The coronavirus has reached Bangladesh’s Rohingya refugee camps. Now, weeks of preparation will be put to the test as aid responders dive into uncharted territory: containing and treating a pandemic in a refugee camp.
The first two COVID-19 cases – a Rohingya refugee and a Bangladeshi from the surrounding community – were confirmed on 14 May. Epidemiologists fear the virus could tear through the sprawling settlements, home to roughly 900,000 people living in bamboo and tarpaulin tents.
At a glance: From preparation to containment
- Coronavirus could spread slowly at first, but may begin to overwhelm after a month.
- The camps have a largely young population, meaning there could be fewer severe cases.
- Social distancing has been difficult. Untested containment measures could be a fallback.
- Isolation facilities and treatment plans have been scaled up, but it may not be enough.
- Health services have been diverted to target COVID-19, raising risks from other diseases.
- Fear and rumours have escalated. Rohingya say they don’t have enough information.
The UN’s refugee agency, UNHCR, said investigation teams had been deployed to isolate the patients, and to trace and test contacts. So far, there has only been minimal testing – only 145 people had been tested as of 15 May – which could slow containment plans. With such low testing numbers, the true reach of the outbreak remains uncertain.
“People are very worried,” said Khin Maung, a refugee and youth activist. “How can we protect our people in the long term? We cannot see any kind of option.”
Humanitarians in Bangladesh have long feared the worst in grappling with a pandemic that has overwhelmed much wealthier nations across the globe. Healthcare and hygiene services are basic even at the best of times, and chronic malnutrition endures nearly three years after a Myanmar military purge pushed hundreds of thousands more people into the camps.
Isolation and treatment beds are scarce even in the surrounding communities, though aid groups say new facilities under construction will be available within days.
A host of volatile factors is complicating the response, from figuring out how to contain the virus in close quarters, to maintaining aid, to balancing an increasingly fractious relationship with the local community and the government, which is already dealing with a growing national outbreak of more than 18,000 infections by 15 May.
Here’s a rundown of five key issues as the COVID-19 response in the Rohingya camps pivots from preparation to containment:
How many people could be affected?
The first step in designing a response is knowing how quickly the virus could spread, and how many people are likely to need hospitalisation. Aid groups have relied in part on a study by Johns Hopkins University researchers, published in March, which projects that the epidemic will spread slowly before rapidly cascading within a year as infections build.
The study projects between 119 and 504 transmissions within a month after the first case, rising to anywhere between 3,000 and half a million after three months, and nearly 600,000 after a year.
Under the most conservative scenarios, the study suggests the number of severe cases will exceed available hospital beds 83 days after the first confirmed case. The worst-case scenario projects hospitals and clinics would be overwhelmed just over a month into the outbreak – assuming all available beds are used to treat only severe coronavirus cases.
But the researchers also say there will likely be fewer severe cases than other countries have seen. The Rohingya camps are overwhelmingly young: more than half the residents are children under 18. By comparison, only about a third of the population in Bangladesh and in Myanmar are in this age group, according to UNICEF statistics (the global average is about 30 percent).
This means there could be fewer severe cases – fewer people needing hospitalisation and intensive care, and fewer people dying – compared to older countries.
“We have examined numerous refugee camps around the world and we have seen large differences” in the proportions of deaths, Paul Spiegel, director of JHU’s Centre for Humanitarian Health and a co-author of the study, told The New Humanitarian. “If a population has a higher proportion of persons 60 years and older, then severity, hospital bed and ICU use, and death rates increase significantly.”
Still, the study projects anywhere between three and roughly 1,500 deaths three months after the first infection, and more than 2,100 deaths in a year’s time.
“I am very concerned about the next few weeks and how the transmission of the virus will occur,” Spiegel said.
What treatment is available?
Aid groups and the government have scaled up isolation and treatment options, but it may not be enough.
In late March, aid groups had mapped about 400 available beds in isolation facilities, for both refugees and the local communities.
Nearly two months later, two new isolation and treatment centres for “severe acute respiratory infections” are set to open next week in Cox’s Bazar, the district that includes most of the camps, UNHCR spokesperson Louise Donovan said.
The facilities will hold nearly 200 beds altogether. They’re part of a group of 12 separate isolation and treatment centres in the pipeline. Current plans call for 1,900 treatment beds across the district, in addition to other quarantine and isolation facilities, Donovan said.
But, even under the study’s most conservative scenarios, the area will still need more than 4,100 hospital beds to treat severe cases.
And intensive care beds to treat the most critical cases are still rare. One understaffed hospital in Cox’s Bazar has an intensive care unit, or ICU, but the JHU researchers said it was unclear whether the facility was even functioning. Donovan said UNHCR is helping the hospital to create a unit with 10 ICU beds and eight high-dependency beds. The JHU study projects there could be anywhere between 16 and 4,400 ICU admissions after three months.
If not social distancing, then what?
It’s still unclear if the social distancing recommendations used across the world will work in a packed refugee camp.
While aid groups and volunteers are trying to spread the message, camp residents told TNH that many people simply don’t have the space to self-isolate – if they’ve even received the message.
“We live in small shelters. There are almost four to eight members in a family,” said Mohammed Arfaat, a refugee and social activist. “So it’s very difficult to maintain social distancing.”
Spiegel said the government and aid groups may need to try “novel and untested” strategies – particularly in trying to protect the camps’ most vulnerable, including more than 30,000 people older than 60.
“We live in small shelters. There are almost four to eight members in a family. So it’s very difficult to maintain social distancing.”
One early suggestion was to practice “shielding”: putting the elderly in separate sections, for example. However, UNHCR ruled this out after pushback from Rohingya.
An early focus group discussion showed that many Rohingya bristled against plans that would split up multi-generational households. One woman questioned why she would be forced into “the prison” when she’s not sick, according to a summary of the discussions.
There are other untested strategies, Spiegel said: “segmentation”, for example, which would see sections of the camp cordoned off when coronavirus infections are reported; or “task shifting”, which is used to counter health worker shortages. This would see doctors concentrate exclusively on severe cases, while nurses and community health workers take on moderate and mild cases.
Currently, aid groups and the government plan to treat all suspected and confirmed cases in isolation wards. If infections escalate, however, available beds will be reserved for severe cases and others will be asked to self-isolate and get care at home, according to a 14 May planning document.
There are also plans to deliver COVID-19 care at home in mild cases, as well as food and other relief aid for up to 75,000 refugees, UNHCR’s Donovan said.
What about other diseases and risks?
The pandemic response will come alongside aid shortfalls that were already threatening critical services in the camps.
Bangladesh’s government put the camps on lockdown in early April, ordering local and international humanitarian agencies to deliver only essential aid. Rights groups warned of “drastic” service reductions as staff access was scaled back – another potential roadblock to a swift health response.
Humanitarian groups are already reporting increases in gender-based violence and child marriage.
Then there are the dangers posed by other infectious diseases beyond the coronavirus itself. The camp has seen multiple diseases fester, including a measles outbreak that “overwhelmed” health clinics for weeks into January, a Médecins Sans Frontières staffer told TNH.
Since then, health services have been diverted to target COVID-19. Access to routine immunisations has fallen, health workers said, caused in part by vaccine availability and the camps’ coronavirus lockdowns.
Fear of contamination and movement restrictions have kept people from going to health centres; aid groups say consultations have dropped by half since mid-March.
What are Rohingya saying?
Fear, rumours, and misunderstandings persist in the camps, and these have escalated alongside the coronavirus risks.
Groups that work with Rohingya say humanitarian organisations have often failed to adequately consult with refugees on everything from biometric ID cards to education and the current pandemic threats.
Bangladesh has also cut off mobile internet in the camps since September, severing a vital source of information – and a way of getting preparedness messages out – for most residents.
“People staying by the main road know how to maintain distancing. They hear messages on the loudspeaker. But there are so many camps far away inside the hilly areas.”
“Most of the people don’t know about social distancing,” said Arfaat, who has created videos promoting hygiene and coronavirus safety.
“People staying by the main road know how to maintain distancing,” he said. “They hear messages on the loudspeaker. But there are so many camps far away inside the hilly areas.”
While some Rohingya are trying to stay indoors, others continue to gather in large numbers even as news of the first cases spread, Khin Maung said. Rohingya volunteers and aid groups have run awareness campaigns for weeks, but many are still in the dark due to the internet ban, he said.
“The thing is a lack of information; a lack of knowledge,” he said. “People are only saying one thing: ‘Allah will save us’. Because people cannot see the options.”