Rohingya refugees in Bangladesh: A massive humanitarian crisis

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

Last fall, over 693,000 Rohingya refugees fled from Myanmar into Bangladesh, and the influx still continues today. Nearly one year on, living conditions for refugees remain unacceptable; they are still living in makeshift shelters in overpopulated camps. Conditions need to be massively improved, with particular focus on safe drinking water, hygiene and sanitation, shelter, and reducing population density. What Doctors Without Borders/Médecins Sans Frontières (MSF) teams see on the ground remains an acute emergency situation with huge humanitarian needs. 

With the arrival of the rainy season, MSF's work is even more crucial, and even more difficult. The first rains and winds have started, affecting over a thousand shelters and structures. Emergency preparedness and mitigation is a key priority, but the window for putting these strategies in place is quickly closing. 

In current conditions, the risk of illness is high. Rohingya refugees had been vulnerable even before leaving Myanmar, with little or no access to routine healthcare including vaccinations. Settlements are already experiencing a resurgence of measles and diphtheria. 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.

Opinion: MSF Canada director Joe Belliveau on why Canada should play a lead role in resolving the Rohingya refugee crisis

In June, as Canada played host to a gathering of G7 leaders at a summit in Quebec, MSF Canada executive director Joe Belliveau published an op-ed in the Ottawa Citizen calling on Canada to use its leadership to spur international action in response to the ongoing Rohingya refugee crisis on the border between Bangladesh and Myanmar. 

"It is essential that Canada demonstrate leadership and use this opportunity to obtain not just vague statements but real commitment from some of the world’s most influential states to a consolidated and resolute international response to the Rohingya crisis.

The status quo – perpetual statelessness – is not an option. And humanitarian aid cannot substitute for a political solution. The only way forward is for the G7 and other states to recognize and fight for the Rohingyas’ shared humanity, the fact that they belong somewhere – and to take concrete steps to make it possible for Rohingya children born today to have the chance for a real and viable future."

Read Joe Belliveau's complete op-ed in the Ottawa Citizen

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

As of May 24, 2018:

Number of health facilities: 10 health posts, three primary health centres, and five inpatient health facilities.

Number of staff: MSF’s team has increased to more than 2,800 national and international staff - the majority of them Bangladeshi nationals.

Number of patients: 506,324 patients have been treated at MSF outpatient facilities and 10,655 patients in inpatient facilities.

Main morbidities: Respiratory infections, diarrheal diseases, skin diseases - all related to poor living conditions.

Water and Sanitation: In order to prevent disease, MSF is working to improve infrastructure. Drilling boreholes and tube wells, installing a gravity-powered water supply system, trucking in water, de-sludging old latrines, constructing new sustainable latrines, chlorinating water and distributing water filters are some of our activities. 

Mental Health Services: have been scaled up, with more counsellors added to existing teams, services available at additional health posts, and outreach workers being trained to offer basic psychosocial support.

Outreach: Educating the population on health promotion, outbreak prevention, alert and response procedures. Surveillance teams gather demographic, nutritional, and mortality and natality rates in the refugee settlements. An all-female team supports the community on sexual and reproductive health. 

Vaccination

Coverage rates for routine immunization are low. This, combined with crowded living conditions, lack of adequate water and sanitation, and the lack of access the Rohingya population in Myanmar previously had to routine healthcare represent a public health risk.

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 immunizations for measles and rubella, oral polio and tetanus according to national protocols.

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

  • Total number of sexual violence cases from August 25 – April 30: 377

Since August, MSF has treated 377 survivors of sexual and gender-based violence, between nine and 50 years of age. However, the real figure of SGBV survivors is impossible to determine, as MSF likely only treats a fraction of all cases. Sexual violence is often underreported due to the shame and stigma associated with sexual assault, limited knowledge about medical and psychological support available, and the fact that access to healthcare in Myanmar had previously been restricted heavily.

MSF has specialised 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 organisation offers, including treatment for sexual violence. At our clinic, we offer these women comprehensive health care, including mental health care and counselling. We also discuss possibilities and support options with them, based on their individual needs.

MSF is intensifying its activities focusing on mother-and-child and reproductive healthcare. Only a minority of expected deliveries occur in a health facility, while home deliveries often happen in unsafe and unhygienic conditions. Moreover, MSF sees many women and girls seeking medical care for pregnancies which are the result of rape. The lack of support mechanism for rape-related pregnancy can have dangerous consequences, such as unsafe abortions and death. 

CURRENT PUBLIC HEALTH CONCERNS:

Upcoming rainy season: The rainy season has begun and brings with it increased risk of respiratory tract infections, effects on mental health and the exacerbation of existing illnesses, as well as waterborne diseases.

Acute jaundice syndrome: Between December and April 30, MSF has seen 1,259 patients with acute jaundice symptoms. Suspected cases are tested, while water and sanitation teams assess facilities in the area and respond as necessary. 

Measles: Between September and April 30, we saw 4,680 cases of measles across all the MSF health facilities. The epidemiological curve of measles is decreasing significantly. All children under 5 years newly arriving in the camps are vaccinated against measles. 

Diphtheria: MSF has treated more than 5,883 cases of diphtheria as of April 30, with the majority of cases involving patients aged between five and 14 years old. Diphtheria can result in a high fatality rate without Diphtheria anti-toxin (DAT). Administering this anti-toxin requires skilled human resources. At Rubber Garden, MSF has set up a new diphtheria treatment centre and treated more than 1,000 patients between December 2017 and March 2018. 

Conditions in 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 of ethnic Rohingya Muslims are fleeing after being targeted by 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. 

A new report from MSF summarizes in detail the testimony of Rohingya patients in Bangladesh who fled ethnic violence in Myanmar.

In the early hours of August 25, 2017, the Myanmar military launched “clearance operations” in Rakhine State, ostensibly in response to coordinated attacks by Rohingya armed groups on Border Guard Police outposts.

This resulted in an estimated 688,000 mainly Rohingya people from Rakhine State fleeing into neighbouring Bangladesh. The speed and scale of displacement resulted in a critical humanitarian emergency; together with previously displaced people, this took the total number of Rohingya in Bangladesh to more than 900,000.

In November 2017, MSF conducted a total of six health surveys in Cox’s Bazar district which aimed at quantifying the current scale of the emergency by assessing factors including levels of mortality over time. Findings show that the Rohingya have been targeted, and are the clearest indication yet of the widespread violence that started on August 25. Now, MSF has released a report, "No One Was Left": Death and Violence Against the Rohingya in Rakhine State, Myanmar,  summarizing the health survey results and painting a picture of the violence that led to the Rohingya refugee crisis still taking place 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. 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."

 

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.

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."

 

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