"The upcoming rainy season presents an obvious greater potential for waterborne diseases such as acute watery diarrhea, which is a significant concern. We have already seen how people's vulnerability can increase rapidly—right now we’re treating people for measles and diphtheria."
Thousands of Rohingya refugees continue to cross the border into Bangladesh, fleeing targeted violence and persecution in Myanmar. Here, Doctors Without Borders/Médecins Sans Frontières (MSF) emergency coordinator Kate Nolan describes the current situation and the challenges on the horizon.
Nearly 700,000 Rohingya refugees have fled to Bangladesh since August 25, 2017. They join tens of thousands who were already in the country from previous periods of tension and violence in neighboring Rakhine state, Myanmar. The thing I find most striking about this situation is its magnitude—the sheer number of people who have crossed the border in a short space of time, barely six months. In fact, people continue to arrive.
The numbers of people arriving now are not massive, like in the beginning of the crisis, but we still see a few hundred reaching the country every week after crossing the Naf river. The newly arrived refugees say that they feel unsafe, threatened, and harassed at home. In villages that are often abandoned they try to sell their goods in any way they can in order to board a boat to reach [Bangladesh], a country that has made and continues to make a huge effort to accommodate them.
The refugees end up in densely crowded and overpopulated makeshift settlements in the southern district of Cox’s Bazar. Their shelters are mostly made of plastic and bamboo, packed closely together and with inadequate water and sanitation conditions.
As we see through our medical consultations in all the settlements, the Rohingya were already marginalized and excluded in Myanmar. They had very little or no access to health care and were not routinely vaccinated against communicable diseases, so their immunization status is very low. Our medics treat many people with diarrhea and respiratory tract infections—diseases related to the living conditions in the camps.
We also see wounds that have developed into serious infections after not being properly treated, chronic diseases that have never been properly addressed, and fragmented families in which children or disabled people have to look after many others, secure essential supplies, or build their own shelters. All these factors combined—the sheer size of the population, the densely crowded conditions, the inadequate shelter, and the apparently very low immunization status—create a perfect storm for the public health situation. It is a very fragile situation that requires constant attention from our personnel and other organizations working on the ground.
Something I am concerned about is fresh emergencies within the current emergency. For example, the upcoming rainy season, with the monsoon and tropical storms in an area that is prone to heavy cyclones, presents an obvious greater potential for waterborne diseases such as acute watery diarrhea, which is a significant concern. We have already seen how people's vulnerability can increase rapidly—right now we’re treating people for measles and diphtheria.
There is always a risk of facing diseases for which aid workers and the health system are ill-prepared. In this regard, there is an opportunity for all actors responding to this crisis to increase both the number of people targeted for vaccination coverage as well as the number of diseases to vaccinate against.
Furthermore, there are very few settlements that can be accessed by vehicle—a lot of them still can only be reached on foot. We are concerned about the nature of the shelters, how robust they are, and if they are really prepared and equipped for the heavy rains. We’re considering the possibility of landslides, or even something as simple as the pathways becoming very muddy, leading to more people falling and incurring injuries and fractures. We are currently preparing our own emergency response, trying to anticipate the potential damage to our health structures, so we have supplies to make quick repairs and become operational again.
An Adaptive Approach
After the rush of the last few months here, our priority now is to consolidate our medical activities, focus on secondary health care services and our emergency response to outbreaks, and to be ready to respond if the crisis becomes protracted and forgotten.
In the early days water and sanitation and primary health care were priorities for us, but now we see other actors working on this. However, there remains a gap in hospital services. Beyond this, mental health services remain an important part of the intervention for people who have experienced extremely high levels of violence, as confirmed by the retrospective mortality surveys we published in December.
While we continue responding to the emergency, in coordination with the Bangladeshi authorities, it is important to make an effort to improve the acceptance and understanding of our crucial humanitarian work. The area has seen its population increase drastically, with the subsequent added pressure to the local economy, environment, and daily life of a host community and country that has kept its borders open in a crisis that is far from over.
Since August 25, 2017, MSF has massively scaled up its operations and now manages 15 health posts, three primary health centers, and five inpatient facilities in the Cox’s Bazar area. The main morbidities among patients in our clinics are respiratory tract infections and diarrheal diseases, which are directly related to the poor shelter and water and sanitation conditions in the settlements.
Over 200,000 patients have been treated at MSF outpatient facilities and 4,938 patients in inpatient facilities from the end of August to the end of December.