Writing in the BMJ,[1] Vince describes a dangerous, and soon to be dire, situation in the Cox’s Bazar Forcibly Displaced Myanmar Nationals (FDMN) camp with regards to the COVID-19 pandemic. The camp in South-East Bangladesh is, for the most part, very densely packed, making separation between people and families impossible. These families, often consisting of at least five people, live in rooms no larger than 16m2 , with almost no separation from other families – often just a thin sheet or a bamboo wall separates ‘households’. Compounding this, large numbers of different households share the same key resources, such as water and toilets, and queue in packed lines to access said resources, as well as key items such as food, cooking gas, and soap. Further, households and families are often multi-generational, making shielding of vulnerable members near impossible as somebody must venture out of the home for supplies.

Vince correctly states that a possible saving grace in the camp is the high percentage of inhabitants who are children, but tempers this by mentioning that malnutrition and other comorbidities are widespread. In addition, I would suspect that a large number of the adult inhabitants have chronic diseases, such as diabetes and hypertension, due in large part to a lack of adequate healthcare both prior to coming to Bangladesh and also while in Bangladesh. Little evidence exists on this, however. Further, these chronic conditions are likely to be un(der)treated, due to barriers in accessing healthcare. When we visited Cox’s Bazar, we heard informally that people fear accessing healthcare in formal facilities due to their perceived risk of harassment and deportation. Instead, people often seek care at unlicensed pharmacies, but these facilities are likely to provide little effective treatment.

Vince goes on to discuss the interventions taking place in Cox’s Bazar, primarily messaging and the provision of facilities for handwashing. While the correct approach for the context appears to be taken regarding messaging (using respected community leaders), the roll-out of handwashing in such a large area is challenging. Although handwashing is likely to be a high impact and cheap intervention, it requires soap and water reserves to be refilled multiple times a day on order to ensure a continuous supply. Even if proper supply was achieved, which in itself is a gargantuan feat given the size of the camp and the camp’s proclivity to occasional unrest, I suspect that soap and water from communal handwashing stations would not be used consistently, particularly at night, due to fear of going outside while dark. This fear is mostly experienced by marginalised groups such as women, the elderly, and the disabled. Gender-based violence is a large threat to women in such environments when going outside at night to the toilet, resulting in using a bucket in the home.

In my opinion, which Vince also touches on, the biggest barrier to effective outbreak control in any such setting is the difficulty in testing, tracing and isolation. As Vince states, the testing capacity of Bangladesh is already very limited, with the FDMNs likely being the last group to receive the needed supplies. Regardless, I very much doubt that any FDMN would come forward for testing, especially given the threat of isolation if found positive. Akin to the threat of isolation, recent reports of refoulement back to Myanmar, and movement of the FDMNs to the Bhasan Char Island in the Bay of Bengal, create fear of standing out and great hesitancy in being made to go anywhere, even if that is for isolation. We’ve seen in nations around the world that testing, contact tracing and isolation are the only ways of stopping the spread of SARSCoV-2 without a vaccine. However, this does not seem to be feasible in Cox’s Bazar.

So, what is the solution? If the FDMNs were given adequate rights on arrival, such as being able to live anywhere in Bangladesh and the right to work, we would not have this problem. Malaysia, for example, is home to a large Rohingya refugee population, but due to the legal ability of the refugees to live and work almost freely in urban settings, they do not see large outbreaks among the refugee population. In the camp setting, however, options are very limited – shielding and social distancing do not work due to multigenerational households, the need for supplies, and population density; and testing and isolation does not work due to mistrust. As Bangladesh has fewer than 2,000 ventilators, of which none are in Cox’s Bazar, COVID-19 is close to a death sentence for the elderly and those with chronic conditions. [2] In all honesty, other than the eventual vaccine, I see little recourse against the virus.

Ryan Rego

References:

1. Vince G. The World’s Largest Refugee Camp Prepares for COVID-19. BMJ. 2020; 368: m1205.
2. Save the Children. COVID-19: Bangladesh Has Less Than 2,000 Ventilators Serving a Population of 165m, Warns Save the Children. 6 April 2020.