I stand on a hill in the middle of the largest of the Rohingya camps in Bangladesh beside a hospital run by Médecins Sans Frontières and see the huts of the Rohingya running away over the rippling hills to the distant horizon. “A sea of humanity,” says Azharul Islam Khan (known to all as Azhar), a doctor who has led the setting up of five diarrhoea treatment centres in and around the camps. We walk through the camp to one of the centres, and laughing children shout at us from all sides “How are you?” Some are in a school and some outside playing, improvising a swing on one of the bamboo bridges built by the Bangladesh Army. It’s sunny and warm but not oppressively hot, as it was earlier in the year. The atmosphere is light, even jolly with all the high-spirited children. But I also see a naked child of perhaps three carrying water on his head. What is the future for these displaced people and their children?
We walk on, going up and down the paths built by the army. The huts we pass are built from a variety of materials, including wood and bamboo, and are covered in tarpaulin held down with rocks with the hope of keeping the roof on when the cyclones come. Many roofs have a solar panel. The one thing that every family brought with them, Azhar tells us, is a solar panel. Three children come and shake my hand. The oldest, a girl of perhaps 6, shows a child of less than 2 how to shake my hand. He has a snotty nose, but most of children seem healthy, although I know from studies that malnutrition is common. I meet a man, who doesn’t speak English, but who gives me a card. “Goodness,” I think, “now even people in the camps have cards in Asia.” But when I read the card it says “ Rushanara Ali MP for Bethnal and Bow.” I think back to hearing her speak at a meeting with the All Party Parliamentary Committee on Bangladesh and hearing her on the radio highlighting the plight of the Rohingya and the brutality of the Myanmar Army. I give him back the guide. “He’s a teacher,” one of my companions tells me.
We walk on to the treatment centre. This is the fifth of the five centres set up by icddr,b [formerly the International Centre for Diarrhoeal Disease Research] with funding from UNICEF that we have visited in two days. I’m the chair of the board of iccdr,b, which is why I’m visiting. I feel rather like the Queen: we are being driven around in a secure and very comfortable UNICEF car: a crowd meets us at each of the centres; we are photographed all the time; and I shake hands and thank and congratulate the doctors, nurses, community health workers and others for their work.
The treatment centres all follow a similar design. This one is made with bamboo. The patients enter first a triage room, where a doctor and nurse evaluate the severity of their diarrhoea and any dehydration. About three quarters of cases are children, and among the adults women outnumber men—because many men were likely to have been murdered back in Myanmar. Milder cases might be sent to a room where they can be given oral rehydration therapy, which was invented by icddr,b, while more severe cases are admitted to a ward. They lie on cholera cots, which have a hole in the middle for collecting their diarrhoea. Severe cases need a drip, and a very few cases, probably around 2%, need antibiotics. To enter the wards we must walk over a mat soaked in chlorine.
In addition to the wards the centres have a surveillance centre that uses a rapid test developed by icddr,b to test for cholera. It gives an immediate result, but the specimens are all sent to icddr,b’s labs in Dhaka for confirmation. icddr,b also has surveillance centres in four clinics run by non-governmental organisations (NGOs), and data from the nine centres should provide early warning of a possible cholera outbreak. The centres also include a logistics room, where drugs and equipment are stored; an operations room, chlorine solutions are prepared; a kitchen; and a mortuary. Most of the centres also had a disinfectant room for washing the body, but there have been no deaths so far.
The centre in the middle of the camp does not have a kitchen as it is currently not open at night. The doctors and nurses, like all the aid workers, must be away from the camps by 4.30. Should there be a major outbreak of diarrhoea then the centre might open for 24 hours. Sixty per cent of deaths from cholera usually occur in later parts of night, one of the doctors tells me. The doctors and nurses come for shifting duties, commuting for some 90 minutes from Cox’s Bazar, where they stay. Most of the doctors and nurses are from Dhaka, so a long way from home.
Recruiting the staff was one of many logistic challenges overcome in setting up the centres. In addition to doctors and nurses, the centres need community health workers, cooks, electricians, and security staff. Sites had to be found, and structures either built or refurbished. A safe water supply was needed and electricity, which meant a generator in these places off the grid. In one centre a canvas ward was blown away in a storm. Another centre was infested with snakes and had to be closed, the surrounding area soaked in carbolic acid, and a protective fence erected.
The Rohingya are in two broad areas. Of the one million displaced people about 700 000 are in the main camp, where all the huts were newly built, and in an older settlement close by. The only Bangladeshis in the main camp are aid workers, but in the older settlement Rohingya mix with Bangladeshis in crowded narrow streets that reminded me very much of the slums of Dhaka. It’s hard, indeed impossible, most of the time, to tell who is a Rohingya and who a Bangladeshi. The Rohingya are not allowed to work and expected to stay in the camps. They have identity cards that they need to get food and assistance. They are held not by fences, but by the safety and support offered by the camps.
Most of the Rohingya came in a surge starting in August 2017, but some 300 000 were there before that. Some have been living in the area for as long as 25 years and have learnt Bengali. Their conditions are not that different from local Bangladeshis, most of whom are poor, and the Rohingya value greatly that they are not at risk of being murdered, tortured, or raped, as they were in Myanmar. We were there days after the repatriation scheme was introduced, and the Rohingya were fearful that they might be forcibly repatriated, probably to camps run by people who hated them rather than by people who supported them.
The previous day we visited treatment centres in the other main area of camps, further south and close to the Naf River that many of the Rohingya crossed from Myanmar on the far side. It’s an area of great natural beauty, close to the famous 120 km-long beach that is the main holiday destination of Bangladeshis. We were told that when they first arrived conditions for the Rohingya were dreadful: after wading rivers carrying their children, they were without shelter, water, and food in heavy rain and mud, scattered, sad, and unsure what to do. A massive relief effort got underway, and huts were built; and food, clean water, latrines, and services provided.
Many United Nations Agencies were involved, and some 140 different health organisations are providing care. This might seem like a recipe for competitive chaos, but the iccdr,b staff, who have attended humanitarian disasters all over the world, insist that the Rohingya relief effort is better coordinated than any other that they have experienced. It’s easy to be cynical about the United Nations, particularly with the failures of the Security Council, but seeing the UN bodies at work in the camps made me feel much more positive about the United Nations.
Four of the five diarrhoea treatment centres we visited provide care to the local host population as well as the Rohingya; indeed, in three of them most patients were from the local population. It’s important not to neglect the local population in humanitarian disasters and to try and avoid the understandable resentment and antagonism that might arise. I tried to imagine how it would be if a million displaced people with almost nothing suddenly came to live beside me in Clapham. Many European countries have struggled to adapt to far fewer migrants, many of them skilled not impoverished, arriving over years not in one rush. Bangladesh deserves to be proud of how they have cared for the displaced Rohingya, although they have denied them refugee status.
icddr,b staff have trained health workers in the management of cholera and diarrhoea in outbreaks across the world. As well as running five treatment centres, icddr,b senior physicians have trained a thousand health providers, including doctors, nurses, and community health workers. They find that some of the health non-governmental organisations have dubious protocols for managing diarrhoea, often overusing antibiotics.
It was striking that the diarrhoea treatment centres had few patients. Altogether there are 22 centres run by different organisations, and they were created because of a high chance of a cholera epidemic. All the ingredients were there: an area with high levels of endemic cholera, as iccdr,b knew from nationwide surveillance; densely crowded living quarters; poor sanitation; and a limited and, studies have shown, contaminated water supply. And nobody knew the vaccination status of the Rohingya, but as they were a neglected and abused population it was sensible to suspect it was poor.
An epidemic has been prevented by a combination of mass vaccination (see accompanying piece), 6000 wells drilled for water, 12 000 latrines, and programmes to encourage hand washing and hygiene. The success of preventive efforts means that many of the treatment centres are likely to be frozen temporarily, but it was essential to set them up to be ready to respond to an epidemic.
Although we saw many children in the camps, we did not see adolescent girls—because they are confined to the huts for religious and security reasons. Aid workers worry most about female and male adolescents: feeling confined and with their futures gone, they are likely to have mental health problems, but may also turn to drugs, crime, or terrorism. As well as shelter, food, and water people need meaning in their lives, and this is hard to find for the stateless, abused, and displaced Rohingya. Their future is uncertain: Bangladesh would like them to return, but Myanmar seems unlikely to offer them a safe environment.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: RS has been the unpaid chair of the board of trustees of icddr,b for the past five years but has now stepped down. Icddr,b paid his expenses to travel to Dhaka for the board meeting and on to Cox’s Bazar to visit the Rohingya camps.