Addressing the needs of the largest refugee settlement in the world is daunting enough. Now, the challenge is compounded by the coronavirus pandemic. The combination is a crisis within a crisis.
The largest refugee settlement in the world is in Cox’s Bazar, Bangladesh, where around 900,000 Rohingya refugees from Myanmar are sheltering. As of June 30, 50 cases of COVID-19 had been confirmed in the Rohingya settlements, but the full extent of infection is not known. The pandemic is widespread in Bangladesh — with more than 260,000 cases confirmed — and the tightly packed conditions of the camps make their residents especially vulnerable.
To address this extraordinary set of circumstances, BRAC — the largest nongovernment responder to the humanitarian crisis in Cox’s Bazar — has developed a three-pronged approach that reflects its experience creating programs in the global south by listening to those most in need. The approach may prove instructive to aid workers facing other challenging settings around the world.
Prioritizing primary health care
First, one of the lessons we learned from the West African Ebola crisis was the importance of maintaining essential primary health services.
The rising deaths and COVID-19 cases in Cox's Bazar highlight the need for continued vigilance in the world’s largest refugee camp, where testing capacity remains low.
More than 11,000 people died from the 2014-2016 Ebola outbreak, but the closure of health facilities resulted in thousands more preventable deaths. Pregnant women who lacked medical care, for instance, were found lying unconscious outside of closed maternity centers. The COVID-19 pandemic similarly threatens the availability of primary health services and, with them, more lives.
Amid the pandemic, 11 health facilities we run in the Cox’s Bazar refugee camps, including two primary health care centers and nine health posts, are open. Each has a maternity unit providing essential health care to pregnant and lactating women, while also making contraceptives available to help reduce the risk of pregnancy and limit the number of babies being delivered during the health crisis.
To maximize safety at maternity units, each patient must call in advance to book an appointment, at which time a midwife asks questions to determine if the patient has symptoms of COVID-19. When screened patients arrive, they must immediately wash their hands, their shoes and sandals are sprayed with disinfectant, and they are met by midwives in personal protective equipment. The clinics are also sprayed with bleaching powder on a regular basis.
By maintaining and scaling primary health services, responders facing the pandemic in the most challenging situations can reduce excess preventable deaths.
Innovating to adapt preventive measures
Second, aid groups should prioritize adapting preventive measures for challenging contexts, such as facilitating hand-washing without running water in environments where water is scarce.
Masks are also a critical preventive tool. Amid global shortages of personal protective equipment, one innovative solution has found a way to provide masks for refugee families.
In Cox’s Bazar, aid groups face a dilemma. In an effort to stall a COVID-19 outbreak, they must reduce staff numbers and scale back services. But what unintended consequences will this have on nearly 1 million of the world’s most vulnerable people?
Through a program funded by UN Women and led by BRAC, women in the camps of Cox’s Bazar are learning to make reusable cloth masks, enabling 127 refugee women to earn income to support their families while sewing masks for camp residents. Mask-making began in April and operates in women’s centers in two camps, with hygiene measures maintained to keep the women safe from the virus. Together, refugee women have made more than 30,000 masks.
By adopting creative and cost-effective preventive solutions that enable hand-washing and mask-wearing in even the most under-resourced contexts, we can save countless lives.
Spreading essential knowledge through community-based outreach
Finally, the need to educate the public is essential and ongoing. This has two key components: conveying vital information about COVID-19 and dispelling myths that can become dangerous.
In Cox’s Bazar, we must draw on the expertise of the refugee camps’ community health workers, who are part of the largest nongovernmental pool of community health workers in the world. These health workers, who live and work in the communities they serve, are trained to make regular visits to households, provide basic health information and screenings, and link the households to institutional care.
Since the onset of COVID-19, community health workers have played a critical role in sharing information about how the virus spreads, educating refugee families on its symptoms, and instructing them on what to do if they get sick. Community health workers know the ins and outs of the refugee settlements and how people communicate within them, enabling them to dispel rumors and myths about the spread of the virus.
Responding to COVID-19 in an already dire humanitarian crisis is an unprecedented challenge. Refugee needs are extraordinary without a pandemic, and COVID-19 only adds to the complexity. But by using lessons learned from experience providing health services, engaging refugees in taking preventive measures, and drawing on the network of community health workers, we can help create the conditions needed to defeat the pandemic.