Rohingya refugees in Bangladesh: A massive humanitarian crisis

Risks of a public health disaster remains dangerously high following the arrival of hundreds of thousands of Rohingya refugees fleeing violence in Myanmar.

Since last August, over 688,000 Rohingya refugees have fled from Myanmar into Bangladesh and the influx still continues today. Six months on, the situation for refugees remains precarious; they are still living in makeshift shelters in overly populated settlements. Many lack access to safe drinking water and have poor hygiene and sanitation conditions. What Doctors Without Borders/Médecins Sans Frontières (MSF) teams see on the ground remains an acute emergency situation with huge humanitarian needs. Living conditions for the refugees need to be massively improved, with a particular focus on water, sanitation, shelter and reducing population density.

In current conditions, the risk of people falling ill is high. Rohingya refugees make up a vulnerable population, members of which had little or no access to routine healthcare including vaccinations in Myanmar. People are already facing the spread of measles and diphtheria in the settlements. Although the government of Bangladesh has implemented a mass vaccination campaign for these diseases, the risk of an outbreak will remain unless living conditions are improved. There is an urgent need for a better response from organizations providing healthcare to mitigate the risk of additional diseases spreading and to ensure that all those who need vaccinations receive them.

As the settlements continue to expand, refugees face unequal access to basic services such as healthcare, food and water, which increases their vulnerability. Work is continuing on a new road but additional improvements to access need to be made to ensure aid reaches everyone.

More challenges lie ahead: "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,"  writes Kate Nolan, MSF's emergency coordinator in Bangladesh.

 

'This crisis is not over': MSF's emergency coordinator describes the situation in Bangladesh six months after the latest Rohingya influx began

Kate Nolan is MSF's emergency coordinator in Bangladesh, and she describes the challenges that remain on the border with Myanmar since violence in that country began driving hundreds of thousands of refugees in search of safety across the border.

"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 today."

"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 marginalised and excluded in Myanmar. They had very little or no access to healthcare and were not routinely vaccinated against communicable diseases, so their immunization coverage is very low. Our medics treat many people with diarrhea and respiratory tract infections – diseases related to the living conditions in the camps. We see wounds that have developed into serious infections after not being properly treated, and chronic diseases that have never been properly addressed."

"All these factors combined: the sheer size of the population, the densely crowded conditions, the inadequate shelter, and the apparently very low level of immunisation, create a perfect storm for the public health situation. I am concerned about fresh emergencies evolving 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."

 

'We only survived by eating the leaves of the trees': One Rohingya woman's harrowing journey to flee violence in Myanmar

Humaira is a 25-year-old Rohingya refugee from Maungdaw district in Rakhine state. She arrived in Bangladesh in October 2017, after the violence reached her hometown. In late January 2018, she was found in a state of shock by an MSF outreach team in the Jamtoli makeshift settlement and brought to the Doctors Without Borders/Médecins Sans Frontières (MSF) primary healthcare centre there, where she is being treated.

"When the violence broke out, my husband was taken by the Myanmar military. I don’t know whether he is dead or alive. They took us from our homes, burned them to the ground and beat us very badly. When we fled, I was already heavily pregnant. I left with my son and another woman, but lost contact with her during the journey. I couldn’t take any belongings with me. We walked for several days through the forest. We were starving and only survived by eating the leaves of the trees. We slept in the bush. We finally reached the riverside and boarded a boat that would take us to Bangladesh."

 

MSF medical action for Rohingya refugees in Cox's Bazar, Bangladesh

As of January 25, 2018:

Number of health facilities:  15 health posts, three primary health centres and five in-patient health facilities

Number of staff: Over 2,000 national and international staff as of the end of November

Number of patients: Over 200,000 patients have been treated at MSF outpatient facilities and 4,938 patients in inpatient facilities between the end of August and the end of December

Main morbidities: respiratory infections, diarrheal diseases, diphtheria cases

Other activities: water and sanitation (water trucking and hand pump, tube well and latrine installation) and mental health services

CURRENT PUBLIC HEALTH CONCERNS:

Measles: Between September and January, we saw 3,539 cases of measles across all the MSF health facilities. The epidemiological curve of measles is decreasing significantly.

Diphtheria: MSF has treated more than 4,371 cases of diphtheria as of January 22.

The majority of cases involve patients aged between five and 14 years old. Diphtheria can result in a high case-fatality rate without anti-toxin. MSF has been administering anti-toxin to patients, but it requires a number of skilled human resources. At Rubber Garden, which used be a transit centre for new arrivals, MSF has set up a new diphtheria treatment centre and has treated more than 1,000 admitted patients since December 26, 2017. MSF has treated a total of 231 patients with DAT (Diphtheria anti-toxin).  Active case investigation continues throughout the settlements and contacts are being treated prophylactically with antibiotics via the health facilities.

Vaccination

MSF is supporting the government in expanding routine vaccination in the camps through initiating vaccination for children and pregnant women at MSF facilities. Staff at all MSF health facilities will have the capacity to administer immunization for measles and rubella, oral polio and tetanus according to national protocols.

The Ministry of Health completed a measles and rubella vaccination campaign on December 6. It targeted more than 336,000 children between the ages of 6 months and 15 years. MSF supported this campaign with community mobilization, site identification, logistics and transportation of vaccines. Some 156,679 people in Kutupalong and 41,066 in Balukhali were vaccinated

Treating survivors of sexual and gender-based violence (SGBV)

  • Total number of sexual violence cases from 25 August – 31 December: 120
  • Number of rape cases:  101
  • Number of SGBV cases under 18:  45

Since August, MSF has treated 120 survivors of sexual violence at MSF’s Sexual and Reproductive Health Unit in Kutupalong. Of the survivors, 33% are under the age of 18, including one under the age of ten.

Sexual violence is often underreported due to stigma and shame, fear of reprisals, a lack of knowledge about the medical consequences of sexual violence and the need for timely medical care, and a lack of awareness about the medical and psychological support available. Given these barriers, it is likely that the number of SGBV survivors MSF has treated so far is just a fraction of the real figure.

MSF has specialized staff on the ground to treat survivors who are referred for treatment as a result of trauma, including sexual assault and rape. MSF’s local community outreach workers visit people living in the settlements, informing them about the free services the organization offers, including treatment for sexual violence.

'We should not be seeing diphtheria': An MSF doctor on the outbreak affecting Rohingya refugees in Myanmar

Dr. Rosie Burton, a British physician based in South Africa, has just returned from one month in Bangladesh, where she was working in a diphtheria treatment centre for Rohingya refugees from Myanmar, run by Doctors Without Borders/Médecins Sans Frontières (MSF).

Most patients with diphtheria have a fever, sore throat and difficulty swallowing. For some people it can be very serious; they can have difficulty breathing, their tonsils can become inflamed. Diphtheria forms a thick covering of the throat, which can be dislodged, obstruct the airway and cause swelling of the neck that can compress or block a person’s airways. This often happens to children and can cause them to die. 

What makes diphtheria a serious infection is that it makes a toxin, basically a poison, which can spread around the body. This can cause complications, including with the heart; making it beat too slow, too fast, or even cause it to stop. It can also cause paralysis, including of the muscles used for breathing, so people suffocate.

 

Bangladesh: MSF surveys estimate that at least 6,700 Rohingya were killed during attacks in Myanmar

Surveys conducted by Doctors Without Borders/Médecins Sans Frontières (MSF) in refugee settlement camps in Bangladesh estimate that at least 9,000 Rohingya died in Myanmar, in Rakhine State, between August 25 and September 24.

As 71.7% of the reported deaths were caused by violence, at least 6,700 Rohingya, in the most conservative estimations, are estimated to have been killed, including at least 730 children below the age of 5 years.

The findings of MSF’s surveys show that the Rohingya have been targeted, and are the clearest indication yet of the widespread violence that started on August 25 when the Myanmar military, police and local militias launched the latest "clearance operations" in Rakhine in response to attacks by the Arakan Rohingya Salvation Army. Since then, more than 688,000 Rohingya have fled from Myanmar into Bangladesh.

 

Myanmar

Independent international humanitarian organizations are still blocked from accessing and operating in northern Rakhine State in Myanmar — the region from which hundreds of thousands ethnic Rohingya Muslims fled after being targeted with severe violence. MSF is urging for unfettered access to Rakhine State to ensure the impartial delivery of aid. For now people have no, or very limited, access to medical care.

The crisis is not over: people are still fleeing from Myanmar to Bangladesh, fearing for their lives and seeking safety. It is clear that any return or repatriation of Rohingya refugees to Myanmar can only take place if it is voluntary, their safety is guaranteed and the root causes of the violence have been addressed.

MSF considers that the establishment of camps for internally displaced people (IDPs), or returnees in northern Rakhine, would exacerbate the ongoing segregation between ethnic Rakhine and Rohingya communities and would further complicate long-term solutions. 

MSF President Dr. Joanne Liu on the Rohingya crisis in Bangladesh and Myanmar: 'People are in survival mode'

October 26, 2017 — Doctors Without Borders/Médecins Sans Frontières (MSF) International President Dr. Joanne Liu, a physician from Montreal, recently visited Cox’s Bazar, Bangladesh, where a refugee crisis is unfolding after renewed violence in Rakhine State, Myanmar. On October 23, she spoke at a Pledging Conference for the Rohingya Refugee Crisis organized by UN agencies, and called for more organizations to prevent what she called a "public-health time-bomb."

"There are almost no services available and the vulnerability of people’s living conditions is shocking," she says. "Whole families are living under plastic sheeting in muddy and flood-prone terrain. They have very few belongings, are vulnerable to attacks from elephants, and have no access to clean water, latrines, food or healthcare.

"It’s a very fresh displacement and people are in survival mode, which you can clearly see in everybody’s body language. People are taking each day as it comes, trying to secure the basics to get through the day. Currently the humanitarian response is quite scattered: plastic sheeting is handed out in one location, while bags of rice or water are distributed elsewhere."

 

Bangladesh: Voices from the Violence — an MSF Exodus photo story

 

Rohingya refugees in Bangladesh: Immediate action needed to avert massive public health disaster

September 21, 2017 — A massive scale-up of humanitarian aid in Bangladesh is needed to avoid a massive public health disaster following the arrival of hundreds of thousands of Rohingya refugees, says the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF).

Following a wave of targeted violence against Rohingyas, more than 422,000 people have fled to Bangladesh from Rakhine State in Myanmar within a three week period. The most recent influx of Rohingya refugees has added to the hundreds of thousands of Rohingyas who fled across the border during episodes of violence in previous years.

Most of the newly arrived refugees have moved into makeshift settlements without adequate access to shelter, food, clean water, or latrines. Two of the main pre-existing settlements in Kutupalong and Balukhali have effectively merged into one densely populated mega-settlement of nearly 500,000 refugees, making it one of the largest refugee concentrations in the world.

“These settlements are essentially rural slums that have been built on the side of the only two-lane road that runs through this part of the district,” says Kate White, MSF’s emergency medical coordinator. “There are no roads in or out of the settlement, making aid delivery very difficult. The terrain is hilly and prone to landslides, and there is a complete absence of latrines. When you walk through the settlement, you have to wade through streams of dirty water and human feces.”

 

Myanmar: International humanitarian access to Rakhine State must urgently be permitted

September 18, 2017 — International humanitarian organizations must immediately be granted independent and unfettered access, including for international staff, to alleviate massive humanitarian needs in Rakhine State, Myanmar, says the international medical humanitarian organization Doctors Without Borders/ Médecins Sans Frontières (MSF).  

The call for urgent access comes amidst the ongoing military operations in Rakhine, which started on August 25 after a new spate of attacks against police stations and a military base claimed by the Arakan Rohingya Salvation Army (ARSA). As a consequence, over 400,000 Rohingya have fled to Bangladesh and are living in extremely precarious conditions with limited access to health care, potable water, latrines and food.

The remaining population in Northern Rakhine, thought to be hundreds of thousands of people, is without any meaningful form of humanitarian assistance. “Our teams in Bangladesh are hearing alarming stories of severe violence against civilians in Northern Rakhine. Reports are that there is significant internal displacement of Rohingya, ethnic Rakhine populations and other minorities. Villages and houses have been burned down, including at least two out of four of MSF’s clinics. Prior to being put on hold due to a lack of travel authorization and a ban on international staff in mid-August, MSF was providing healthcare services in Maungdaw and Buthidaung townships in Northern Rakhine. We fear that those remaining there are unable to access the help they may need,” says Karline Kleijer, emergency desk manager at MSF. “Injured, sick or chronically ill people in Northern Rakhine must be accessed without further delay, while emergency healthcare and other humanitarian assistance should be provided.”

 

Rohingyas: MSF scaling up activities in Bangladesh while concerned about those still in Myanmar

September 6, 2017 — Rohingya refugees fleeing to Bangladesh are in urgent need of medical and humanitarian assistance as an already dire humanitarian situation along the border with Myanmar worsens, says the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF).

By September 6, over 146,000 people had crossed into Bangladesh, fleeing violence in Rakhine state, Myanmar. This figure, coming on top of 75,000 people who have arrived since violence began in October 2016, represents one of the largest influxes ever of Rohingyas into Bangladesh. The majority of the new arrivals are now staying in existing makeshift settlements or UNHCR-registered camps, in three new makeshift camps that have emerged, or among the host community. Many refugees are stranded in no-man’s land between the borders of Bangladesh and Myanmar. Even prior to the most recent influx, many Rohingya refugees in Bangladesh lived in unsafe, overcrowded and unhygienic conditions with little protection from the elements.

“We’ve not had something on this scale here in many years,” says Pavlo Kolovos, MSF head of mission in Bangladesh. “Our teams are seeing streams of people arriving destitute and extremely traumatized, and who have had no access to medical care. Many of the arrivals have serious medical needs, such as violence-related injuries, severely infected wounds, and advanced obstetric complications. Without a scale-up of humanitarian support, the potential health risks are extremely concerning.”

One 49-year old father told MSF: “I fled home with my whole family, but my son was shot while running away. I brought him to the hospital here in Bangladesh, but left the other family members in the forest in Myanmar, in the open air, just hiding there. I haven’t heard from them for days now. I don’t know what to do, I feel so desperate.”

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