Since August 25, 2017, more than 693,000 Rohingya refugees have crossed the border from Myanmar into Bangladesh’s Cox’s Bazar district, fleeing a campaign of targeted violence by Myanmar’s military in Rakhine state. Combined with the Rohingya refugees already living in Bangladesh after fleeing previous outbreaks of violence, there are now more than 905,000 refugees in the sprawling Cox’s Bazar camps.
In response to the fastest growing refugee crisis in the world, MSF has scaled up operations in Cox’s Bazar with the help of more than 2,000 staff—the vast majority of them Bangladeshi nationals. Teams are running 10 health posts, three primary health centers, and five inpatient health facilities providing secondary health care.
Seasonal rains and heavy winds have started, with landslides already causing deaths and injuries, and damaging fragile shelters in the camps. Hundreds of thousands of Rohingya are at risk of disease outbreaks, aid disruptions, and complicated access to health care. MSF is preparing to respond to the medical needs in the aftermath of natural disasters and other health emergencies.
MSF Operations Overview
|Number of health facilities||10 health posts; 3 primary health centers (open 24 hours); and five inpatient health facilities (24-hour secondary health care)|
|Number of staff||To respond to the fastest growing refugee crisis in the world, MSF’s team in Cox’s Bazar has increased to more than 2,000 staff, the majority of them Bangladeshi nationals|
|Number of patients||From August 2017 to the end of April 2018, our teams carried out 506,324 outpatient and 10,655 inpatient consultations|
|Main morbidities||Respiratory infections, diarrheal diseases, and skin diseases—all related to poor living conditions—and non-communicable diseases|
|Water and sanitation||This is key to preventing the spread of disease in the camps. Activities include drilling boreholes and tube wells, installing a gravity-fed water supply system, trucking in water, cleaning old latrines and constructing sustainable new ones, and chlorinating buckets and distributing domestic water filters|
|Mental health services||More counselors have been added to existing teams. Services are now available at additional health posts, and we are training outreach workers to provide basic psychosocial support in the camps|
|Outreach||Teams focus on health promotion, outbreak prevention, and alert and response, while a surveillance team gathers demographic, nutritional, mortality, and natality indicators covering 80 percent of refugee settlements. Teams also do active case-finding and referral to health facilities for diagnosis and treatment as well as defaulter tracing and mobilization for vaccination. An all-female team spreads messages about sexual and reproductive health in the community|
Fewer but continued arrivals
Rohingya refugees continue to cross over into Bangladesh, though in smaller numbers than were witnessed over the past year. Since the beginning of 2018 more than 8,000 people have arrived in Cox’s Bazar. Those who manage to cross the Naf river are often required to wait at entry points upon arrival in Bangladesh. Access for humanitarian agencies at the border points in Bangladesh is complicated, making it difficult for people to obtain basic assistance like food, water, and health care. New arrivals are relocated mainly to Nayapara refugee camp or the United Nations Refugee Agency’s transit center in Kutupalong, from where they are resettled in the Kutupalong-Balukhali expansion site. This site is already dangerously overcrowded.
A group of Rohingya refugees has been living in a so-called no man’s land on the border between Myanmar and Bangladesh since the end of August 2017. While they were ordered to vacate the area by the Myanmar authorities, as Bangladesh included the group in the initial repatriation list, no progress has been made to relocate the group to either side of the border. The area is susceptible to flooding, sparking concerns that they could be further displaced as the rainy season progresses.
The monsoon season has started, with more than ten landslides recorded up to May 14 affecting over one thousand shelters and structures. Hundreds of thousands of Rohingya are also at risk of disease outbreaks, aid disruptions, and complicated access to health care. Emergency preparedness in the camps remains a key priority, but efforts are hampered by a lack of sufficient useable land and a lack of time, as the window for flood mitigation is quickly closing.
The government of Bangladesh has proposed Bhasan Char, a hitherto uninhabited island in the Bay of Bengal, as a temporary living arrangement for Rohingya refugees to ease congestion in the Cox’s Bazar camps and mitigate the risks posed by the impending monsoon season. The relocation of up to 100,000 refugees is expected to launch in June or July. This plan does not, however, address the risks faced by the much larger population that would remain exposed to the elements in congested living conditions under bamboo and plastic sheeting shelters. The rains have started and MSF is already treating patients injured in landslides. Several people have already died.
A stalled repatriation agreement
On November 23, 2017, the governments of Bangladesh and Myanmar signed an agreement for the repatriation of Rohingya refugees, and on January 15 agreed on the physical arrangements for returns. Continued monitoring is needed given that both governments appear to be moving forward with practical arrangements. A memorandum of understanding was signed last month between Bangladesh and the UNHCR, which provides a framework of cooperation on the safe, voluntary, and dignified return of refugees.
A key inclusion is on birth registration of refugee children. UNHCR has, however, said conditions in Myanmar are not yet conducive for returns to be safe, dignified, and sustainable. So far, just one family of five has returned to Myanmar. However, both the Bangladeshi government and UNHCR denied having any involvement.
Developments in Bangladesh
The Kutupalong-Balukhali expansion site continues to grow westward, where the land consists of remote, hilly terrain that has been stripped of trees and vegetation. Overcrowding and congestion at the site continue to be of major concern. This also applies to Nayapara, the main refugee site in the south of the peninsula. While additional land is being prepared, there is not enough suitable space available for the population to relocate away from risk zones. About 200,000 Rohingya refugees in the district are at direct risk of flooding, which could also cause overflowing toilets and the contamination of drinking water.
Access to safe drinking water and sanitation services is insufficient in both existing camps and in new camps along the western fringes of the expansion site, which increases the vulnerability of the people there. Without adequate access to water, sanitation, and hygiene services, communicable disease outbreaks are inevitable.
In response, MSF has set up several diarrhea treatment units in the makeshift settlements.
The majority of the Rohingya refugees had extremely low immunization coverage on arrival in Bangladesh as a result of poor access to health care in Myanmar. Despite several vaccination rounds over the last nine months gaps remain within the huge refugee population.
Mental health needs are also significant. The trauma of what people experienced in Rakhine is compounded by the daily stresses of camp life, including a lack of sufficient food, a lack of opportunities to make a living, an inability to travel freely beyond the camps, and fears for personal security.
CURRENT HEALTH CONCERNS
Upcoming monsoon season
The approaching monsoon rains and other natural hazards may lead to deaths in the camps, with hundreds of thousands of Rohingya at risk of disease outbreaks and aid disruptions. Current shelters and structures are unable to withstanding extreme weather conditions and do not sufficiently meet protection needs of the most vulnerable refugees. Landslides have already occurred in the pre-monsoon rains. MSF is prepared for mass casualty scenarios to respond to the medical needs in the aftermath of these natural disasters.
Due to the poor infrastructure in the camp, access to our health posts and clinics will be even more difficult for patients and health care staff during the rains.
Waterborne diseases such as acute watery diarrhea, cholera, typhoid, hepatitis, shigellosis, or mosquito-borne diseases such as malaria and dengue fever.
Non-communicable diseases (NCDs)
MSF currently offers clinical stabilization and management of acute, life-threatening exacerbation of diseases such as asthma, diabetes, hypertension, and chronic obstructive pulmonary diseases. However, MSF is struggling to address continuation of care for patients with non-communicable diseases, which requires proper referral pathways, facilities, laboratory follow-up, and human resources, all of which still need to be put in place. This gap will be reduced by provision of comprehensive care for NCD patients through inpatient care for severe cases at the Hospital on the Hill and specific outpatient follow-up for NCD patients in health posts as part of the integrated health services provided there.
Vaccinations and vaccine preventable diseases
Vaccine-preventable diseases continue to be an issue in the camps, as evidenced by ongoing outbreaks of measles and diphtheria. However, incidences of these diseases have dropped since the initiation of mass vaccination campaigns.
Coverage for routine immunization is low. Combined with crowded living conditions, lack of adequate water and sanitation services, and the little access the Rohingya population had to routine health care in Myanmar, this represents a public health risk to both new arrivals and the host population. MSF supports the Bangladeshi government in expanding routine vaccination in the camps by vaccinating children and pregnant women at MSF facilities.
Staff at all MSF health facilities will have the capacity to administer measles and rubella, oral polio, pneumococcal conjugate vaccines (PCV), pentavalent vaccines, and tetanus vaccines according to national protocols. With the support of other actors, the Ministry of Health and Family Welfare is implementing a measles and a diphtheria (pentavalent) vaccination campaign. MSF has been supporting this by setting up fixed points in our health posts, reinforcing mobile teams with human resources, and implementing vaccinations with an outreach team.
From September to the end of April 2018 we saw 4,680 cases of measles across all MSF health facilities. Case numbers are now decreasing, though the outbreak is far from over. All children under five years old newly arriving in the camps are now vaccinated against measles. This remains one of MSF’s top priorities. Two rounds of a mass vaccination campaign were organized by the Ministry of Health with MSF support.
MSF has treated 5,883 people for diphtheria in the Cox’s Bazar district as of the end of April. At the peak of the outbreak, MSF ran three dedicated health facilities. At Rubber Garden, MSF has set up a dedicated diphtheria treatment center and follows up throughout the settlements with family members and other people who have been in contact with patients. These contacts are treated preventatively with antibiotics via an outreach team who follow up to ensure medication is taken on a daily basis.
The contacts are also sent to the health post to be vaccinated against diphtheria. An MSF team also traces patients after 30 days from the date of admission to ensure medical care for post-diphtheria complications is received. Any person who reports having symptoms indicative of post-diphtheria complications or other illness are referred to MSF’s health facilities for a clinical assessment, where appropriate treatment is given or patients are referred to other health care providers who offer palliative or rehabilitative services if needed. The Bangladeshi government has implemented a vaccination campaign against diphtheria.
Sexual and gender-based violence
From August 25, 2017, to April 30, 2018, MSF 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 available medical and psychological support, and heavily restricted access to health care for Rohingya people in Myanmar.
Sexual and reproductive health
MSF is intensifying its activities focusing on mother-and-child and reproductive health care. Only a minority of expected deliveries in Cox’s Bazar occur in a health facility, while home deliveries often happen in unsafe and unhygienic conditions.
MSF teams also see many women and girls seeking medical care for pregnancies that are the result of rape. The lack of support mechanisms for rape-related pregnancy can have dangerous consequences, such as unsafe abortions and death. Some rape-related pregnancies are quite advanced and women are unable to return to their community. MSF refers these women and girls to a safe shelter under the care of a dedicated organization, though existing capacity in the camp is extremely limited.
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 on offer, including treatment for sexual violence. At our clinic, we offer these women comprehensive health care, including mental health care and counseling. We also discuss possibilities and support options with them, based on their individual needs.
Mental and psychosocial health
The mental and psychosocial impact of being forcibly displaced and living in such difficult conditions continue to take a heavy toll on Rohingya refugees. Mental health services remain an important part of MSF’s assistance to people who have experienced extremely high levels of violence, as confirmed by the retrospective mortality surveys we published in December.
Water and sanitation (WASH)
Access to clean water and sanitation activities play a crucial role in preventing the spread of diseases.
Outside of the medical response, improving water and sanitation is a major part of our work to prevent the spread of disease. Emergency facilities that were put up quickly in the first phase of response are of low quality. Congestion is a major concern and overburdening existing facilities and complicating access for emptying latrines increases the public health risk in these sites. Desludging and decommissioning of these latrines remains a priority to improve the inadequate sanitation environment. So far, MSF has desludged 438 full or overflowing latrines.
MSF has built 1,050 latrines in the camps, serving around 50,000 people every day.
Considering the potential for contamination of the shallow groundwater, MSF has drilled ten deep productive boreholes—up to 200 meters—to provide clean water. These feed MSF health facilities and piped networks, which reach between 5,000 and 30,000 people each. MSF has drilled 296 tube wells and maintains the hand pumps in order to provide clean water to refugees where the topography does not allow such network construction.
A recently completed gravity water network has provided 1,790,000 liters of clean and chlorinated water to the community in the five weeks since it was put into operation. MSF also provides nearly 90,000 liters of water per day to health facilities and refugees using water trucking.
To provide access to clean water at the household level, MSF has distributed over 1,000 bucket water filters to refugees who are being relocated to the expansion areas of the camp, which lack infrastructure. Priority is given to the most vulnerable people (pregnant women, families with babies under 12 months old, households with no adults, the elderly, and widows). These water filters are also distributed as a preventive measure in areas where outbreaks of waterborne diseases are suspected.
The availability of safe drinking water is of growing concern in the settlements. MSF monitors water quality to ensure proper maintenance of every facility, with the aim of increasing their uptake and use by refugees. Given the huge number of people living together, outbreaks of waterborne diseases are inevitable (acute watery diarrhea, hepatitis E, typhoid). To ensure access to clean drinking water MSF assesses water sources, promotes hygiene messaging, and chlorinates buckets at 35 water source points.
MSF includes water supply and sanitation in its emergency response for new arrivals, and deploys teams to arrival, transit, and settlement locations to ensure that newly arrived refugees have access to safe drinking water and adequate sanitation facilities.
MSF PROJECT LOCATIONS IN COX’S BAZAR
Sadar Hospital in Cox’s Bazar City
By the end of May, MSF will start providing support to the Ministry of Health and Family Welfare at the district hospital in Cox’s Bazar. Located in the center of the town, this 250-bed district hospital manages around 500 patients per day. MSF’s support will focus on implementing infection prevention and control measures for the benefit of patients and hospital staff. MSF will train all medical and non-medical staff on standard infection prevention and control protocols, provide all required material for the implementation of these protocols, and recruit 50 additional cleaning staff. The team will also construct a new medical waste area and a laundry room to manage linens from the surgical and maternity departments, as well as rehabilitate the external gray water system.
Close to the Rubber Garden transit center for new arrivals outside Camp 7, near Kutupalong makeshift settlement, MSF opened a dedicated diphtheria treatment center in December in response to an outbreak of the disease. The treatment center now has 35 beds for patients with diphtheria and capacity to increase to up to 70 beds if needed. In order to reduce the spread of the disease, the team is also involved in active case finding, contact tracing (finding the patient’s household and ensuring that their family members complete the prophylactic treatment), and follow-up.
Patients are traced by the MSF outreach team 30 days after the date of admission in order to ensure that people needing medical care for post-diphtheria complications receive it. Moreover, as part of our preparedness plans for potential outbreaks, MSF is increasing the capacity of the facility with 100 more beds for a multi-outbreak response center, including for illnesses such as acute watery diarrhea. MSF is also working to improve public awareness of the signs and symptoms of a number of diseases.
Kutupalong inpatient department, just outside Camp 2E, has been operating since 2009 and is the largest MSF health facility in Cox’s Bazar. Services in the clinic include a 24-hour emergency room, an outpatient department (OPD), an inpatient department (IPD) including a pediatric and neonatal ward, isolation beds, a diarrhea treatment ward, sexual and reproductive health care services including 24-hour care for survivors of sexual violence, a mental health department, and basic laboratory services including blood transfusion for life-threatening emergencies.
Since August 25, 2017, the IPD has been expanded from 50 to 79 beds to cope with the influx and the increasing numbers of patients. Isolation capacity was also expanded due to the potential outbreak of communicable diseases. In order to increase the number of beds available and improve the overall infrastructure in the hospital to meet the needs of the growing population, construction projects are ongoing.
A temporary OPD was opened on December 24 to be used until a new and larger OPD is finished. This OPD currently treats more than 300 patients per day. MSF is also currently expanding services for maternity, sexual and gender-based violence, and newborn and pediatric care. Renovation and future expansion of the inpatient buildings are ongoing to reach a patient capacity of 110 beds.
MSF runs three health posts throughout the Kutupalong makeshift settlement expansion area (camps 3, 5, and 7) to provide basic primary health care. The health posts in total treat more than 300 patients per day. They will be used as fixed vaccination sites for EPI (the expanded program on immunization).
An inpatient facility in Balukhali (Camp 9) had been functioning as a 75-bed diphtheria treatment center since early December, leaving only the ER functional for other morbidities. On January 12, 2018, the facility changed back to a mother-and-child health care facility. Services include pediatric (15 beds) and neonatal care/inpatient therapeutic feeding center (ITFC) (15 beds), maternity (10 beds), emergency room and observation (five beds), and an isolation ward (20 beds). MSF also runs two health posts and an outpatient facility in the settlement to provide basic primary health care.
Additionally, we have a stand-alone facility which, when activated, has an isolation ward with 30 beds. Health posts will be used as fixed vaccination sites for EPI following the completion of the third round of diphtheria vaccinations. During the month of February, teams carried out over 10,000 outpatient consultations.
Camps 11 and 18
MSF has been running two health posts providing comprehensive primary health care and sexual and reproductive health care services (including antenatal, postnatal, and sexual and gender-based violence services; gynecological consultations; and family planning). Each health posts treats more than 200 patients per day.
On April 14 MSF opened a 100-bed inpatient facility known as the Hospital on the Hill. The semi-permanent structure includes a 24-hour emergency room, adult and pediatric wards, an intensive care unit, isolation beds, a 50-bed isolation unit in case of outbreak, a maternity unit with sexual and reproductive health care services, non-communicable disease care and follow up, laboratory services, and an ambulance referral system.
At a health post, MSF provides OPD services, sexual and reproductive health activities (antenatal, postnatal, and sexual and gender-based violence services; gynecological consultations; and family planning), and mental health care. Around 22 percent of consultations are for children under five.
There are around 34,000 refugees living in Hakimpara makeshift settlement. MSF has been running a primary health center that includes a 24-hour emergency room with eight observation beds, six isolation beds, an OPD, sexual and reproductive health care including a delivery room, and care for survivors of sexual and gender-based violence and mental health services. The clinic currently sees around 150 patients per day and operates an ambulance referral system. MSF’s outreach teams focus on health promotion, outbreak prevention, and alert and response, while a surveillance team gathers demographic, nutritional, mortality, and natality indicators.
There are around 55,000 refugees living in Jamtoli makeshift settlement. MSF has been running a primary health center that includes a 24-hour emergency room, an OPD, pediatric and adult wards, sexual and reproductive health care, and care for survivors of sexual and gender-based violence and mental health services. The clinic currently sees around 280 patients per day and offers 24-hour primary health care service with a delivery room, eight observation beds, six isolations beds, and an ambulance referral system. MSF’s outreach teams focus on health promotion, outbreak prevention, and alert and response, while a surveillance team gathers demographic, nutritional, mortality, and natality indicators.
There are more than 22,000 refugees living in Moynarghona makeshift settlement. MSF started a mobile clinic in September 2017, which has since been upgraded to a health post. The team carries out nearly 160 consultations per day on average. Services in this health post include emergency and outpatient departments, including sexual and reproductive health care and mental health services.
MSF´s outreach teams work in Moynarghona makeshift camp as well, with the same focus on health promotion, outbreak prevention, and alert and response, while a surveillance team gathers demographic, nutritional, mortality, and natality indicators.
In the context of our Emergency Preparedness Plan and in line with the overall ISCG/Ministry of Health preparations for a potential outbreak of acute watery diarrhea, a diarrhea treatment unit (DTU) with a 30-bed capacity was built at a walking distance from the MSF health post. The DTU is ready to be activated immediately if an outbreak indication is presented.
In February 2018, MSF opened a health care facility with a capacity of up to 74 beds. Thus facility includes an OPD, expanded program on immunization (EPI), mental health, and sexual and gender-based violence services. The inpatient department includes pediatric, neonatal, isolation, and maternity wards (with 24-hour capacity for deliveries). There is also a 24/7 emergency department with ambulance services available. This facility was under construction in December when it was temporarily transformed into a diphtheria treatment center until mid-February, due to the outbreak. The hospital is located outside the refugee camps, and treats patients from both the host and refugee communities.
There are more than 22,000 refugees living in Unchiprang makeshift settlement. MSF runs a primary health center and remains the main health care provider in the settlement. The team carries out around 200 consultations per day. The structure includes an OPD (including EPI, mental health, and sexual and reproductive health services), a 24-hour emergency room, six beds for observation, and a delivery room as part of the sexual and reproductive health component. Isolation capacity is also available.
The teams also perform active case-finding and referral to health facilities for diagnosis and treatment, as well as defaulter tracing and mobilization for vaccination. In the context of our Emergency Preparedness Plan and in line with the overall ISCG/Ministry of Health preparations for a potential outbreak of acute watery diarrhea, a diarrhea treatment unit (DTU) with a 36-bed capacity was built near the MSF primary health center. The DTU is ready to be activated immediately if an outbreak indication is presented.
There are more than 75,000 refugees living in Nayapara refugee camp and the informal settlements around it. MSF runs a primary health center, which was recently upgraded to include 24/7 emergency room service with five observation beds and two isolation beds. Referral capacity is also available 24/7. Services provided include an OPD, sexual and reproductive health care services, and mental health care. The team carries out around 200 consultations per day.
In line with our emergency preparedness plan, MSF is currently setting up a new diarrhea treatment center with skeleton infrastructure and a 100-bed capacity to be activated if an outbreak is detected.
Sabrang entry point
At the border point in Sabrang, MSF launched a mobile clinic on October 8 offering nutritional screening and basic primary health care and monitoring. These services have been integrated into the reception center. The mobile clinic team screens and provides consultations to all new arrivals. Services include OPD consultations (adult and pediatric), identification of severe cases, psychological first-aid, and referrals.
MSF first established a mission in Bangladesh in 1985 and has had a continuous presence in the country since 1992. Following the most recent influx of refugees in late 2017, MSF launched additional emergency projects in Cox’s Bazar.