to prevent and manage the outbreak of EVD (Blair et al. 2017; Vinck et al. 2019). For example, Vinck et al. (2019) found that low political trust and belief in misinformation about Ebola were negatively associated with commitment to preventive behaviors (Vinck et al. 2019). Furthermore, the study found that the inhabitants of Eastern Democratic Republic of the Congo (DRC) actively avoided medical care and EVD vaccination because they did not believe the Ebola virus was real. The low level of political trust was attributed to a long-term decline in security and political confidence (Vinck et al. 2019). Similarly, Blair et al. (2017) also found that Liberians who lacked trust in the government were less likely to adhere to government mandates to control the spread of EVD. This refusal was because participants did not trust the capacity or integrity of government institutions, not because they lacked an understanding of the symptoms or transmission of the virus (Blair et al. 2017).

This pattern has also been observed during the COVID-19 pandemic. Nigerians defied COVID-19 restriction measures to mitigate the spread of the pandemic, including lockdown, mainly because they did not trust the government (Ezeibe et al. 2020). Political mistrust was largely attributed to “long years of deceit, corruption and human rights abuse” (Ezeibe et al. 2020, p. 1757). Similarly, Black Americans’ lower participation in COVID-19 trials was attributed to a ‘deep and justified’ lack of trust in the American healthcare system (Warren et al. 2020). On the other hand, trust has been linked to adherence to health initiatives, either to prevent or cure illness or manage pandemics, including vaccine acceptance and changes in individual behaviors to reduce risk (O’Malley et al. 2004; Yaqub et al. 2014). In light of the suggestions that South Africa’s COVID-19 response has increased healthcare discrimination and inequality for refugees, this paper explores refugees’ experiences with the healthcare system during the COVID-19 pandemic, as well as how that influences their views on COVID-19 and COVID-19 prevention, including vaccination, using a lens of social trust.

2. Methods

The study was conducted in Durban, a port city located on the east coast of South Africa in the province of KwaZulu-Natal (KZN). This province is known for recurrent xenophobic violence targeting migrants (Sphelelisiwe and Ntini 2020). There are about 3.12 million people in Durban and an unknown number of residents living as refugees or asylum seekers (StatsSA 2020).

The study focused on the consequences of inequality in accessing healthcare, so interviews were the most effective method of obtaining detailed descriptions of individuals’ experiences, particularly when context does not permit observation. Furthermore, the conversational nature of interviews makes it possible to seek complete and clear answers, as well as probe the emerging topic (Kvale 1996). The barrier of a lack of trust among members of these communities was further complicated by COVID-19 restrictions, which made it impossible to attend group events or use other forms of trust-building recruitment. Snowball sampling is particularly useful for recruiting participants from hard-to-access populations (Faugier and Sargeant 1997).

2.1. Participants

Snowball sampling was used to recruit 11 key stakeholders from the refugee community, 7 community leaders, and 4 NGO staff members who served refugee communities. Their ages ranged from 18 to 56, and five of the participants were males and six were females. They were from the DRC, Burundi, Kenya, Rwanda, and Zimbabwe and had been in South Africa from eight to twenty-four years. The study was advertised on refugee social media platforms, e.g., WhatsApp groups. After initial contact were made, other participants were recruited using a snowball sampling strategy. Arrangements were made with the participants for virtual data collection via Zoom, in line with COVID-19 restrictions. Participants were paid a small honorarium of ZAR200.

2.2. Procedures

A semi-structured interview guide was developed by the first two authors (AT and MH), which included questions about refugee communities’ experiences of help, healthcare-seeking practices, and accessing public healthcare during the COVID-19 pandemic, including the following: confidence in government responses to COVID-19; perceptions and actions towards COVID-19 and public health responses; and the impact of COVID-19 responses, including vaccine roll-out strategies.

Information sheets and informed consent were sent to participants either via email or WhatsApp and signed prior to the interviews. Verbal consent from each participant was also sought for the recording of the interview before commencement of the interviews. Recruitment and interviews were conducted until data saturation was reached. All interviews were conducted in English without the aid of interpreters and lasted about an hour. Data were collected in November 2021.

The recorded audio interviews were transcribed using software Otter.ai for voice meeting notes and real-time transcription (https://otter.ai/ (accessed on 1 December 2021)) and checked manually for errors. Ethical clearance for this study was obtained from the researchers’ institutional review boards.

2.3. Analysis

The interviews were subjected to critical thematic analysis (CTA) as outlined by Lawless and Chen (2019). CTA connects discourses with larger social and cultural practices found among those in unequal power relations (Lawless and Chen 2019). CTA borrows Owen’s (1984) criteria of recurrence, repetition, and forcefulness for thematic analysis in communication studies, which are applied in the first step of analysis, which involves open coding. The criteria of repetition, recurrence, and forcefulness of experiences (descriptions) were applied to identify salient or shared patterns of experiences important to participants, or to look at what the interview discourse reveals, individually or collectively. A description is defined as recurring when meaning is repeated in the text, regardless of expression and words. In contrast, repetition is when keywords or phrases are repeated across the data. Tone, volume, and variation in the expression are used to assign forcefulness.

In the second step, closed coding, an understanding of the discourse is developed, and silent patterns are identified to develop themes and subthemes. Rigor in the analysis process was ensured through consensus of codes between the first two authors (AT and MH). Discrepancies were discussed and consensus was reached on the codes for the themes. In some instances, new codes were identified and old codes were collated. Later, another discussion took place regarding the themes and how they relate to theories and power relations in the literature. Themes were developed from these processes by associating the themes with dominant societal ideologies or existing theories. We attempted to highlight and expose what is taken for granted, i.e., the experiences or domination of power which have played out in ways of marginalization and the exclusion of refugees.

The first author is himself a refugee and has previously volunteered with NGOs supporting refugees and collected data from the community. He was aware of his position as a refugee scholar and activist and remained a researcher during data collection (participation in the study was solely voluntary) and analysis by thoroughly practicing bracketing to avoid personal experiences and knowledge impacting the research, though complete reduction is impossible. However, his familiarity with the community helped him to easily gain access and trust that enhanced open engagement regarding the lived experiences of the refugee community. The second and third authors are academics in Canada (MH) and South Africa (AMW), respectively. MH immigrated to Canada as a child and engages in community-based research on the social determinants of health and migration but has limited experience with forced migration in South Africa. AMW has researched the broad areas of health promotion, wellbeing, and the healthcare system in South Africa and is involved in health promotion interventions among refugees in Durban, South Africa.

3. Results

The following five themes emerged: discrimination in healthcare; the impact of COVID-19 on access; alternatives to the public healthcare system; misperceptions and ‘othering’ of the COVID-19 pandemic; and feelings of belonging.

1.

Discrimination in Healthcare

This theme includes both negative attitudes and lack of accommodation. Participants noted that refugees experience discrimination in multiple settings, as mentioned by a female participant:

Refugees have been experiencing the discrimination from many years in all departments …. They have fear always triggered by their past experiences… which means there is no good experience someone is expecting [from] healthcare services.

(Female, NGO staff)

The participants described disturbing experiences of encounters with healthcare workers among members of their community, particularly negative encounters with nurses. Interestingly, refugees reported having much better experiences when encountering doctors for tertiary care. These negative experiences meant that refugees typically avoided going to public healthcare facilities. Delaying healthcare seeking was said to be commonplace, with refugees only accessing public healthcare facilities when their condition reached a severe level. A female NGO staff member stated:

It seemed like a lot of our clients would make sure they are very, very sick before they go to hospitals…. They completely avoid going. They say until I feel like I am about to die I won’t go, because I don’t want to face that system.

Experiences of discrimination were mostly shared about or by women, who had more contact with public healthcare facilities because they needed reproductive services. Those admitted for delivery regularly reported dehumanizing treatment from healthcare workers as evident from an interview with a female community leader who said:

Women who go to give birth don’t have a choice. Others have choices to make it here and there. But the mothers who got to give birth, the only one who don’t have choices. So, there is a lot of stories everyone is scared.

Participants shared that there was often a lack of immediate assistance for women admitted to delivery. According to some respondents, pregnant women can be ignored until she ‘breaks her water.’ The participants also described nurses communicating with contempt and rejecting refugee mothers who give birth in South Africa. A male community leader stated that “… nurses are not happy with them, the fact that they’re making children in this country”. Refugees were accused of draining resources that are meant only for South Africans.

Language barriers were a primary source of problems between migrants and healthcare workers. The Department of Health has not taken any steps to accommodate refugees’ interpretation needs, and neither have healthcare workers. Even refugees who can speak English reported negative experiences. Although English is the official language at the national level, in KwaZulu Natal (KZN), the local language is isiZulu, and participants reported that healthcare workers communicate with patients in isiZulu even after knowing the patient does not speak it. A female community leader said:

If you cannot speak like in isiZulu here in KZN, they will just go on with their languages until you feel like you can go crazy. And then you start to answer things you don’t even know. You are not expected to say I don’t understand isiZulu.

2.

The Impact of COVID-19 on Access

Most participants mentioned that access was not qualitatively different during the COVID-19 pandemic, just somehow worse. For some of the participants, it was pointless to link the experience of discrimination during the pandemic with COVID-19. They underlined that discrimination in the healthcare system and other institutions are a long-existing reality. As a female NGO staff member observed:

It is now building on what it has been even before COVID-19 because discrimination has been channeled through all system [against refugees] in this country. That makes it difficult to say the healthcare system is really welcoming or accepting or including. It’s always an excluding system.

However, government responses to COVID-19 did seem to have negative impacts on refugees’ ability to access healthcare. As noted earlier, Refugee Reception Offices were closed and thus refugees’ documents expired. Despite the Department of Home Affairs (DHA) periodically extending the validity of expired documents, service providers did not comply and denied refugees services, stating their documents were expired. COVID-19 protocols also restricted the number of people in healthcare facilities, and thus community interpreters accompanying patients were denied access to the facilities. This meant that those using healthcare facilities who did not speak the local language or English did not have interpreters to help them communicate, which is known to both act as a barrier to access and place patients at risk.

In my community I am an interpret for newcomers. When I went with a patient, they block me from the gate and say this is COVID-19 restrictions, you cannot enter the gate. The patient can’t speak English, even isiZulu.

(Female, Community Leader)

Furthermore, due to lockdown, the majority of refugees, who typically work in the informal economy, were even more economically constrained and were unable to even buy PPE, which prevented them from protecting themselves and accessing social spaces that often required PPE for access, as noted by this community leader.

… not everyone had access and affordability to masks or sanitizer specially in the weeks of the lockdown… the pandemic created difficulty even in economy and working people have been laid off.

(Male, community leader)

3.

Alternatives to Using the Public Healthcare System

Participants reported that refugees would seek out alternatives to the public healthcare system rather than exposing themselves to the discrimination they experienced there. However, COVID-19 itself was also a deterrent, as a male NGO Staff member reflected:

… even if they are sick, they are reluctant to go to the hospitals because they feel like going to the hospital is a place where you can get more COVID-19.

The fear of infection in hospitals where COVID-19 patients were treated exacerbated avoidance of the public healthcare system and prompted reliance on over-the-counter prescriptions from a chemist or medications suggested by doctors on social media. Some people used private hospitals for treatment if they could afford them. However, this was often not an option. Participants described how the community also relied heavily on herbal or traditional home remedies for protection and treatment during the COVID-19 pandemic. Community members used steaming and boiled water with lemon or ginger and garlic to prevent flu-like symptoms. As noted by the community leader below, this treatment strategy is widely practiced and is strongly believed to cure the flu.

If they ever get like a flu, they don’t go for test just to confirm that this is COVID-19. They quickly get a concoction of herbs, and then either they drink it or get steam.

(Male, Community Leader)

Some participants alluded to this being practiced before COVID-19, but its prominence increased during the pandemic due to the fear of going to healthcare facilities for treatment and mistrust in healthcare.

Even before COVID-19 people were scared of hospital … even myself, going to the hospital is the last thing I can wish. I go to the pharmacy, I try those ways to avoid the reality to go and meet the person who can look at you as just not a human being. So, you don’t want to experience that.

(Female, community leader)

4.

Misperceptions and ‘Othering’ of COVID-19

There were three subthemes that emerged in this theme. The first is the consequence of a lack of information outreach to these communities. The second is the belief that the disease does not affect their communities. The third is mistrust of official messages regarding COVID-19 and COVID-19 initiatives and the emergence of conspiracy theories.

3.1. Lack of Information

There was a notable lack of reliable information sources about COVID-19 distributed in the languages that community members understood. The South African media response and campaigns around COVID-19 relied on English and other local languages, which most of the refugees did not understand. Respondents expressed concern about the lack of awareness and education campaigns specifically directed at the community and widespread vaccine hesitancy among community members. They believed that there were few in the refugee community who really understood the health benefits of COVID-19 initiatives. Community leaders noted that their members relied primarily upon social networks for information and communication.

There’s a less education campaign or awareness campaign on refugees and asylum seekers in terms of COVID-19. So many people don’t have enough information on COVID-19 in their language and that makes them to be very reluctant.

(Male, NGO staff)

The participants shared that there was a slight indication of a slow change in attitude and perceptions, although many are still hesitant to receive vaccination. The acceptance among few is attributed to community members personally experiencing and witnessing someone close to them infected with COVID-19.

3.2. COVID-19 Denial

Denial of the existence of COVID-19 was widespread. Participants reported that refugees believed COVID-19 does not exist or is ‘not a real disease’ but a cover for something else. Another common belief is that COVID-19 is a ‘white person’s disease’ that could not affect Africans. Thus, even those who showed symptoms of COVID-19 denied it was COVID-19 and claimed it was the flu or a cold. As one male community leader noted:

In some cases, people have died and have been diagnosed of COVID-19 and they’ve been in big denial they have not accepted that those people have died of COVID-19.

Some leaders attributed the wide denial of COVID-19 to a perceived lower infection rate in refugee communities, as reflected in the excerpt below:

There are few who have been tested, and few who have died of it. You know, many people do not believe in it… because it hasn’t affected us, the communities that much.

(Male, community leader)

3.3. Mistrust and Conspiracies

The lack of linguistically accessible media resulted in some refugees following media from their home countries rather than local media in South Africa, which may not have been relevant or reliable. Participants explained that social media (mainly WhatsApp) played a significant role in disseminating unverified information and in influencing communities to accept or develop conspiracy theories. Conspiracy theories regarding the pandemic seemed to be more readily accepted than scientifically based information from the government or health authorities. A male community leader said: ‘… there is something else besides the pandemic’. Most believe it is manufactured to control or undermine people, particularly Africans. Therefore, community members only adhered to guidelines because of law enforcement and because they were a requirement to access social spaces and services. Another participant had to say:

… so, if it’s a requirement, if they know that they cannot access that place unless do this and that they abide, but where they are free or in their own life in their own area nobody will.

(Male, community leader)

This resistance was also reflected in the hesitancy to undergo COVID-19 testing, even if symptoms were present. Several conspiracies circulating among the community focused on the vaccine. Vaccine hesitancy was common, along with fear that one might be deliberately infected with coronavirus via injection. Other discourses included the notion that COVID-19 vaccines are “devilish and anti-Christ,” developed to kill and control people, as expressed below:

they don’t go for vaccine because it is evil or devil, or they believe that they will put something in you and they will be controlling you wherever you go. and there is another theory that says that if you vaccinate yourself, you will be weaker, and you may not be able to get better again.

(Female, community leader)

There were also concerns that vaccines were not properly developed, and the virus and vaccine were both created only to make a profit, as expressed below:

they don’t go for vaccine because they believe it is evil or that they will put something in you, and they will be controlling you wherever you go.

(Male, community leader)

It seemed that information regarding vaccination uptake were viewed with skepticism, as reported by an NGO staff member below:

When people are invited for vaccine, they feel like no, this vaccine is a mere way of wanting to kill us or to finish us because that is what they’ve been going through for many years… the confidence and the trust are broken.

(Male, NGO staff)

Respondents clearly linked mistrust of scientific messages about COVID-19 with general mistrust of the South African government. Given other experiences that this population have had with the government, as well as its active efforts of exclusion towards their communities, these concerns seem justified. The participants reported that they themselves believed that public health responses to COVID-19 in South Africa are based on scientific information, guided by the global health system (mainly the WHO) and authorities. However, they were unable to convince community members of the authenticity of this information. In addressing misperceptions about COVID-19 and vaccinations, leaders and NGOs have attempted to engage and inform members. However, they spoke of how unsuccessful their attempts were and that they were met with strong defense against vaccination. Community members were perceived to follow a “wait and see” process to assess the effect of the vaccine on others before they decided to receive a COVID-19 vaccination.

Mistrust could lead to self-exclusion. Respondents were concerned that the refugee community would have reduced access to social services if they did not comply with COVID-19 mandates, compromising opportunities that could personally benefit them, as seen in the excerpt below:

“… even a migrant community would be affected in terms of the accessing the services that are accessible to them. Because of the trust deficit.”

(Male, NGO staff)

Growing mistrust, compounded with misperceptions of COVID-19 symptoms as a flu or cold, further supported the strong reliance on home remedies, as described above, and the neglect of COVID-19 responses outlined by government and health authorities. An NGO staff member described the impact of this mistrust among refugee communities below:

I think because there’s no trust, then whatever messages or whatever kind of responses the government has … they are resistant. Because it’s like you don’t watch out for us. Why should we believe them now?

(Female, NGO staff)

5.

Refugees do not belong in South Africa

The fifth theme looks at the relationship between experiences of exclusion and discrimination and the perception of belonging among refugees in South African communities. The participants were asked whether policies are inclusive and whether policymakers understand the challenges refugees face in South Africa. When responding, they reflected upon the issue of belongingness.

Respondents had different opinions about the policies themselves. Some believed that South Africa has policies in place to mitigate refugees’ problems, mainly with respect to access to public healthcare. Others, however, believed the problem is the policies themselves and that policymakers lack a proper understanding of refugee communities’ challenges. These latter respondents expressed their frustration with policymakers’ lack of concern about refugees’ access to healthcare and, more generally, with the welfare of the refugee community. Furthermore, they believed that policymakers lack a proper understanding of why there is considerable vaccine hesitancy among refugees. Moreover, they were angry about how politicians use migrants as political expediency and foster division and hatred between communities.

Despite their differences in their perceptions of policymakers’ understanding of the challenges of refugees, the participants had a common understanding regarding the policies concerning refugees and migrants in general, which they say ‘largely remain on paper’. They noted significant discrepancies between policies and the reality refugees experience. The NGO staff member below described how law enforcement institutions and individuals often act in contradiction to policies and regulations.

The policy we have are very good policies. When it comes to implementation, they become a problem. And you find people are implementing the policy themselves. Some of them xenophobic, some, they don’t care. They’re just doing it because it’s work, but they don’t really implement the policy and that is the challenge we face.

(Male, NGO staff)

The refugee community’s negative experiences with health and social institutions contributed to feelings of deliberate rejection and exclusion. Community leaders explained how the refugee community is made to feel it does not belong in South Africa:

They feel almost disillusioned because they feel that the government doesn’t really want them to be here, they’re seen as a threat by the government, and the government doesn’t support them.

(Male, community leader)

They feel highly discriminated … that it’s a deliberate decision to upset the migrants. So, people are very frustrated. They think the country is deliberately rejecting them, and it’s very unfair.

(Male, community leader)

The participants also blamed the South African government for failing to make meaningful interventions. Mistrust at all levels was pervasive and led to feelings of hopelessness, of being abandoned by the government, and even of intentional neglect from United Nations Higher Commissioner for Refugees (UNHCR). They also feared the terrible encounters experienced by other refugees, such as killing, looting, and injuries, which reveal a lack of protection from authorities.

… imagine where no government plans whatsoever in health sector or social life, refugees were left out. So, for many, they wish to go somewhere else, but they know with the UNHCR, there is no hope, and they know they don’t have a government that care for them.

(Female, NGO staff)

4. Discussion

This study’s focus was to explore the consequences of consistent discrimination on refugees’ responses to COVID-19 initiatives. During the COVID-19 pandemic, public health services were overwhelmed globally, and South Africa was no exception. The pressures of COVID-19 limited healthcare for everyone in South Africa, but as these findings reflect, pandemic responses in South Africa exacerbated discrimination and abuse faced by refugee communities, who already faced a number of barriers to healthcare access, even before COVID-19. This pattern of exclusion, at both the interpersonal and institutional levels, contributed to refugees avoiding seeking care or services, even when they were available. The findings of this study suggest that discrimination itself is a pandemic for refugees in South Africa, and the COVID-19 pandemic was just another opportunity for its expression. These sets of experiences of discrimination among refugees represent the structural discrimination vulnerable groups experience in public healthcare due to systemic issues that impact access and the quality of healthcare.

Both political and generalized social mistrust emerged as key elements in refugees’ access to healthcare during this pandemic, further jeopardizing an already vulnerable population. The findings are consistent with arguments that the roots of mistrust can be found in these communities’ histories of colonization and exploitation (Richardson et al. 2016; Richardson et al. 2019), as well as resulting from the actions of present-day institutions and hostile intergroup relations. The findings of widespread mistrust towards those promoting public health measures and conspiracy theories surrounding COVID-19 are similar to those described in West African responses to public health measures during EVD. Richardson et al. (2019) attributed Western Africa communities’ mistrust of authorities and non-compliance with EVD regulation to centuries of violent abuse, persistent conflicts, and resource exploitation by powers. Furthermore, a study in Austria found an association between mistrusting government responses to COVID-19 and supporting COVID-19 conspiracy theories (Knobel et al. 2021).

Likewise in the current study, COVID-19 interacted with refugees’ experiences of exclusion, neglect, and intentional discrimination and helped fuel refugees’ rejection of public health messages about the pandemic, denying its existence and considering it a conspiracy to kill or control Africans. These are similar to conspiracy theories with adverse effects on health initiatives that were common among Nigerians (Gagliardone et al. 2021; Wonodi et al. 2022). As a consequence, there were reports of increased allegiance to alternative treatments, mainly traditional home remedies. A survey among Finnish residents found a similar pattern, where individuals with less trust in information sources and a greater endorsement of complementary and alternative medication were less willing to have a COVID-19 vaccine (Soveri et al. 2021).

Participants acknowledged the existence of policies stipulating refugees’ rights, which might suggest that they trust policymakers (political trust) more than law enforcement or service providers (generalized social trust). This concurs with the wide praise the South African refugee protection policy received as a progressive rights-based approach, but also with criticisms that it remains idealistic and is actually progressively eroding the rights of refugees to even remain in the country (Crush et al. 2017; Amit 2015), thus feeding mistrust rather than cohesion. Institutional responses to COVID-19 actually reinforced this mistrust through both action and inaction, thereby undermining government efforts to implement public health policies. Actions such as removing access to document renewal actively increased barriers to healthcare. This was exacerbated by language barriers, which the government had not only failed to address but even increased by limiting access to healthcare spaces for interpreters. Studies indicate that language barriers have an adverse effect on both health and healthcare (Flores et al. 2012). Lockdowns also greatly reduced employment and income opportunities among refugees, who often work in the informal sector (Mukumbang et al. 2020; Mutambara et al. 2022). Failing to include refugees in economic policies meant that even if refugees wanted to follow public health protocols, they lacked the means to do so because costs limited refugees’ ability to access PPE and COVID-19 tests.

Failing to communicate COVID-19 information directly to refugee communities in languages they understand also indirectly exacerbated both health risks and mistrust by increasing communities’ reliance on social media. COVID-19 has been associated with an “infodemic”, where huge amounts of information surfaced about the pandemic, including low-credibility, fake, and unverified misinformation (Biancovilli et al. 2021; Ferrara et al. 2020). Reliance on social networks for unverified information is recorded as a downside of social capital, where trust in (mis)information from groups might inhibit access to reliable sources and independent thinking, as was also documented here (Meyer-Weitz et al. 2018). Furthermore, the limited availability of relevant and accurate information for refugees and migrants limited communities’ abilities to coordinate effective self-protection. Nonetheless, what information was provided by the state and other organizations was not trusted, including information about vaccines.

However, social media has also been used by urban refugees in Uganda to respond to exclusion from official communication (Sseviiri et al. 2022). In our study, there was also evidence of both community leaders and NGOs organizing to share accurate information and reporting a slow shift in knowledge and attitudes. Even reliance on traditional treatments or remedies for medical care as an alternative to interacting with a hostile healthcare system could be interpreted as community and individuals sharing information and self-organizing health responses to allow them to avoid the humiliation and trauma of discrimination.

Avoidance of healthcare services by refugee communities during the COVID-19 pandemic may not have been explicitly intended, but it could be seen as a positive outcome by those who do not welcome refugees in South Africa. Systemic exclusion from and avoidance of the public healthcare system by refugees reserved services for citizens during a time of limited capacity in the healthcare system. Participants’ reports of pre-COVID-19 accusations of overusing the system for reproductive services is consistent with this view. The exclusion of refugees and migrants from the public systems also results in profit for the parallel private system, where our respondents felt more welcomed and which was a preferred option, when they could afford to pay.

Respondents also ‘othered the infection’, denying that COVID-19 is real or could affect Africans. Similar to a study with Black South Africans (Schmidt et al. 2020), our respondents saw COVID-19 as ‘white-man’s disease’, and considered themselves at lower risk. This kind of othering has been interpreted as a defense mechanism to manage perceptions of risk and reduce stigmatization. Petros and colleagues (Petros et al. 2006) reported an ‘othering’ of those with HIV/AIDS among South Africans, who blamed other demographic groups as either the source of HIV or responsible for spreading it. They argued that perceptions of HIV/AIDS as an illness of other communities creates a false sense of security through the denial of one’s own group’s vulnerability (Petros et al. 2006). Similarly, Dionne and Turkmen (2020) viewed COVID-19 as contemporary example in a long history of othering pandemics. They argued that besides delaying help-seeking, ‘othering’ exacerbates tensions and inequalities existing between and within communities.

Limitations of the Study

In line with COVID-19 social-distancing measures, the data were collected online via Zoom. Thus, it missed the opportunity to physically interact with participants, which might have enriched the data. Logistical issues of COVID-19 data collection, such as access to smartphones and internet connection, further meant we relied on community leaders and NGO workers to discuss community-wide observations rather than the lived experiences of individual refugees. We were limited to accessing those who could communicate with us virtually. However, these informants were able to share patterns they had seen across multiple individuals and offered a range of perspectives. Snowball sampling started through the networks of the first author, so there may have been bias to align with his particular views or experiences. However, his position as a member of these communities also enhanced trust, thus contributing to the trustworthiness of the data, and facilitated access that might not have been possible without these relationships.

5. Conclusions

Our results explored how mistrust threatens the health of the refugee community by limiting access to the prevention and treatment of COVID-19. However, this also impacts the potential of various public health initiatives and responses intended to mitigate COVID-19 countrywide because public health during a pandemic requires whole-population initiatives to mitigate disease spread. Overlooking refugees’ needs for information and services in the pandemic response implies that, at best, refugees are not seen as belonging to the South African community; however, at worst, oversights and exclusions can be seen as aligning with systemic goals, benefitting a strained healthcare system in the short term, and bolstering stated governmental goals of encouraging refugees’ departure from South Africa overall. Thus, the mistrust identified in refugee communities in our sample could be seen as a justified response to the systemic and social barriers they experience in the healthcare system.