COVID-19 in refugee camps: Five challenges in Bangladesh

07 Mar 2020

Across Cox´s Bazar, Bangladesh, nearly one million Rohingya refugees live in overcrowded, unsanitary conditions. As COVID-19 spreads through one of the most densely populated countries in the world, there are five key challenges to overcome.

COVID-19 in refugee camps: Five challenges in Bangladesh

Nazrul Islam, medical assistant, and Mahabuba Khatun, nurse aid, triage a patient at MSF’s Jamtoli primary healthcare clinic in the Cox’s Bazar refugee camps. © MSF/Daniella Ritzau-Reid

1. Highly vulnerable populations

After decades of persecution and restricted access to healthcare in Myanmar, the Rohingya generally have low levels of health and lack the protection of routine immunisations. Before COVID-19, around 30 per cent of patients treated by MSF in Rohingya refugee camps presented with respiratory tract symptoms, such as shortness of breath. With the introduction of COVID-19, these people are at already at higher risk. 

In addition, the crowded conditions where impoverished communities live make them particularly vulnerable to COVID-19. Many Bangladeshis live in densely populated urban and slum areas, and Rohingya refugees are stuck in cramped, squalid shelters, with up to 10 family members to a room. Maintaining physical distance in these settings is near impossible. 

“If you have only 11 litres [of water] per day, how is this enough to wash your hands all the time?” 

2. Maintaining essential services

As many essential health workers are being redirected to deal with the spread of the coronavirus, the humanitarian response in Bangladesh has been significantly reduced. But the demand for essential healthcare hasn't stopped – mothers continue to give birth, children are still getting sick with diarrhoea, and chronic patients still need access to medication. It is crucial that these essential, life-saving activities are maintained.

For the Rohingya, the approach of the heavy monsoon rains means the risk of outbreaks of water-borne diseases, such as cholera, will increase. Keeping the water and sanitation infrastructure running for such a large camp population is an even greater challenge with the current restrictions. Latrines need to be cleared of sludge, and water networks maintained and repaired – all tasks that require supplies, materials and manpower, now in limited supply. 

Travel restrictions, though key to limiting the spread of COVID-19, are also making it difficult for people to access healthcare. Those with ‘invisible illnesses’—psychiatric disorders or non-communicable diseases, such as diabetes—are also enduring greater difficulties in accessing treatment. They might appear healthy, but if their regular treatments are interrupted, they risk regression and reappearance of very harmful symptoms. In the last week, one patient arrived at an MSF facility in tears. It had taken her five days to arrange transport to come to the hospital, and she was afraid she’d be turned away.

3. Erosion of trust 

In this time of crisis, fear of the unknown is making the situation in Bangladesh worse. Over the last few weeks, MSF staff have seen a stark decline in consultations. At the Kutupalong field hospital in Cox’s Bazar, where we normally see 80–100 patients for wound dressings every day, only around 30 patients are now attending. Many of these are chronic wounds, which need regular cleaning and dressing every two or three days, and without these wound dressings there is a serious risk of infection, sepsis and even death. 

Through our experiences of providing healthcare during other infectious disease outbreaks, MSF has learned how crucial it is to involve and educate the communities we are there to help. This is vital to ensure they understand how to protect themselves, to tackle rumours and reduce fear, and to give people a sense of control. Bangladeshi and Rohingya communities are understandably frightened. Rumours and misinformation can spread as fast as the virus. 

COVID-19 in refugee camps: Five challenges in Bangladesh

Kawsar Mohammad Shamim, water and sanitation manager and Opu Biswas, nurse supervisor, demonstrate how to put on personal protective equipment (PPE) to newly recruited hygiene agents at MSF’s Rubber Garden COVID-19 treatment centre, in Cox’s Bazar, Bangladesh. © MSF/Daniella Ritzau-Reid

Our outreach teams in the camps and the neighbouring villages are working to share advice on how to prevent the spread of COVID-19. To avoid gathering people in groups, staff go house-to-house, speaking with individual family members. MSF teams are also working with community and religious leaders to help share health messages and organise tours of our isolation facilities to build trust with the communities.  

4. Protecting frontline workers

Healthcare workers are on the frontline of the COVID-19 response. Without them, there is no way to combat this impending health crisis or to address other medical needs. But in Bangladesh, as elsewhere in the world, MSF is facing shortages of essential personal protective equipment (PPE) – masks, gowns, goggles and gloves.  

“The limitations will determine our ability to respond to the COVID-19 outbreak, as well as our capacity to maintain ordinary medical activities,” says Muriel Boursier, MSF Head of Mission. “This uncertainty and having no guarantee that we’ll be able to keep our commitment to our patients, is a huge pressure on the team.” 

While we have witnessed inspiring displays of solidarity with frontline workers across the world, we have also seen fear driving cruel behaviour. Bangladesh has not been exempt of these situations. Some of our staff have received verbal abuse or threats by communities fearful of COVID-19; others are facing eviction by landlords unwilling to house frontline staff.   

Healthcare workers are most at risk of contracting COVID-19. MSF will not expose any of our staff to unnecessary risks of infection, but this lack of protective equipment will affect the work we can do. If healthcare workers feel unsafe or unsupported in their roles, there be serious impact on the response to COVID-19. 

COVID-19 in refugee camps: Five challenges in Bangladesh

5. Managing COVID-19 patients

MSF has created isolation wards in all our medical facilities in Cox’s Bazar, and our teams are preparing two dedicated treatment centres. In total we have made 300 isolation beds available – but this is just a fraction of the beds that will be necessary if there is widespread outbreak within the Rohingya community. Our clinics in the refugee camps are not able to treat severe cases given the lack of ventilators and limited availability of concentrated oxygen.

“This uncertainty and having no guarantee that we’ll be able to keep our commitment to our patients is a huge pressure on the team.” 

Increasing our response in this pandemic has required a large recruitment effort to bring on local Bangladeshi staff.  Our teams need additional international expertise, but restrictions on travel into Bangladesh have caused numerous delays and cancellations. Around 30 per cent of our international staff scheduled to be deployed in this crisis are currently stuck outside the country, severely stretching our internal capacity. In addition to needing medical staff, logistical staff and hospital manager roles are still needed to ensure medical supplies are available when needed. Currently, MSF is using hired buses to shuttle hundreds of staff to MSF hospitals and clinics across Cox’s Bazar – a huge and time-consuming daily logistical exercise, but essential to ensure care is being provided as effectively as possible.

MSF is working round the clock despite these difficulties. To have a realistic chance at tackling COVID-19 amongst Bangladesh’s most vulnerable communities, all health actors and authorities must all work together hand in hand, in solidarity. Only through solidarity can we provide the best care to patients during the COVID-19 crisis.