Bangladesh: How MSF is bringing diabetes care to Rohingya refugees
Simple, innovative solutions are improving access to insulin in the world’s largest refugee camps.
One night, in the summer of 2017, Lalu Begum awoke to her next-door neighbour’s house on fire.
Their town was being attacked as a wave of horrific violence swept across Myanmar’s Rakhine state. On Aug. 25, 2017, the Myanmar government had launched a military campaign against the Rohingya people, a predominantly Muslim ethnic minority group who had suffered decades of discrimination and persecution.
As military forces moved through the neighbourhood, setting homes alight, Begum, along with her husband and two sons, gathered what they could and made for the Naf River, which separates Myanmar from neighbouring Bangladesh. The family spent the rest of the night in the forest, keeping hidden as best they could, until they found an abandoned boat at the river’s edge and crossed the border.
Begum and her family were among more than 700,000 Rohingya people who were driven out of Myanmar in a matter of weeks. In Bangladesh they joined hundreds of thousands more who had fled their homes in previous cycles of violence, settling in the sprawling Kutupalong refugee camps.
“Often these people were walking three hours or more to come to their clinic visits, and they’re walking because no motorized transportation — or wheeled transportation at all — is permitted within the camp.”
Anjoli Anand, an MSF noncommunicable diseases advisor
Today, more than one million Rohingya people remain stateless in Kutupalong and Balukhali near the coastal city of Cox’s Bazar. Kutupalong is itself, the largest refugee camp in the world. Most people live in shelters built from strips of bamboo and plastic sheeting set among the hills of what was once the Ukhiya forest area. Unable to leave the camps or return home and barred from working, Rohingya refugees are totally dependent on humanitarian assistance for essential services, including healthcare.
After nine years of living in the camp, Begum began to feel sick. She visited a Doctors Without Borders/Médecins Sans Frontières (MSF) hospital and was diagnosed with diabetes.
An evolving emergency
MSF has worked continuously in the Kutupalong refugee camp since the early 1990s, providing a range of services to both Rohingya people and Bangladeshi communities in the region, including both inpatient and outpatient care, 24/7 emergency room services, neonatal and pediatric care and more at three hospitals. As successive waves of refugees arrived in the camps over the decades, MSF adapted medical services to meet the needs of the growing — and aging — community, which included a need to treat noncommunicable diseases like hypertension and diabetes.
For Rohingya refugees living in the camps, every aspect of daily life is challenging. Vast stretches of forest were hastily cleared to make room for the exodus of people forced to flee from Myanmar. The makeshift camps are prone to flooding and landslides during the long rainy season.
Refugees receive food rations and other services from government donors and nongovernmental organizations, but it is nowhere near enough to meet the massive needs. Those living with chronic diseases like diabetes face even greater challenges.
When MSF began providing diabetes care in the camps, patients had no choice but to travel to hospitals for glucose testing, and to receive medication.
“It’s difficult to overstate just how challenging it can be to get around in a place like this,” says Anjoli Anand, a physician and MSF noncommunicable diseases advisor who provides medical guidance and direction to our humanitarian teams. “Often these people were walking three hours or more to come to their clinic visits, and they’re walking because no motorized transportation — or wheeled transportation at all — is permitted within the camp.”
As the number of diabetes patients grew, MSF teams faced a challenge: If people were struggling to reach treatment for diabetes, how could we bring care to them?
Old-fashioned solutions to modern challenges
In many parts of the world, diabetes is largely managed by patients at home. People living with the illness are taught to monitor their own glucose levels and administer insulin themselves using a syringe or injection pen. But insulin needs to be kept cool, which poses a unique challenge in a setting where average high temperatures hover around 32 degrees Celsius and most people live without access to electricity.
Enter the humble clay pot.
“Historically, when people were trying to store vegetables at home or keep water cool for longer periods of time, they often stored these things in clay pots,” says Anand. “Clay pots are cheap and widely available; they can be found in local markets almost anywhere MSF works.”
The pots help regulate temperature through a simple process called evaporative cooling. At MSF facilities, patients living with diabetes are given sets of nesting clay pots and taught how to put one inside the other and fill the gap between them with wet sand. Patients keep the sand damp, and as the moisture evaporates it pulls heat away from the inner pot, keeping the insulin stored inside cool.
For two years Abdur Shukkur, had to travel to a clinic every day to get his insulin injections.
“We don’t have money, or electricity, for a freezer,” says Shukkur. “So, the clay pot service is a huge support for me.”
Spreading the word
Many people living with diabetes in the Rohingya refugee camps were not aware of the disease before being diagnosed, and misconceptions and social stigma can deter people from seeking care. That’s where MSF’s health promoters come in.
Several times a week, MSF community promotion volunteers Ferojdul Haque and Yeasin Juhar crisscross a section of the refugee camps to spread the word about the services MSF provides and teach people about diabetes and other noncommunicable diseases.
Both Haque and Juhar — and the rest of MSF’s community promotion team in the camps — are themselves Rohingya refugees. It’s this connection to the community that helps them reach people with important messaging about their health.
“It’s helpful because I know everyone in the area,” says Haque. “It makes it easier for me to teach them. They accept what I have to say because they are my relatives and friends.” He’s noticed the positive impact his years of work has had in the community.
“At first there were a lot of rumours about diabetes,” he says. “[For example], if a woman got diabetes, her husband might send her out of the house out of fear that the disease was contagious. Now we don’t see anything like that — they understand what diabetes is and how it works. That’s the thing I love most about this work: helping people.”
Calling for equitable access to care
While simple solutions like clay pots and health education have had major impacts on the health of people living with diabetes, many advances in medicine and technology remain out of reach. Most people living with diabetes in the camps who use insulin to control the disease get it in vials, from which they need to measure dosages and use syringes to inject the medicine. Insulin pens, which are widely available in high-income countries like Canada, are much simpler and safer for people to use.
The number of people living with diabetes around the world is skyrocketing: from around 200 million in 1990 to 830 million in 2022. However, access to insulin pens is extremely limited in low- and middle-income countries, where more than 80 per cent of people affected by diabetes live. MSF is calling on governments, funders and pharmaceutical corporations to improve access to insulin pens and ensure that people with diabetes everywhere have more equitable access to care.
MSF has provided some patients with insulin pens in the Rohingya camps and is in the process of making them the standard of diabetes care. While the pens are still too expensive to implement widely, the patients who are using them describe improved quality of life.
“[Using the pen] makes it easier to take insulin regularly, so my diabetes is under control,” says Lalu Begum, who has been using insulin pens prescribed by MSF for several months. “I am feeling much better than before.”
