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The COVID-19 epidemic and COVID-19

epidemic and
evaluating the corresponding response to crisis
management
responses to crisis management in
refugees: a system 347
dynamic approach Received 1 September 2020
Revised 15 November 2020
Accepted 4 January 2021
Fahimeh Allahi
Business School, University of Kent, Canterbury, UK, and
Amirreza Fateh, Roberto Revetria and Roberto Cianci
DIME, University of Genoa, Genoa, Italy

Abstract
Purpose – The COVID-19 pandemic is a new crisis in the world that caused many restrictions, from personal
life to social and business. In this situation, the most vulnerable groups such as refugees who are living in the
camps are faced with more serious problems. Therefore, a system dynamic approach has been developed to
evaluate the effect of applying different scenarios to find out the best response to COVID-19 to improve
refugees’ health and education.
Design/methodology/approach – The interaction of several health and education factors during an
epidemic crisis among refugees leads to behavioral responses that consequently make the crisis control a
complex problem. This research has developed an SD model based on the SIER model that responds to the
public health and education system of Syrian refugees in Turkey affected by the COVID-19 virus and
considered three policies of isolation, social distance/hygiene behavior and financial aid using the available
data from various references.
Findings – The findings from the SD simulation results of applying three different policies identify that public
health and education systems can increase much more by implementing the policy of social distance/hygiene
behavior, and it has a significant impact on the control of the epidemic in comparison with the other two
responses.
Originality/value – This paper contributes to humanitarian organizations, governments and refugees by
discussing useful insights. Implementing the policy of social distance and hygiene behavior policies would help
in a sharp reduction of death in refugees group. and public financial support has improved distance education
during this pandemic.
Keywords COVID-19, Crisis management, System dynamic model, Causal loop model, Syrian refugee,
SIER model
Paper type Research paper

1. Introduction
The COVID-19 pandemic was started in Wuhan, China in December 2019 (WHO,
April 2020a, b), and it was recognized as a pandemic on March 11, 2020 (WHO, January
2020; WHO, March 2020a, b). It is spreading almost all around the world, and based on its
impacts, it is crucial to consider vulnerable people and in particular refugees and other people
who are living in camps. They usually are faced with complicated challenges in their life and
need to be more attentive during crises like COVID-19. This virus can spread swift through
direct contact with the infected person or indirect contact where the infected person has had
Journal of Humanitarian Logistics
coughing, sneezing or was talking (WHO February 2020; ECDC March 2020). Thus, it is also and Supply Chain Management
essential to prevent the speed of spreading which reaching this goal needs to define Vol. 11 No. 2, 2021
pp. 347-366
comprehensive instructions and policies to be able to minimize the death toll (WHO March © Emerald Publishing Limited
2042-6747
2020a, b; WHO April 2020a, b; IASC, 2020). DOI 10.1108/JHLSCM-09-2020-0077
JHLSCM Because of its importance, a joint group of the International Federation of Red Cross and
11,2 Red Crescent Societies (IFRCs), the International Organization for Migration (IOM), the
United Nations High Commissioner for Refugees (UNHCRs) and the World Health
Organization (WHO) have developed interim guidance in humanitarian settings. This
document explained their needs including camps, camp-like settings and the surrounding
host communities in scaling-up readiness and response operations for the COVID-19
outbreak through effective multi-sectorial partnership (WHO March 2020a, b; IASC, 2020).
348 Most of the refugees’ camps are built in countries with low financial income, and a wide
range of refugees are living in compressed areas without any reasonable access to health and
food services. In Europe, M
edicins san Frontieres has the capacity of 6,000 hosts and has
asked discharge of 42,000 asylum seekers on the Greek islands to appropriate
accommodation (Hans Henri et al., 2020). In Lesbos, there are more than 20,000 refugees in
the area which is suitable for 2,840, not more, and about 6,000 people are living in a center
which is adequate for 650 persons. On the other hand, there are some limitations on the
refugee camps, for instance, in the Moria camp, water access, showers and toilets are sort of
an important issue, and there is only one water tap without adequate soap for every 1,300
refugees (M
edecins Sans Frontieres, 2020), and about 5,000 refugees do not have any access to
the mentioned issue (Hargreaves et al., March 2020). Privation of access to water and personal
hygiene causes increase in the risk of infections and speed of disease outbreaks (Jones et al.,
2016; WHO, 2020); therefore applying the strategies like self-isolation and social distancing in
this very complex society can be a difficult challenge for governments (Iacobucci, 2020). In
addition, in Asia, about 1m refugees are living in southern Bangladesh, one of the poorest and
most densely populated countries in the world. They are living in a petite area with low access
to public health services (Gaia, March 2020).
Based on the findings and WHO guideline (WHO, April 2020a, b), (WHO, March 2020a, b),
(WHO, February 2020), if the affected countries can prevent the spread of the virus in a short
time, the control of the virus and the death rate will sharply fall in a short time. In this case,
most of the affected countries have developed instructions and new policies from the start of
the crisis in December 2019, and because of the limited time, there are not adequate researches
on the social responses. There are several different ways to predict the social behavior act on
the spreading time, which simulation models are particularly practicing to forecast the effect
of newly developed policies in the kind of disasters such as Ebola (Sharare et al., 2016).
Merler et al. (2015), modeled the movements of individuals, including patients not infected
with the Ebola virus, seeking assistance in health-care facilities. They calibrated an agent-
based model through the Markov chain Monte Carlo approach. The model predicted Ebola
virus transmission parameters and examined the effectiveness of interventions such as
availability of Ebola treatment units, safe burial procedures and household protection kits.
They estimated that 38.3% of infections (95% CI 17.4–76.4) were acquired in hospitals, 30.7%
(14.1–46.4) in households, and 8.6% (3.2–11.8) while participating in funerals.
Recently, four main modeling methods of discrete event simulation, agent-based
modeling, hybrid simulation and system dynamics regarding the COVID-19 challenge
have been considered in research; it was discussed how simulation tools can help decision-
makers have a better decision for this very complicated crisis (Currie et al., 2020), and the
structural review of the most relevant humanitarian publications associated with system
dynamics since 2003 has been done to explain how the SD model can help humanitarian
organizations to develop their complex policies with professional and reliable methods
(Allahi et al., 2018). In addition, a system dynamic model was developed to assess complex
impact factors regarding refugees’ dignity to provide optimal support to beneficiaries. The
developed model has described a decision-making framework with a high-level overview of
the interactions between the economy, education, health and the psychological aspects of the
recipient’s life (Allahi et al., 2020).
 Because of model complexities and variables overlaps, using a structural simulation can COVID-19
play an important role in having a comprehensive simulation and consequently policies. epidemic and
There has been some research in terms of developing a model to make a better decision on
rebuilding of supply chain during long-term global pandemics such as COVID-19. These
response to crisis
kinds of models can evaluate the epidemic impacts on supply chain management (Queiroz management
et al., 2020; Ivanov, 2020) which can be considerable in humanitarian area and the supply
management of hygiene and food materials to refugees. While the availability of essential
goods are important during the pandemic, what can be the best policy response in terms of 349
reducing the COVID-19 impact on health and education regarding refuges limitations such as
lack of space in camps? Such studies in terms of COVID-19 pandemic have not provided more
specific directions on ways to evaluate policies to reduce the infected rate and as a result,
death rate of vulnerable community such as refugees. As mentioned in the literatures, there is
a research gap to simulate the effect of a pandemic such as COVID-19 in refugees considering
the best possible policies for reducing mortality rate.
This study explores the research question of what would be a dynamic model of a
pandemic for refugees and finding the best policy to reduce the impact of COVID-19 on
significant affected aspects of refugees’ life regarding their limitation in the virus pandemic
such as accommodation, hygiene facilities, etc. Therefore, the study subject is: evaluation of
different response policies to the pandemic and the impact of responses’ policy on the health
and education growth of the Syrian refugees affected by COVID-19.
We address the research question by developing a system dynamic model for assessing
the impact of three different policies on refugees’ health and education. It examined through
hypotheses of different scenarios of isolation, social distance/hygiene behavior and financial
aid policies. The proposed model is based on SIER model and relies upon real statistical data.
The results of the study enabled to state that public health and education systems can grow
more by implementing the policy of social distance/hygiene behavior. It has a significant
impact on the control of the epidemic in comparison with the other two responses, and
without it, the number of death may be up to 3% of refugees, and by applying the defined
policy it would be less than 1% which would be considerable.
The rest of this study is structured as follows. In section 2, we elaborate on the
methodology and system dynamic development and discuss the development of a
multilayers causal loop and stock-flow model to simulate the current epidemic impact on
refugees. In section 3, we describe the model verification and related data. Section 4 is
created to map out a scenario analysis and some directions of a future research plan
regarding COVID-19. We conclude the paper in section 5 by summarizing the most
remarkable insights.

2. Methodology and system dynamic model development

SD is a simulation methodology that has been introduced originally by Forrester (1958) and
highlighted understanding the connection between the elements of a system and
demonstrates dynamic behaviors created through multiple interacting feedback loops
(Sterman, 2000). This approach is particularly useful in describing policy implementation and
the reason for changing plans which allows policymakers to recognize detailed components
and their complex relations and as a result the potential effects of alternative strategies to
make more desirable decisions regarding directions from the model (Revetria et al., 2008,
Bruzzone et al., 2014; Briano et al., 2010).
In this paper, a system dynamics (SDs) approach is employed to study the impact of
COVID-19 spread on Syrian refugees’ population, education and health and also to identify
how applying some alternative policies regarding the situation can have different effects on
managing epidemics and crafting public health and education responses and policies.
JHLSCM In order to develop the system dynamics model, the main factors in Syrian refugees’ life
11,2 affected by COVID-19 should be identified and illustrate within the causal loop diagram
(CLD). The CLD systemically demonstrates and interprets the dynamic complexity and
significant feedback loops associated with the number of infected, recovered and dead from
COVID-19 leading to affect public health and education system. Reviewing literature in terms
of the importance addressing the specific needs of refugees in the COVID-19 pandemic (WHO,
2020), this section evaluates and brings awareness of the subsequent impact on the spread of
350 COVID-19 in refugees’ life categorized in the main subjects of health and education and
discusses relevant decision-making policies like camp and isolation effectiveness, social
distance and hygiene behavior and financial aid impacts on the education service. The
interaction between factors is widely described, and on such interactions and applying some
alternative improving factors are discussed. By using the SD model, dynamic complexity
perspectives of all the interventions among the variables can be described. The SD model has
captured the trend of susceptible, dead, infected, recovered, emigrated and the number of
children accesses to distance education for the outbreak, and by applying different policies
and comparing the results, the best response has been introduced.
For the quantitative model, a stock and flow diagram has been developed to run
simulations and validation of our primary assumption specified in the CLD, and for this
purpose, Vensim software was used to demonstrate and understand the effect of changes in
polices in the improvement of public health and education system of refugees in Turkey. As
the discussion progresses, a causal loop diagram and stock-flow model will be provided as a
result of this section.

2.1 Causal loop qualitative model of responses of COVID-19 effects on Syrian refugees’
health and education
CLDs are visual qualitative model aids in imaginng how various variables in a system are
interrelated, and it explains the feedback loops of complex systems by using links between
the variables (Allahi et al., 2018). The key concept to comprehend CLDs includes the polarity
of the arrows and the overall feedback loop which explains what would happen if there was a
change while the detailed behavior of the variables will not be described (Sterman, 2000). It
has been used in academic achievement for a long time and commonly applied in
organizations to quickly capture assumptions about the causes of dynamics (Revetria et al.,
2008). The outcomes of connections among the variables can be further simulated through the
model to assess and improve the understanding of complex systems.
Figure 1 presents the causal loop diagram of the feedback loop and causal connections
between described factors in a system and provides a framework to better understand the
multiple implications of decisions in this complex situation involving many interconnected
factors that are responding to the crisis of COVID-19. The causal interconnections
corresponding to these factors are defined, and the key responses and financial aid are
specified with green and dark red color, respectively. The figure displays eight basic
structure loops in different colors which are considered in Table 1; The plus sign of links in
the loops outline effect variable changes in the same direction of the cause variable, and the
minus sign of links indicates that the two nodes change in the opposite direction of each other.
While the number of links in a loop is odd, that loop signifies a negative feedback loop
(balancing – “B”) which is associated with an increasing/decreasing goal-seeking behavior,
and otherwise, it is a positive feedback loop (reinforcing – “R”) which is associated with
exponential increases/decreases. Reinforcing and balancing loops can be combined to
describe more complex behavior, and balancing loops try to lead the system to the desired
state and keep it there (Sterman, 2000; Allahi et al., 2020). This qualitative model has been
developed based on the “SEIR model” (SEIR is an acronym referring to susceptible, exposed,
 COVID-19
epidemic and
response to crisis
management

351

Figure 1.
Causal loop diagram of
COVID-19 crisis among
Syrian refugees
JHLSCM Loop
11,2 name Components

R1 Contagion rate 5> infection rate 5> number of exposed 5> developing symptoms
rate 5> number of infected 5> number of deaths 5> mental stress 5> emigrating
rate 5> number of immigrated people 5> number of susceptible
R2 Infection rate 5> number of exposed 5> developing symptoms rate 5> number of
352 infected 5> active infected
R3 Isolation effectiveness 5> active infected 5> infection rate 5> number of
exposed 5> developing symptoms rate 5> number of infected 5> available camp capacity
R4 Camp effectiveness 5> active infected 5> infection rate 5> number of exposed 5> developing
symptoms rate 5> number of infected 5> available camp capacity
R5 Number of infected 5> serious cases 5> health service strain 5> mortality rate 5> recovering
Rate
R6 Access to distance education service 5> desired access to distance education 5> access to
distance education service rate
B1 Number of infected 5> serious cases 5> health service strain 5> mortality rate 5> dying rate
B2 Number of deaths 5> mental stress 5> emigrating rate 5> number of immigrated
Table 1. people 5> number of susceptible 5> number of exposed 5> developing symptoms
Causal loop elements rate 5> number of infected 5> dying rate

infectious and removed or recovered). Susceptible indicates refugees who can get the COVID-
19 infection, exposed refers to asymptomatic infected refugees, infected refugees have
symptoms of infection and can spread the virus and recovered indicates previously infected
but are already healthy and immune to the COVID-19 (Rachah and Torres, 2018).
Word Health Organization indicates that the COVID-19 virus is transferred through
contact of people, and contact rate rises when people ignore the social distance of 2 m. Also,
interventions that were effective at reducing the spread of the COVID-19 virus within the
systematic review included health care facilities, hand washing for a minimum of 11 times
daily, sanitation and hygienic behaviors which are essential to protecting human health
during the infectious outbreak and will further help to prevent human-to-human
transmission of the COVID-19 virus. Hence, respecting social distance and applying
hygiene behavior are effective responses to prevent the spread of the COVID-19 virus and
decrease the contagion rate which is designated by green color in the causal loop (Jones and
Carver, 2020; WHO (b), 2020). The reinforcing feedback loop signified by R1 and dark red
color in Figure 1 shows the infection rate grows by high contagion rate and the number of
those exposed by the virus will rise. In addition, as the number of infected increases,
symptoms develop; and the number of infected will increase, consequently increasing the
number of death. Furthermore, emigrating of Syrian refugees is rising because of
coronavirus, due to fear and mental stress that the COVID-19 outbreak could have
harmful consequences such as dying (Clark et al., 2020). The impact of dying because of the
virus on increasing the number of migrated people will reduce the number of susceptible. As
the susceptible population decreases, the contagion rate will decline. Also, in the balancing
feedback loop B1 (black color), which is identified as the depletion loop in the SEIR model, as
the number of susceptible refugees diminishes, the number of exposed will decrease and the
number of infected will gradually level off to reduce the dead people and migrated people and
finally cause a rise in the number of susceptible people.
The global spread of COVID-19 has overwhelmed the health system and caused widespread
social and economic disruption in humanitarian situations (Heymann and Shindo, 2020; WHO,
2020). Since humanitarian organizations have been required to stay home, they have stopped
the financial support aid, neglecting refugees and relying on the local governments, which
consist of poor support with regard to COVID-19 situation in their country (Vlagyiszlav, 2020).
With the COVID-19 outbreak in Turkey continuing and the refugee health and education being COVID-19
threatened, there is a need for ongoing financial aid from humanitarian organizations to epidemic and
support Syrian refugees to meet essential service needs such as health and education (UNHCR,
2020). By getting more financial aid from humanitarian organizations and accordingly more
response to crisis
financial aid to strengthen the health system response to COVID-19, health service capacity is management
one the most important factors in the health system which will increase and is expressed as the
number of temporary health care tent, beds, ventilation and staff. In particular, health
emergencies like this outbreak cause health systems and their ability to deliver health care 353
services strain, and when the health service capacity will increase, the health service strain
decreases. The balancing feedback loop denoted by B1 and red color in Figure 1 show that as
health service strain declines the mortality rate drops, and consequently, the dying rate
diminishes and generates an increasing goal-seeking behavior in the number of infected.
Besides, as the number of infected increases, the number of serious cases will rise and put more
strain on health services (WHO (b), 2020).
Based on the reported data of COVID-19, the elderly and those with underlying diseases
become more seriously ill once infected thereby increasing the mortality rate (Guan et al.,
2020); consequently, the vulnerability rate factor is assumed for these groups of refugees in
this paper. On the other hand, the nonvulnerability group can be assumed for the group of
children, young and healthy refugees that have a less mortality rate in the outbreak (WHO (b),
2020). As the vulnerability rate increases, the mortality rate will rise and the number of
recovered refugees will decrease with less recovering rate and more infected people which
consequently will increase the number of serious cases in need of health service and raise the
strain on the health sector (loop R5 with light purple color).
People affected by humanitarian crises, particularly refugees displaced and/or living in camps
and camp-like settings, are faced with this challenge, and vulnerable refugees should be taken into
consideration more than others when planning for implementing some policies to control the
COVID-19 spread. Refugees are frequently ignored and may face challenges in lack of camp as
well as accessing education and health services. Presenting the inclusive health system and
connected factors affected by COVID-19 spread ensures refugees’ requirements in this area.
Although, many refugees in humanitarian situations face difficulties to find proper
accommodation and they settle in formal or informal collective sites, such as camps or
informal and spontaneous settlements, all of which may be of a temporary or long-term shelter
(WHO (a), 2020). WHO has published patient management guidance to inform governments that
those with COVID-19, mild and severe symptoms need immediate isolation and appropriate
accommodation to reduce the number of active infected (effective number of infected people, after
adjusting for a reduction in infectiousness from isolation). Therefore, some amount of financial aid
should be spent on camps to increase the availability of camp capacity and the effectiveness of
camps and isolation. Moreover, the impact of more extra camp capacity on enhancing responses
like camp and isolation effectiveness (green color) and reducing the number of active infected,
infected and exposed refugees can be visualized in feedback loops R3 and R4.
The background of online learning in refugee camps starts with the refugee crisis, and the
expanding COVID-19 outbreak has driven decision-makers to shut down schools, and many
courses have been shifted to online lectures. However, a lack of necessary facilities for online
education like teachers and digital devices for refugees can be costly, and it is essential to
support them financially. Since March 2019, over 28,000 Syrian refugees in Turkey have
received online language courses through e-learning methods, but it would be better to cover
more students and more funding (Reinhardt, 2018). The education elements have been
highlighted in blue. The positive feedback loop labeled as R6 represents the effects of
financial support on refugee children’s education and illustrates the requirements of online
education services in the COVID-19 pandemic.
In the next subsection, a stock and flow quantitative model is presented.
JHLSCM 2.2 Stock flow quantitative model of responses to COVID-19 effects on Syrian refugees’
11,2 health and education
To estimate the early dynamics of the COVID-19 effect and the subsequent responses system,
dynamics concepts such as stocks and flows and feedbacks are inevitable to define the state
of the system (Sterman, 2000). The base of the stock-flow model presented in Figure 2 is
derived from the susceptible-infected-recovered (SEIR) model (http://vensim.com/
coronavirus/) and developed to a new model for evaluating the public health and
354 education system of Syrian refugees in Turkey in the COVID-19 epidemic and investigate
responses like isolation, hygiene behavior and camp capacity to enhance health and
education system. In order to test our dynamic hypothesis outlined in the discussed causal
loop model, a quantified stock and flow diagram was developed using Vensim software and
presented in Figure 2. Furthermore, modeling process, simulations and sensitivity analyses
were performed using Vensim DSS software v. 5.7a.
In the quantitative stock-flow model, the refugee individuals were divided into six stocks,
as follows: “Susceptible”, “Emigrated”, “Exposed” (but not yet infected), “Infected”,
“Recovered” and “Death”. It is assumed that the population susceptible to COVID-19 is the
total number of people who will eventually be infected. In addition, some of the susceptible
populations have been immigrating to Europe due to fear of death from COVID-19 (Clarke,
2020) which is indexed by emigrated stock and remaining individuals with symptoms of the
disease considered as infected people.
A dynamic model of the COVID- 19 epidemic is proposed to provide a more reliable view of
the state of the disease based on existing data. The generic SEIR framework consisted of the
endogenous changes in the social distance, hygiene behavioral risk reduction, camp capacity,
isolation, camp effectiveness, reaction time, and financial aid for the health and education
system. In addition, It would be possible to see changes in the number of death, recovered, and
infected people using this framework.
In addition, it is assumed that the social distance factor defines as a slope of decline in
contacts as the infection penetrates to less-connected portions of the social network, and the
hygiene behavioral risk factor refers to the fractional reduction in risk from social distancing,
increased handwashing, and other behavioral measures.
While other critical requirements of refugees such as health and sanitation are being
responded to, educational demands cannot be ignored, and these have an identically harmful
impact if omitted during the global COVID-19 pandemic. As governments’ finances are being
strained and out-of-school children are more faced with risks like family violence, child labor
and forced marriage, so delivery of education online, as soon as possible, must also be a
topmost priority to respond to this crisis and its consequences (ECW, 2020). Overall current
receiving support from humanitarian organizations is low in response to COVID-19 for the
half population of refugees who are children, and it should be discussed in the simulation
(Nott, 2020). As a result, another stock named “Access to Distance Education Service” is
considered in the model, and the “Desired access to education service” variable demonstrate
the number of refugees that have access to education variable and assumed as the whole
children population. The COVID-19 outbreak directly affects the mental and physical health
of refugees which leads to death, and the whole responses in the model indexed by green color
are assumed to decrease the number of deaths and increase recovered refugees infected by
this virus. This model is an attempt to include response factors and presents the changes from
applying them in the number of infected, recovered and dead in studying the epidemic, which
can be used as a framework for further policy analysis. There is now an urgent need to
strengthen the COVID-19 response for the most vulnerable people in Turkey, where there is
limited support for the response to COVID-19. Humanitarian pressure must be put to inform
organizations to financially support to respond to limitations on essential services such as
health and education to ensure humanitarian assistance (Nott, 2020). Besides, “Aid for service
 COVID-19
epidemic and
response to crisis
management

355

Figure 2.
Stock-flow model of
COVID-19
JHLSCM health” ramp up the “health service capacity” to reduce the health service strain and help
11,2 serious infected cases from dying. In addition, part of the money will also cover beneficiaries’
educational expenditure which is presented as “Aid for education system” in the model.
In general, governments and humanitarian organizations are required to respond early in
this pandemic regarding isolating and quarantining the infected people in the “Available
camps”, and increasing the “Camp capacity” could be an essential alternative to increase
“Effectiveness of isolation” and both “Isolation reaction time” and “Applying camp reaction
356 time” effect on a more desirable response to COVID-19 (WHO (a), 2020). Although, by
employing isolation response, the effective number of infected people, after adjusting for the
reduction in infectiousness from isolation, quarantine and monitoring is outlined by the
“Active infected” variable in the model.
WHO in 2020 indicates that the COVID-19 virus is transferred through contact of people
and further from surfaces by contaminated hands, which facilitates indirect contact
transmission which impacts on “Contagion rate”. Consequently, there is the provision of safe
water, sanitation, hygiene and washing hand facilities which is assumed as “Hygiene
Behavioral Risk Reduction” and which is essential to protecting refugee’s health from
infections and prevent the spread of the COVID-19 virus. In addition, the “Hygiene Behavioral
Reaction Time” is a significant factor to diminish the time from the first infection and hence
the contagion rate. The main equations of the SD model are presented in Table 2.

3. Model validation and related data

The model is validated by applying various structural and behavioral validity tests (Sterman,
2000). Various data sources, including literature or reports published for the COVID-19
outbreaks, are used in order to determine input parameters (Table 3) of the simulation model.
On the other hand, due to the lack of experimental data of COVID-19, some model parameters
that are significant in determining model behavior are determined by calibration and
presented in Table 3.
The model also passes the dimensional consistency and extreme condition analysis tests.
The model calibration estimates the values of different parameters to best fit the base SIER
model of COVID-19 (http://vensim.com/coronavirus/) and using related data of COVID-19 and
Syrian refugees in Turkey. The time horizon of 360 days (January 2020–December 2020) is
considered; a 1-year period is selected based on the spread of COVID-19 and provides a more
reliable view of the state of the disease on Syrian refugee’s health and education based on
existing data and evaluating the changes in the number of infected, recovered and dead
people by applying different policies.
The first confirmed COVID-19 case was announced in March 10, 2020 in Turkey, and then
the number of cases has increased rapidly; over 20,000 people as of April 3rd and
approximately 425 people have lost their lives in this period (Tekin-Koru, 2020). The
transmissibility of a COVID-19 virus is considered as “Basic reproduction ratio”, and it
outlines the average number of new infections created by an infectious person which is
presenting the risk of an infectious agent for epidemic spread. It is a fundamental concept in
the infectious virus epidemic which is estimated as 3.3 (Liu et al., 2020). Besides, social
distance is considered as a slope of decline in contacts as the infection penetrates to less-
connected portions of the social network, and the value is considered zero to evaluate its
impact on the number of infected when the value changes to more than zero. The “Diseases
Duration” is the duration of infection and, for simplification, it is assumed the same duration,
average 14 days, for recovery and death (Although in reality, serious cases might have a
longer duration (WHO (a), 2020). Contact rate refers to a decline in contacts as the infection
penetrates to less-connected portions of the social network (Bi et al., 2020); the effect is real,
but the functional form is notional here. In addition, the incubation period is assumed as the
No Variable Equation Units
COVID-19
epidemic and
1 Access to distance INTEG (Access to education service rate) þ 50 People response to crisis
education service
2 Access to education MAX(0,1-(access to distance education service/desired Dmnl [1] management
service index access to education service))
3 Access to education Humanitarian aid for education/distance education People/day
service rate facilities cost * access to education service Index/TIME 357
STEP
4 Active infected Infected * (1-isolation effectiveness-camp effectiveness) People
5 Available camp capacity Infected/camp capacity Index
8 Camp effectiveness SMOOTH3(STEP(Potential camp effectiveness, import Fraction
time), reaction time of applying camp)/(1 þ available camp
capacity^2)
10 Contact density decline 0 dmnl
11 Contact rate 1/(1 þ contact density decline * (1-fraction susceptible)) dmnl
12 Contagion rate Initial uncontrolled contagion rate * relative performance of Fraction/
hygiene behavior risk * fraction susceptible * contact rate day
13 Deaths INTEG (dying, 0) People
14 Desired access to Child population People
education service
15 Developing symptoms Exposed/incubation Period People/day
18 Dying Infected * mortality rate/disease duration People/day
19 Emigration Mental stress impact/TIME STEP People/day
20 Exposed INTEG (infecting-developing symptoms, 0) People
23 Fraction susceptible Susceptible/initial population Fraction
24 Health service capacity population þ (humanitarian aid/health service cost) People
26 Health service strain5 Serious cases/health service capacity Index
33 Infected INTEG (Developing symptoms-dying-recovering, 1) People
34 Infecting Active infected * contagion rate People/day
37 Initial uncontrolled Base reproduction ratio/disease duration People/
contagion rate person/day
38 Isolation effectiveness SMOOTH3(STEP(Potential isolation effectiveness, import Fraction
time), isolation reaction time)//(1 þ available camp
capacity^2)
41 Mortality rate Untreated mortality rate þ (treated mortality rate- Fraction
untreated mortality rate)/(1 þ health service strain)
45 Recovered INTEG(recovering,0) People
46 Recovering Infected/disease duration * (1-mortality rate) People/day
47 Relative performance of SMOOTH3 (1-STEP(hygiene behavioral risk reduction, dmnl
hygiene behavior risk import time), hygiene behavioral reaction time) Table 2.
49 Serious cases Infected * fraction requiring hospitalization People Main equations of
50 Susceptible INTEG (emigration-infecting, initial population) People SD model

time for onset of symptoms among exposed people which is an average of five or six days
(WHO (a), 2020). Furthermore, the fatality rate is considered as 0.04 when minimally treated
due to being overwhelmed, and it varies by location and vulnerability rate defined as fatality
rate with good health care.
Humanitarian organizations provide aid to support the essential needs of refugees with
services like health and education; spending of 83 USD per month on health and education are
reported wherein 60% portion of it goes through health service (Ulrichs et al., 2017).
Regarding the research of Rumble in 2012, the distance education facility cost per person
could be 100 $, while the total population of Syrian refugees’ children in 2020 is half of their
population (Allahi et al., 2020).
The model has been calibrated using a payoff function as a linear combination of
differences between real data and model to minimizing the difference between them
JHLSCM No Variable Value based on available data Units References
11,2
1 Essential services financial aid 83 $ Ulrichs et al. (2017)
2 Aid for education system 37 $ Ulrichs et al. (2017)
3 Aid for health system 46 $ Ulrichs et al. (2017)
4 Base reproduction ratio 3.3 dmnl Liu (2020)
5 Diseases duration 14 Day WHO (a) (2020)
358 6 Distance education facilities cost 100 $ Rumble (2012)
7 Child population 1,700,000 People Allahi et al. (2020)
8 Camp capacity 400,000 People UNHCR (2013)
Table 3. 9 Initial population 3,600,000 People Allahi et al. (2020)
Input parameters of 10 Contact rate 1.9 dmnl Bi et al. (2020)
simulation model 11 Incubation period 5 Day WHO (a) (2020)

employing the best estimation of the model parameters using Vensim’s built-in Powell
conjugate search algorithm (Allahi et al., 2020). The values of calibrated values are presented
in Table 4.
In addition, some of the variables’ values in the model are assumed as constant to evaluate
their impact on improving health while changing the value. It is important to remark that our
research is the first attempt of applying SD to respond to the pandemic of COVID-19 for the
case of refugees; the model has been created based on available real and calibrated data. and
lack of series real data made some limitations to restrict applying validation with the series
data, but the model is based on the real input parameters and some other validation tests to
make it sensible and applicable. The core point is that the data presented here are based on
the preliminary results of the SIER model and previous research regarding Syrian refugees in
Turkey.

4. Discussion and scenario analysis

Research in humanitarian operation management has received expanding attention during
the COVID-19 pandemic. However, two significant gaps can be observed from the current
research; first, a large number of the studies concentrate on supply chain aspects of crisis
operation management to get all the essential materials to the beneficiaries as immediately as
possible (Manoj and Maneesh, 2020), and second, there is limited evidence of research on the
understanding of the best response for the COVID-19-affected refugees while the usual
response policies such as the basic public health measures, social distancing, proper hand
hygiene and self-isolation cannot be easily implemented or are extremely difficult to apply in
refugee camps (Kluge et al., 2020). Therefore, a simulation model has been developed to study
the COVID-19 impact on different aspects of refugees and consider all the possible responses
to evaluate the best policy in this special case with the existence limitation.

No Variable Value based on calibration Units

1 Access to education service index 0.3 Dmnl

2 Fatality rate 0.04 Constant
3 Vulnerability rate 0.01 Constant
Table 4. 4 Health service cost 100 $/people
Input variables 5 Mental stress impact 26,000 People
determined by 6 Isolation reaction time 2 Day
calibration 7 Reaction time of applying camp 2 Day
 To study the impact of COVID-19 on refugees, we have examined a base simulation model COVID-19
without consideration of applying any policies and responses to the COVID-19 outbreak; epidemic and
besides, three other policies are proposed to discuss the impact of applying these policies on
the spread of the virus, and the seven stocks in the model such as the number of infected and
response to crisis
death among refugees in Turkey are illustrated in Figure 3. The final model can reasonably management
well represent the base simulation model of COVID-19 pandemic based on the original
COVID-19 SEIR model of Vensim in the time horizon of January 2020 until the end of
December 2020, and based on the first confirmed COVID-19 case announced in March 10, 359
2020 in Turkey which is approximately 100 days after January, the number of cases has
increased rapidly; over 20,000 people as of April 3rd and approximately 425 people have lost
their lives in this period (Tekin-Koru, 2020). As illustrated in Figure 3 graph (b), the number of
infected is almost 20,000 people in April, and the number of death in the graph (d) is around
1,000 people which is similar to the real data. Furthermore, if the government would not apply
any policies and respond to the pandemic, over 100,000 refugees will die by the end of 2020
(graph (d)), and also around 100,000 of them immigrated to Europe or other countries as a
result of fear of dying (graph (e)) which is a huge disaster. So, we have examined the
behavioral factors and responses that have a significant influence on curbing the outbreak
including the change of social distance and hygiene behavior during the epidemic, the process
of quarantining and isolating of infected people and the financial aid to build more camps and
health services and also providing fundamental conditions for distance education services
which are the essential parts in order to study the COVID-19 crisis. However, in terms of
distance education and applying hygiene behavioral policy, one of the challenges would be
the lack of equipment to successfully implement the response policies and reduce the
impact of this virus. If governments face a shortage of medical/healthcare and education
equipment, the mentioned policies cannot be applied to improve the level of essential aspects
of refugees, but recently some researchers have found out an effective way for demand
management in the supply chain considering COVID-19 pandemic and control the outbreak
of an epidemic to mitigate its impact on the supply chain challenges which would be
considerable and solve this problem (Govindan et al. (2020); Dubey et al., 2020; Dubey et al.,
2019). So the next challenge which should be considered is decision-making in terms of
implementing the best policy to reduce the impact of COVID-19 on the health and education
aspect of refugees.
Based on the qualitative and quantitative analysis of the system structure outlined above,
five alternative policies, namely, “Isolation effectiveness”, “Camp effectiveness”, “Social
distance”, “Essential service financial aid” and “hygiene behavioral risk reduction” have been
analyzed in order to evaluate their potential effects on the model’s performance during the
pandemic in which different colors correspond to each policy.
As depicted in Figure 3, isolation, camp, social distance and hygiene behavior policies
differ by the degree of effectiveness, which ranges from 0 (very low response quality) to
1 (very high response quality): in the base simulation model, the policy is aimed at
maintaining the lowest quality in the pandemic which is zero and for the financial aid is $83m
(the base aid from humanitarian organizations in the year) to estimate the pandemic result
without any response. In the SD model, three different policy scenarios have been considered
to analyze the impact of each scenario on the COVID-19 pandemic and evaluate the best
response;
(1) Scenario 1: Policy of isolation and camp capacity
It is hypothesized that the camp capacity increased to cover 800,000 people, the potential
camp and isolation effectiveness was assumed as 0.5, and the reaction time of applying camp
and isolation was found for 15 days.
 11,2

360

Figure 3.

trajectory of
JHLSCM

(a), infected (b),

1,2 and 3 of the
Bases simulation

emigrated (e) and

until the end of D

access to distance

from January 2020

number of children

education service (f),

model and scenario of

cumulative susceptible

recovered (c), death (d),

Susceptible Recovered Emigrated
3M 3M 200000

2M 2M
100000

people

people
people
1M 1M

0 0 0
0 100 200 300 0 100 200 300 0 100 200 300
Time (day) Time (day) Time (day)
Base Simulation Model Base Simulation Model Base Simulation Model
Scenario 1- Policy of Isolation and Camp Capacity Scenario 1- Policy of Isolation and Camp Capacity Scenario 1- Policy of isolation and camp capacity
Scenario 2- Policy of Hygiene behavior and Social Distance Scenario 2- Policy of hygiene behavior and social distance
Scenario 2- Policy of Hygiene behavior and Social Distance
Scenario 3- Policy of Applying Financial Aid Scenario 3- Policy of applying financial aid
Scenario 3- Policy of Applying Financial Aid
(a) (c) (e)

Infected Deaths
1M Access to Distance Education Service
200000 31000

30000
500000 100000
people

people
people
29000

0 0 28000
0 100 200 300 0 100 200 300 0 100 200 300
Time (day) Time (day) Time (day)
Base Simulation Model
Base Simulation Model Base Simulation Model
Scenario 1- Policy of Isolation and Camp Capacity
Scenario 1- Policy of Isolation and Camp Capacity Scenario 1- Policy of Isolation and Camp Capacity
Scenario 2- Policy of Hygiene behavior and Social Distance
Scenario 2- Policy of Hygiene behavior and Social Distance Scenario 2- Policy of Hygiene behavior and Social Distance
Scenario 3- Policy of Applying Financial Aid
Scenario 3- Policy of Applying Financial Aid Scenario 3- Policy of Applying Financial Aid

(b) (d) (f)

 (2) Scenario 2: Policy of hygiene behavior and social distance COVID-19
It is presumed that hygiene behavioral risk reduction is 0.5 for the reaction time of 15 days, epidemic and
and the social distance range is also expected as 2 in the range of [0 4] with respect to the response to crisis
current level. management
(3) Scenario 3: Policy of applying financial aid
In the last one, the essential service financial aid supposed to be 249m $ (triple of the current 361
value) in order to analyze the number of children with access to education in the pandemic.
According to the graphs in Figure 3, the base simulation model was set in accordance with
the COVID-19 spread development situation without any additional policy. Graph (b) shows
that without applying any policy by the government, the number of infected refugees could
be about one-fourth of the population, and the epidemic seems to cause death of about 120,000
people by the end of 2020 (graph (e)). In order to save lives and prevent existing crises from
increasing uncontrollably, an appropriate response needs to be in place. Besides, by applying
scenario 1 which is implementing the policy of isolation in the camps and increasing the
capacity of camps in 15 days after the first infected case has been seen, the number of infected
would reduce to about 400,000 people gradually in three months (graph (b),), and almost
90,000 refugees would die (graph (d)). In this case, the number of refugees with the decision to
immigrate to Europe will reduce to about 50,000 cases. Furthermore, people living in
collective sites are vulnerable to COVID-19 in part because of the health risks associated with
movement or displacement, overcrowding, increased climatic exposure due to sub-standard
shelter and poor health status among affected populations; considering some adaptations of
camps plans and maximizing site planning for better distancing among residents can reduce
the number of infection, but adherence to infection prevention and control standards, hygiene
behavior and social distance should be considered to greatly reduce the spread of COVID-19
and reduce mortality among those infected with the virus. In consequence, it is necessary to
apply the second policy, policy of hygiene and social distance, that had a significant influence
on curbing the outbreak including the reduction of infected cases to 250,000 cases (graph (b))
and a number of death to 50,000 cases (graph (b)) during the epidemic which is remarkable in
the study of the COVID-19 crisis. In addition, it can postpone the peak time more than the
other two policies, about nine months which can increase the chance of providing more
medicine and healthcare materials for the infected people and prevent dying caused by the
virus. While the number of infected reduces, it would significantly decrease the number of the
serious cases which need hospitalization as well and provide more space in the hospital to
reduce the probability of dying in case of lack of health services. By implementing this policy,
the number of refugees with the decision of emigration can considerably decrease to 20,000
cases (graph (e)) and can explain a high reduction in the level of mental stress in refugees.
In addition, the COVID-19 has resulted in schools shut all across the world (Basilaia and
Kvavadze, 2020). The population of children among refugees in 2020 is about 1.7m which are
out of classroom in the virus pandemic. As a result, education should change to e-learning,
whereby teaching is undertaken remotely and on digital platforms which take less time but can
improve learning in the pandemic. As shown in graph (f), increasing the financial aid from
humanitarian organizations can improve the access to online education for up to 3,000 more
children during the pandemic to encourage them to study and use the time in quarantine,
responding to significant demand for education until the delivery of a safe and effective vaccine
to enable virus transmission and maintaining safety. Without access to government support
for unemployed citizens, many refugees rely on insufficient cash assistance from humanitarian
agencies. As mentioned in Table 3, the financial aid is divided into aid for education and
health; just 30% of the whole amount is allocated to education, and the other 70% assigned
to the health service to improve the facilities and hygiene materials during the pandemic.
JHLSCM As a result, by implementing the policy of hygiene behavior and social distance among
11,2 refugees, the peak time can be postponed up to nine months, and the number of infected and
dead people can significantly reduce to 8% and 1%, respectively which is considerable in
comparison with the other response policies. UNHCR camps have not enough space per
person, which makes it difficult to apply the social distancing policy or self-isolating. In
informal camps and accommodations such as shelters and tents, there is not enough space
(Ibrahim, 2020). In this case and in terms of real-life action, the only proper policy response to
362 the COVID-19 pandemic can be implementing hygiene behavior which would be washing
hands and wearing masks. Regarding the limitation in hygiene materials in camps (Alemi
et al., 2020), vulnerable people can be advised to wear masks and separate from others in
specified camps for social distancing. Hopefully, the results in (graph (b)) represent that peak
time can be postponed, and humanitarian organizations would have much more time to
support financially and supplying healthcare materials.

5. Conclusion
The coronavirus (COVID-19) outbreak shows that pandemics can seriously impact health and
education aspects of refugees considering the lack of support from humanitarian
organizations. In this paper, a more sober picture of the COVID-19 outbreak among
refugees has been provided using a system dynamic model that goes beyond evaluating some
responses to this pandemic and recommend the best one to reduce the mortality caused by the
virus. The system dynamics approach is a very effective tool in perceiving the whole picture
and helping key factors to better understand and act utilizing the best decision and evaluate
the impact on an epidemic. Overall, response to any infectious virus such as COVID-19
requires continuous monitoring to create a working baseline for future policy implementation
modeling to diminish the mortality rate.
In this paper, the impact of COVID-19 in dealing with refugees’ life, especially the health
and education aspects have been studied, and a system dynamics simulation model has been
developed to suggest the best response to improve public health and education systems in the
virus pandemic. The best model according to the available data has been provided from
different references which capture the increasing trend of the infection rate over time due to
not respecting any policies and decreasing the number of death and infected trend in the case
of applying isolation, hygiene behavior and social distances. In this optimistic scenario, the
burden of the disease can be large and lasting for many months. Implementing and
sustaining strong policies that target social distancing and hygiene behavior offer the main
hope for containing the epidemic.
As a result of the simulation model, by applying the policy of isolation and camp capacity,
the number of infected people and the mortality rate can be reduced to 50 and 20%,
representatively. On the other hand, it can have a significant influence on curbing the
outbreak with a reduction of infected cases by 75% and the number of death cases by 50%
applying the policy of hygiene behavior and social distance. Implementing this policy would
help to delay the peak time about nine months which would support the healthcare system
and increase the chance of providing more medicine and healthcare materials for the infected
people and prevent more dying caused by the virus as well.
With the world facing an unprecedented threat, there is an opportunity to invest in stronger
health systems and better collaboration in the world to face the future health crisis specifically
for vulnerable populations like refugees. Considering the immediate and better response to the
COVID-19 crisis and the consequences and lessons of this pandemic now makes the world of the
future a safer place even for refugees while facing another health crisis.
In the future, we plan to use our best simulation model with the real series data to test
different policy scenarios in leveraging public fear and awareness to deal with the spread of
epidemic diseases such as COVID-19. For instance, we can study the effects of crime and COVID-19
psychological factors on refugees’ life when such epidemic crises happen in their region. Also, epidemic and
another direction for future work is to further refine the model by capturing the spread of
disease on other refugees in European countries separately and compare and contrast their
response to crisis
disease management approaches. management

Note
363
1. Dimensions

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Corresponding author
Fahimeh Allahi can be contacted at: F.Allahi@kent.ac.uk

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