In Bangladesh, more than 836 000 Rohingya refugee population is in need of humanitarian
assistance [1]. These refugees faced discrimination in their native land in terms
of various restrictions imposed on them due to the effective denial of their citizenship.
This led to several human rights violations including limited access to health care
services [2]. Currently they are under significant health risks and it has become
a challenge to address their health needs. Due to the increasing number of Rohingya
refugees and their congested living conditions in camps, there has been an overwhelming
increase in their health risks [3]. Refugees and affected community require 9 million
liters of safe water daily, and water, sanitation and hygiene (WASH) services are
reaching only 30% of the Rohingya people in need. Thus leaving them with no other
option than to fetch dirty water from muddy streams [4]. 85% of the refugees still
have no access to latrines [5]. All of which in turn increases the risk of communicable
disease outbreak [4]. There has been reports of measles outbreak amongst new arrivals,
the number of cases reported is 419 [6]. The largest oral cholera vaccination was
held in the refugee camps and even though it was able to reach 100% of the targeted
population, the risks of waterborne and other infectious diseases are still exceptionally
high due to their unhygienic living conditions [7]. Diphtheria outbreak has resulted
in 38 deaths and more than 5800 suspected cases of diphtheria have been reported as
of February 2018 [8]. There have also been reports on respiratory problems and skin
diseases among the refugees who have arrived since 25th August-with 10 846 and 3422
cases respectively [9].
Among the refugees, 720 000 are children [4]. 14 740 orphan Rohingya children have
been identified since September 20, 2017 in the settlements in Ukhia and Teknaf [10].
An estimated 250 000 children under the age of 8 require life-saving interventions
through community-based activities such as vaccination campaigns whereas 240 000 children
under-five years need malnutrition prevention and treatment support through nutritious
supplementary food.16 965 children with severe acute malnutrition (SAM) require inpatient
and outpatient treatment. 204 000 adolescent girls need nutritional support and 237 500
children from 6 months to 15 years need to receive measles-rubella (MR) vaccine [11].
Photo: Some of the shelters at Kutupalong camp site for the Rohingyas in Cox's Bazar
(from the collection of Helena Derwash, used with permission)
In the refugee camps, 54% of the Rohingya are below the age of 18; 52% are women with
23% of them between the ages of 18 and 59 years [12]. Among 91 556 adolescent girls
and women, 54 633 are pregnant or lactating mothers [4]. Lactating mothers (9.2% of
total refugees) and pregnant women (4.9% of the total population) have been identified
as the two highest numbers of vulnerable group within the Rohingya Refugees [13].
As of 22nd October, an estimated 42 000 pregnant women, 72 000 lactating mothers and
240 000 under-five children need health assistance [11]. Majority of women are giving
births at home, and only 22% of births occur in health facilities [14]. 2592 lactating
women and 1145 pregnant women have been admitted for malnutrition treatment [5]. They
are also among the first to experience additional barriers in accessing the scarce
and overstretched humanitarian relief services. Furthermore, not only are they among
the most affected groups but are also usually the last to be consulted (if at all)
about their needs and provided with the least information about where and how to claim
relief services [10]. 120 000 pregnant and lactating mothers require prevention and
treatment from malnutrition through nutritious supplementary food [11]. Even though
both Myanmar and Bangladesh have low prevalence of HIV among the South Asian countries,
however the Rakhine state had the highest prevalence of HIV in 2015. In addition to
this, the current predicament makes the victims of sexual violence more predisposed
to the risks and transmission of HIV [15]. There have also been 21 cases of HIV patients
reported among the refugees until Oct 8, 2017 [16].
There is an inadequate supply of essential reproductive along with maternal, child
and new-born health services. Furthermore, there is insufficient clinical management
of rape survivors, family planning as well as adolescent friendly health services,
especially in the provision of these services in hard-to-reach areas. Moreover, there
are no extensive HIV and TB services, although there have been cases of HIV reported
among the refugees [17]. There is limited accessibility to inpatient as well as secondary
health services which also includes referral system and quality of care and health
care services implemented at the settlement lack standardization [8]. Overcrowded
settlements and the rapid influx of refugees challenge the ability of service providers
to identify private and safe services for women. There is incessant new influx of
refugees which leads to overburdening of the existing facilities like WASH or health
facilities and thus services are still not available and accessible to many of the
refugees. The sheer size, density and unplanned nature of the make-shift settlements
hosting refugees remain a major obstacle to setting up the communal infrastructures
necessary to coordinate services at site level [17].
Mental health impact on the forcibly displaced refuges are significant. Refugees are
reported to suffer from the flashback of the massacre, anxiety, acute stress, recurring
nightmares, sleep deprivation, eating or even speaking disorder [18]. Methodical rape
on women and girls and violent deaths of family members have compounded the mental
health situation of the survivors of this physical violence. Women and children reported
facing sexual violence including gang rapes which resulted in vaginal tears, infections
and posttraumatic disorders [19]. There has been increase in the incidence of sexual
violence among the refugees in Bangladesh which was exacerbated by the unavailability
and low quality of post-rape care services [20]. From the end of August 2017 to the
end of February 2018, MSF has treated 226 survivors of sexual violence at MSF’s Sexual
and Reproductive Health Units, out of which 162 of them were rape survivors. Majority
of the survivors were below 18 years [21]. Children face the danger of long-term psychological
and social distress [22]. Since refugees are dependent on the humanitarian assistance
for their survival and struggle daily for food assistance, this acts as a stressor
for majority of them as well [23].
In addition, the overall situation and health risks will be exacerbated when the monsoon
season arrives as flooding will adversely affect the latrines, tube wells and health
facilities built in the camps [24]. The international community and Bangladesh government
need to address the vulnerability of these refugees by giving humanitarian and financial
assistance to them. There is need to scale up health services and increase access
to essential reproductive health and child newborn care, especially for Rohingyas
living in hard-to-reach areas. Community health workers need to be effectively trained
to ensure adequate health promotion, promotion of hygiene and home visits to pregnant
women. Scaling up of mental health service provision in primary health care settings
is needed. Information needs to be adequately provided to the refugees. Furthermore,
in the case of epidemics, rapid response is necessary and to ensure that reliable
health statistics remain paramount. Thus, organizations need to give more attention
to the collection and dissemination of data. As refugees, their condition has aggravated
because of limited financial aids and overcrowded unhealthy living conditions in settlements
and camps. All of which will exacerbate their access to health care services, predisposing
them to numerous health risks and increase the chance of disease outbreak. Thus along
with the government, private sectors and international communities must collaborate
to assist the refugees in their dire condition for the improvement of their health
status.