Bangladesh: One million consultations in the world’s largest refugee settlement

Rohingya Exodus - 6 months

Bangladesh 2018 © Anna Surinyach/MSF

Today the magnitude of the Rohingya refugee crisis and response can be captured in an astonishing figure: One million.

Doctors Without Borders/ Médecins Sans Frontières (MSF) teams have provided more than one million medical consultations in the world’s largest refugee settlement—in Cox's Bazar, Bangladesh—since the crisis exploded in August 2017.*

A year and a half ago, more than 700,000 ethnic Rohingya from Myanmar fled to Bangladesh following a campaign of targeted violence against the community that began in August 2017. They joined some 200,000 Rohingya displaced by earlier cycles of violence and persecution. Most of these refugees are living in fragile shelters in overcrowded settlements where they are vulnerable to the spread of disease.

MSF medical coordinator Jessica Patti lays out the key findings from our medical and psychosocial teams involved in the emergency response.

1. All of the main diseases are linked to people’s poor living conditions

Almost 9 percent (92,766) of our medical consultations were for acute watery diarrhea, most of them for children under five. Young children are particularly vulnerable to diarrheal diseases, which can be deadly if left untreated. While severe cases need to be admitted to the hospital, most people can go home after being properly rehydrated.

The prevalence of diarrhea is directly related to the poor and overcrowded living conditions in the camps. Most refugees live in small shelters built from bamboo and plastic sheeting and shared with many family members. Clean drinking water and well-maintained latrines are key factors in preventing diarrhea, and health promotion activities focused on improving hygiene are crucial.

The simple practice of washing one’s hands with soap and water would help to prevent many of the skin conditions we treat, such as fungus and scabies. But when you live in a refugee settlement, where clean water is scarce, washing one’s hands isn’t so simple. That’s why water and sanitation activities have been such an important part of MSF’s work. So far, our teams have distributed over 23 million gallons of clean water in the camps.

Poor living conditions are also behind the other main diseases we treat. These are upper and lower respiratory tract infections, skin diseases, and fevers of unknown origin, which can be hard to diagnose when laboratory services are not widely available. Reducing overcrowding and creating more space in the camps would help mitigate the spread of some viral infections.

BANGLADESH 2018 © Anna Surinyach

2. Despite vaccination campaigns, the risk of disease outbreaks still exists

In the early months of the emergency, medical organizations and the Bangladeshi Ministry of Health responded to various outbreaks of disease—mostly resulting from the low immunization coverage and limited access to routine vaccinations and health care available to the Rohingya community in Myanmar’s Rakhine state.

Since August 2017, MSF teams have treated 6,547 people for diphtheria and 4,885 people for measles. While these represent barely 1 percent of our total consultations, the quick response was crucial to containing these outbreaks. In any emergency involving the mass displacement of populations, the first thing you try to do is to vaccinate for measles, as it is a recurrent disease. The emergence of diphtheria was more challenging, as outbreaks are rare, and most of our medical staff had to learn how to treat it from scratch. We have also supported vaccination campaigns for cholera.

Today, people in the camps are better protected from disease outbreaks, and our teams continue to do routine vaccinations—but the risk still exists. In recent weeks, we have treated several hundred cases of chicken pox, a disease that is uncommon in South Asia and can have complications for pregnant women or for people already suffering from other diseases.

BANGLADESH 2018 © Daphne Tolis/MSF

3. With the future so uncertain, mental health services are key

Most of the Rohingya have experienced traumatic events. Many have suffered or witnessed violence and lost close relatives and friends. A lot of people would like to go home, but that’s not possible [until conditions are safe, dignified, and sustainable]. So they feel hopeless. Since the very beginning, providing mental health services has been a priority for MSF. Mental health consultations represent 4.7 percent (49,401) of our total consultations.

Mental health care is unfamiliar to many people [in the Rohingya community] and often stigmatized, so we had to create awareness of our services. Our teams provide individual and group sessions, conduct psychosocial stimulation for malnourished children, and treat people for psychiatric conditions. We see signs of progress: drop-out rates are low and there are a good number of discharges.


Creating a place of peace for Rohingya survivors in Bangladesh

4. People’s needs are still not being met for chronic conditions and maternity care

Chronic diseases, such as diabetes and high blood pressure, are common among our patients, particularly the elderly. However, this is a significant need that is not being properly met. When we receive patients who need urgent treatment for chronic diseases, we stabilize them and then refer them to another medical organization for longer-term care. Among children, there is also a significant prevalence of thalassemia—a congenital disease which is difficult to treat and requires blood transfusions. The major needs are for specialist care, including for non-communicable diseases.

Unlike in other contexts where MSF works, deliveries represent a small proportion of our consultations—our teams have assisted just 2,192 births. This is because most women choose to give birth at home, attended by traditional birth attendants, as they did in Myanmar. But when home is a basic shelter in an overcrowded camp, this practice is a worrisome. Those women who do come to the hospital often arrive very late, without seeking antenatal care beforehand. Antenatal consultations made up just 3.36 percent (35,392) of total consultations. As a result, our medical staff often see women with conditions such as pre-eclampsia, eclampsia, prolonged labors, and retained placentas. 

BANGLADESH 2018 © Pablo Tosco

5. From an emergency situation to a protracted crisis

At the start of our emergency response, we treated people for violence-related injuries suffered in Myanmar. Today, the patients we treat for violence are often harmed by members of the community or their own family, including cases of sexual and gender-based violence. As at the beginning of the emergency, though now for different reasons, sexual violence remains an important focus for MSF. A number of women also arrive at our facilities with sexually transmitted infections that have gone untreated for a long time.

MSF’s continued presence in the Cox’s Bazar peninsula is also leading to an increase in consultations for members of the local Bangladeshi community, particularly in those health facilities that are not located in the middle of the Rohingya camps.


Strong women: Helping women and girls survive in emergencies

* Between August 2017 and December 2018, MSF teams provided 1.05 million medical consultations to refugees and the local community in Cox’s Bazar, Bangladesh.